Smile: fun things to look for in your dental x-rays

April 28, 2017

Here’s my face.

I went to the dentists’ office recently for a regular checkup and cleaning, and when my dentist learned that I taught human anatomy, he volunteered to send me a high-res copy of my panoramic x-ray. I couldn’t think of any plausible scenario wherein someone could use it for evil, and it has lots of cool stuff in it besides teeth, so decided to post it so I could yakk about it.

First things first: my teeth are in pretty good shape. I had to have my wisdom teeth (3rd molars) pulled back in 2009, and my upper 1st molar on the left has a root canal and a porcelain crown, which stands out bright white on the radiograph. Everyone else is present and looking good. If it’s been a while since you’ve covered this, the full human dentition consists of 2 incisors, 1 canine, 2 premolars, and 3 molars on each side, top and bottom, for a total of 32 teeth. Because I’ve had all four 3rd molars removed, I’m down to 28.

I could go on and on about the cool stuff in this image. Here are 12 things that stand out:

  1. The mandibular condyle, which is the articular end of the mandible that fits into the mandibular fossa, a shallow socket on the inferior surface of the temporal bone, to form the temporomandibular joint (TMJ). There’s an articular disk made of fibrocartilage inside the joint, which separates it into two fluid-filled spaces, one against the condyle and one against the fossa. This allows us to do all kinds of wacky stuff with our lower jaws besides simply opening and closing them, such as slide the jaw fore and aft or side to side. This is a strong contrast to most carnivores, which bite down hard and therefore need a jaw joint that works as a pure hinge. See this post for pictures and discussion of the jaw joint in a bear skull.
  2. The coronoid process of the mandible, which is a muscle attachment site. A few fibers of the masseter and buccinator muscles can encroach onto the coronoid process, but mostly it is buried in the temporalis, one of the primary jaw-closing muscles. Put your fingers on the side of your head a little above and in front of your ear and bite down. That muscle you feel bulging outward is the temporalis. Back in the 1960s, Melvin Moss (1968) discovered that if he removed the temporalis muscles from newborn rats, the coronoid processes would fail to develop. Moss’s ambition was to discover the quanta of anatomy, which in his view were “functional matrices” – finite sets of soft tissues related by development and function, which might contain “skeletal units” that grew because of the morphogenetic demands of the functional matrices. His tagline was, “Functional matrices evolve, skeletal units respond”. Not all of Moss’s ideas have aged well in light of what we now know about the genetic underpinnings of skeletal development, but he wasn’t completely wrong, either, and functional matrix theory is still an interesting and frequently productive way to think about the interrelationships of bones and soft tissues. For more horrifying/enlightening Moss experiments on baby rats, see this post.
  3. The mandibular angle, which is another muscle attachment. The medial pterygoid muscle attaches to the medial surface, and the masseter attaches laterally. You can feel this, too, by putting your fingers over your mandibular angle and biting down – that’s the masseter you feel bulging outward. Note that the angle flares downward and outward on either side of my jaw. This flaring of the angle tends to be more pronounced in males than in females, and it is one of many features that forensic anthropologists (like the one I belong to) take into account when attempting to determine biological sex from human skeletal remains. Like most sexually dimorphic features of the skeleton, this is a tendency along a spectrum of variation rather than a binary yes/no thing. There are women with flared jaw angles (Courtney Thorne-Smith, probably) and men with slender mandibles, so you wouldn’t want to sex a skeleton by that feature alone.
  4. The mandibular canal, a tubular channel through the mandible that houses the inferior alveolar artery, vein, and nerve. This neurovascular bundle provides innervation and blood supply to the tooth-bearing part of the mandible and to the teeth themselves, and emerges through the mental foramen to provide sensory innervation and blood supply to the chin.
  5. The upper surface of the hard palate, formed by the palatine process of the maxilla anteriorly and by the palatine bones posteriorly. The palate is the roof of the mouth and the floor of the nasal airways.
  6. The median septum of the nasal cavity, formed by cartilage anteriorly, the perpendicular plate of the ethmoid bone superiorly, and the vomer posteriorly and inferiorly.
  7. The blue lines are the inferior margins of my maxillary sinuses – air-filled spaces created when pneumatic diverticula of the nasal cavity hollow out the maxillae. You have these, too, as well as air spaces in your frontal, ethmoid, sphenoid, and temporal bones. It looks like many of the roots of my upper molars stick up into my maxillary sinuses. This is not an illusion, as shown below.
  8. When I had the root canal on my left upper 2nd molar, the endodontist filled the pulp cavities of the tooth roots with gutta-percha, a rigid natural latex made from the sap of the tree Palaquium gutta. Gutta-percha is bioinert, so it makes a good filling material (it was also used to insulate transoceanic telegraph cables), and it’s radiopaque, which allows endodontists to confirm that the cavities have been filled completely. The other teeth show the typical structure of a dense enamel crown, less dense dentine forming the bulk of the tooth, and radiolucent pulp cavities containing blood vessels and nerves.
  9. This is the rubber bit I gripped with my incisors to keep my teeth apart and my head motionless while the CT machine rotated around me to make the scan. Not that cool in a science sense, but I figured it deserved a label.
  10. Note that the roots of the canines go farther into the jaws than those of the other teeth. This is true for all four canines, it’s just easiest to see with this one. This is a pretty standard mammalian thing, for taxa that still have canines – they tend to be big and mechanically important, so they have deep roots. Even though our canines are absolutely and proportionally much smaller than those in the other great apes, we can still see traces of their earlier importance, like these deep roots.
  11. In places you can see the trabecular internal structure of my mandible clearly. As someone who geeks out pretty much anytime I get a look inside a bone, this tickled me.
  12. The remains of an alveolus or tooth socket. I had my 3rd molars out almost a decade ago, and by now the sockets will have mostly filled in with new trabecular bone. But you can still see the ghostly outline of at least this one – a sort of morphogenetic trace fossil buried inside my mandible. I assume that in another decade or two this will have disappeared through regular bone remodeling.

Here’s a closeup of my left upper 2nd premolar and first two (and only remaining) molars. The gutta-percha filling the pulp cavities of the three roots of the 1st molar is obvious. The disparity in root length is mostly illusory – this was an oblique shot and the two ‘short’ roots are foreshortened.

Here’s the same image with the roots of the 2nd molar traced in pink, and the inferior margin of the maxillary sinus traced in blue. It’s not that uncommon for upper molar roots to stick up into the maxillary sinuses. That was true of my 3rd molars as well, and when I had them taken out, the endodontist had to put stitches into my gums to close the holes. Otherwise I would have had open connections between my oral cavity and maxillary sinuses, which would have sucked and been dangerous. Nasal mucus in the maxillary sinuses could have drained into my mouth, and food I was chewing could have been forced up into the sinuses, where it would have decomposed and caused a truly vile sinus infection.

In a developmental sense, it’s not that the roots of the teeth grow upward into the sinuses, it’s that the sinuses grow downward, eroding the bone around the roots of the teeth. This happens well after the teeth are done forming – the sinuses continue to expand as long as the skull is growing, and they retain the potential to remodel the surrounding bone for as long as we live. Even in cases like mine where the roots of the molars stick up into the sinuses, the tooth roots are still covered by soft tissue, including branches of the superior alveolar artery, vein, and nerve that enter the pulp cavities of the tooth roots through foramina at their tips.

If you ask your dentist for copies of your own dental x-rays, you’ll probably get them. If you do, have fun exploring the weird territory inside your head.

Reference

  • Moss, M. L. (1968). A theoretical analysis of the functional matrix. Acta Biotheoretica, 18(1), 195-202.
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7 Responses to “Smile: fun things to look for in your dental x-rays”

  1. ijreid Says:

    Well at least you have all your teeth :P I was born with no 2nd molars on both sides of my lower jaw, and absolutely no 3rd molars at all. I don’t have a copy of an x-ray though, would be a nice addition.

  2. Mike Taylor Says:

    Deeply disappointed that Moss (1968) was unable to get his article into the New England Journal of Evil. What is the world coming to?

  3. Mike Taylor Says:

    Also: “the mental foramen” — seriously?

    And can’t we all agree that there really ought to be a bone in the roof of the mouth called the palpatine?

  4. Mike Taylor Says:

    Wait — you only mention rotating cameras and CT scans near the end. So does that mean you have a 3d model? Or did they fob you off with this lame 2d approximation?

  5. Matt Wedel Says:

    Also: “the mental foramen” — seriously?

    Yup. From the Latin mentum for ‘chin’, as opposed to mens/mentalis for ‘mind’.

    And can’t we all agree that there really ought to be a bone in the roof of the mouth called the palpatine?

    In my headcanon, there is.

    Wait — you only mention rotating cameras and CT scans near the end. So does that mean you have a 3d model? Or did they fob you off with this lame 2d approximation?

    The gizmo, like most* CT machines, is basically a rotating x-ray machine hooked up to a computer that processes a bunch of 2D x-ray images to reconstruct a virtually-sliced 3D model (in the same sense that early iPods were basically hard drives with headphone jacks and fancy buttons). IME with other medical CT machines, you can do a quick-and-dirty pass to generate a 2D “scout” image – like we used in figures 11, 13, and 16A of our 2013 cartilage paper – or a full scan to generate a stack of slices/voxels/3D model (any or all are implied in the ‘computed’ part of ‘computed tomography’).

    * The only exceptions I know of keep the scanner stationary and spin the target (or ‘patient’).

    The full scan takes longer and means a higher x-ray dose than the quick 2D scout, which is basically just a plane x-ray shot with a much more capable machine, sort of like shooting a still with a video camera. Without a compelling medical reason, like investigating a bump under the tongue that might be a tumor or might just be a sialolith (salivary stone), there’s no reason to subject the patient to the higher x-ray dose, nor to overwork the machine, which is fearsomely expensive and good for a high but finite number of duty cycles. So the ‘lame 2d approximation’ here was for my own good, and theirs.

  6. Mike Taylor Says:

    I get the “for your own good” argument …

    But, dude! A 3d model of your own skull? If you could get that printed at life size and keep it on your shelf, wouldn’t that be worth a couple of oral cancers?


  7. WELP now I need a copy of my dental X-rays.


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