Involvement of the maxillary sinus in bisphosphonate-related osteonecrosis of the jaw: Radiologic aspects.

BACKGROUND: The use of bisphosphonates is very common among patients with osteoporosis and multiple myeloma as well as those with bone metastases from various malignancies. The benefits of bisphosphonates are well recognized, but it became evident during the past decade that these medications portend the major adverse effect of osteonecrosis of the jaw, known as bisphosphonate-related osteonecrosis of the jaw. OBJECTIVE: Our aim was to evaluate the specific manifestations of bisphosphonate use on the maxillary sinus in patients with documented bisphosphonate-related osteonecrosis of the jaw. METHODS: A retrospective review of all the patients diagnosed between October 2003 to August 2014 as having bisphosphonate-related osteonecrosis of the jaw in a large university-affiliated tertiary care medical center. The records of 173 patients diagnosed as having bisphosphonate-related osteonecrosis of the jaw during the study period were retrieved. The available head and neck computed tomographic images were analyzed for cases of involvement of the maxilla. MAIN OUTCOME MEASURES: Manifestations of bisphosphonate-related osteonecrosis of the jaw as observed on physical examination and on imaging studies. RESULTS: Seventy-one patients (41%) had involvement of the maxilla, 86 patients (49%) had involvement of the mandible, and 16 patients (9%) had involvement of both the maxilla and the mandible. Computerized tomography studies were available for 50 patients with involvement of the maxilla: 36 (72%) had evidence of maxillary sinus opacification (in comparison, the incidence of maxillary sinus opacification as an incidental finding in the general population is reported to be 19%, p < 0.0001). Sixteen patients (32%) had evidence of oroantral fistula, and five patients (10%) had oronasal fistula. CONCLUSION: In addition to its well-established effects on the mandible and maxilla, bisphosphonate-related osteonecrosis of the jaw significantly affected the maxillary sinus. Its radiologic manifestations should be recognized by clinicians and especially by otolaryngologists.

Are different imaging methods affecting the treatment decision of extractions of mandibular third molars?

OBJECTIVES: To find the differences between treatment decisions of lower impacted third molars among experts of oral and maxillofacial surgery according to panoramic radiographic and CBCT findings. METHODS: A retrospective analysis of 62 panoramic radiographs and CBCT of lower third molars evaluated for treatment decisions by 9 independent experts of oral and maxillofacial surgery. RESULTS: Differences in interpretation of the panoramic radiography were found between surgeons. The absence of radiological signs suspected for risk to the inferior alveolar nerve lead to the decision of extraction according to panoramic radiography without CBCT (p < 0.01). The presence of those signs lead to referral to CBCT by surgeons before treatment but did not change their decision. CONCLUSIONS: Treatment decision for surgical treatment of the lower third molar can be accepted without CBCT findings. The use of CBCT is popular before extraction of lower third molars. We found that it has a little effect on the treatment decision of the surgical intervention in comparison to panoramic radiography.

Clinical and radiological profile of ameloblastic fibro-odontoma: an update on an uncommon odontogenic tumor based on a critical analysis of 114 cases.

Ameloblastic fibro-odontoma is an uncommon benign tumor of the jaws that belongs to the group of mixed odontogenic tumors. The descriptions of its clinical and radiological features in the literature are not always accurate and sometimes even contradictory. The aim of the present study was to critically evaluate their clinical and radiological features as reported in the English-language literature. A total of 114 well-documented cases of ameloblastic fibro-odontomas (103 from publications and 11 of our own new cases) were analyzed. The patients' age ranged from 8 months to 26 years (mean 9.6). There were 74 (65 %) males, with a male-to-female ratio of 1.85:1 (P = 0.001). The mandible was involved in 74 (65 %) cases, and the mandible-to-maxilla ratio was 1.85:1 (P < 0.001). Nearly 80 % of the lesions were located in the posterior region of the jaws, and most (58 %) were in the posterior mandible. Radiographically, most of the lesions were unilocular and only a few (~10 %) were multilocular. Most lesions were mixed radiolucent-radiopaque, and only a few (~5 %) were radiolucent. Almost all lesions (~92 %) were associated with the crown of an unerupted tooth/teeth. This comprehensive analysis of a large number of patients with an uncommon lesion revealed that ameloblastic fibro-odontomas are significantly more common in males and in the mandible, and that multilocular lesions are uncommon. It also revealed that, based on their clinical and radiological features, some of them are probably true neoplasms while others appear to be developing odontomas (hamartomas).

Clinical and radiological presentation of hemimaxillofacial dysplasia/segmental odontomaxillary dysplasia: critical analysis and report of a case.

OBJECTIVES: The purpose of the present study was to critically evaluate the literature, describe the clinical and radiographic features of HD-SOD (hemimaxillofacial dysplasia/segmental odontomaxillary dysplasia), and describe one new case, involving a 12-year-old boy, with detailed radiological, clinical, and histologic characteristics. METHODS: Thirty-six cases published between 1987 and 2010, together with the present case, were evaluated according to criteria that included gender, age, location of the lesion, findings, and symptoms. RESULTS: We found that the lesion is discovered mainly in the first decade of life (71%), and has a male predilection (64%, 23/64). The maxillary alveolar process was affected unilaterally in all cases, with gingival and bone enlargement and facial asymmetry being constant findings. Missing premolars and skin manifestations were found to be common features. CONCLUSIONS: New case reports should include clinical, radiographic, and histologic findings; follow-up reports; and treatment protocols to improve dentist and parent information regarding HD.

Common errors in digital panoramic radiographs of patients with mixed dentition and patients with permanent dentition.

Purpose. To compare errors in digital panoramic radiographs of permanent and mixed dentitions. Methods. 143 and 146 digital radiographs of mixed and permanent dentitions were examined. Results. Significantly fewer errors presented in the mixed dentition. Positioning too forward significantly prevalent in the mixed dentition; slumped position and nonpositioning of chin properly were significantly prevailed in the permanent dentition. Blurred or shortened upper incisors were significantly more prevalent in the mixed dentition. Diagnostic ability could be improved by manipulating the brightness or contrast in nearly 45% of all radiographs. In the mixed dentition, tilting the chin down and a slumped position made the lower incisors significantly nondiagnostic. In the permanent dentition, tilting the chin down made the lower incisors to be significantly nondiagnostic. Conclusions. More errors were prevalent in panoramic radiographs of permanent dentitions. Properly positioning the patient is the most important factor in preventing a cascade of errors.

Diagnosis of artificially induced external root resorption using conventional intraoral film radiography, CCD, and PSP: an ex vivo study.

OBJECTIVE: To compare diagnosis of artificially induced external root resorption cavities using conventional intraoral film radiography (Kodak Insight), CCD sensor (Sopix wireless) and PSP sensor (Orex Digident). STUDY DESIGN: Two mandibles were obtained from cadavers and teeth extracted from their alveolus. Artificial external root resorptions were simulated using ISO 0.5 mm, 0.8 mm, and 1.2 mm diameter round burs by drilling to the entire depth in different locations at the cervical, middle, and apical thirds of the proximal and buccal root surfaces of 6 teeth in increasing order. Conventional and digital radiographs were obtained from 3 different views of each tooth in 3 steps (small = 0.5 mm; medium = 0.8 mm; and large = 1.2 mm diameter round burs). Three observers examined all images for the presence of resorption cavities. In the first session, each image was evaluated separately; in the second, examiners had access to all views. Data were statistically analyzed using 4-way analysis of variance. Pair-wise comparison between receptors, projection views, size, and location were made by Tukey test. RESULTS: Higher proportions of correct readings were obtained with the conventional film (Kodak Insight) and CCD receptor compared with the PSP receptor used in this study (PSP < CCD

Condylar guidance: correlation between articular morphology and panoramic radiographic images in dry human skulls.

STATEMENT OF PROBLEM: Several studies have shown the unreliability of recording and reproducing the condylar guidance in semiadjustable articulators. PURPOSE: The purpose of this study was to determine the correlation between the anatomic shape of the articular eminence and the corresponding panoramic radiographic image in dry skulls. MATERIAL AND METHODS: Two metal wires were adapted and fixed to the inner and outer surfaces of the articular eminences in 25 human skulls. The inner (thicker) wire was fixed to the middle of the most concave aspect of the articular eminence in an anterior-posterior direction. The outer (thinner) wire was attached to the inferior aspect of the zygomatic arch adjacent to the articular eminence. Panoramic radiographic images were recorded by the same operator at the same time and with the same panoramic radiographic unit (Orthoralix SD). Impressions were made of the condylar fossae in 25 human dry skulls. Tracings of the incline of the articular eminence on the panoramic radiographs and the impression sections were compared. Each measurement was repeated twice by 2 operators. The results were subjected to the Pearson correlation statistical analysis (alpha=.05). RESULTS: The outline of the articular eminence in a panoramic radiographic image was identified as a thinner superior radio-opaque line above a thicker radio-opaque outline of the inferior-lateral aspect of the zygomatic arch. A significant correlation was found between the sagittal inclination of the anatomic articular eminence outline and the corresponding panoramic radiographic image for both right (R=0.802; P=.001) and left (R=0.561; P=.004) sides. A significant correlation was found between articular eminences on left and right sides in the same skull (P=.025). CONCLUSIONS: The panoramic radiographic image of the sagittal inclination of the articular eminence consistently replicated the eminence inclinations in the 25 human skulls evaluated.

Comparison of digital with conventional radiography in detection of vertical root fractures in endodontically treated maxillary premolars: an ex vivo study.

OBJECTIVE: The purpose of the present study was to compare the diagnostic ability of conventional intraoral film radiography and a charged-coupled device (CCD) sensor in detecting vertical root fractures (VRF) in endodontically treated single-rooted extracted human maxillary premolars. STUDY DESIGN: The study consisted of 60 extracted single-rooted endodontically treated maxillary premolars: 30 with clinically confirmed VRF (experimental group) and 30 with no VRF (control group). An intraoral CCD sensor and conventional Kodak Insight Film were used. Two observers evaluated the digital and conventional radiographs twice with an interval of 4 weeks. Specificity and sensitivity for each radiographic technique were calculated and subjected to statistical analysis. Kappa values were calculated for intra- and interobserver agreement. Fisher's exact test was used to evaluate detection of VRF. The overall differences in sensitivity and specificity between radiographic techniques were evaluated by McNemar test. RESULTS: The specificity of the digital system was significantly better (P = .016) for the second observer at the first reading. There were no significant differences in sensitivity and specificity for both observers between the 2 systems for other readings (P > .05). CONCLUSIONS: No difference was found between the intraoral CCD sensor and conventional radiography in detecting vertical root fractures for single rooted maxillary premolars ex vivo.

Comparison of conventional film with different digital and digitally filtered images in the detection of simulated internal resorption cavities--an ex vivo study in human cadaver jaws.

OBJECTIVE: To determine observers' ability to detect experimentally induced simulated internal resorption cavities using conventional film, digital images and digitally filtered images. STUDY DESIGN: In the coronal plane, 11 single-rooted teeth with radiographically visible pulps were split in half. Four artificial internal resorptions were simulated in each tooth at the coronal, cervical, mid-root, and apical locations of the buccal/labial wall. Conventional and digital radiographs were taken from 3 different views in 4 steps. Three observers examined conventional, digital, and digitally filtered images for the presence of resorption cavities. Data were statistically analyzed using analysis of variance. Pair-wise comparison between receptors, location, and size were made by Tukey post hoc test. RESULTS: One digital system produced a significantly lower proportion of correct readings, with no significant difference between other imaging types (P < .001). In the apical region, internal resorption was the most difficult to detect. The cervical region had the highest proportion of correct readings (P < .001). False-positive readings were higher in the apical and mid-root locations (P < .001). Defect size increased detection ability. Interaction was significant between receptor and size and between size and location (P < .001). CONCLUSIONS: All systems, except PSP, produced similar results in detecting simulated internal resorption.

Retromolar ridge in edentulous patients: clinical considerations.

PURPOSE: A removable denture base should cover the mandibular retromolar regions to provide proper basal seal and denture function in edentulous patients. The bony residual ridge form, attached muscles, and covering mucosa provide support, stability, and retention of the planned prosthesis. There is insufficient information regarding bone anatomy, mucosal tissues, and muscles in the retromolar region after tooth loss. The purpose of this study was to examine the tissue morphology in the mandibular retromolar area of edentulous subjects and report on the clinical inferences in prosthetic and implant dentistry. MATERIALS AND METHODS: Specimens included 75 edentulous and eight dentate dry mandibles examined by macroscopic observations and linear measurements for size determinants in the left and right retromolar regions. Buccolingual histological sections of the mandibular retromolar region from seven edentulous subjects were also examined. The specimens were from the Department of Anatomy and Anthropology, Sackler School of Medicine, Tel Aviv University. RESULTS: The specimens evaluated in this study revealed that a bony retromolar ridge can be large, with adjacent muscles attached several millimeters below its edentulous bone crest, or small, with muscles attached to the buccal and lingual bone crests. In all examined jaws, bony mylohyoid ridges (MR) and buccal shelves with affixed muscle fibers were present regardless of the remaining mandibular bone form and size. CONCLUSIONS: The mylohyoid muscles attached to MRs and the buccinator muscles affixed to buccal bony shelves are some of the barriers to the chronic but limited bone resorption, following tooth loss, time of edentulism, systemic factors, and denture wear.

Morphologic characteristics of bony edentulous jaws.

PURPOSE: The objective of this study was to examine bone tissue characteristics of edentulous arches and residual ridges in different regions of the human jaws. MATERIALS AND METHODS: For the study, 24 maxillary and 99 mandibular completely edentulous dry specimens were examined macroscopically and by linear and caliper measurements. Width and length of the edentulous arches were registered from the molar regions to the crest of the incisor zone. Residual ridges were quantified at the incisor, premolar, and molar regions. RESULTS: Arches and ridges varied in size and shape. A trabecular bone track was present at the edentulous surface. In the maxillary arch, trabecular tissue was external to the cortical palatal vault, and in the mandible, the trabecular bony stretch was inside the cortical plates along the entire edentulous surface of the jaw. Of the ridges, 38% were thin knife-edged. In the maxilla, bone resorption was centripetal, and the crest of the edentulous arch was external to the osseous base of the cranium. In the mandible, resorption was centrifugal, forming an edentulous crest lingual to the mental protuberance anteriorly and to the mandibular base posteriorly. This discrepancy produced a reverse horizontal overlap of the residual crests, where the edentulous maxilla was at the same level or internal to the facing edentulous mandible. CONCLUSIONS: This study, performed on 123 human edentulous dry bone specimens, indicates that the edentulous arch and the residual ridge take many forms. At the occlusal surface of the edentulous jaw a trabecular track is the remaining scar after tooth extraction. To accommodate an entire metal osseointegrated implant within the residual bone volume, crest reduction and bone grafts may be required as preprosthetic surgical measures. After tooth loss, maxillary resorption was centripetal and apical, whereas mandibular resorption was centrifugal and also apical, resulting in a reversed horizontal relationship in fully edentulous subjects.

Detection of cavitated carious lesions in approximal tooth surfaces by ultrasonic caries detector.

OBJECTIVE: A new diagnostic method for detecting cavitated carious lesions in approximal surfaces with the aid of an ultrasonic caries detector (UCD) was tested for clinical use. The objective of this study was to evaluate the efficacy and clinical performance of the UCD system and to compare it with bite-wing radiography by using direct visual inspection during restoration preparation as a validation method. STUDY DESIGN: One hundred ninety-seven directly inspected approximal sites, 95 as cavitated carious lesions and 102 as intact sites, of adults 22 to 45 years of age were examined by UCD and radiography. RESULTS: Ultrasonic caries detector sensitivity was 0.82 compared with 0.75 for bite-wing radiographs when the threshold was determined as radiolucency in inner enamel and dentin, and 0.49 when the threshold of radiolucency was in dentin. The specificity of UCD was 0.75 versus 0.9 for radiographs. CONCLUSIONS: The UCD exhibited a higher sensitivity than the radiographs but a lower specificity. This study presents a new diagnostic tool that can reduce patient exposure to ionizing radiation and improve caries detection.

Radiographic features of vertically fractured endodontically treated mesial roots of mandibular molars.

OBJECTIVE: The purpose of this study was to evaluate the most frequent radiographic appearance of bony lesions around endodontically treated vertically fractured mesial roots of mandibular molars. STUDY DESIGN: For the study, 49 extracted mesial roots with vertical fractures (study group) were evaluated and compared to 52 extracted roots without fractures (control). RESULTS: The "halo" (36.7%) and "periodontal" (28.6%) type radiolucencies were the most typical appearances of periradicular areas around the mesial roots of mandibular molars with vertical root fractures. By itself, bifurcation radiolucency was statistically insignificant (6.1%), however in conjunction with other areas of radiolucency, it was significant (63.3%, P < .0378). No radiolucency (38.5%) and periapical radiolucency (32.7%) were predominant features in the control (nonfractured roots). Amalgam dowel in the coronal part (1-2 mm) of the root was found in 67.3% of the vertically fractured roots (P < .0006). Defined but not corticated (57.2%) or diffuse (32.6%) borders were typical for vertically fractured mesial roots. CONCLUSIONS: The use of significant variables, such as "periodontal" and "halo" bony radiolucencies, bifurcation involvement, and the presence of amalgam dowel, has prediction sensitivity of 77.6% (VRF group) and specificity of 82.7% (nonfractured roots).

A radiographic evaluation of cervical bone loss associated with immediate and delayed implants placed for fixed restorations in edentulous jaws.

BACKGROUND: Placement of dental implants is considered a successful and predictable procedure. An important biological benefit is the preservation of bone height following implantation. The purpose of this study was to examine the cervical bone loss (CBL) and its correlation with implant characteristics and anatomic factors, 1 to 8 years post-implantation of immediate and delayed implants. METHODS: A total of 381 implants (144 immediate and 237 delayed) were placed in 44 edentulous patients (53 jaws) for fixed ceramometal restoration from 1989 to 1996. The mean mesial and distal cervical bone resorption of each implant was measured using panoramic radiographs, by an objective examiner using a computerized scanner before second stage surgery and 1 to 8 years (mean 3.5 years) follow-up. The length of the implant served as an internal standard. The examiner had no prior information on the examined implants. RESULTS: Total CBL was 0.78 +/- 1.22 mm. There was a significant difference (P = 0.049) between CBL of immediate implants compared to delayed ones. Implants > 13 mm showed a significantly (P < 0.001) lower CBL than shorter implants. Hydroxyapatite-coated implants had a higher CBL (P < 0.001) compared to commercially pure titanium implants (P < 0.001). The CBL of maxillary implants was higher than mandibular implants (P < 0.001). Step-wise multiple regression pr.obability tests demonstrated that implant location followed by coating, length, and timing of placement were the most important parameters for implant success (R2 = 0.102). CONCLUSION: Cervical bone loss around dental implants is influenced by location, coating, length, and implant timing.

A retrospective radiographic study of root-end surgery with amalgam and intermediate restorative material.

OBJECTIVE: We sought to compare amalgam with intermediate restorative material in terms of their effectiveness as root-end filling materials during root-end surgeries. STUDY DESIGN: A root-end operation was performed on 228 patients with 262 endodontically treated teeth with periapical lesions. Of these teeth, 122 from 101 patients were available for follow-up. Radiographs were taken immediately postoperatively and again at a mean of 11.25 months (range, 6-45 months) postoperatively. The radiographs were digitized, and the diameter of the periapical lesion was measured by means of a computerized system. The mesiodistal distance at the cementoenamel junction served as an internal standard. Radiographic findings were classified into 1 of 3 groups: complete healing, incomplete healing, or unsatisfactory (no) healing. RESULTS: Complete healing was observed in 44.3% of the teeth, incomplete healing in 21.3%, and unsatisfactory healing in 34.4%. No statistical significance was found for amalgam versus intermediate restorative material, but teeth that underwent additional operations had a significantly worse success rate than those that underwent only first-time operations. No correlation was found between the subjective prognosis by the surgeons and the long-term outcome. CONCLUSION: As root-end filling materials, amalgam and intermediate restorative material had the same clinical effectiveness. The classic root-end operation is unpredictable. Reoperations should be reconsidered and avoided if possible.

Developmental stages of the third molar in Israeli children.

PURPOSE: The purpose of this study was to examine the developmental stages of the third molar in Israeli children, compare its development in boys and girls, in the maxilla and mandible, right to left sides in various age groups, and relate the developmental stage to chronological age. METHODS: Panoramic radiographs of 693 healthy children and adolescents (328 boys and 365 girls) ages 7 to 16 were analyzed using a modified 6-stage method. Since the 16-year-old group was too small for statistical analysis, it was later excluded from the study. Radiographs were obtained from patient files. RESULTS: There were no significant differences in the development of the third molar between boys and girls and between right and left sides. Slight differences were found between the maxilla and mandible. The first appearance of a radiolucent bud was at age 8.7 in the mandible and 9.3 in the maxilla. Crown completion was observed on average at age 11.7 in the maxilla and 11.8 in the mandible. CONCLUSIONS: There was a high correlation between third molar development and chronological age. Agenesis can be determined conclusively if no radiolucent bud is present beyond age 14. The modified 6-stage method allowed more accurate determination of developmental stages.

Diagnosis of approximal caries: bite-wing radiology versus the Ultrasound Caries Detector. An in vitro study.

OBJECTIVE: We sought to examine the validity, sensitivity, and specificity of bite-wing radiographs and a high-frequency sound wave device (the Ultrasound Caries Detector) used to detect caries on contacting approximal surfaces. METHODS: A total of 36 extracted premolars and molars were first visually examined for the presence of caries; then a probe was used. Twelve models were prepared, each containing 3 teeth with 2 approximal surfaces and 2 contacted surfaces (of adjacent teeth). Bite-wing radiographs were taken and evaluated for proximal caries lesions. A high-frequency sound wave (ultrasound) device called the Ultrasound Caries Detector was also used to detect caries. Examinations were repeated after 1 week. Teeth were then sectioned and viewed under a stereomicroscope at 20x magnification, with which the true interproximal caries diagnosis was validated. The receiver operating characteristic curves were computed to establish the accuracy of the observer data. RESULTS: The efficacy of the ultrasound diagnostic device for cavitated carious lesion detection was assessed by determining its specificity and sensitivity, 1.0 for each, in comparison with those of bite-wing radiography, 0.92 and 0.90, respectively (P <.001). The mean receiver operating characteristic value for the area under the curve was 0.934 with bite-wing radiography and 1 with the ultrasound diagnostic device. CONCLUSIONS: Under in vitro conditions, the ultrasound diagnostic device had a higher sensitivity and specificity, in terms of the detection of approximal carious lesions, than bite-wing radiographs.