Silvia Teslaru, Silvia Ma r u

THE ROLE OF CT EXAMINATION IN DIAGNOSIS AND TREATMENT OF ADVANCED PERIODONTITIS

ROLUL EXAMENULUI CT N DIAGNOSTICUL I TRATAMENTUL PARODONTITELOR AVANSATE Silvia Teslaru1,
1

PhD., Department of Periodontology, Facul

ABSTRACT
Today, in periodontology, the diagnosis is based not only upon clinical examination, but also upon laboratory examinations (microbiological, radiographic, possibly genetic). Radiographic evaluation of bone is an indispensable classic diagnosis method that completes the data obtained from deep periodontal measurements, allowing estimation of the amount of peripheral bone and possibly interradiculare, but that can not portray the exact topography and morphology of apical lesions. Keywords: radiographic evaluation, periodontal dissesses

REZUMAT
paraclinice (microbiologic, radiografic, eventual

un element indispensabil diagnosticului, completand

ntual interradicular, dar nu poate vizualiza exact topografia si morfologia leziunilor infraosoase. Cuvinte cheie: parodontala

INTRODUCTION
In current periodontology, the diagnosis is based not only upon clinical examination, but also upon laboratory examinations (microbiological, radiographic, possibly genetical methods). Radiographic evaluation of bone is an indispensable classic diagnosis method that completes the data obtained from deep periodontal measurements and allows estimation of the amount of peripheral and possibly interradiculare bone, but can not portray the exact topography and morphology of apical lesions. As Meyer states, the items that are followed in a radiographic examination are: the dental anatomy, the degree and the shape of bone loss (interdental and interradiculare septum), lamina durra, the cortical vestibular oral bone (the gap between them), the trabecular bone, the desmo-

INTRODUCERE
examenelor paraclinice radiografic, eventual genetic). element indispensabil (microbiologic,

diagnosticului,

exact topografia infraosoase.

si

morfologia

leziunilor

interradicular), lamina dura, corticalele osoase

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THE ROLE OF CT EXAMINATION IN DIAGNOSIS AND TREATMENT OF ADVANCED PERIODONTITIS

dontal space, and the root proximities [1, 2, 3]. The classic radiographic examination, the ortopantomographics, the retro-tooth alveolar and bite-wing radiographs are limited as a means of investigation; they do not reveal the early alterations of the periodontium and it is a two-dimensional representation of a threedimensional object. Radiographic analysis does not allow determination of the following aspects: morphology of bone defects (number of bone vertical walls), the exact position of the vestibular and oral cortical, the presence and the severity of periodontal pockets, septum interradiculare illness at the superior molars by overlapping roots, view intraosseous pockets. Some of these deficiencies are clinically detectable, while others require further investigations, such as: CT examination (computer tomography or classical beam-con CBCT). In the absence of such information, diagnostic data are insufficient for establishing an appropriate treatment strategy for each case.

Examenul radiografic clasic, pe ortopantomografie, radiografii retrodent -wing, este limitat ca

bi-

-dimensional. orfologia defectelor

afectarea septului interradicular la molarii vizualizarea pungilor infraosoase serpiginoase.

suplimentare, cum ar fi prin examen CT (computer tomograf clasic sau cu fascicul-con e de unei strategii terapeutice adecvate fiec rui caz.

MATERIAL AND METHOD CASE STUDY

To illustrate the benefits of computer tomography exploration and of the data analysis using the Dental CT program we propose the study of a 27 year old patient, diagnosed with aggressive periodontitis in advanced stage, located in the teeth 16, 11,21, 36 and lower frontal group.

STUDIU DE CAZ
rii datelor prin programul Den

inferior.

RESULTS
Reason for the patient referral to the office was the aesthetics issue of pathological migration located at the superior central incisors, with the development of pathological trema by vestibular and distal-vestibular-rotation (fig. 1). The appearance of longer teeth and the emergence of the interdental free spaces in the lower front group were embarrassing for the patient. Family history shows no significant issues. The presence of an increased sensitivity in the upper respiratory tract should be noted in from tonsillitis and pharyngitis. The patient is non-smoking, with a good hygiene. Clinical examination shows deep periodontal

REZULTATE
fost problema estetica generate de migrarea

-vestibuloDeranjant pentru pacienta era si aspectul de dinte lung, cu aparitia spatiilor interdentare libere la nivelul grupului frontal inferior. Antecedentele heredocolaterale nu antecedentele personale ar fi de remarcat

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Silvia Teslaru, Silvia Ma r u

pockets, located in teeth 15-16, 11, 21, 36 and moderately active periodontal recession in the lower front group (fig. 2, 3).

-16, 11, 21, 36, moderat active, recesiuni parodontale la nivelul grupului frontal inferior (fig 2, 3).

Fig.1. Patient P.A., 28 years, the initial clinical aspects.

Fig. 4. Ortopantomographics, patient P.A Ortopantomografie, pacienta P.A.

Fig 2, 3. Patient P.A. Periodontal survey in teeth 11 and 22 reveal deep periodontal pockets of 8 and 7mm Pacienta P.A. Sondajul 7mm.

Ortopantomographics is an essential complementary test that focuses on overall damage of periodontal support; it shows marked loss of alveolar bone in these teeth, the vertical and alveolar loss predominantly affecting interradiculare bone in the 36 region (fig. 4). Measurements performed on ortopantomographics are not exact, only indicative considering changes of teeth image, due to the characteristics of this technique. However, the level of alveolar bone crest can be measured by applying a correction factor that is characteristic for each device. Also the horizontal size measurement is not real due to the bidimensional character of the image. All panoramic radiographs also involves image distortions 30% in horizontal direction and at least 50% in vertical direction. Consequently, panoramic radiography, although a first choice examination in periodontology, represents an insufficient method for assessing the periodontal status, because it does not reveal thickness of alveolar the ridge, the vestibular and oral

Ortopantomografia este un examen paraclinic

ize predominant verticale si afectarea osului interradicular la nivelul lui 36 (fig. 4). M sur torile efectuate pe ortopantomografie nu sunt exacte, ci doar orientative urmare a deform ririi imaginii, caracteristice acestei tehnici. Cu toate acestea, se poate realiza m fiec rui aparat. De asemenea, m surarea dimensiunilor pe orizontal nu este real datorit red rii bidimensionale a imaginii. Toate radiografiile panoramice implic imaginii de pan , radiografia panoramic prim o metod insuficient de apreciere a statusului parodontal, deoarece nu ofer

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cortical bone architectural defects and the measurement of the alveolar bone loss is generating significant errors. The major disadvantage of this type of examination in fact is that the image is very unclear due to the movement flux (video and tube) and to the overlap of cervical spine. Supplementatal investigation with radiographs is required at 18-17 due to the presence and proximity of root, at 11-21, at 3242 due to changes of image by superimposing of the image of the cervical vertebrae (fig. 5, 6) at 36 - 37 in order to explain the cortically vestibular and lingual gap and architectural intraosseous defects. Information on horizontal alveolar loss in the lower front group is superior by ortopantomographics, as well as at 11-21, where it is observed a sharp alveolar loss without complete removal trabecular structure at this level, which allows presuming the existence of intraosseous defects with one or two vertical bone walls. One can notice the lack of contour with high density at the interdental bone; this is a sign of periodontal illness activity in the patient. In so far the examination points out clearly at some important issues: the vestibular and oral cortical, the number of vertical bone walls at periodontal pockets infraosseoss, the size of these defects in vestibular -oral, topography of interradiculare septum damage, especially in maxilla molars (e.g. 16); these are the necessary data for establishing a correct and complete diagnosis and also in order to choose the best treatment methods (regenerative or surgical).

grosimea

crestei

alveolare,

corticalelor

infraosoase, iar m surarea dimensiunilor alveolizelor genereaz erori semnificative. Inconvenientul major al acestui tip de examinare rezid imaginea nu este foarte clar din cauza fluudatorit suprapunerii coloanei cervicale. Se impune suplimentarea cu radiografii retrodentoalveolare la 18-17 da -21, 32-42 datorita imaginii fluu prin suprapunerea vertebrelor cervicale; (fig. 5, 6) la 36 - 37 pentru aosos.

Se poate observa lipsa conturului mai radioopac al septurilor interdentare, acesta fiind un semn de activitate al parodontitei pacientei. cateva aspecte importante: nivelul corticalelor verticali ai pungilor parodontale infraosoase, -oral, tului interradicular, mai ales la molarii superiori (exemplu 16), date

celei mai bune metode (regenerativ sau rezectiv).

de

tratament

Fig. 5, 6. Patient P.A. Retro-dental-alveolar radiographs Pacienta P.A. Radiografii retrodentoalveolare

This information is obtained after complete exploration and interpretation of the results by computer-tomography and Dental CT program.

telor prin programul Dental CT.

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Silvia Teslaru, Silvia Ma r u

For this purpose we used a Somatom Emotion, Siemens device; the exploration was done at Explore-Rx Center in Iasi,; Syngo software (eFilm software from Merge eMed) was used to measured bone density (in Hounsfield units) and for measurement of distances. Section thickness was 1 mm (130 kV, 90mAs). We used sections parallel to axe incremented mm by mm, allowing bone defects measurement of in subsequent sections (fig. 7-11).

Pentru acesta s-a folosit un aparat Somatom Emotion, Siemens,explorarea s-a realizat la Centrul Explora-Rx din Iasi, programul Syngo (soft eFilm, de la Merge eMed) a fost utilizat pentru masurarea densitatii osoase (in unitati Hounsfield) si pentru masurarea distantelor. Grosimea sectiunilor a fost de 1mm ( 130 kV, 90mAs). Am fo -11 ).

Fig. 7. In which, plans are parallel to axe sections at the upper jaw. Planurile in care se fac sectiunile paraxiale, maxilar superior

10

11

Fig. 8 - 10. Patient P.A. Sections parallel to axe show advanced bone loss at 11.

Sections in planes parallel to the hard palate, with 1mm thick, made in 0.5 mm to 0.5 mm from the apex of 11 to the cervical area (or incised edge) allow the visualization of bone defect morphology and depth of measurement by the number of sections. One can also observe and intraosseous defect level 16 (fig. 12-28). Processing program through the CT imaging acquisitions Syngo (eFilm software from Merge eMed) allowed and two-dimensional reconstruction of successive plans, separated by thickness of 2mm between them highlights the superiority of the classical method, ortopantomographics, alveolar lyses at level 12, 11, 21, 22, and also at 16-15 level. Data provided by computer-tomography examination is closest to the reality of intraosseous defects and are summarized below (fig. 31, 32).

nivelul marginii incizale) permit atat vizualizarea morfologiei profunzimii lui, prin defectul infraosos de la nivelul 16 (fig. 12-28). Programul de prelucrare a achizitiilor imagistice CT prin programul Syngo (soft eFilm, de la Merge eMed) a permis si reconstructia bidimensionala in planuri succesive, la grosimi de clasice, ortopantomografice, alveolizele de la nivelul -15. Datele oferite de examenul computertomografic este cel mai apropiat de realitatea intraoperatorie a defectelor infraosoase (fig. 31, 32).

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12

13

14

15

16

17

18

19

22 20 21

23

24

25

26
Fig. 12-27. Patient P.A. Horizontal CT sections

27

Fig. 29. Patient P.A. Plotting successive plans and 2D reconstruction of the upper jaw.

The method has provided valuable data that have guided treatment towards a regenerative therapy that required sampling the coagulum mentoniere bone (fig. 33, 34).

Acesta a oferit date pretioase care au orientat tratamentul spre o terapie regenerativa ce a impus si recoltarea de coagulum osos din simfiza mentoniera (fig. 33, 34).

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Silvia Teslaru, Silvia Ma r u

Fig. 31, 32. Patient P.A. Probing reveals periodontal intra-operator interdental areas at 12- 11 and 21-22 of periodontal defects intraosseous with two vertical bony walls, vestibular and palate -22

Fig. 33. Menton collection of bone area.

Fig. 34. Coagulum bone

Fig. 35. Suture mentoniere donor area.

Fig. 36. Realizarea aditiei la nivelul defectelor infraosoase

Classic radiographic examination retrodental-alveolar at upper front group showed an improvement of periodontal support tissues even though there are still apparent unresorbable fragments in the combling areas. The price of examination is high and, most importantly, the patient receives significant irradiation (2.8mSv for a CT cranial compared with 0.5 mSv for an X-ray panoramic). CT examination (axial and coronal sections) has the disadvantage of artefacts caused by the presence of metallic structures (see fig. 26) and computing errors (alveolar diameter) caused by the variable shape of dental arches.

Examenul radiografic clasic retrodentoalveolar la nivelul grupului frontal superior arat t parodontal, chiar dac se observ neresorbite complet la nivelul zonelor de comblaj (fig. 38, 39). Costul examin important, iradierea pacientului este semnificativ (2,8 mSv pentru o CT cranian comparativ cu 0,5 mSv pentru o radiografie panoramic ).

de

calcul

(diametrul alveolar) cauzate a arcadelor dentare.

de

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THE ROLE OF CT EXAMINATION IN DIAGNOSIS AND TREATMENT OF ADVANCED PERIODONTITIS

Fig. 37. Access aesthetic flap

Fig. 38, 39. Radiographic appearances at 11-21-22 at 12-11 at 3 months post-operator. Aspect radiografic retrodentoalveolar la nivelul 12-11 si 11-21-22, la 3 luni postoperator

DISCUSSIONS
Ortopantomographics remains a guidance examination for detection and control; it is a comprehensive study, receiving the image on a single system-dental-alveolar [1]. Its simplicity is due to relatively mild positioning, coupled with rapid implementation, low price and irradiation recommended that as an initial examination in periodontology because it allows overall assessment of the proximal bone and interradiculare the type of bone lyses (horizontal or vertical), the topography of alveolar destructions [2, 3]. The disadvantages are that it does not offer information in connection with the bone at vestibular and oral areas of the teeth and, neither on the morphology of intraosseous lesions: number of vertical bone walls, extension of intraosseous lesion, morphology of interradiculare bone defect (see fig. 2). Due to overlapping of anatomical formations (cervical spine) or distortions from positioning, on ortopantomographics some areas appear blurred (upper and lower front group), for they shall undertake retro-dental-alveolar or bitewing radiographs (interproximal). It is preferable to choose a device with long cone technique using parallel planes method, because it has many advantages: no deformation of the teeth, no projection of neighbouring structures, perfect view of lamina durra and alveolar ridge, interdental and interradicular bone defects. Exploring limits remain the same, since both are bi-dimensional reflections of a threedimensional reality, so one of these dimensions of space (depth) is inevitably lost [3, 4]. Computer-tomography (CT) and then spiral computer-tomography (spiral CT) and manyorientare, depistar dento-

ie, deoarece

alveolizelor [2, 3].

infraosoase, morfologia interradicular vezi fig. 2.

defectului

osos a-

dentoalveolare sau bite-wing (interproximale). Este de preferat alegerea unui aparat cu con

crestei alveolare, a defectelor septurilor osoase

tridimensionale, deci una dintre dimensiunile l

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Silvia Teslaru, Silvia Ma r u

slices CT type (MSCT) technology have revolutionized exploration techniques by fine sections achieved in axial and coronal plane, 2D and 3D reconstruction in low time for acquiring images, the quality of bone and dental imaging that allows detailed exploration of intraosseous defects: their depth, width, number of bone walls, the vertical extent and spatial configuration of pockets, morphology of interradiculare alveolar loss [4, 5]. The method permits also quality evaluation of bone support on the basis of Hounsfield density.

-ul tip plan timpul redu

infraosoase serpiginoase, morfologia alveolizelor interradiculare [4, 5].

CONCLUSIONS
Today, in periodontology, the clinical examination and ortopantomographics or radiographies only do not provide sufficient data to make a correct therapeutic decision, especially in the case of periodontal intraosseous pockets and interradiculare lesions combined with intraosseous pockets. Computer tomography examination processed by dental CT program brings valuable data in these cases, pointing to a better therapeutic decision: regenerative or radical, depending on the spatial architecture of bone defects, the prognosis of the large lesions being more reserved than the one of the narrow and deep lesions, with several vertical bone walls.

CONCLUZII
retro-

interradiculare combinate cu pungi infraosoase. Examenul computertomografic prelucrat prin

prognosticul leziunilor largi fiind mai rezervat deca

REFERENCES
1. Barthe M, Marchal MF. Stomatologiques 1993; 181: 21-34 2. maxillaire.Approche radio-clinique. Paris. Masson, 1995 4. 5. www.osseosnews Cap. I: 26-30 3. -

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