DMD3 **RADIOLOGY WORKSHOP** PART 1. LUCENCIES & OPACITIES Dr Dayea Oh DMD3 Dr. Dayea Oh KEY POINTS OF OPG INTERPRETATION * Review the initial indication for OPG * Identify OPG artefacts * Must know normal radiographic anatomy of maxillofacial region * Study radiographic features of various jaw pathologies * Lucent or Opaque? * **Systematic approach** * Have a routine  - Review the initial indication for OPG - Identify OPG artefacts - Must know normal radiographic anatomy of maxillofacial region - Study radiographic features of various jaw pathologies - Lucent or Opaque? - **Systematic approach** - Have a routine A text-based procedural checklist outlining the 'KEY POINTS OF OPG INTERPRETATION'. The list includes steps such as reviewing indications, identifying artifacts, knowing normal anatomy, studying pathologies (specifically noting the distinction between 'Lucent or Opaque?'), and following a systematic approach with a routine. # OPG ARTEFACTS REVISION * Foreign materials eg. Earrings, necklace, denture left in situ, etc. * Ghost images * Incorrect patient positioning * Chin down * Chin up * Head tilting * Head rotation * Movement * Horizontal (following the beam or opposite to the beam direction) * Vertical * Swallowing * Soft tissue position * Tongue to the palate * Lips closed * Focal trough position * Head in front of the focal trough * Head behind the focal trough * Neck extension * Collision with shoulder #### Patient and Equipment Related Artefacts - Foreign materials (e.g., earrings, necklace, denture left in situ, etc.) - Ghost images - Incorrect patient positioning - Chin down - Chin up - Head tilting - Head rotation - Movement - Horizontal (following the beam or opposite to the beam direction) - Vertical - Swallowing - Soft tissue position - Tongue to the palate - Lips closed - Focal trough position - Head in front of the focal trough - Head behind the focal trough - Neck extension - Collision with shoulder # SYSTEMATIC APPROACH 1. **Address Clinical Concerns** 2. **Dentoalveolar** a) Count teeth & identify ectopic and/or impacted teeth b) **Dental Anomalies** (Position, Shape,...) c) Periodontal bone loss d) Dental pathology (non-carious tooth loss, caries, fracture, periapical pathologies, etc.) 3. **Maxilla and Mandible** a) **Abnormal (radio)lucencies** b) **Abnormal (radio)opacities** c) Altered trabecular pattern d) Fractures e) Jaw Asymmetry 4. Maxillary sinuses (esp. mucosal changes) 5. TM Joints (esp. morphological change of condyles) 6. Soft Tissues (swelling, soft tissue calcifications eg. Tonsiloliths, salivary gland stones, etc. ) 7. Other sites: Spine, orbits, etc. (structural changes) 1. **Address Clinical Concerns** 2. **Dentoalveolar** 1. Count teeth & identify ectopic and/or impacted teeth 2. **Dental Anomalies** (Position, Shape, etc.) 3. Periodontal bone loss 4. Dental pathology (non-carious tooth loss, caries, fracture, periapical pathologies, etc.) 3. **Maxilla and Mandible** 1. **Abnormal (radio)lucencies** 2. **Abnormal (radio)opacities** 3. Altered trabecular pattern 4. Fractures 5. Jaw Asymmetry 4. **Maxillary sinuses** (especially mucosal changes) 5. **TM Joints** (especially morphological change of condyles) 6. **Soft Tissues** (swelling, soft tissue calcifications e.g., tonsilloliths, salivary gland stones, etc.) 7. **Other sites**: Spine, orbits, etc. (structural changes) # LUCENCIES & OPACITIES ## Where are they located (in relation to anatomical / dental structures)? - How many are there? - Are they unilateral or bilateral? - Are they well defined? - What is the shape? Eg. round, ovoid, teardrop, lobulated, irregular, etc.. - How big are they (use anatomical / dental landmarks)? Eg. 38-34 region - Are they homogenous? - Do they have internal architecture? - What are they doing to the adjacent anatomical structures? Eg. displacement of structures such as, teeth, sinus floor, and mandibular canals, resorption of teeth, scalloping around the adjacent teeth, sclerosis of the surrounding bone, etc. #### Lesion Localization and Characterization - Where are they located (in relation to anatomical / dental structures)? - How many are there? - Are they unilateral or bilateral? - Are they well defined? - What is the shape? (e.g., round, ovoid, teardrop, lobulated, irregular, etc.) - How big are they? (use anatomical / dental landmarks, e.g., 38-34 region) - Are they homogenous? - Do they have internal architecture? - What are they doing to the adjacent anatomical structures? (e.g., displacement of structures such as teeth, sinus floor, and mandibular canals; resorption of teeth; scalloping around the adjacent teeth; sclerosis of the surrounding bone, etc.) <style> table { font-family: arial, sans-serif; border-collapse: collapse; width: 100%; border: 5px solid black; } td, th { border: 1px solid #dddddd; text-align: center; text-transform: capitalize; width: 22%; font-size: 1.15em; padding: 14px; } </style> <table> <tr> <th colspan="5">Surgical Sieve — Identifying the Nature of the Lesion</th> </tr> <tr> <td>Artefactual</td> <td>Anatomical</td> <td>Anomaly</td> <td>Inflammatory /</td> <td>Cysts / Cyst-like Lesions</td> </tr> <tr> <td>Hamartoma</td> <td>Benign Tumour<br>• Odontogenic<br>• Non- odontogenic</td> <td>Idiopathic</td> <td>Fibro-osseous</td> <td>Malignancy</td> </tr> <tr> <td>Trauma</td> <td>Vascular<br>Anomalies</td> <td>Metabolic /</td> <td>Other (giant cell lesion,</td> <td></td> </tr> <tr> <td></td> <td></td> <td>Systemic Disease</td> <td>syndromes, etc.)</td> <td></td> </tr> </table>  #### Categories for Identifying the Nature of the Lesion - Artefactual - Anatomical - Anomaly - Inflammatory / Infection - Cysts / Cyst-like Lesions - Hamartoma - Benign Tumour - Odontogenic - Non-odontogenic - Idiopathic - Fibro-osseous - Malignancy - Trauma - Vascular Anomalies - Metabolic / Systemic Disease - Other (giant cell lesion, syndromes, etc.) A structured table titled 'SURGICAL SIEVE — IDENTIFYING THE NATURE OF THE LESION' displaying categories of lesions. The table is organized into rows and columns with orange rectangular cells containing white text. Categories include Artefactual, Anatomical, Anomaly, Inflammatory / Infection, Cysts / Cyst-like Lesions, Hamartoma, Benign Tumour (subdivided into Odontogenic and Non-odontogenic), Idiopathic, Fibro-osseous Lesions, Malignancy, Trauma, Vascular Anomalies, Metabolic / Systemic Disease, and Other (giant cell lesion, syndromes, etc.). FURTHER IMAGING REQUIRED? - CBCT - MSCT - MRI - Unsure? → contact radiologist  - CBCT - MSCT - MRI - Unsure? → contact radiologist Text-based procedural instruction reading 'Unsure? → contact radiologist', indicating a decision point for further medical imaging consultation. **Case 1.** **Pain upon biting** **Sensitive to cold** Describe this radiograph - What type of radiograph is this? - Which side of mouth? - Which teeth are imaged? - Describe the 45 appearance and give a diagnosis. - Describe what is happening to the 46. - Any further imaging? Why?  #### Patient Presentation - Primary complaint: Pain upon biting - Sensitivity: Reactive to cold stimuli #### Radiographic Analysis 1. **Radiograph Identification** - Determine the type of radiograph. - Identify the side of the mouth being imaged. - List the specific teeth visible in the image. 2. **Clinical Findings** - **Tooth 45:** Describe the radiographic appearance and provide a diagnosis. - **Tooth 46:** Describe the current condition or pathological process affecting this tooth. 3. **Follow-up Protocol** - Determine if further imaging is required and provide a clinical justification. Dental radiograph showing the mandibular left quadrant. The image features a large, radiopaque restoration on tooth 45 (mandibular first molar) with an irregular outline and a radiolucent area at the distal root suggesting caries or periodontal bone loss. Tooth 46 (second molar) shows signs of pathology, possibly periapical radiolucency or furcation involvement. The upper teeth are also visible. **Case 2.** **C/O gingival recession** **Identify abnormal lucencies** **& describe them** **(list at least 3 features)** **Give ddx.** **Any further imaging?**  #### Clinical Presentation - Chief complaint: Gingival recession #### Diagnostic Requirements - **Identification:** Locate and identify abnormal lucencies. - **Description:** List at least three distinct radiographic features of the identified lucencies. - **Differential Diagnosis:** Provide a list of potential diagnoses (ddx). #### Further Management - Assess the necessity for additional imaging modalities. Dental radiograph (periapical view) of anterior teeth. The image shows the crowns and roots of four central incisors and lateral incisors. There are visible radiolucent areas around the apices of the teeth, suggesting possible periapical pathology or bone loss. The text on the right side provides context: 'Case 2. C/O gingival recession' and asks to identify abnormal lucencies, describe them (list at least 3 features), give a differential diagnosis (ddx), and consider further imaging. # Case 3. **Routine OPG** **Identify abnormal lucencies / opacities & describe them (list at least 3 features)** **Give dx.** **Any further imaging?**   #### Clinical Context - Routine Orthopantomogram (OPG) examination. #### Radiographic Evaluation - **Observation:** Identify any abnormal lucencies or opacities. - **Description:** Provide a detailed description including at least three specific features. - **Diagnosis:** State the definitive diagnosis (dx). #### Next Steps - Determine if further imaging is indicated for this case. Clinical radiograph (OPG) of the mandible and maxilla showing multiple abnormal lucencies in the posterior mandible. The image includes 'Case 3' and 'R/L' markers. Text-based instructional diagram containing headings: 'Routine OPG', 'Identify abnormal lucencies / opacities & describe them (list at least 3 features)', 'Give ddx.', and 'Any further imaging?'. This serves as a visual guide for clinical analysis of the radiograph. Case 4. Orthodontic assessment Identify and describe the abnormal lucency & opacity. Further imaging required?  #### Radiographic Findings - Identify and describe the characteristics of the abnormal lucency and opacity present in the orthodontic assessment. #### Clinical Recommendation - Evaluate whether further imaging is required to complete the assessment. Orthopantomogram (OPG) radiograph showing a full view of the maxillary and mandibular dentition. The image is labeled 'Case 4. Orthodontic assessment' at the top and includes an 'L' marker for the left side. A caption at the bottom asks to identify abnormal lucency and opacity. Visually, there is a large radiolucent area in the right posterior mandible associated with the developing third molar (wisdom tooth), which appears impacted and possibly ectopic. Additionally, there are areas of radiopacity within the crowns of the upper molars on both sides, suggestive of dental restorations or caries. CASE 5. - Discomfort in the jaws - Stiffness in TMJs & limited mouth opening - Joint crepitus #### Clinical Symptoms - Discomfort localized in the jaws. - Stiffness in the Temporomandibular Joints (TMJs). - Limited range of motion during mouth opening. - Presence of joint crepitus. Describe the TMJs Would you consider further imaging? Which modality and why?  #### Radiographic Description - Provide a detailed description of the Temporomandibular Joints (TMJs) based on the available imaging. #### Advanced Imaging Assessment - Evaluate the need for further imaging. - Specify the preferred imaging modality and provide the clinical rationale for its use. Radiograph (panoramic X-ray) of the maxillofacial region showing dentition and temporomandibular joints. The image includes multiple dental restorations (fillings/crowns). Text above reads: 'Describe the TMJs' and 'Would you consider further imaging? Which modality and why?' [^1]: Original PDF page 1: [[W4.1 Radiology Workshop.pdf#page=1|W4.1 Radiology Workshop, p.1]] [^2]: Original PDF page 2: [[W4.1 Radiology Workshop.pdf#page=2|W4.1 Radiology Workshop, p.2]] [^3]: Original PDF page 3: [[W4.1 Radiology Workshop.pdf#page=3|W4.1 Radiology Workshop, p.3]] [^4]: Original PDF page 4: [[W4.1 Radiology Workshop.pdf#page=4|W4.1 Radiology Workshop, p.4]] [^5]: Original PDF page 5: [[W4.1 Radiology Workshop.pdf#page=5|W4.1 Radiology Workshop, p.5]] [^6]: Original PDF page 6: [[W4.1 Radiology Workshop.pdf#page=6|W4.1 Radiology Workshop, p.6]] [^7]: Original PDF page 7: [[W4.1 Radiology Workshop.pdf#page=7|W4.1 Radiology Workshop, p.7]] [^8]: Original PDF page 8: [[W4.1 Radiology Workshop.pdf#page=8|W4.1 Radiology Workshop, p.8]] [^9]: Original PDF page 9: [[W4.1 Radiology Workshop.pdf#page=9|W4.1 Radiology Workshop, p.9]] [^10]: Original PDF page 10: [[W4.1 Radiology Workshop.pdf#page=10|W4.1 Radiology Workshop, p.10]] [^11]: Original PDF page 11: [[W4.1 Radiology Workshop.pdf#page=11|W4.1 Radiology Workshop, p.11]] [^12]: Original PDF page 12: [[W4.1 Radiology Workshop.pdf#page=12|W4.1 Radiology Workshop, p.12]] [^13]: Original PDF page 13: [[W4.1 Radiology Workshop.pdf#page=13|W4.1 Radiology Workshop, p.13]]