Radiographic imaging pattern of ossifying fibroma mimicking ameloblastoma: a case report

Radiographic examinations complement the anamnesis and physical exam with the purpose of reaching diagnosis, prognosis and treatment planning. In this case report, a 48 year-old male Caucasian patient was referred to an oral and maxillofacial surgeon by a general practitioner after a panoramic radiography for treatment planning; the implant surgery follow-up portrayed a multilocular radiolucent image at the left posterior mandible. Based solely on the panoramic radiography, the diagnostic hypothesis was ameloblastoma. The surgeon decided to perform an incisional biopsy. However, during the procedure, the professional noted that the lesion was easily detached from the adjacent bone and opted for the total removal of the lesion, thus altering its diagnostic hypothesis to central ossifying fibroma (COF). The histopathological result confirmed the diagnostic hypothesis provided by the surgeon, i.e. COF. Although multilocular presentation is not common, COF should be considered in the scope of multilocular radiolucent lesions of the jaws. In addition, computerized tomography imaging exam complemented by surgical and histopathological aspects should be considered for establishing the final diagnosis and conducting the therapeutic approach.Os exames radiográficos complementam a anamnese e o exame físico a fim de estabelecer o diagnóstico, o prognóstico e o planejamento do tratamento. Neste relato de caso, um paciente do sexo masculino, de 48 anos, foi encaminhado a um cirurgião bucomaxilofacial por um clínico geral após uma radiografia panorâmica para o planejamento do tratamento; o seguimento da cirurgia de implante retratou uma imagem radiotransparente multilocular na mandíbula posterior esquerda. Baseado apenas na radiografia panorâmica, a hipótese diagnóstica foi ameloblastoma. O cirurgião decidiu realizar uma biópsia incisional. No entanto, durante o procedimento, o profissional notou que a lesão era facilmente separada do osso adjacente e optou pela retirada total da lesão, alterando sua hipótese diagnóstica para fibroma ossificante central (FCO). O resultado histopatológico confirmou a hipótese diagnóstica do cirurgião, ou seja, o COF. Embora a apresentação multilocular não seja comum, o FCO deve ser considerado em casos de lesões radiotransparentes multiloculares das mandíbulas. Além disso, o exame de tomografia computadorizada complementado por aspectos cirúrgicos e histopatológicos deve ser considerado para estabelecer o diagnóstico final e conduzir a abordagem terapêutica

Diagnosis of alveolar and root fractures: an in vitro study comparing CBCT imaging with periapical radiographs

Objective To compare periapical radiograph (PR) and cone-beam computed tomography (CBCT) in the diagnosis of alveolar and root fractures. Material and Methods Sixty incisor teeth (20 higid and 40 with root fracture) from dogs were inserted in 60 anterior alveolar sockets (40 higid and 20 with alveolar fracture) of 15 macerated canine maxillae. Each fractured socket had a root fractured tooth inserted in it. Afterwards, each maxilla was submitted to PR in two different vertical angulation incidences, and to CBCT imaging with a small field of view (FOV) and high-definition protocol. Images were randomized and posteriorly analyzed by two oral and maxillofacial radiologists two times, with a two-week interval between observations. Results Sensitivity and specificity values were good for root fractures for PR and CBCT. For alveolar fractures, sensitivity ranged from 0.10 to 0.90 for PR and from 0.50 to 0.65 for CBCT. Specificity for alveolar fractures showed lower results than for root fractures for PR and CBCT. Areas under the ROC curve showed good results for both PR and CBCT for root fractures. However, results were fair for both PR and CBCT for alveolar fractures. When submitted to repeated measures ANOVA tests, there was a statistically significant difference between PR and CBCT for root fractures. Root fracture intraobserver agreement ranged from 0.90 to 0.93, and alveolar fracture intraobserver agreement ranged from 0.30 to 0.57. Interobserver agreement results were substantial for root fractures and poor/fair for alveolar fractures (0.11 for PR and 0.30 for CBCT). Conclusion Periapical radiograph with two different vertical angulations may be considered an accurate method to detect root fractures. However, PR showed poorer results than CBCT for the diagnosis of alveolar fractures. When no fractures are diagnosed in PR and the patient describes pain symptoms, the subsequent exam of choice is CBCT

Modalidades de imagem na osteonecrose dos maxilares relacionada à medicamentos: revisão de literatura

Osteonecrosis occurs by cellular death of the bone tissue due to an irreversible external factor. This disorder may be clinically unidentified in the early stages and result in degradation of the bone architectural structure, leading to pain, bone destruction, and loss of function. Thus, imaging exams become relevant to the recognition and definition of the bone necroses. The aim of this study was to review the literature on imaging exams frequently used for the diagnosis and evaluation of patients undergoing drug therapies associated with osteonecrosis of the jaw, such as panoramic radiography, computed tomography, magnetic resonance imaging and bone scintigraphy.A osteonecrose ocorre pela morte celular do tecido ósseo devido a um fator externo irreversível. Esse distúrbio pode não ser clinicamente identificado nos estágios iniciais gerando quadros de dor, destruição da arquitetura óssea e perda de função. Assim, os exames de imagem se tornam relevantes para o reconhecimento e a definição das necroses ósseas. O objetivo deste estudo foi revisar a literatura a respeito das diferentes modalidades de exames de imagem frequentemente utilizados para diagnóstico e avaliação de pacientes submetidos a terapias medicamentosas associadas à osteonecrose dos maxilares, como a radiografia panorâmica, tomografia computadorizada, ressonância magnética e cintilografia óssea

Indução de artefato por materiais endodônticos: uma análise de TCFC

Metallic objects, such as intracanal posts and restorations, may produce severe interference, thus diminishing the quality of CBCT imaging. Objective: The purpose of this study was to analyze the influence of conventional and bioceramic gutta-percha points on the production of artifacts in CBCT images. Methods: Extracted single- -rooted premolar teeth (n=20) were instrumented and scanned with a CBCT device to create three groups: the Control group, the Gutta-Percha group and the Bioceramic Gutta-Percha group. Two types of analysis were executed: an objective one, using the Region of Interest (ROI) to measure the pixel density of each tooth, and a subjective one, to compare the groups’ images. For the statistical analysis, Student’s t-test, descriptive statistics and the frequency distribution analysis were used for both objective and subjective analyses. Results: The agreement between the observers ranged from moderate to excellent. Similar grayscale values were obtained in both the GP and BCGP groups. These results were endorsed by the p-values obtained with Student’s t test. For the subjective analysis, the observers indicated the BCGP group as the one that developed the highest number of artifacts. Conclusions: Both materials produced artifacts in the CBCT images. However, in the subjective analysis, the BCGP group showed higher levels of artifact production than the GP group, which could result in the misdiagnosis of root fracture and in a worse prognosis for that tooth.Objetos metálicos, tais como retentores intrarradiculares e restaurações, podem produzir interferência grave, assim, diminuindo a qualidade de imagem TCFC (Tomografia Computadorizada de Feixe Cônico). Objetivo: o propósito deste estudo foi analisar a influência de cones de guta-percha convencionais e de biocerâmica na produção de artefatos nas imagens TCFC. Métodos: um dente pré-molar unirradicular extraído (n=20) foi instrumentalizado e escaneado com aparelho TCFC criando três grupos: o grupo Controle (C), o grupo Guta-Percha (GP) e o grupo Guta-Percha de Biocerâmica (GPB). Foram executados dois tipos de análises: uma objetiva, usando a Região de Interesse (ROI) para medir a densidade de pixels de cada dente; e uma subjetiva, para comparar as imagens dos grupos. Para a análise estatística, o teste t de Student, estatística descritiva e a análise de distribuição de frequência foram usadas tanto para a análise objetiva quanta para a subjetiva. Resultados: a concordância entre os observadores se deu entre moderado e excelente. Foram obtidos valores de escalas de cinza semelhantes no grupo GP e no grupo GPB. Tais resultados foram reforçados pelos valores-p obtidos pelo teste t de Student. Para a análise subjetiva, os observadores indicaram o grupo GPB como o que desenvolveu o maior número de artefatos. Conclusões: ambos os materiais produziram artefatos nas imagens TCFC. Entretanto, na análise subjetiva, o grupo GPB mostrou níveis maiores de produção de artefatos do que o grupo GP, o qual poderia resultar em um diagnóstico incorreto de fratura da raiz e em um prognóstico pior para aquele dente

Computed tomography bone density variations in oncological patients undergoing antiresorptive medication

The purpose of this study was to compare jaw and cervical vertebrae bone density in computed tomography (CT) analyses of oncological patients undergoing antiresorptive medication with control patients, aiming to find information that may assist the radiologist and clinician in predicting risks and monitoring osteonecrosis in the jaw. Thirty-one patients treated with zoledronic acid and 37 control were included in the study. Two areas in regions of interest were chosen and standardized, one in the lower portion of the mandible and another in the axial cervical vertebra (C2) of patients undergoing antiresorptive drug treatment (experimental group) and the control group. Density analysis was performed using Hounsfield scale grayscale values obtained from multislice CT exams. Interclass correlation coefficient test (ICC) was performed to assess reproducibility and repeatability. The test of normality of the samples was demonstrated using the Shapiro-Wilk test and the comparison performed using Mann-Whitney U non-parametric test. When compared to patients in the control group, patients undergoing antiresorptive medication depicted an increase in bone density in both jaw bone (p=0.021) and cervical vertebrae (p=0.002). The same pattern could be observed in patients who used the medication on a monthly basis for analysis of jaw bone (p=0.021), the cervical vertebrae (p=0.002), and the cervical vertebrae of the patients who used the medication on a quarterly basis (p=0.003). CT can be a potentially useful method for detecting alterations associated with antiresorptive therapy, serving as a possible tool in the prediction of the disease progression

Detection of root and alveolar fractures in macerated canine maxillae upper incisors by means of digital periapical radiographs and cone-beam computed tomography

O objetivo deste trabalho foi comparar radiografias periapicais (RP) com quatro protocolos diferentes de tomografia computadorizada por feixe cônico (TCFC) para o diagnóstico de fraturas alveolares e radiculares. Oitenta incisivos superiores (40 hígidos e 40 com fratura radicular) de cães foram inseridos em 80 alvéolos anteriores (40 hígidos e 40 com fratura alveolar) de 20 maxilas caninas maceradas em posições randomizadas previamente. Cada maxila foi submetida a duas RP com diferentes angulações verticais e a quatro protocolos de TCFC com variações em kV (72 kV ou 80 kV), mA (4 mA ou 8 mA) e número de projeções (400 ou 500). As imagens obtidas foram randomizadas e analisadas por dois radiologistas odontológicos por duas vezes, com um intervalo de duas semanas entre as observações. Valores de sensibilidade, especificidade e acurácia para as análises binárias foram melhores para TCFC do que RP; fraturas radiculares apresentaram melhores resultados corretos de diagnóstico do que fraturas alveolares para RP e TCFC. Para a verificação da acurácia através da área sob a curva (ASC) de característica de operação do receptor (ROC), resultados de TCFC foram melhores do que resultados de RP; fraturas radiculares apresentaram melhores resultados corretos de diagnóstico do que fraturas alveolares para RP e TCFC. Quando a localização da fratura alveolar (porção vestibular ou porção palatina do alvéolo) ou da fratura radicular (terço cervical, médio ou apical) foi levada em consideração para a realização das análises estatísticas, os mesmos apresentaram uma discreta redução. RP com duas angulações verticais diferentes podem ser consideradas um bom método para diagnosticar fraturas radiculares. Quando não é possível diagnosticar fraturas radiculares e alveolares em RP, o próximo exame de escolha é a TCFC.The purpose of this study was to compare periapical radiograph (PR) and four different protocols of cone-beam computed tomography (CBCT) in the diagnosis of alveolar and root fractures. Eighty incisor teeth (40 higid and 40 with root fracture) from the canine species were inserted in 80 anterior alveolar sockets (40 higid sockets and 40 sockets with alveolar fracture) of 20 macerated canine maxillae in previously randomized positions. Afterwards, each maxilla was submitted to periapical radiograph in two different vertical angulation incidences, and to four different CBCT protocols, with variations in kV values (72 kV or 80 kV), mA values (4 mA or 8 mA) and number of frames (400 ou 500). The images were randomized and posteriorly analyzed by two oral and maxillofacial radiologists two times, with a two-week interval between observations. Sensitivity, specificity and accuracy values for binary analyses were better for CBCT than for PR; root fractures showed better diagnosis results than alveolar fractures for both CBCT and PR. When accuracy was calculated through area under the receiver operating characteristic (ROC) curve, CBCT showed better results than PR; root fractures showed better diagnosis results than alveolar fractures for both CBCT and PR. There was a slight reduction in value results when we considered the alveolar fracture (buccal or palatine portion of alveolus) or root fracture (cervical, median or apical third) location to perform the statistical analyses. Periapical radiograph with two different vertical angulations may be considered an accurate method to detect root fractures. When no fractures are diagnosed in PR and the patient describes pain symptoms, the subsequent exam of choice is CBCT

Analysis of cone beam computed tomography learning by undergraduate students at Universidade de São Paulo School of Dentistry

O objetivo deste estudo foi avaliar uma metodologia de aprendizado híbrido para o ensino de tomografia computadorizada de feixe cônico (TCFC) aplicada a estudantes de graduação, através da aplicação de questionário e análise das notas das avaliações práticas realizadas através de slides em PowerPoint. A disciplina ODE 0308 - Métodos de diagnóstico por imagem foi ministrada no último semestre de quatro turmas, que foram divididas em dois grupos: grupo controle (Noturno 2018 e Noturno 2019) e grupo teste (Diurno 2018 e Diurno 2019). Os alunos do grupo teste recebiam o material didático para a aula prática uma semana antes da aula, enquanto os do grupo controle recebiam o material no dia da aula prática. Os alunos responderam questionários utilizando escala Likert de 5 pontos; o questionário foi divido nas seguintes seções: \"ambiente de aprendizado\", \"professores\", \"software e material didático\", \"avaliação\", e \"o que aprendi sobre tomografia computadorizada por feixe cônico\". Uma questão dissertativa abordando sugestões para melhorar a disciplina também fazia parte do questionário. Foram realizados testes estatísticos para comparar as notas das avaliações e as respostas dos questionários entre grupo teste e grupo controle, e uma análise qualitativa das respostas da questão discursiva. Após a análise estatística, observou-se que não houve diferença estatisticamente significante entre as respostas dos questionários preenchidos pelos alunos do grupo teste (Diurno) e grupo controle (Noturno). As sugestões para a melhoria da disciplina foram semelhantes para os dois grupos. Não houve diferença estatisticamente significante entre as notas das avaliações práticas dos alunos que receberam o material das aulas práticas antecipadamente (grupo teste - Diurno) com os alunos que receberam o material das aulas práticas no laboratório (grupo controle - Noturno), sugerindo que a presença de instrutores nas aulas práticas foi importante para o aprendizado.The objective of this study was to evaluate a hybrid learning methodology for cone beam computed tomography (CBCT) imaging applied to undergraduate students, through surveys and analysis of mid and end-term quizzes at anatomical structures by means of PowerPoint slides. The discipline ODE 0308 - Diagnostic imaging methods was taught in the last semester of four classes, which were divided into two groups: control group (Night time Class of 2018 and Class 2019) and test group (Daytime Class of 2018 and Class 2019). The students in the test group received the material for the hands-on class one week before the class, while the students in the control group received the material on the day of the hands-onl class. Students answered surveys by using a 5-point Likert scale; the survey was divided into the following sections: \"learning environment\", \"instructors\", \"software and learning material\", \"assessment\", and \"what I learned about cone beam computed tomography\". A written question addressing suggestions for improving the discipline was also part of the questionnaire. Statistical tests were performed to compare the quiz scores and questionnaire responses between test group and control group, and a qualitative analysis of the answers to the discursive question. After the statistical analysis, it was observed that there was no statistically significant difference between the answers of the surveys completed by the students of the test group (Daytime classes) and control group (Nighttime classes). The suggestions for improving the discipline were similar for both groups. There was no statistically significant difference between the assessments grades of students who received material from practical classes in advance (test group - Daytime classes) with students who received material from practical classes in the laboratory (control group - Nighttime classes), suggesting that the presence of instructors in hands-on classes was important for the learning process

Localização do forame mandibular: um estudo de TCFC para melhorar o índice de sucesso da anestesia do nervo alveolar inferior

Objective: This study proposed to locate the mandibular foramen position by using cone beam computed tomography (CBCT) imaging, based on landmarks used at inferior alveolar nerve block (IANB) technique in order to increase the success rate of this procedure. Materials and methods: 58 mandibular foramina of 29 adult patients were evaluated. Linear and angular CBCT measurements were defined for the mandibular foramen based on the IANB technique. The measurements were performed by two radiologists. Data analyses consisted of verifying the normality, obtaining the mean value of all patients and comparing the data obtained between male and female patients. Results: Student’s t and Mann-Whitney’s U tests were used to calculate the mean mandibular foramen position. The three mean position measurements of the mandibular foramen were 13.5 mm above the occlusal plan (15.5 mm for male and 11.7 mm for female patients), 14.6 mm below the mandibular notch (14.9 mm for male and 13.7 mm for female patients) and 14.2 mm from the anterior border of mandibular ramus (14.6 mm for male and 13.8 mm for female patients). The angle formed by the molar lines and contralateral premolar lines was 25.8° and the angle formed by the molar lines and contralateral second premolar/molar lines was 31.5°. Conclusion: CBCT images were a useful method to provide the measurements of the mandibular foramen position based on landmarks used by the IANB technique. We encourage the use of these measurements as reference to increase the clinical success when performing the IANB technique.Objetivo: Este estudo propôs a localização da posição do forame mandibular através da tomografia computadorizada de feixe cônico (TCFC) baseada em pontos de referência utilizados na técnica do bloqueio do nervo alveolar inferior (BNAI) para aumentar a taxa de sucesso desse procedimento. Materiais e métodos: 58 forames mandibulares de 29 pacientes adultos foram avaliados. Medições lineares e angulares de TCFC foram definidas para o forame mandibular baseadas na técnica do BNAI. As medições foram realizadas por dois radiologistas. A análise dos dados consistiu em verificar a normalidade, obtendo o valor médio de todos os pacientes e comparando os dados obtidos entre pacientes do sexo masculino e feminino. Resultados: Os testes t de Student e U de Mann-Whitney foram usados para calcular a posição média do forame mandibular. As três medições de posição média do forame mandibular foram 13,5 mm acima do plano oclusal (15,5 mm para pacientes do sexo masculino e 11,7 mm para pacientes do sexo feminino), 14,6 mm abaixo da incisura mandibular (14,9 mm para pacientes do sexo masculino e 13,8 mm para pacientes do sexo feminino) e 14,2 mm da borda anterior do ramo mandibular (14,6 mm para o sexo masculino e 13,7 mm para o sexo feminino). O ângulo formado pelas linhas molares e pré-molares contralaterais foi de 25,8º e o ângulo formado pelas linhas molares e pelo segundo pré-molar/molar contralateral foi de 31,5º. Conclusão: as imagens de TCFC foram um método útil para fornecer as medições da posição do forame mandibular com base nos pontos de referência usados pela técnica do BNAI. Encorajamos o uso dessas medidas como referência para aumentar o sucesso clínico ao realizar a técnica do BNAI

Diagnosis of alveolar and root fractures: an in vitro study comparing CBCT imaging with periapical radiographs

Abstract Objective To compare periapical radiograph (PR) and cone-beam computed tomography (CBCT) in the diagnosis of alveolar and root fractures. Material and Methods Sixty incisor teeth (20 higid and 40 with root fracture) from dogs were inserted in 60 anterior alveolar sockets (40 higid and 20 with alveolar fracture) of 15 macerated canine maxillae. Each fractured socket had a root fractured tooth inserted in it. Afterwards, each maxilla was submitted to PR in two different vertical angulation incidences, and to CBCT imaging with a small field of view (FOV) and high-definition protocol. Images were randomized and posteriorly analyzed by two oral and maxillofacial radiologists two times, with a two-week interval between observations. Results Sensitivity and specificity values were good for root fractures for PR and CBCT. For alveolar fractures, sensitivity ranged from 0.10 to 0.90 for PR and from 0.50 to 0.65 for CBCT. Specificity for alveolar fractures showed lower results than for root fractures for PR and CBCT. Areas under the ROC curve showed good results for both PR and CBCT for root fractures. However, results were fair for both PR and CBCT for alveolar fractures. When submitted to repeated measures ANOVA tests, there was a statistically significant difference between PR and CBCT for root fractures. Root fracture intraobserver agreement ranged from 0.90 to 0.93, and alveolar fracture intraobserver agreement ranged from 0.30 to 0.57. Interobserver agreement results were substantial for root fractures and poor/fair for alveolar fractures (0.11 for PR and 0.30 for CBCT). Conclusion Periapical radiograph with two different vertical angulations may be considered an accurate method to detect root fractures. However, PR showed poorer results than CBCT for the diagnosis of alveolar fractures. When no fractures are diagnosed in PR and the patient describes pain symptoms, the subsequent exam of choice is CBCT