Differential Diagnosis of Radiolucent & Radiopaque Lesions of Jaws PDF

Dr. Abeer Ahmad Aljoujou PhD- Oral Medicine  ‫ الشفافٌة الشعاعٌة ‪ :‬هً الصورة أو الخٌال الشعاعً لبنى‬ ‫نسٌجٌة أو تشرٌحٌة طبٌعٌة أو آفات مرضٌة قلٌلة أو عدٌمة‬ ‫الكثافة حٌث تمر عبرها األشعة دون أن تمتصها (أو ٌحدث‬ ‫امتصاص بسٌط لألشعة) ‪ ,‬حٌث تظهر هذه البنى على الفٌلم‬ ‫الشعاعً المعر...

Dr. Abeer Ahmad Aljoujou PhD- Oral Medicine  ‫ الشفافٌة الشعاعٌة ‪ :‬هً الصورة أو الخٌال الشعاعً لبنى‬ ‫نسٌجٌة أو تشرٌحٌة طبٌعٌة أو آفات مرضٌة قلٌلة أو عدٌمة‬ ‫الكثافة حٌث تمر عبرها األشعة دون أن تمتصها (أو ٌحدث‬ ‫امتصاص بسٌط لألشعة) ‪ ,‬حٌث تظهر هذه البنى على الفٌلم‬ ‫الشعاعً المعرض قاتمة ‪ dark‬أو سوداء ‪.black‬‬  ‫ الظاللٌة الشعاعٌة ‪ :‬هً الصورة أو الخٌال الشعاعً لبنى‬ ‫نسٌجٌة أو تشرٌحٌة طبٌعٌة أو مرضٌة ذات كثافة عالٌة حٌث‬ ‫تعترض مرور األشعة عبرها وتقوم بامتصاصها ‪ ,‬فتظهر‬ ‫على الفٌلم المعرض فاتحة ‪ light‬أو بٌضاء ‪. white‬‬  Jaw lesions can be described as having either a radiolucent, radiopaque, or mixed appearance, relative to density of the adjacent bone. The majority of jaw lesions are radiolucent (> 80%). Unilocular radiolucent lesions with well-defined borders usually indicate a slow proliferating benign process. Multilocular lesions with well-defined borders indicate a benign yet aggressive process.  Radiopaque lesions which are well-defined, usually represent a benign or inflammatory aetiology. In general, lesions with well-defined borders are usually benign whereas lesions with ill-defined borders invariably represent aggressive, inflammatory or neoplastic processes. lesion with ill-defined borders  Mixed radiolucent-radiopaque lesions can be due to inflammatory, metabolic conditions , fibro-osseous lesions, or less commonly, malignant processes. ‫بؤر ورمٌة ( سرطان دم) شفوفٌات شعاعٌة غٌر محددة الحواف مع‬ ‫شظاٌا عظمٌة وفقدان أسنان‬  ‫‪Jaw Deformities in thalassemia patients‬‬ ‫مظهر الملح والفلفل لعظام الفكٌن لدى مرضى التالسٌمٌا ( توسع المسافات النقٌوٌة‬ ‫للتعوٌض عن سوء وظٌفة الكرٌات الحمراء)‬ ‫‪9‬‬ ‫‪Dr.Abeer A Aljoujou‬‬ ‫‪ 25‬أٌار‪24 ,‬‬  sickle cell anaemia 10 Dr.Abeer A Aljoujou 24 ,‫ أٌار‬25  ‫ اآلفات الشافة شعاعٌا ‪:Radiolucent lesions‬‬ ‫‪ -‬تتكون آفات الفكٌن الشافة من مجموعة كبٌرة من اآلفات ‪,‬‬ ‫ٌمكن تصنٌفها حسب صفاتها الشعاعٌة ( محددة الحواف أو‬ ‫غٌر محددة الحواف‪ ,‬وحٌدة البؤرة أو متعددة البؤر ‪,)....‬‬ ‫كما ٌمكن تصنٌفها حسب العامل المسبب ( سنٌة المنشأ أو‬ ‫غٌر سنٌة المنشأ ‪ ,‬ورمٌة أو سلٌمة ‪)...‬‬ ‫‪ -‬معظم آفات الفكٌن تكون شافة شعاعٌا (أكثر من ‪) %80‬‬  ‫الشفافٌة الشعاعٌة‬ ‫خطأ ما أو مظهر خادع‬ ‫آفة مرضٌة‬ ‫بنى تشرٌحٌة طبٌعٌة‬ ‫آفة مكتسبة أو انتانٌة‬ ‫آفة والدٌة تطورٌة‬ ‫انتان موضعً أو منتشر‬ ‫رض‬ ‫آفة كٌسٌة‬ ‫آفة ورمٌة أو مشبهة بالورمٌة‬ ‫آفات عظمٌة‬  Certain lesions have a predilection for a particular site ,whereas others can occur anywhere in the jaw. Non-odontogenic lesions usually have no specific relationship to the dentition or can involve the bone around two or more teeth, whereas odontogenic lesions typically involve only one tooth or a specific part of the tooth.  If the abnormal appearance affects all the structure of maxillofacial region, systemic disorders such as metabolic or endocrine abnormality should be considered.  Slow-growing lesions often cause expansion with cortical bowing, while cortical destruction denotes aggressive inflammatory or neoplastic lesions  Effect on surrounding structures Evaluating the effect of a lesion on the surrounding structure helps in inferring behaviour of the lesion. Displacement of teeth is seen more commonly with slow-growing, space-occupying lesions. Resorption of the tooth usually occurs in more chronic and slow-growing processes; however, malignant lesions also occasionally resorb teeth.  Differential diagnosis of jaw lesions based on radiographical appearance  ‫‪ -1‬اآلفات الشافة شعاعٌا وواضحة الحدود‬ ‫‪Well-circumscribed radiolucent‬‬ ‫‪-2‬اآلفات الشافة شعاعٌا وغٌر واضحة الحدود‬ ‫‪Poorly-circumscribed radiolucent‬‬ ‫‪ -3‬اآلفات الظلٌلة شعاعٌا ‪Radiopaque‬‬ ‫‪ -4‬اآلفات المختلطة ‪Mixed density‬‬ Well-circumscribed radiolucent Lesions ‫اآلفات الشافة شعاعيا ً و واضحة الحدود‬ periapical cysts ‫األكٌاس حول الذروٌة‬ - dentigerous cysts ‫األكٌاس السنٌة‬ - Odontogenic keratocyst ‫الكٌس السنً المتقرن‬ - Ameloblastoma ‫األمٌلوبالستوما‬ - Incisive canal cyst ‫كٌس القناة القاطعة‬ - Simple bone cyst ‫األكٌاس العظمٌة البسٌطة‬ - ‫الورم الحبٌبً ذو الخالٌا العرطلة المركزي‬ - Central giant cell granuloma  cone-beam computed tomography for odontogenic keratocyst  Odontogenic keratocyst. Root resorption was not noted on PAN (Figure a) but the irregular and blunted root apices were noted on CBCT (Figure b, sagittal view) Odontogenic keratocyst. Continuity of corticated borders were noted on PAN (Figure a) but discontinuity was noted on CBCT (Figure b, sagittal view) Dentigerous cyst. Expansion of boundaries in the anterior maxilla was not noted on PAN (Figure a) but clearly shown on CBCT with expansion and cortical thinning on the labial side (Figure b, axial view)  Ameloblastoma. The incisive canal was not involved on PAN (Figure a), but was destructed on CBCT (Figure b, sagittal view)  ‫اآلفات الشافة شعاعيا ً و غير واضحة الحدود‬ ‫‪Poorly-circumscribed radiolucent‬‬ ‫‪ -‬التهاب العظم والنقً الحاد ‪acute osteomilitis‬‬ ‫‪ -‬التنشؤات الورمٌة العظمٌة ‪Bone neoplasm‬‬ ‫‪ -‬أورام ثانوٌة انتقالٌة أو اجتٌاحٌة ‪Secondary Metastatic‬‬ ‫‪lesions.‬‬  Periapical showing a poorly defined area of radiolucency in the apical region. Features of concern are the ragged bone margin (solid arrows) and the extensive resorption of teeth (open arrows). Biopsy revealed an osteosarcoma. (B) Part of a panoramic radiograph showing a large poorly defined area of radiolucency in region (arrowed). Both premolars were caries free and unrestored, but mobile. histopathology revealed a secondary metastatic malignant tumour from a breast primary. ‫اآلفات الظليلة شعاعيا ‪Radiopaque lesions‬‬ ‫األورام السنٌة ‪odontoma‬‬ ‫‪-‬‬ ‫األعران العظمٌة ‪Torus‬‬ ‫‪-‬‬ ‫األورام العظمٌة ‪osteoma‬‬ ‫‪-‬‬ ‫األورام العظمٌة الغضروفٌة ‪Osteochondroma‬‬ ‫‪-‬‬ ‫ورم مصورات المالط ‪cementoblastoma‬‬ ‫‪-‬‬ ‫سوء التصنع اللٌفً ‪fibrous dysplasia‬‬ ‫‪-‬‬ ‫التهاب العظم التكثفً ‪condensing osteitis‬‬ ‫‪-‬‬  ‫اآلفات المختلطة ‪Mixed density‬‬ ‫سوء التصنع اللٌفً ‪fibrous dysplasia‬‬ ‫‪-‬‬ ‫األورام اللٌفٌة المتعظمة ( المتكلسة) ‪ossifying fibroma‬‬ ‫‪-‬‬ ‫سوء التصنع المالطً العظمً ‪cemento-osseous dysplasia‬‬ ‫‪-‬‬ ‫التهاب العظم والنقً المزمن ‪chronic osteomilitis‬‬ ‫‪-‬‬ ‫سرطان العظم ‪osteosarcoma‬‬ ‫‪-‬‬ ‫األورام الثانوٌة ‪metastasis‬‬ ‫‪-‬‬ osteonecrosis  Typical Radiographic Features of periapical Cysts This inflammatory cyst develops from the epithelial remnants of Hertwig’s root sheath – the cell rests of Malassez. typical radicular (dental) cyst Residual Radicular Cyst Dentigerous Cyst Basal cell nevus syndrome. ‫الكيس حول السني الجانبي‬  Radiographic Features of periapical lesion The radiographic features of periapical inflammatory lesions vary depending on the time course of the lesion: may show no radiographic change in the normal bone pattern. The earliest detectable change is loss of bone density, which usually results in widening of the periodontal ligament space at the apex of the tooth and later involves a larger diameter of surrounding bone. At this early stage no evidence may be seen of a sclerotic bone reaction.  The radiographic features of periapical inflammatory lesions vary depending on the time course of the lesion:  Granuloma Periapical are the most common periapical radiolucency’s encountered in dental practice. Radiographically the lesion is not fully dark but it has greyish appearance with well defined borders , there is a loss of lamina dura in relation with the affected tooth , the size of radiolucency is less than 1.5 cm in diameter if the size larger so it consider periapical cyst. Granuloma Periapical Radiograph Image  Chronic periapical abscess Radiographic appearance of the lesion may be quite variable, the lesion may have radiolucent appearance with ill- defined borders and in this time it hard to differentiate from granuloma. ‫خراج ذروي‬  Relationship of the lesion with respect to the inferior alveolar canal indicates tissue types that compose the lesion. Lesions above the canal are likely to be odontogenic, whereas lesions below it are usually non-odontogenic in nature. ‫كيس ستيفن‬ ‫كيس ستيفن‬ ‫كيس ستيفن‬ Stafne defect  ‫‪ -2‬اآلفات متعددة البؤر‪:‬‬ ‫‪ -‬أمام الرحى األولى والثانٌة السفلٌة‪:‬الورم الحبٌبً ذو الخالٌا‬ ‫العرطلة المركزي‪ ,‬اأكٌاس العظمٌة البسٌطة‬ ‫‪ -‬المنطقة الخلفٌة من الفك السفلً والرأد‪ :‬األمٌلوبالستوما‪,‬‬ ‫األورام المخاطٌة السنٌة‪.....‬‬  ODONTOGENIC TUMOURS 1- Odontoma: The result of a developmental anomaly they may obstruct tooth eruption and are most commonly seen in children. -Most cases are diagnosed in the second decade of life, and are usually associated with an impacted tooth. Odontomas are classified as simple, compound , or complex. Radiologically, it is seen as a radiopaque mass surrounded by thin radiolucent space. The compound odontomas are composed of multiple well-formed teeth. whereas the complex odontomas appear as an irregular calcified tissue. Odontoma Complex odontoma  Brown Tumor Brown tumor, also known as osteoclastoma, is one of the manifestations of hyperparathyroidism. Radiographic features: Well-defined, purely lytic lesions that provoke little reactive bone. The cortex may be thinned and expanded, but will not be penetrated.  Pathology: In chronic renal disease, continual and excessive urinary calcium excretion can lower serum calcium level and lead to a rise in parathyroid hormone secretion. This results in mobilization of skeletal calcium through rapid osteoclastic turnover of bone to maintain normal serum calcium levels. In localized regions where bone loss is particularly rapid, hemorrhage, and reparative granulation tissue, with active, vascular, proliferating fibrous tissue may replace the normal marrow contents, resulting in a brown tumor. Hemosiderin imparts the brown color (hence the name of the lesions). Brown Tumor  Ameloblastoma The majority of ameloblastoma are benign, with less than1% showing malignant behaviour. The most common site of ameloblastoma is the ascending ramus and proximal body of the mandible (80%). Ameloblastomas are divided into two subtypes, based on radiological appearance.  Multicystic ameloblastomas account for approximately 85% of all ameloblastomas and occur in the third to seventh decades of life. On radiographs, there is marked buccolingual cortical expansion with internal osseous septae, giving rise to a “soap bubble” appearance. - Tooth displacement or root resorption may occur -Unicystic ameloblastomas: occur in a younger age group and tend to be non- invasive. -They present as a well-circumscribed, unicystic, radiolucent lesion, mostly in the region of the mandibular third molar Unicystic ameloblastomas Recurrent Ameloplastoma  Odontogenic myxoma Odontogenic myxoma is a rare, locally-aggressive benign tumour and manifests in the second to fourth decades of life. Clinically and radiologically, it closely resembles ameloblastoma. Myxomas occur more commonly in the mandible, with tooth-bearing area involved mostly. It appears as multilocular radiolucency with well- developed internal bony septae which may be lost as the lesion grows. Root resorption and teeth displacement may occur. Odontogenic myxoma  Osteoma An osteoma is a benign bone-forming tumour that almost always occurs in the skull and face. The common location in jaw includes the lingual side of the ramus or the inferior mandibular border below the molars. These lesions are usually asymptomatic and can occur at any age. Radiologically, an osteoma is seen as a well- defined,dense, radiopaque mass. osteoma  ‫األعران العظمية‬Torus Tori are exostosis »‫ «ضخامات‬in specific locations in the jaw and are named accordingly. Torus palatinus are nodular bony protuberances arising in the middle of the hard palate. Torus mandibularis are located on the lingual aspect of the mandible and usually bilateral. Torus Torus in mandible  Fibrous dysplasia FD is an idiopathic, nonheritable condition, in which normal bone is replaced with fibro-osseous tissue. FD mostly affects patients younger than 30 years of age, and may be a monostotic (70%) or polyostotic type (30%). Association of polyostotic FD with endocrine disorders and cutaneous hyperpigmentation is known as the McCune-Albright syndrome  It occurs more frequently in the maxilla than in the mandible. Radiographical changes range from lucent zones to diffuse areas of sclerosis, depending on amount of fibrous tissue and bony matrix. Craniofacial fibrous dysplasia. (a) Waters view radiograph shows expansion and radiopacity with a ground glass appearance of left maxillary sinus, nasal bone, frontal bone, zygomatic process and the left mandible (arrow). (b) Coronal CT image (bone window) shows osseous expansion, cortical thinning and areas of varying radiopacity reflecting the degree of maturation of fibrous tissue. ‫سوء تكون لٌفً عظمً‬  Osteogenic sarcoma Osteogenic sarcoma ‫ سرطان العظم‬is an osteoid- producing highly malignant tumour of the bone. Primary osteogenic sarcoma of the jaw is quite uncommon, with peak incidence between 30 and 39 years of age. Lesions can occur anywhere in jaw but the posterior part of the mandible is most commonly affected. Osteogenic sarcoma can cause lytic bone destruction with indefinite margins (osteolytictype), areas of sclerosis (osteoblastic type), or a mixed pattern. ‫النمط االنحاللً‬ ‫‪Osteo-sarcoma‬‬ Osteo-sarcoma  ‫التهاب عظم تكثفي‬ condensed Osteitis: caused by tooth inflammation or infection Condensed osteitis  Cementoblastoma If a radio-opaque lesion is periapical, the differential diagnosis includes : - cementoblastoma. - cemento-osseous dysplasia - condensing osteitis If it is pericoronal, odontoma should be considered.  Cementoblastoma, a rare benign periapical lesion, represents less than 1% of all odontogenic tumors. More than 75% of cementoblastomas occur in the mandible; of those, 90% develop in the molar or premolar region. Cementoblastomas are most common in children and young adults, with 50% occurring before age 20 and 75% occurring before age 30  At imaging, cementoblastomas appear as a periapical, sclerotic, sharply marginated lesion with a low-attenuation halo. They directly fuse to the root of the tooth.Some cementoblastomas may fuse to more than one tooth root or invade the root canal and pulp chamber.Management of cementoblastomas typically involves complete removal of the associated tooth to reduce the likelihood of recurrence.  Cemento-osseous Dysplasia Cemento-osseous dysplasia usually produces no symptoms, but it may cause a dull ache. Florid cemento-osseous dysplasia may be complicated by osteomyelitis and drainage of necrotic bone debris into the oral cavity or to the skin surface through osteocutaneous sinus tracts  Both cementoblastoma and cemento-osseous dysplasia are periapical, sclerotic, sharply marginated lesions with a low-attenuation halo. However, cementoblastoma occurs in children and young adults and fuses directly to the tooth root, whereas cemento-osseous dysplasia is more common among black women and women of Asian descent who are in the 4th or 5th decade of life and does not fuse to the tooth root. Cemento-osseous Dysplasia Cemento-osseous Dysplasia  Mixed Lytic and Sclerotic Lesions of the Jaw: Osteoradionecrosis Bisphosphonate-related osteonecrosis Mandibular osteomyelitis osteoradionecrosis Ameloblastic fibro-odontoma Ameloblastic fibro-odontoma Simple bone cyst  conditions causing generalised loss of lamina dura: Hyperparathyroidism and Paget’s disease. fibrous dysplasia osteomalacia multiple myeloma. osteoporosis. Pyle’s disease. Hypophosphatasia. renal osteodystrophy. leukemia. While thinning is seen in osteoporosis and Cushing’s syndrome  the conditions in which thickening of lamina dura is seen Local trauma from occlusion. Marked malposition or served as abutments for fixed bridges. Systemic hypoparathyroidism. bisphosphonate related osteonecrosis of jaw.  Simple Bone Cyst Simple bone cyst (SBC) is also known as solitary/traumatic/ hemorrhagic bone cyst. This is a pseudocyst with no epithelial lining. It is an uncommon cyst that is proposed to result from intramedullary hemorrhage from trauma which results in the formation of a cavity within the jaw. This is usually picked up incidentally in an asymptomatic individual, usually before 20 years of age and shows a female predominance. The typical location of SBC is the posterior mandible, where it is seen as a unilocular cyst that may have expansile, scalloped margins. It is seen to characteristically extend between the roots of adjacent teeth resulting in superior scalloped margins with preservation of lamina dura. Simple bone cyst  Alterations observed on panoramic radiographs that might compromise oral and general health Due to the broad coverage of panoramic radiographs, sometimes we can visualize some structures that affect more than the patient's oral health, but also general health. Many changes are asymptomatic and can be identified casually, as when the panoramic radiography is required for dental evaluation. Among them, there are the calcified stylohyoid complex, arterial calcifications and other soft tissue calcifications. 1- Calcified stylohyoid complex ‫تكلس الناتئ اإلبري‬ 2- Arterial calcifications ‫تكلس الشراٌٌن‬. 3- Sialolithiasis ‫حصٌات لعابٌة‬ 4- Phleboliths ‫تكلس األنسجة‬ 5- Tonsilloliths ‫الحصٌات اللوزٌة‬  Calcified stylohyoid complex. ‫ مم‬30-25 ‫ٌتراوح طول الناتئ اإلبري الطبٌعً بٌن‬ ‫ٌعتبر الناتئ متطاول أو متكلس عندما ٌتجاوز طوله المقدار‬.‫السابق‬ The literature reports that calcified styloid process is considered normal when it does not extend below the mandibular foramen. It is considered elongated when it extends below the mandibular foramen.  Causes: - local chronic irritations. - history of trauma. - endocrine disorders in female at menopause. - persistence of mesenchymal elements,bone tissue growth and mechanical stress or trauma during stylohyoid ligament development. Calcified stylohyoid complex  Digital panoramic radiography shows a thick calcified stylohyoid complex on the right side  Arterial calcifications t is considered a dystrophic calcification where there are deposited calcium salts in chronically inflamed or necrotic tissues. The presence of an atheromatous plaque in the extracranial carotid vascular path is the main cause for vasculocerebral embolism and obstructive diseases. Carotid artery atherosclerotic plaques develop when fatty substances, cholesterol, platelets, cellular waste products, and calcium are deposited in the lining of the artery.  Some risk factors for atherosclerosis are: diabetes mellitus, obesity, hypertension, smoking, inadequate diet, chronic kidney disease and menopause. Radiographically, calcified carotid atheroma is initially developed at the bifurcation of arteries, soft tissues of the neck, and adjacent to the greater horn of the hyoid bone and the cervical vertebrae C3 and C4 or the intervertebral space between them. They are radiopaque, usually multiple and irregularly shaped, with a vertical distribution and they have an internally heterogeneous radiopacity. Digital panoramic radiography with images suggesting the presence of atheroma on both sides  Sialolithiasis is the most common disease of the salivary glands characterized by obstruction of salivary secretion by a calculus, associated with swelling, pain and infection of the affected gland. a single sialolith in the right submandibular gland calcification in the right parotid gland and in its duct. calcifications in the right submandibular and parotid glands multiple microliths in the parotid gland on both sides  Phleboliths Phleboliths ‫ تكلس األنسجة‬are idiopathic calcification (or calcinosis) that results from deposition of calcium in the normal tissue. This calcification results from deposition of calcium in the normal tissue, despite normal serum levels of calcium and phosphate. Phleboliths are calcified thrombi found within vascular channels, often in the presence of hemangiomas or vascular malformations. multiple phleboliths on the right side  Tonsilloliths Tonsilloliths are calcifications within a tonsillar crypt, which involve primarily the palatine tonsil caused by dystrophic calcification as a result of chronic inflammation. multiple tonsilloliths in the lower one third of the mandibular ramus on both sides. CGCG CGCG: Central Giant Cell Granuloma