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A roentgenographic study of experimental bone destruction
ORAL ROENTGENOLOGY American Academy
of Oral Roentgenology
Arthur If. Wuehrmann, Editor
.
.
.
.
.
.
.
.
.
.
.
A ROENTGENOGRAPHIC DESTRUCTION
STUDY
A&u-B&r Ekaid Ramadun, Ph.D.,* Indianapolis, Id.
B.Ch.D.,
University
Indima
School
of
.
.
.
.
.
.
.
OF EXPERIMENTAL
X.S.D.,
..r...
BONE
uncl Da,uicl 3’. Jlitchell~, D.D.N.,
Ikntistry
T
HE purpose of this investigation was to evaluate the eficacy of the rocntgenogram in disclosing the amounts of supporting cortical and cacntral trabecular bone in relation to teeth, in detecting periodontal and periapical alveolar bone loss, and in determining whether an effective registration of either the buccal or the lingual alveolar plate on conventional intraoral roentgenograms is possible.
MATERIALS
AND
METHODS
One human dry skull and mandible were used in this study. The maxillact, with the zygomatic arches and hard palate present, contained teeth from the central incisors to the second molars, inclusive; comparable mandibular tcctll, Initial roent,genograms, comparable to plus the third molars, were present. routine intraoral periapical films, were prepared before any sections were made. These revealed the relationship of the roots of the teeth to the bone and peg*mitted block sectioning of bhe jaws without destruction of the roots. A cranial autopsy saw was used to section t,he jaws into blocks of convenient size. The mandible was divided into five blocks in addition to the remaining rami. Roentgenograms were made of t,hese blocks; occlusal films were used instead of the standard periapical ones in order to obtain pictures of the entire blocks (Fig. 1). The films were placed parallel to the long axes of the teeth, and the central rays were directed at right angles to the films by the long-cone Indiana
From a portion of a thesis prepared University, September, 1960. *Professor and Chairman, Department
for
the
of Oral
934
master Diagnosis.
of
science
degree
in
dentistry,
Volume 15 Number 8
EXPERIIvIEKTAI,
BONE DESTRUCT108
Fig. l.-Mandibular blocks before the producti& of any (B ), the lingual aspect (A ), and with roentgeno,wams aspect of the facial plates in I3 is not apparent in C.
defects, viewed from CC), Note that the
935
the facial resorption
t,echnique. The films were esposed for l/i, second and dercloped for 3 minutes at 68” F. The x-ray machine was set at 65 KVP and 10 Ma. Eastman Kodak ultraspeed film and fast Eastman Kodak solutions were used. Similarly, the maxillae were divided into four blocks after removal of the palate and the zygomatic arch as shown in Fig. 2. Artefacts Created and Tllustmted.-A No. 559 fissure bur, mounted on a straight handpiece, was used to produce bone dcfccts simulating the results of pathoses. Left mandibular molar: Three vertical defects, 1, 2, and 3 mm. in depth and the same circumference as the bur, were made in the alveolar crest on the buccal surface between the lower left second and third molars and on the lingual surface between the left first, and second molars; roentgenograms were made after each defect was induced, and then the defect was increased in depth from 1 to 2 to 3 mm. (In Fig. 3 only the final results are shown.) Next, a circular hole in a horizontal plane, 15 mm. in diameter, was produced through the buccal cortical plate in the middle third of the mesial root of the lower left second molar, and a roentgenogram was made; this was subsequently
EXPERIMENTAL
c. the the
BONE
DESTRUCTION
937
D.
Fig. 3.-A, Roentgenogram of the left molar mandibular block after removal of much of ru’ote that there is little change in spongy bone, leaving the junctional trabeculae intact. architectural pattern in the roentgenogram. B, Tin foil placed in the created cavity to demonstrate the outline of the defect. C, Removal of both the central and junctional trabeculae shows a definite radiolucent
area. D, Note the effect of putting beef into the created defect. The slight change toward roentgenopacity Is due to this muscular tissue. See also results of the vertical 3 mm. defects placed in the buccal and lingual interproximal alveolar crests. The defects 1 mm. and 2 mm. deep (not illustrated) could not be seen roentgenographically. The defect on the buccal crest cannot be differentiated from that on the lingual crest in the roentgenogram.
buccal surfaces of the roots, and photographs and roentgenograms mere made (Fig. 1, C and D). Right mandibular premolar region: Cortical bone, 15 mm. in diameter, from the buccal plate was removed opposite the apices of the right lower premolars, exposing the underlying spongy bone. Photographs and roentgcnograms were made (Fig. 5). Eight ma~xillary premolar and molar region: The alveolar buccal plate was removed, exposing the buccal surfaces of the buccal roots of the upper right second molar. The junctional trabeculae linin g the buccal and lingual plates of bone above the apices of the upper right first and second premolars were then removed, leaving the central spongy bone intact. Photographs and roentgenograms were madtl to illustrate these defects (Fig. 6). Artefacts Creclted untl Not Tll~~struterl.--8ftcr completion of the following procedures, rocnt,genograms and photographs were made for study purposes but are not included in this report. Left maxillary molar and premolnr region: The buccal alveolar bone was removed, exposing the roots and the spongy bone in the interradicular area of
B.
A.
Fig. 5.-A,, The buccal cortical plate of the right mandibular premolar B, Roentgenogram showing removed, exposmg the underlying spongy bone. of the cortical plate alone had only a slight effect on the roentgenolurency.
block has been that the removal
c. Fig.
The buccal B The junctional g%%h th& flrst and second not affected after production 6.-A,
plate of bone is removed, exposing roots of the upper right leaving the central trabeculae trabeculae were removed premolar% C The archite’ctural pattern of the roentgenogram of the above’defects.
second intact was
Volume
15
Number 8
ESPERIMENTAL
BONE
DESTRUCTION
941
roentgenogram, except after reduction in the height of the crest of the’ interradicular bone (Fig. 6). Thus, in examining the interradicular area, one must probe thoroughly in all directions. Removal of the complete buccal or lingual cortical plate had practically no effect on the trabeeular pattern around the teeth in the mandible and in the maxillae or on the lamina dura, as shown in the rocntgenograms (Fig. 4). The periodontal membrane space and trabccular pattern remained essentialI>the same in these cases. This confirms the work reported hy Goldman and associates.” It was found that removal of the central trabeculae of the mandible and the maxillae, leaving the junctional trabeculae intact,, did not product an! apparent roentgenographic change (Fig. 3). This fiinding is in agreement with that, of Bender and Seltzer,“. o who demonstrated the same thing in the mandible and concluded that a central lesion may cause dcstroction of t,hc spongy bone, leaving the junctional trabeculae and corticcs intact, without being detected rocntgenographically. It was shown also (Fig. 6) that removal of the junctional trabeculae, leaving the central portion of the spongy bone intact, causes no change in the density of the roentgenogram. These findings rna~- explain why early destructive lesions of bone do not show in the roentgcnogram.
Fig.
i.-Aspirating
syringe
demonstrating
the clear blood.
brown
fluid
from
a cyst
and
a little
dark
Thus, some evidence is furnished that periapical roentgenolucent lesions are apparent only when a cortical plate is destroyed along with its attached junctional trabeculae and probably some central trabeculae. Since most periapical lesions tend to point toward the facial (labial or buccal) plate because of t,he proximity of most root apices to this surface, as shown by Bender and Seltzer,* one might expect that the diagnosis of most periapical lesions would be enhanced by using an aspiration technique through the missing or very thin facial plate. This has been borne out by our experience in which cysts and abscesses have been differentiated prior to surgery by aspiration of a clear fluid (Fig. 7) or pus, respectively. Also, it would seem likely that a cavernous central hemangioma might be recognized by obtaining considerable blood. If the roentgenolucent area is penetrated by the aspirating needle and no fluid is obtained, further exploration and excision would be necessary to establish a diagnosis.
bone
loss
without
cannot being
be denied, detected
c!saminations
must,
resorption
and
for
trabeculae
destruction
junctional
trabeculae
apparent
when
I~ut
bc made
together
Cvaluation
both
did also types
not
show
the
roentgenogrsm
of
trabcculae
and
should
tc:sts, aspiration,
ma,v and
destruction a cortical
depend surgical
in
OWIIY
IJOI~CS
roentgenograpllic
tlctection
or pcriapical Such
by palpation,
tests
accurate
destroyed.
pulp
clinical
in
chang:es Clinical
\vcrc
of the roentgenogrnm
appropriate
for
of periodontal
Interpretation
probing,
destructive
nmn~-
~~ocntgcnograpf~icall~~.
of
alveolar
disease. unless becamt3 plate
strongly esploration,
I~ollc~
Gntral Ironcs neighboring much
were
more
removctl.
on findings ant1 any
elicited other
available.
RFFFRFSCFS ,,1 1 1. I’ntur,
2. 3. 4. 5. 6. 7. 8. 9.
B. : Roentgenographic: Evaluation of i\lveolar Honc~ Changes iu Periodontal Theax’, I). Clin. North America, pp. 4i-54, March, 1960. A Comparison Between Anatomical and Radiographic Tnterpwtatiorr of Friitrlich, E.: Marginal Periodontal Disease, Paradontal. 12: 89, 1958. Origin of Registration of the Goldman, II. M., Millsap, J. S., and Brenman, H. S.: Crest in the IJt~ntnl Architectural Pattern, the Lamina nnra, and the Alveolar Radiograph, ORAL SURG., OEAT, MED. & ORAL PATII. 10: il-9, 1957. Greenfield, L. A. : X-ray Tcclmir and Tntcrprctation of lkntnl Roentgenograms, Ilondon, 1938, Henry Kimpton, p. 170. A Correlation Hrtween Periodontal IXseasc and Caries, Xiller, S. C., and Seidlcr, B. B.: J. D. Res. 19: 549, 1940. Dental Cosmos 78: 1075, 1936. Sheppard, T. M. : Alveolar Resorption in Uiabctcs hfellitus, Glickman, I.: Clinical Periodontolo:;p : the f’c,riodontinrn in Health and Disease, Phik delphia, 1958, W. B. Saunders Company, p. 257. and Direct Observation of E:xporimcrrtal Bender, I. B., and Seltzer, S.: Rocntgcnographic Lesions in Bone. Part I, J. Am. Dent. A. 62: 152, 1961. Bender, 1. B., and Seltzer, 8.: Roentgenographic and Direct Observation of Expcrimrntal Lesions in Bone. Part TJ, .T. ,Zm. Dent. A. 62: 708, 1961.
EXPERIMENTAL EDITOR’S
RONE
DESTRUCTION
943
NOTE”
It should be emphasized that the experimental efforts reported in this article were carried on using dried bone, a fixed kilovoltage technique, and presumably no added filtration. The relatively low kilovoltage employed (65 KVP) and the probable lack of added filtration would tend to produce short-scale film contrast. Higher kilovoltages and added filtration could be expected to broaden the “gray scale” and thus more effectively portray structures having small variations in either density or thickness. Equal emphasis must be placed on the fact that the kilovoltage used is consistent with that customarily employed in the average dental office. The use of a dried specimen further adds to high film contrast and the tendency to minimize small differences in hard-tissue density and/or thickness. Soft tissue has an x-ray beam attenuation effect which “softens” the harsh contrast of dried-specimen films. Any repetition of the experiment reported in this article might include the infiltration of dried bone with a suitably prepared wax (which should have the attenuation characteristics of water) and the simulation of buccal or labial soft tissue with the same material.
*This
Editor’s
N’ote
is included
with
the
knowledge
and
permission
of the
authors.
of Oral Roentgenology
Arthur If. Wuehrmann, Editor
.
.
.
.
.
.
.
.
.
.
.
A ROENTGENOGRAPHIC DESTRUCTION
STUDY
A&u-B&r Ekaid Ramadun, Ph.D.,* Indianapolis, Id.
B.Ch.D.,
University
Indima
School
of
.
.
.
.
.
.
.
OF EXPERIMENTAL
X.S.D.,
..r...
BONE
uncl Da,uicl 3’. Jlitchell~, D.D.N.,
Ikntistry
T
HE purpose of this investigation was to evaluate the eficacy of the rocntgenogram in disclosing the amounts of supporting cortical and cacntral trabecular bone in relation to teeth, in detecting periodontal and periapical alveolar bone loss, and in determining whether an effective registration of either the buccal or the lingual alveolar plate on conventional intraoral roentgenograms is possible.
MATERIALS
AND
METHODS
One human dry skull and mandible were used in this study. The maxillact, with the zygomatic arches and hard palate present, contained teeth from the central incisors to the second molars, inclusive; comparable mandibular tcctll, Initial roent,genograms, comparable to plus the third molars, were present. routine intraoral periapical films, were prepared before any sections were made. These revealed the relationship of the roots of the teeth to the bone and peg*mitted block sectioning of bhe jaws without destruction of the roots. A cranial autopsy saw was used to section t,he jaws into blocks of convenient size. The mandible was divided into five blocks in addition to the remaining rami. Roentgenograms were made of t,hese blocks; occlusal films were used instead of the standard periapical ones in order to obtain pictures of the entire blocks (Fig. 1). The films were placed parallel to the long axes of the teeth, and the central rays were directed at right angles to the films by the long-cone Indiana
From a portion of a thesis prepared University, September, 1960. *Professor and Chairman, Department
for
the
of Oral
934
master Diagnosis.
of
science
degree
in
dentistry,
Volume 15 Number 8
EXPERIIvIEKTAI,
BONE DESTRUCT108
Fig. l.-Mandibular blocks before the producti& of any (B ), the lingual aspect (A ), and with roentgeno,wams aspect of the facial plates in I3 is not apparent in C.
defects, viewed from CC), Note that the
935
the facial resorption
t,echnique. The films were esposed for l/i, second and dercloped for 3 minutes at 68” F. The x-ray machine was set at 65 KVP and 10 Ma. Eastman Kodak ultraspeed film and fast Eastman Kodak solutions were used. Similarly, the maxillae were divided into four blocks after removal of the palate and the zygomatic arch as shown in Fig. 2. Artefacts Created and Tllustmted.-A No. 559 fissure bur, mounted on a straight handpiece, was used to produce bone dcfccts simulating the results of pathoses. Left mandibular molar: Three vertical defects, 1, 2, and 3 mm. in depth and the same circumference as the bur, were made in the alveolar crest on the buccal surface between the lower left second and third molars and on the lingual surface between the left first, and second molars; roentgenograms were made after each defect was induced, and then the defect was increased in depth from 1 to 2 to 3 mm. (In Fig. 3 only the final results are shown.) Next, a circular hole in a horizontal plane, 15 mm. in diameter, was produced through the buccal cortical plate in the middle third of the mesial root of the lower left second molar, and a roentgenogram was made; this was subsequently
EXPERIMENTAL
c. the the
BONE
DESTRUCTION
937
D.
Fig. 3.-A, Roentgenogram of the left molar mandibular block after removal of much of ru’ote that there is little change in spongy bone, leaving the junctional trabeculae intact. architectural pattern in the roentgenogram. B, Tin foil placed in the created cavity to demonstrate the outline of the defect. C, Removal of both the central and junctional trabeculae shows a definite radiolucent
area. D, Note the effect of putting beef into the created defect. The slight change toward roentgenopacity Is due to this muscular tissue. See also results of the vertical 3 mm. defects placed in the buccal and lingual interproximal alveolar crests. The defects 1 mm. and 2 mm. deep (not illustrated) could not be seen roentgenographically. The defect on the buccal crest cannot be differentiated from that on the lingual crest in the roentgenogram.
buccal surfaces of the roots, and photographs and roentgenograms mere made (Fig. 1, C and D). Right mandibular premolar region: Cortical bone, 15 mm. in diameter, from the buccal plate was removed opposite the apices of the right lower premolars, exposing the underlying spongy bone. Photographs and roentgcnograms were made (Fig. 5). Eight ma~xillary premolar and molar region: The alveolar buccal plate was removed, exposing the buccal surfaces of the buccal roots of the upper right second molar. The junctional trabeculae linin g the buccal and lingual plates of bone above the apices of the upper right first and second premolars were then removed, leaving the central spongy bone intact. Photographs and roentgenograms were madtl to illustrate these defects (Fig. 6). Artefacts Creclted untl Not Tll~~struterl.--8ftcr completion of the following procedures, rocnt,genograms and photographs were made for study purposes but are not included in this report. Left maxillary molar and premolnr region: The buccal alveolar bone was removed, exposing the roots and the spongy bone in the interradicular area of
B.
A.
Fig. 5.-A,, The buccal cortical plate of the right mandibular premolar B, Roentgenogram showing removed, exposmg the underlying spongy bone. of the cortical plate alone had only a slight effect on the roentgenolurency.
block has been that the removal
c. Fig.
The buccal B The junctional g%%h th& flrst and second not affected after production 6.-A,
plate of bone is removed, exposing roots of the upper right leaving the central trabeculae trabeculae were removed premolar% C The archite’ctural pattern of the roentgenogram of the above’defects.
second intact was
Volume
15
Number 8
ESPERIMENTAL
BONE
DESTRUCTION
941
roentgenogram, except after reduction in the height of the crest of the’ interradicular bone (Fig. 6). Thus, in examining the interradicular area, one must probe thoroughly in all directions. Removal of the complete buccal or lingual cortical plate had practically no effect on the trabeeular pattern around the teeth in the mandible and in the maxillae or on the lamina dura, as shown in the rocntgenograms (Fig. 4). The periodontal membrane space and trabccular pattern remained essentialI>the same in these cases. This confirms the work reported hy Goldman and associates.” It was found that removal of the central trabeculae of the mandible and the maxillae, leaving the junctional trabeculae intact,, did not product an! apparent roentgenographic change (Fig. 3). This fiinding is in agreement with that, of Bender and Seltzer,“. o who demonstrated the same thing in the mandible and concluded that a central lesion may cause dcstroction of t,hc spongy bone, leaving the junctional trabeculae and corticcs intact, without being detected rocntgenographically. It was shown also (Fig. 6) that removal of the junctional trabeculae, leaving the central portion of the spongy bone intact, causes no change in the density of the roentgenogram. These findings rna~- explain why early destructive lesions of bone do not show in the roentgcnogram.
Fig.
i.-Aspirating
syringe
demonstrating
the clear blood.
brown
fluid
from
a cyst
and
a little
dark
Thus, some evidence is furnished that periapical roentgenolucent lesions are apparent only when a cortical plate is destroyed along with its attached junctional trabeculae and probably some central trabeculae. Since most periapical lesions tend to point toward the facial (labial or buccal) plate because of t,he proximity of most root apices to this surface, as shown by Bender and Seltzer,* one might expect that the diagnosis of most periapical lesions would be enhanced by using an aspiration technique through the missing or very thin facial plate. This has been borne out by our experience in which cysts and abscesses have been differentiated prior to surgery by aspiration of a clear fluid (Fig. 7) or pus, respectively. Also, it would seem likely that a cavernous central hemangioma might be recognized by obtaining considerable blood. If the roentgenolucent area is penetrated by the aspirating needle and no fluid is obtained, further exploration and excision would be necessary to establish a diagnosis.
bone
loss
without
cannot being
be denied, detected
c!saminations
must,
resorption
and
for
trabeculae
destruction
junctional
trabeculae
apparent
when
I~ut
bc made
together
Cvaluation
both
did also types
not
show
the
roentgenogrsm
of
trabcculae
and
should
tc:sts, aspiration,
ma,v and
destruction a cortical
depend surgical
in
OWIIY
IJOI~CS
roentgenograpllic
tlctection
or pcriapical Such
by palpation,
tests
accurate
destroyed.
pulp
clinical
in
chang:es Clinical
\vcrc
of the roentgenogrnm
appropriate
for
of periodontal
Interpretation
probing,
destructive
nmn~-
~~ocntgcnograpf~icall~~.
of
alveolar
disease. unless becamt3 plate
strongly esploration,
I~ollc~
Gntral Ironcs neighboring much
were
more
removctl.
on findings ant1 any
elicited other
available.
RFFFRFSCFS ,,1 1 1. I’ntur,
2. 3. 4. 5. 6. 7. 8. 9.
B. : Roentgenographic: Evaluation of i\lveolar Honc~ Changes iu Periodontal Theax’, I). Clin. North America, pp. 4i-54, March, 1960. A Comparison Between Anatomical and Radiographic Tnterpwtatiorr of Friitrlich, E.: Marginal Periodontal Disease, Paradontal. 12: 89, 1958. Origin of Registration of the Goldman, II. M., Millsap, J. S., and Brenman, H. S.: Crest in the IJt~ntnl Architectural Pattern, the Lamina nnra, and the Alveolar Radiograph, ORAL SURG., OEAT, MED. & ORAL PATII. 10: il-9, 1957. Greenfield, L. A. : X-ray Tcclmir and Tntcrprctation of lkntnl Roentgenograms, Ilondon, 1938, Henry Kimpton, p. 170. A Correlation Hrtween Periodontal IXseasc and Caries, Xiller, S. C., and Seidlcr, B. B.: J. D. Res. 19: 549, 1940. Dental Cosmos 78: 1075, 1936. Sheppard, T. M. : Alveolar Resorption in Uiabctcs hfellitus, Glickman, I.: Clinical Periodontolo:;p : the f’c,riodontinrn in Health and Disease, Phik delphia, 1958, W. B. Saunders Company, p. 257. and Direct Observation of E:xporimcrrtal Bender, I. B., and Seltzer, S.: Rocntgcnographic Lesions in Bone. Part I, J. Am. Dent. A. 62: 152, 1961. Bender, 1. B., and Seltzer, 8.: Roentgenographic and Direct Observation of Expcrimrntal Lesions in Bone. Part TJ, .T. ,Zm. Dent. A. 62: 708, 1961.
EXPERIMENTAL EDITOR’S
RONE
DESTRUCTION
943
NOTE”
It should be emphasized that the experimental efforts reported in this article were carried on using dried bone, a fixed kilovoltage technique, and presumably no added filtration. The relatively low kilovoltage employed (65 KVP) and the probable lack of added filtration would tend to produce short-scale film contrast. Higher kilovoltages and added filtration could be expected to broaden the “gray scale” and thus more effectively portray structures having small variations in either density or thickness. Equal emphasis must be placed on the fact that the kilovoltage used is consistent with that customarily employed in the average dental office. The use of a dried specimen further adds to high film contrast and the tendency to minimize small differences in hard-tissue density and/or thickness. Soft tissue has an x-ray beam attenuation effect which “softens” the harsh contrast of dried-specimen films. Any repetition of the experiment reported in this article might include the infiltration of dried bone with a suitably prepared wax (which should have the attenuation characteristics of water) and the simulation of buccal or labial soft tissue with the same material.
*This
Editor’s
N’ote
is included
with
the
knowledge
and
permission
of the
authors.