Radiological explorations in Pediatric Dentistry
1. Introduction: Radiography is a necessary and indispensable piece of information, on which the diagnosis and the organization of the treatment plan are inevitably based.
In pediatric dentistry, its indication presents particularities which include:
– The poverty of clinical signs in childhood dental pathology.
– To the uncertainty of subjective signs.
– Bone and root remodeling.
2. Assessment of the need for a radiological examination : The radiographic examination has the following objectives:
– Guide the practitioner in his diagnosis
– Check the different teeth
– Help the practitioner in his therapy
– Monitor the therapies implemented
1.1. Indications for additional examination in pediatrics:
The radiographic examination is considered a complementary examination to the clinical examination in pediatric dentistry. However, it becomes the rule in emergency situations.
In traumatology, it is systematic, not only to make a precise diagnosis of the injury but also to evaluate its short and long term consequences. It is also a crucial examination for the prognosis.
However, this additional examination should not be systematic; it must be justified by the patient’s history and clinical examination and only be considered to the extent that it can improve the diagnosis.
The main reasons for an additional radiographic examination can be summarized as:
– Detection of oral pathological conditions (carious or traumatic)
– Detection of development anomalies
– Post-operative evaluation of different therapies in pediatric dentistry
– Control and management of eruption problems
– Evaluation of growth problems and orthodontic monitoring
1. 2. Radiation protection :
X-ray examination must be carried out with protective measures because children are more sensitive to ionizing radiation than adults.
In order to limit the risk as much as possible, it is recommended to:
– Protect the small patient with a lead apron
– Have the child wear a thyroid collar in case of thyroid gland exposure.
– Reduce exposure by 50% compared to that of adults in very young children (0 to 3 years) and by 25% for subjects aged 3 to 15 years.
Radiological explorations in Pediatric Dentistry
1.3. PRECAUTIONS TO BE TAKEN IN CHILDREN:
- Make the child wear a lead apron,
- Use high-speed movies.
- Reduce exposure time compared to adults.
- Limit the number of shots.
- Avoid radiological examinations too close together in time.
3. Necessary material
– X-ray generator
– X-ray films of size No. 0, 1, 2, and 4 or radiovisiographic sensors (RVG), or radio-luminescent memory screens (ERLM)
– Rinn angulator
– Plastic or self-adhesive film holder (Flap)
– Radiation protection clothing
Radiological explorations in Pediatric Dentistry
Radiological explorations in Pediatric Dentistry
Radiological explorations in Pediatric Dentistry
4. The different techniques
4.1. Intraoral techniques:
4.1.1. Retro-coronary:
4.1.1.1. Technique: The choice of film depends on the age of the child and the type of X-ray used:
Conventional imaging:
– Use ISO child size films size 0 (2×3 cm) in temporary dentition and early mixed dentition. After the age of 8 years, standard size films ISO size 2 (3×4 cm) can be used.
– Silver films must belong to the fastest category, that is to say, be of type ISO E or ISO F. They give images of diagnostic value almost equivalent to that of class D films for an exposure reduced by half.
Digital imaging:
– Direct technique sensors (CCD/CMOS or charge coupled device/complementary mental oxide semi-conductor) to be used in children and adolescents are size 0 or 1 (2×4 cm), size 2 being too large.
– In indirect technology, ERLM (radioluminescent memory screens) sensors have the advantage of being cable-free and more flexible. They are equivalent in size to silver films.
To successfully take this X-ray, the film is placed behind the temporary molars and the cone is oriented perpendicular to the film because the passage of the incident ray tangentially to the proximal faces is the essential condition for the diagnostic value of these images.
Radiological explorations in Pediatric Dentistry
In younger children, the use of a flap film holder stuck perpendicularly to the film can facilitate their retention in the mouth, parallel to the axis of the teeth examined, by reducing the bulk.
Radiological explorations in Pediatric Dentistry
- Goals
- Determine the presence or absence of early interproximal caries.
- Determine the limits of the pulp chamber and the height of the pulp horns.
- Provide a better definition of the enamel-dentin junction (important area in children).
- Detect caries recurrence under amalgam.
- Determine the caries/pulp ratio.
4.1.1.2. Indications:
– In temporary dentition, retro-coronal (or bite wing) images are exclusively taken in subjects at high risk of caries under 5 years of age. They are then renewed every 6 to 12 months.
– These images improve the detection of proximal caries and hidden occlusal (ampullary) caries in addition to the clinical examination.
– Whatever the risk, they become useless, in the presence of diastema, when the proximal faces are visible and can be probed.
– On the other hand, they are systematic during the 6th year.
– In mixed dentition as in young adult dentition, they are carried out at least once a year in subjects at high risk of caries.
– Otherwise, they are systematic only in children aged 8 or 9 years without a history of caries. In the absence of caries, the examination is repeated every 2 or 3 years until the age of 15.
4.1.2. Retro-alveolar:
4.1.2.1. Technique: These shots are taken using the bisector technique with films of a size adapted to the child’s age.
A Rinn angulator of suitable size allows the beam applicator tube to be correctly positioned in relation to the intraoral film. It should be perpendicular to the bisecting plane of the angle formed by the axis of the tooth and the axis of the film. If the child cannot tolerate the Rinn angulator, the film can be held in the mouth by a film holder flap offset on one of the edges.
In the case of anterior teeth, ISO size 1 films can also be used.
Radiological explorations in Pediatric Dentistry
Interests
- Allows you to see the degree of resorption of temporary teeth, and the degree of maturation of permanent teeth.
- Axis of tooth evolution.
- Root anatomy of teeth.
- Tooth and anatomical elements (sinuses, nasal cavities, dental canal) report.
- Allows to specify the volume of caries and relation with the pulp.
- Allows to specify the apical, latero-radicular foci, the damage to the interdental septum and the inter-radicular bone rarefactions.
4.1.2.2. Indications:
In cariology : These X-rays are used in addition to retro-coronal X-rays on teeth with severe carious disease (significant coronal decay, pulpo-periodontal disease, etc.) to provide information on:
– possible pulp involvement and pulpo-periodontal complications.
– the physiological stage of the tooth or on the temporary tooth/underlying germ ratio in order to make the right therapeutic decision.
Radiological explorations in Pediatric Dentistry
In traumatology : they are essential for:
– look for a root fracture line.
– observe periodontal damage.
– assess post-traumatic complications.
– follow traumatized teeth.
Others : They replace retro-coronary procedures when they are not feasible. They can also be used for:
– The performance and monitoring of pulp treatments carried out after carious, traumatic or other damage.
– Monitor the delay in the development of a temporary or permanent tooth.
– Diagnosis and treatment of dental anomalies, etc.
4.1.3. Occlusal bite:
4.1.3.1. Technique: This X-ray is easy to take even in a very young child. He bites on an ISO size 2 film, if he has temporary teeth, or on an ISO size 4 film (5×7 cm), if he has permanent teeth. The beam is directed at the base of the nose making a 90° angle with the film. 4.1.3.2.
- Goals
- Specify the position of included and ectopic teeth, particularly permanent canines.
- Show the presence of excess germs.
- Specify the extent of the cysts.
- Specify the nature, extent and anatomical relationships of certain lesions.
- Trauma in very young children
Radiological explorations in Pediatric Dentistry
Indications : The occlusal image on a bitten film sometimes complements the retro-alveolar images or the panoramic radiograph; it can be performed in the following cases:
– In mixed dentition, between 8 and 10 years, to assess root maturation, control the presence of germs and the eruption of permanent teeth (delayed eruption).
– Delayed eruption of permanent teeth.
– Number anomalies (suspicion of supernumerary and/or impacted teeth),
– Shape anomalies (all types of teeth).
– In polycarious patients (all types of teeth).
– In traumatology, it can be used to highlight a gap between the tooth and the alveolus.
– Also in traumatology, when fractures of the mandible and/or condyles are suspected (all types of teeth).
– In order to specify the vestibulo-lingual relationships of the anatomical elements analyzed, for example an odontoma.
4.2. Extra-oral techniques
4.2.1. Panoramic: Panoramic radiography has a lower diagnostic contribution for the detection of carious lesions than intraoral images. Nevertheless, it is a fundamental first-line examination when there are warning signs.
This is what allows us to best assess the normality of the teeth.
Radiological explorations in Pediatric Dentistry
- Goals
- Assess dental age.
- Determine dental agenesis.
- Impacted teeth, supernumeraries and odontomas.
- Cysts and infectious foci
- Report of dental lesions and neighboring anatomical structures: Incisal hole,
- nasal cavity, maxillary sinus, inferior dental canal.
Fractures of the horizontal branches of the mandible.
Benefits
- Causes less radiation.
- Easily accepted by the child.
Disadvantages
- Radiography not very precise for the detection of interproximal caries.
The indications:
In orthodontics : it is considered:
– For the analysis of needs in interceptive or curative orthodontic treatment. It is necessary at least once in mixed dentition to check the presence of all germs and anticipate an orthodontic problem.
– After the age of 3 years, it can be considered in the event of ectopic dental position, abnormality in number or eruption.
– In case of suspicion of a problem with the eruption of the maxillary canines (if palpation of the vestibule has not revealed the submucosal presence of the maxillary canines around 11 years of age).
– In case of severe decay of the first permanent molars to observe the presence of germs of the third molars which will influence the orthodontic treatment plan.
In cariology : in mixed and adult dentition, it can replace retro-coronal control radiographs if several carious lesions have been highlighted in different quadrants during the clinical examination.
In pathology : if there is suspicion of extractions in a poly-carious context. It is possibly supplemented by retro-alveolar radiographs depending on the radiographic diagnosis.
In trauma: it is performed when the shock, from bottom to top, has resulted in a limitation of the mouth opening.
4.2.2. Frontal and profile teleradiographs: Frontal and profile teleradiographs are systematically considered as part of orthodontic treatment, in addition to panoramic radiography, when this treatment must be started at the end of the mixed dentition or in young adult dentition. They are essential for cephalometric analysis.
They are indicated in children who must undergo radiotherapy or chemotherapy in order to monitor growth factors.
2.4. Cone Beam: “ Cone Beam Computerized Tomography (CBCT )”: Sectional imaging can complement conventional examinations if the relationships between the different anatomical elements or between a pathology and neighboring organs are poorly determined.
It is less irradiating than CT scanning.
Radiological explorations in Pediatric Dentistry
Cone beam computed tomography should be performed in cases where clinical signs immediately indicate 3D reconstruction for :
– Refine the diagnosis in cases of trauma, particularly in the presence of root fractures.
– Facilitate certain complex surgical cases.
– Carry out the topographical and morphological study of included dental elements or a three-dimensional cephalometric study.
– Perform the preoperative examination in the presence of supernumerary germs, the planned avulsion of included or dis-included teeth in order to assess their situation in relation to other anatomical structures.
– Manage complex trauma cases.
– Confirm extensive infection with significant radiolucent lesion related to different anatomical structures.
Extra tooth on panoramic and Cone Beam
4.2.4. Computed tomography : Computed tomography is reserved for people with multiple trauma, disabilities and for exploring malignant facial tumors.
5. READING THE X-RAY IMAGE:
- Dry radiographs must be identified and mounted for observation on a Negatoscope.
- X-rays should be read as if you were looking into your patient’s mouth.
Radiological explorations in Pediatric Dentistry
Example of images obtained using three-dimensional volumetric computed tomography to locate a palatal impacted canine (indicated by the arrows). This ensures that the root of the lateral is not affected by the impacted tooth.
Lateral cephalometric radiography allows the patient’s profile, dentition, jaws to be assessed and a correlation to be made with facial photographs, thus allowing better treatment planning.
Radiological explorations in Pediatric Dentistry
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.