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JADA Specialty Scan - Radiology
Radiology - A Quarterly Newsletter on Dental SpecialtiesJADA Specialty Scan

Anatomic variations of the paranasal sinuses and maxillary sinusitis

Anatomic variations of the paranasal sinuses can cause pathologies and complicate sinus surgery. In a study published online May 11 in The Open Dentistry Journal, researchers examined the association between maxillary sinusitis and anatomic variations, including the presence and surface area of Haller cells, angulation of the uncinate process, and size of the maxillary sinus ostium.

The authors obtained 120 cone-beam computed tomographic (CBCT) images from the archives of an oral and maxillofacial radiology center. Exclusion criteria consisted of a history of sinus tumor or surgery, sinonasal polyposis, and maxillofacial trauma. The researchers also eliminated CBCT images with inaccurate patient orientations.

Of the 120 patients in the study, 57 (47.5%) were female, the authors wrote. Their mean (standard deviation [SD]) age was 27.78 (9.93) years, and the age range was 9 to 57 years.

All CBCT images were acquired with a NewTom VGi device with the following specifications: 36-seconds’ scan time, 15 × 12 centimeters field of view, 110 kilovolt (peak), and 20 milliamperes. The researchers viewed the images in coronal cross-sections using NNT software, Version 6.2 (NewTom). An oral radiologist with more than 20 years’ experience evaluated the images for the presence of Haller cells, Haller cell dimensions in vertical and horizontal orientations, medial or lateral deviation of the uncinate process, size of the maxillary sinus ostia, and mucosal thickening in the maxillary sinuses.

The researchers described Haller cells as air cells located along the medial portion of the orbital floor and continuous with the ethmoid capsule. The oral radiologist measured the size of the cells at the maximum superoinferior and mediolateral dimensions. Deviation of the uncinate process was determined by measuring the angle of the process with a horizontal line passing from its superior edge.

The authors defined the maxillary sinus ostium as the distance between the inferomedial aspect of the orbital rim and the uncinate process. In patients with Haller cells, the ostium was defined as the distance between the Haller cell at its most medial portion and the uncinate process.

The researchers detected unilateral Haller cells in 36 patients (30%) and bilateral Haller cells in 14 patients (11.7%). Of the 36 unilateral Haller cells, 29 (80.5%) were right sided and 7 (19.5%) were left sided. The mean (SD) surface area of right-sided Haller cells was 30 (21.35) millimeters, and that of left-sided Haller cells was 18.06 (10.29) mm, the authors wrote.

The study findings showed that the presence and surface area of Haller cells were associated significantly with mucosal thickening in the ipsilateral maxillary sinus. However, the researchers did not observe any statistically significant associations between patients’ sex and presence of Haller cells, patients’ age and presence of Haller cells, ostium size and presence of mucosal thickening, or angulation of the uncinate process and mucosal thickening of the maxillary sinus.

The significant association between the presence and size of Haller cells and mucosal thickening of the maxillary sinus could be explained by the “critical location of Haller cells immediately lateral to the maxillary infundibulum, which can interfere with the normal drainage of the maxillary sinus,” the authors wrote. They concluded that CBCT could demonstrate fine anatomic details of the ostiomeatal complex at far lower radiation levels than those of multislice CT.

Read the original article here.


Consulting Editor: Laurie C. Carter, DDS, PhD
Past president, American Academy of Oral and Maxillofacial Radiology


Using CBCT to assess the posterior maxillary region after single tooth loss

Posterior maxillary tooth loss may complicate implant treatment because of alterations in alveolar anatomy and maxillary sinus pneumatization. In this retrospective study, researchers used cone-beam computed tomography (CBCT) to examine the anatomic structure of the region. This study was published online September 6 in Implant Dentistry.

This multicenter study was composed of 597 patients (312 men and 285 women) with single tooth loss in the posterior maxilla. Participants’ mean (standard deviation [SD]) age was 50.48 (12.65) years, and their ages ranged from 18 to 84 years, the authors wrote. The distribution of tooth regions—first premolar, second premolar, first molar, second molar—was similar for men and women, and 307 of the 597 lost teeth (51.4%) were first molars.

The researchers categorized the study variables into 3 groups: sinus membrane, sinus dimensions, ostium, septa, and sinus neighborhood; alveolar ridge; and posterior superior alveolar artery and adjacent roots. One calibrated clinician at each of the 6 study centers performed all measurements using CBCT software.

Of the 597 CBCT images, 454 (76.2%) exhibited a sinus membrane thickness of between 0 and 5 millimeters. The authors pointed out that the percentage of sinus membranes in the 5- to 10-mm range was significantly higher (P = .021) in women than in men, but the percentage of membranes with irregular thickening was significantly lower (P = .013) in women than in men.

Evaluation of the CBCT images also revealed that the mean coronal width of the sinus space was approximately 11 mm, and the mean apical width was 16 mm. The investigators noted that a 4-mm flat or semispherical thickening around the space was common, and 51% of the CBCT images exhibited an anterior septum.

Regarding the alveolar ridge width, the study results showed statistically significant differences between men and women. The mean (SD) coronal ridge width was 6.90 (2.44) mm in female patients and 7.47 (3.00) mm in male patients (P = .011), the authors wrote. For middle ridge width, the mean (SD) measurement was 9.04 (2.45) mm in women and 9.66 (2.82) mm in men (P = .006). Finally, the mean (SD) apical ridge width was 10.86 (2.53) mm in women and 11.59 (2.93) mm in men (P = .003). On the other hand, alveolar bone height was similar for men and women (P = .131).

The researchers suggested that differences between male and female patients might be related to the greater tendency of men to have sinus pathology. However, further studies are needed to explore these differences in sinus morphology and crestal anatomy.

Read the original article here.


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Examining the impact of patient shielding on skin-level radiation doses

Cone-beam computed tomography (CBCT) has become a widely used radiographic modality in dentistry. However, concerns have been raised about radiation doses for patients, which are higher than those used in panoramic radiography. In this study, researchers examined the impact of a lead apron on skin-level doses delivered in 5 critical body regions. The study was published in the August issue of Health Physics.

To evaluate radiation doses, the authors used a female anthropomorphic phantom (Alderson Rando Phantom, 155 centimeters in height, 50 kilograms in weight, Radiology Support Devices). They chose the following 5 locations to measure radiation doses because of the radiation sensitivity of the organs in these regions: thyroid, left and right breast, gonad region (skin region of the pubic eminence), and a central region in the back of the torso.

The researchers selected 5 dental CBCT units covering a wide spectrum of fields of view: 3D Exam (KaVo Dental), 3D Accuitomo (J. Morita), Orthophos SL (Sirona Dental Systems), Orthophos XG 3D (Sirona Dental Systems), and VistaSoft (Duerr Dental AG). They used typical exposure settings and fields of view for each device.

To measure the radiation doses, the investigators used a high-sensitivity solid-state dosimeter (QUART didoSVM), with measurements ranging between 3 nanogray and 99 gray and a ±10% uncertainty specified for the entire dynamic range. Because of the dosimeter’s size (10 × 3 × 4 cm), the authors could not place the device inside the phantom; instead, they placed it on the surface.

For each of the 5 measurement regions and 5 CBCT units, the researchers acquired 10 single exposures without use of a lead apron. They then repeated the procedures using a commercial lead apron (Panorama Apron RD635E for adults; lead equivalent value, 0.50 millimeter; Mavig) originally designed for panoramic radiography, the authors wrote. The researchers placed the apron on the phantom according to the manufacturer’s instructions and closed it at the neck.

The authors observed the highest skin doses in the thyroid region, ranging from 117 to 935 microgray. The mean (standard deviation [SD]) measurement without shielding was 339.2 (348.8) μGy, and the mean (SD) measurement with shielding was 450.5 (346.7) μGy (P = .4922), the authors wrote. The second highest levels were found in the unshielded female breast (left breast, 36.7 [21.0] μGy; right breast, 34.3 [23.5] μGy). By contrast, the mean (SD) shielded dose was 2.2 (1.6) μGy in the left breast and 1.7 (1.1) μGy in the right breast, a reduction of approximately 93% (P < .001). Radiation doses at the back of the torso and the gonads were low, the authors wrote. However, the authors pointed out that radiation doses were significantly lower (P < .001) at these locations when a lead apron was used.

In this study, the thyroid region was the only location at which shielding did not result in a lower skin-level radiation dose. However, because of the radiation sensitivity of this area, the authors recommended that further studies be conducted to investigate radiation doses to the thyroid region under unshielded and shielded conditions, including use of a thyroid shield to supplement the lead apron, which was designed for panoramic radiography, not CBCT.

The authors concluded that dental CBCT should be accompanied by appropriate patient shielding with a lead apron whenever possible. They also recommended that further studies be conducted to support their findings.

Read the original article here.


Panoramic radiographs and ghost artifacts

Panoramic radiography is used for many purposes, such as diagnosing caries, periodontal disease, and supernumerary teeth, as well as for orthodontic assessment. However, panoramic radiographs can produce ghost artifacts that limit their effectiveness. In a study published online August 25 in British Dental Journal, researchers present 2 case reports in which use of “nonstandard” imaging programs resulted in potentially confusing artifacts.

Case report 1. The authors described a child who underwent panoramic and cephalometric radiography as part of an orthodontic assessment. The panoramic radiographs were obtained with a ProMax (Planmeca) unit and P2000 (improved orthogonality) program. The orthodontist noticed 2 supernumerary teeth in the upper right quadrant of the panoramic radiograph, the authors wrote. Consequently, the orthodontist requested that a small-volume cone-beam computed tomographic (CBCT) scan be obtained. However, a consulting dental and maxillofacial radiologist reviewed the cephalometric radiograph, which showed no evidence of supernumerary teeth. Further investigation revealed that a nonstandard imaging program had been used to achieve improved orthogonality. The orthodontist was informed of the ghost artifact, which ruled out the need for a CBCT scan.

Case report 2. A patient underwent panoramic radiography for assessment of the dentition. Review of the radiograph revealed a discrepancy with the charted teeth. The researchers reported that the positioning of the patient had been suboptimal, and a large air shadow appeared in the oral cavity. The panoramic radiography had been performed with a nonstandard imaging program. Because of the inadequate image, panoramic radiography was performed again, this time with a standard imaging program, the authors wrote.

In the first panoramic image, a ghost artifact of a mandibular right second molar appeared in the lower left quadrant of the panoramic radiograph. No such artifact appeared in the second image, obtained with the standard imaging program. The mandibular left posterior region was edentulous in the latter image, which corresponded with the patient’s dental record, the authors wrote.

The authors pointed out that the artifacts described in these case reports are not unique to 1 manufacturer, and similar technology may be marketed under various names.

This study offers several takeaways. Before obtaining new radiographs, clinicians should review any existing images. In the first case report, had the radiologist not reviewed the cephalometric radiograph, an unnecessary CBCT scan likely would have been obtained for a child. In addition, operators should be familiar with the settings on the digital panoramic units and aware of the potential for unusual ghost artifacts. The authors urged clinicians to consult with the manufacturer when in doubt. Finally, if a clinician cannot explain something observed on an image, he or she can obtain a second opinion from an oral and maxillofacial radiologist.

Read the original article here.


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JADA+ Specialty Scans and JADA+ Scans

JADA+ Specialty Scans and JADA+ Scans are quarterly newsletters updating dentists on the latest research in selected specialties and disciplines in dentistry. ADA Publishing and the consulting editors from the represented specialties and disciplines aggregate and summarize research from previously published materials, each item attributed to its publication of origin. JADA+ Scan specialties and disciplines include endodontics, oral pathology, orthodontics, pediatric dentistry, periodontics, prosthodontics, radiology, cosmetic/esthetic and osseointegration. The ADA has engaged the specialty organizations in these areas as well as its own Science Institute and Division of Legal Affairs to assist with these newsletters. View past issues here.

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