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Dental RadiographicDental Radiographic Interpretation
Inflammatory jaw lesions
Dr. Ossama EL-Shall
Chairman of Oral Medicine,Chairman of Oral Medicine,
Periodontology, Diagnosis & RadiologyPeriodontology, Diagnosis & Radiology
Department, Faculty of Dental MedicineDepartment, Faculty of Dental Medicine
for girls, Al-Azhar University, Cairofor girls, Al-Azhar University, Cairo
Egypt.Egypt.
E.mail address: oelshall@hotmail.comE.mail address: oelshall@hotmail.com
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Inflammatory jaw lesionsInflammatory jaw lesions
- They are the most common- They are the most common
pathologic conditions of thepathologic conditions of the
jaws.jaws.
- Usually due to infected pulp- Usually due to infected pulp
or periodontal infectionor periodontal infection
- Also it may occurs due to- Also it may occurs due to
trauma or hematologicaltrauma or hematological
diseasedisease
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General Radiographic featuresGeneral Radiographic features
Location:Location:
PeriapicallyPeriapically
Alveolar crestAlveolar crest
Mandibular areaMandibular area
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Changes inside the lesion:Changes inside the lesion:
RL in cases of abscess cyst granulomaRL in cases of abscess cyst granuloma
RO condensing osteitisRO condensing osteitis
RL + RORL + RO
Effects on the surroundingEffects on the surrounding
structures:structures:
1-May cause expansion, resorption, destruction or thinning of bone.
2-Compressed adjacent tissues as max. sinus or nasal cavity
3-Displacement of teeth, divergence or resorption.
4-Affection of lamina dura.
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Periapical Inflamatory LesionsPeriapical Inflamatory Lesions
Bone destruction around apexBone destruction around apex
of tooth, mostly secondaryof tooth, mostly secondary
to pulp exposure due toto pulp exposure due to
caries or trauma.caries or trauma.
Bacterial invasion of pulpBacterial invasion of pulp
produces toxic metabolitesproduces toxic metabolites
which escape to thewhich escape to the
periapical bone throughperiapical bone through
apical foramen and causeapical foramen and cause
inflammation.inflammation.
9. Apical periodontitisApical periodontitis
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It may be acute or chronic
The acute form having no radiographic changes, only
clinical manifestations as tender tooth to palpation
and pain on biting
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Periapical inflammatory lesions.Periapical inflammatory lesions.
Periapical abscessPeriapical abscess
Ill defined RL area, widening of PM space,
loss of LD
13. Periapical abscessPeriapical abscess
Acute: sever throbbingAcute: sever throbbing
pain, tooth mobility,pain, tooth mobility,
tenderness, swelling,tenderness, swelling,
elevation of the toothelevation of the tooth
Chronic: history ofChronic: history of
acute case,acute case,
asymptomatic, fistula,asymptomatic, fistula,
dull paindull pain
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It is a localizedIt is a localized
collection of pus atcollection of pus at
periapical areaperiapical area
It may be acute orIt may be acute or
chronicchronic
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Periapical GranulomaPeriapical Granuloma
Radiographically,Radiographically,
widening of PDL orwidening of PDL or
variable size ofvariable size of
periapical RL may beperiapical RL may be
presentpresent
Loss of lamina duraLoss of lamina dura
AsymptomaticAsymptomatic
Non vital toothNon vital tooth
History of sensitivityHistory of sensitivity
to hotto hot
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Radicular cystsRadicular cysts
It developed around apexIt developed around apex
of a diseases tooth orof a diseases tooth or
around an accessoryaround an accessory
canal from the pulpcanal from the pulp
(lateral radicular cyst)(lateral radicular cyst)
The radiographicThe radiographic
appearance of aappearance of a
clinically symptom-freeclinically symptom-free
cyst reveals a clear, ROcyst reveals a clear, RO
borders that surroundborders that surround
the radiolucency.the radiolucency.
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Radicular cystsRadicular cysts
Rounded RL with RORounded RL with RO
margin at periapicalmargin at periapical
region.region.
Apex of the tooth isApex of the tooth is
within the cystic cavity.within the cystic cavity.
Adjacent teeth andAdjacent teeth and
structures are displaced.structures are displaced.
Infected cysts exhibitsInfected cysts exhibits
poorly demarcatedpoorly demarcated
bordersborders
Small, clinically symptom-Small, clinically symptom-
free radicular cyst that isfree radicular cyst that is
expanding towards the floorexpanding towards the floor
of maxillary sinusof maxillary sinus
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Small, symptomSmall, symptom
free radicular cystfree radicular cyst
with typical ROwith typical RO
boundariesboundaries
Infected radicular cyst, hasInfected radicular cyst, has
lost its typical radiographiclost its typical radiographic
signs as a result of seroussigns as a result of serous
infiltration of theinfiltration of the
surrounding tissue.surrounding tissue.
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This infected radicular cystThis infected radicular cyst
arising from second premolararising from second premolar
and displaces the floor ofand displaces the floor of
maxillary sinusmaxillary sinus
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Atypical manifestation of a
radicular cyst
-This cyst emanates from
the remaining root of
lower canine
-The radiograph showing
a multi-locular pattern
-This picture may
misdiagnosed as
ameloblastoma or
keratocyst
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Radicular maxillary cyst extending from
central and lateral incisors.
The cyst expanded in horizontal plane, which
is clear in the occlusal view.
From the panoramic view we can notice its
relation to max.sinus.
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Lateral Periodontal CystLateral Periodontal Cyst
Arises directly fromArises directly from
epithelial cells inepithelial cells in
PDL on lateral aspectPDL on lateral aspect
of tooth. Origin: cellof tooth. Origin: cell
rests of Mallasez orrests of Mallasez or
remnants of dentalremnants of dental
lamina.lamina.
Tooth is VITAL.Tooth is VITAL.
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Lateral Periodontal CystLateral Periodontal Cyst
How do youHow do you
differentiate this cystdifferentiate this cyst
from radicular cystfrom radicular cyst
which may develop inwhich may develop in
this location?this location?
Seen as a unilocular,Seen as a unilocular,
well-definedwell-defined
radiolucency on lateralradiolucency on lateral
aspect of a vitalaspect of a vital
tooth.tooth.
36. 2- Pericoronitis2- Pericoronitis
Inflammation of theInflammation of the
gingival tissues aroundgingival tissues around
the crown of the tooththe crown of the tooth
Associated with thirdAssociated with third
molarmolar
No radiographicNo radiographic
changes, but may bechanges, but may be
found in sever caseafound in sever casea
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37. 3- Osteomyelitis3- Osteomyelitis
The word “osteomyelitis” originates from the ancient GreekThe word “osteomyelitis” originates from the ancient Greek
words osteon (bone) and muelinos (marrow) and means infectionwords osteon (bone) and muelinos (marrow) and means infection
of medullary portion of the bone.of medullary portion of the bone.
It is an acute & chronic inflammatory process in the medullaryIt is an acute & chronic inflammatory process in the medullary
spaces or cortical surfaces of bone that extends away from thespaces or cortical surfaces of bone that extends away from the
initial site of involvement.initial site of involvement.
It is the inflammation of the bone as a result of spread ofIt is the inflammation of the bone as a result of spread of
inflammatory process to involve bone marrow, cortex cancellousinflammatory process to involve bone marrow, cortex cancellous
parts and periosteumparts and periosteum
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41. ONSET OF
DISEASE 4 WEEKS
Acute suppurative
osteomyelitis
Chronic suppurative
osteomyelitis
Onset of disease:
Deep bacterial invasion into medullary & cortical bone
Suppurative osteomyelitisSuppurative osteomyelitis
42. Suppurative osteomyelitisSuppurative osteomyelitis
Source of infection is usually an adjacent focus of infection
associated with teeth or with local trauma.
It is a polymicrobial infection, predominating anaerobes such
as Bacteriods, Porphyromonas or Provetella.
Staphylococci may be a cause when an open fracture is
involved.
panoramic
radiograph of
suppurative
osteomyelitis at the
right side of mandible.
43. ACUTE SUPPURATIVE OSTEOMYELITIS
Organisms entry into the jaw, mostly mandible, compromising the vascular supply
Medullary infection spreads through marrow spaces
Thrombosis in vessels leading to extensive necrosis of bone
Lacunae empty of osteocytes but filled with pus , proliferate in the dead tissue
Suppurative inflammation extend through the cortical bone to involve the
periosteum
Stripping of periosteum comprises blood supply to cortical plate, predispose to
further bone necrosis
Sequestrum is formed bathed in pus, separated from surrounding vital bone
44. Acute suppurative osteomyelitis
CLINICAL FEATURES
EARLY :
Severe throbbing, deep- seated
pain.
Swelling due to inflammatory
edema.
Gingiva appears red, swollen &
tender.
LATE :
Distension of periosteum with pus.
FINAL:
Subperiosteal bone formation cause
swelling to become firm.
45. Acute suppurative osteomyelitisAcute suppurative osteomyelitis
Radiographic featuers
May be normal in early stages of disease .
Do not appear until after at least 10 days.
After sufficient bone
resorption irregular, mot-
eaten areas of radiolucency
may appear.
Radiograph may demonstrate
ill-defined radiolucency.
47. CHRONIC SUPPURATIVE OSTEOMYELITIS
Inadequate treatment of acute osteomyelitis
Periodontal diseases, Pulpal infections, Extraction wounds
Infected fractures
Infection in the medulllary spaces spread and form granulation
tissue
Granulation tissue forms dense scar to wall off the infected area
Encircled dead space acts as a reserviour for bacteria & antibiotics
have great difficulty reaching the site
49. CHRONIC SUPPURATIVE OSTEOMYELITIS
RADIOLOGY
Patchy, ragged & ill defined radiolucency.
Often contains radiopaque sequestra.
• Sequestra lying close to
the peripheral sclerosis
& lower border.
• New bone formation is
evident below lower
border.
52. FOCAL SCLEROSING OSTEOMYELITIS
Also known as “Condensing
osteitis”.
Localized areas of bone sclerosis.
Bony reaction to low-grade peri-
apical infection or unusually strong host defensive
response.
54. RADIOLOGY
Localized but uniform increased RO related to
tooth.
Widened periodontal ligament space or peri-
apical area.
Sometimes an adjacent radiolucent inflammatory
lesion may be present.
FOCAL SCLEROSING OSTEOMYELITISFOCAL SCLEROSING OSTEOMYELITIS
Increased areas of
radiodensity
surrounding
apices of nonvital
mandibular first
molar
58. DIFFUSE SCLEROSING OSTEOMYELITIS
It is an ill-defined, highly
controversial type of osteomyelitis.
Bone metabolism tipped toward
increased bone formation.
59. RADIOLOGY
Increased radiodensity may be seen
surrounding areas of lesion.
DIFFUSE SCLEROSING OSTEOMYELITIS
Diffuse area of
increased
radiodensity
of Rt. Side of
mandible
63. Proliferative periosteitis
Also known as “ Periostitis ossificans” &
“Garee’s osteomyelitis”.
It represents a periosteal reaction to the
presence of inflammation.
64. ““Garee’s osteomyelitis”.Garee’s osteomyelitis”.
CLINICAL FEATURES
Affected patients are
primarily children & young adults.
Incidence is mean age
of 13 years.
No sex predominance
is noted.
Most cases arise in the
premolar & molar area of mandible.
Hyperplasia is located
most commonly along lower border
of mandible.
Most cases are uni-
focal, multiple quadrants may be
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Radiolucent lesionsRadiolucent lesions
1-1-Lesions related to tooth apexLesions related to tooth apex
2-2-Lesions related to side of rootsLesions related to side of roots
3-3-Lesions related to crown of unerupted orLesions related to crown of unerupted or
impacted toothimpacted tooth
4-4-Unilocular lesions in midline of maxilla.Unilocular lesions in midline of maxilla.
5-5-Unilocular lesions lateral to midline of maxilla.Unilocular lesions lateral to midline of maxilla.
6-6-Solitary RL lesion with either well or ill- definedSolitary RL lesion with either well or ill- defined
margins.margins.
7-7-Multilocular RL lesion with either well or ill-Multilocular RL lesion with either well or ill-
defined margins.defined margins.
8-8-Multiple but separate RL with well-defined orMultiple but separate RL with well-defined or
punched out marginspunched out margins
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2-2-Radiolucent lesions related toRadiolucent lesions related to
sides of roots:sides of roots:
1- Lateral periodontal cyst1- Lateral periodontal cyst
2- Periodontal abscess.2- Periodontal abscess.
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3-3-Lesions related to crown ofLesions related to crown of
unerupted or impacted toothunerupted or impacted tooth
Pericoronal R.L, uni or multilocularPericoronal R.L, uni or multilocular
A-Pericoronal or follicular space.A-Pericoronal or follicular space.
B-Dentigerous cyst.B-Dentigerous cyst.
C-AmeloblastomaC-Ameloblastoma
D-Odontogenic keratocyst.D-Odontogenic keratocyst.
E-Odontogenic fibroma.E-Odontogenic fibroma.
F-Odontogenic myxoma.F-Odontogenic myxoma.
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4-4-RL lesions in the midline of maxilla.RL lesions in the midline of maxilla.
1-Median palatine cyst.1-Median palatine cyst.
2-Incisive canal cyst.2-Incisive canal cyst.
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5-5-RL lesions lateral to midline ofRL lesions lateral to midline of
maxilla.maxilla.
1- Globulomaxillary cyst1- Globulomaxillary cyst
2- Residual cyst of any type2- Residual cyst of any type
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6-6-Solitary R.L lesions with either wellSolitary R.L lesions with either well
or ill-defined margins and notor ill-defined margins and not
necessarily containing teeth.necessarily containing teeth.
Well-defined marginWell-defined margin
1-Residual cyst1-Residual cyst
2-Traumatic bone cyst2-Traumatic bone cyst
3-Primordial cyst3-Primordial cyst
4-Odontogenic keratocyst4-Odontogenic keratocyst
5- Ameloblastoma5- Ameloblastoma
6-Central giant cell6-Central giant cell
granulomagranuloma
7-Central odontogenic7-Central odontogenic
fibromafibroma
Ill-defined marginIll-defined margin
1-Residual infection1-Residual infection
2-bone loss due to PD2-bone loss due to PD
3-Myloma3-Myloma
4-carcinoma4-carcinoma
5-Ameloplastoma5-Ameloplastoma
6-metastasis6-metastasis
7-osteomylitis7-osteomylitis
8-odontoenic fibroma8-odontoenic fibroma
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77-Multilocular RL lesion with either well-Multilocular RL lesion with either well
or ill-defined margins.or ill-defined margins.
Well-definedWell-defined
1-Ameloblastoma1-Ameloblastoma
2-Odontogenic keratocyst2-Odontogenic keratocyst
3-Central g. cell granuloma3-Central g. cell granuloma
4-Odontogenic myxoma4-Odontogenic myxoma
5-Central hemangioma5-Central hemangioma
6-Fibrous dysplasia6-Fibrous dysplasia
7-Cherubism7-Cherubism
8-Anneyrsmal bone cyst8-Anneyrsmal bone cyst
9-Central fibroma9-Central fibroma
10-Traumatic bone cyst10-Traumatic bone cyst
Ill-definedIll-defined
1-Ameloblastoma (late stage)1-Ameloblastoma (late stage)
2-Central myxoma (late stage)2-Central myxoma (late stage)
3-Fibrous dysplasia3-Fibrous dysplasia
4-Cherubism4-Cherubism
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8-8- Multiple but separate RL with well-Multiple but separate RL with well-
defined or punched out marginsdefined or punched out margins
Well-defined marginWell-defined margin
1-Multible myloma.1-Multible myloma.
2-Metastatic carcinoma2-Metastatic carcinoma
3-Histocytosis-X3-Histocytosis-X
4-Cherubism4-Cherubism
Punched out marginsPunched out margins
1-Multible myloma1-Multible myloma
2-Metastatic carcinoma2-Metastatic carcinoma
3-Histocytosis-X3-Histocytosis-X
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2-2-SolitarySolitary R.O lesions notR.O lesions not
contacting teethcontacting teeth
1- All the above item (Periapical R.O)1- All the above item (Periapical R.O)
8-Osteoma8-Osteoma
9-Salivary gland stone9-Salivary gland stone
10-Osteomlitis10-Osteomlitis
11-Remeaning root11-Remeaning root
12-Unerupted tooth12-Unerupted tooth
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3-3-MultipleMultiple separate radio-separate radio-
opacities.opacities.
1-All the first item1-All the first item
8-Paget’s disease8-Paget’s disease
9-Osteogenic sarcoma9-Osteogenic sarcoma
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Most common lesions as seen inMost common lesions as seen in
dental radiographsdental radiographs
1-1- Inflammatory lesions.Inflammatory lesions.
2-2-Cysts and pseudocystsCysts and pseudocysts
3-3- Odontogenic tumors.Odontogenic tumors.
4-4- Non Odontogenic tumors.Non Odontogenic tumors.
5-5- Developmental anomalies of teeth.Developmental anomalies of teeth.
6-6- Foreign bodies.Foreign bodies.
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Cysts affecting oral cavityCysts affecting oral cavity
Cyst;Cyst; is a pathological cavity contains fluid oris a pathological cavity contains fluid or
semi-solid materialssemi-solid materials
Cysts can be true or pseudo according its lining tissues:Cysts can be true or pseudo according its lining tissues:
True cysts:True cysts: cysts which lined with epitheliumcysts which lined with epithelium
Pseudo-cysts:Pseudo-cysts: cysts whichcysts which notnot lined withlined with
epithelium but lined with connective tissueepithelium but lined with connective tissue
membranemembrane
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Classification of true Cysts of interest toClassification of true Cysts of interest to
the dentistthe dentist
I- Odontogenic cystsI- Odontogenic cysts
1-1-Radicular cysts….Radicular cysts…. a-a- Apical…..Apical….. b-b- LateralLateral
2-2-Periodontal cystsPeriodontal cysts
3-3-Odontogenic Keratocysts.Odontogenic Keratocysts.
4-4-DentigerousDentigerous cystcyst
5-5-Residual cysts of all typesResidual cysts of all types..
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III. PseudocystsIII. Pseudocysts
(not lining with epithelial)(not lining with epithelial)
Traumatic bone cyst.Traumatic bone cyst.
Aneurysmal bone cyst.Aneurysmal bone cyst.
Latent bone cyst.Latent bone cyst.
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Radicular cystsRadicular cysts
It developed around apexIt developed around apex
of a diseases tooth orof a diseases tooth or
around an accessory canalaround an accessory canal
from the pulp (lateralfrom the pulp (lateral
radicular cyst)radicular cyst)
The radiographicThe radiographic
appearance of a clinicallyappearance of a clinically
symptom-free cyst revealssymptom-free cyst reveals
a clear,a clear, RORO borders thatborders that
surround the radiolucency.surround the radiolucency.
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Radicular cystsRadicular cysts
RoundedRounded RLRL withwith RORO
margin at periapicalmargin at periapical
region.region.
Apex of the toothApex of the tooth isis withinwithin
the cystic cavity.the cystic cavity.
Adjacent teeth andAdjacent teeth and
structures are displaced.structures are displaced.
Infected cysts exhibitsInfected cysts exhibits
poorly demarcatedpoorly demarcated
bordersborders
Small, clinically symptom-Small, clinically symptom-
free radicular cyst that isfree radicular cyst that is
expanding towards the floorexpanding towards the floor
of maxillary sinusof maxillary sinus
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Small, symptomSmall, symptom
free radicular cystfree radicular cyst
with typical ROwith typical RO
boundariesboundaries
Infected radicular cyst, hasInfected radicular cyst, has
lost its typical radiographiclost its typical radiographic
signs as a result of seroussigns as a result of serous
infiltration of theinfiltration of the
surrounding tissue.surrounding tissue.
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This infected radicular cystThis infected radicular cyst
arising from second premolararising from second premolar
and displaces the floor ofand displaces the floor of
maxillary sinusmaxillary sinus
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Atypical manifestation of a
radicular cyst
-This cyst emanates from
the remaining root of
lower canine
-The radiograph showing
a multi-locular pattern
-This picture may
misdiagnosed as
ameloblastoma or
keratocyst
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Residual cyst
Residual cyst, May developed following partial
removal of any odontogenic cyst.
It may be found after extraction of a tooth with
radicular cyst
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Dentigerous cystDentigerous cyst
Most common site,Most common site,
around the third molararound the third molar
and the midline of theand the midline of the
maxillamaxilla
Radiographically itRadiographically it
appears as wellappears as well
demarcated unilocular,demarcated unilocular,
radiolucent area,radiolucent area,
surrounding a crown ofsurrounding a crown of
unerupted tooth.unerupted tooth.
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It is usually attached to the crown at CEJIt is usually attached to the crown at CEJ
It may appears lateral to the crown.It may appears lateral to the crown.
It may displace the affected tooth from its locationIt may displace the affected tooth from its location
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Dentigerous Cyst (Follicular Cyst)Dentigerous Cyst (Follicular Cyst)
Always associatedAlways associated
with crown of anwith crown of an
impacted orimpacted or
unerupted (normal orunerupted (normal or
supernumerary) tooth.supernumerary) tooth.
Due to accumulationDue to accumulation
of fluid betweenof fluid between
layers of reducedlayers of reduced
enamel epithelium orenamel epithelium or
between epitheliumbetween epithelium
and crown.and crown.
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Coronal Dentigerous cyst surrounding lateralCoronal Dentigerous cyst surrounding lateral
incisor with displaced of canine and retention ofincisor with displaced of canine and retention of
deciduous canine.deciduous canine.
Tooth 22 appears enlarged and overexposed.Tooth 22 appears enlarged and overexposed.
Tooth 23 is displaced in the vistibular direction.Tooth 23 is displaced in the vistibular direction.
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Eruption cyst on upper 8 as seen in Periapical film
It is a type of Dentigerous cysts developed after the
formation of dental hard tissues from the enamel
epithelium
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Odontogenic KeratocystOdontogenic Keratocyst
Originate before tooth development from a remnantsOriginate before tooth development from a remnants
of epithelium has the capacity to produce keratin.of epithelium has the capacity to produce keratin.
it appears asit appears as unilocularunilocular oror multilocularmultilocular well-definedwell-defined
RL lesion with an ability for root divergence andRL lesion with an ability for root divergence and
cortical expansion both buccal & lingual.cortical expansion both buccal & lingual.
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Odontogenic Keratocyst (OKC)Odontogenic Keratocyst (OKC)
Most common site is mandibleMost common site is mandible
Can cause severe bone destruction.Can cause severe bone destruction.
Can displace teeth and cause rootCan displace teeth and cause root
resorption.resorption.
Should be followed for recurrence for 5-10Should be followed for recurrence for 5-10
years.years.
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Lateral Periodontal CystLateral Periodontal Cyst
Arises directly fromArises directly from
epithelial cells in PDLepithelial cells in PDL
on lateral aspect ofon lateral aspect of
tooth.tooth.
Origin: cell rests ofOrigin: cell rests of
Mallasez or remnantsMallasez or remnants
of dental lamina.of dental lamina.
Tooth is VITAL.Tooth is VITAL.
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Lateral Periodontal CystLateral Periodontal Cyst
How do youHow do you
differentiate this cystdifferentiate this cyst
from radicular cystfrom radicular cyst
which may develop inwhich may develop in
this location?this location?
Seen as a unilocular,Seen as a unilocular,
well-definedwell-defined
radiolucency onradiolucency on
lateral aspect of alateral aspect of a
vital tooth.vital tooth.
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Or incisive canal cyst, Or
anterior maxillary cyst
It forms in incisive canal, causing
swelling of incisive papilla
It may enlarge and extend posteriorly,
where it called Median palatine cyst
It may extend anteriorly, between
central incisors, diverge them and
destroy the labial cortical plate,
(median alveolar cyst)
Nasopalatine cyst
125. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 125125
Nasopalatine cystNasopalatine cyst
Nasopalatine cyst in an earlyNasopalatine cyst in an early
stagestage
It developed between the rootsIt developed between the roots
of two central incisors, forcingof two central incisors, forcing
them apart.them apart.
126. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 126126
Typical nasopalatine cyst as seen in a panoramicTypical nasopalatine cyst as seen in a panoramic
radiograph.radiograph.
It appears as a typical heart-shape withoutIt appears as a typical heart-shape without
displacement of roots of central incisorsdisplacement of roots of central incisors
129. Nasoalveolar cystNasoalveolar cyst
Soft tissue cystSoft tissue cyst
Swelling of nasolabial fold in the noseSwelling of nasolabial fold in the nose
Flaring the ala of the noseFlaring the ala of the nose
03/15/1603/15/16 Ossama El-ShallOssama El-Shall 129129
130. Symphyseal area of the mandibleSymphyseal area of the mandible
Well defined RL area.Well defined RL area.
Divergence of the rootsDivergence of the roots
Vital teeth with intact LDVital teeth with intact LD
03/15/1603/15/16 Ossama El-ShallOssama El-Shall 130130
Median mandibular cystMedian mandibular cyst
131. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 131131
Traumatic bone cystTraumatic bone cyst
PseudocystsPseudocysts
Usually affect mandibleUsually affect mandible
Well or ill defined RLWell or ill defined RL
areaarea
Scalloped outlinesScalloped outlines
Displaced of the rootsDisplaced of the roots
133. Aneurysmal bone cystAneurysmal bone cyst
Premolar molar areas of mandiblePremolar molar areas of mandible
Well defined RL area, smooth outlinesWell defined RL area, smooth outlines
Thining of inferior border of the mandibleThining of inferior border of the mandible
Soab bubble appearanceSoab bubble appearance
03/15/1603/15/16 Ossama El-ShallOssama El-Shall 133133
134. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 134134
Developmental Lingual Mandibular SalivaryDevelopmental Lingual Mandibular Salivary
Gland Depression (Gland Depression (Latent bone cyst)Latent bone cyst)
Other names: Stafne’s defect, Stafne’s cyst,Other names: Stafne’s defect, Stafne’s cyst,
static bone cavity, latent bone cyst.static bone cavity, latent bone cyst.
Part of submandibular salivary glandPart of submandibular salivary gland
develops or lies in a deep, well-defineddevelops or lies in a deep, well-defined
depression on lingual surface of mandible.depression on lingual surface of mandible.
Occasionally, glandular tissue may beOccasionally, glandular tissue may be
included centrally within the bone.included centrally within the bone.
135. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 135135
Developmental Lingual MandibularDevelopmental Lingual Mandibular
Salivary Gland Depression (Cont.)Salivary Gland Depression (Cont.)
Radiographically, seen asRadiographically, seen as
a well-defineda well-defined
radiolucency near lowerradiolucency near lower
border and angle ofborder and angle of
mandible, below themandible, below the
inferior alveolar canal.inferior alveolar canal.
Patients arePatients are
asymptomatic; discoveredasymptomatic; discovered
during routineduring routine
radiographic exam.radiographic exam.
May be unilateral orMay be unilateral or
bilateral.bilateral.
142. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 142142
Radiolucent lesionsRadiolucent lesions
1-1-Lesions related to tooth apexLesions related to tooth apex
2-2-Lesions related to side of rootsLesions related to side of roots
3-3-Lesions related to crown of unerupted orLesions related to crown of unerupted or
impacted toothimpacted tooth
4-4-Unilocular lesions in midline of maxilla.Unilocular lesions in midline of maxilla.
5-5-Unilocular lesions lateral to midline of maxilla.Unilocular lesions lateral to midline of maxilla.
6-6-Solitary RL lesion with either well or ill- definedSolitary RL lesion with either well or ill- defined
margins.margins.
7-7-Multilocular RL lesion with either well or ill-Multilocular RL lesion with either well or ill-
defined margins.defined margins.
8-8-Multiple but separate RL with well-defined orMultiple but separate RL with well-defined or
punched out marginspunched out margins
144. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 144144
2-2-Radiolucent lesions related toRadiolucent lesions related to
sides of roots:sides of roots:
1- Lateral periodontal cyst1- Lateral periodontal cyst
2- Periodontal abscess.2- Periodontal abscess.
145. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 145145
3-3-Lesions related to crown ofLesions related to crown of
unerupted or impacted toothunerupted or impacted tooth
Pericoronal R.L, uni or multilocularPericoronal R.L, uni or multilocular
A-Pericoronal or follicular space.A-Pericoronal or follicular space.
B-Dentigerous cyst.B-Dentigerous cyst.
C-AmeloblastomaC-Ameloblastoma
D-Odontogenic keratocyst.D-Odontogenic keratocyst.
E-Odontogenic fibroma.E-Odontogenic fibroma.
F-Odontogenic myxoma.F-Odontogenic myxoma.
146. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 146146
4-4-RL lesions in the midline of maxilla.RL lesions in the midline of maxilla.
1-Median palatine cyst.1-Median palatine cyst.
2-Incisive canal cyst.2-Incisive canal cyst.
147. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 147147
5-5-RL lesions lateral to midline ofRL lesions lateral to midline of
maxilla.maxilla.
1- Globulomaxillary cyst1- Globulomaxillary cyst
2- Residual cyst of any type2- Residual cyst of any type
148. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 148148
6-6-Solitary R.L lesions with either wellSolitary R.L lesions with either well
or ill-defined margins and notor ill-defined margins and not
necessarily containing teeth.necessarily containing teeth.
Well-defined marginWell-defined margin
1-Residual cyst1-Residual cyst
2-Traumatic bone cyst2-Traumatic bone cyst
3-Primordial cyst3-Primordial cyst
4-Odontogenic keratocyst4-Odontogenic keratocyst
5- Ameloblastoma5- Ameloblastoma
6-Central giant cell6-Central giant cell
granulomagranuloma
7-Central odontogenic7-Central odontogenic
fibromafibroma
Ill-defined marginIll-defined margin
1-Residual infection1-Residual infection
2-bone loss due to PD2-bone loss due to PD
3-Myloma3-Myloma
4-carcinoma4-carcinoma
5-Ameloplastoma5-Ameloplastoma
6-metastasis6-metastasis
7-osteomylitis7-osteomylitis
8-odontoenic fibroma8-odontoenic fibroma
149. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 149149
77-Multilocular RL lesion with either well-Multilocular RL lesion with either well
or ill-defined margins.or ill-defined margins.
Well-definedWell-defined
1-Ameloblastoma1-Ameloblastoma
2-Odontogenic keratocyst2-Odontogenic keratocyst
3-Central g. cell granuloma3-Central g. cell granuloma
4-Odontogenic myxoma4-Odontogenic myxoma
5-Central hemangioma5-Central hemangioma
6-Fibrous dysplasia6-Fibrous dysplasia
7-Cherubism7-Cherubism
8-Anneyrsmal bone cyst8-Anneyrsmal bone cyst
9-Central fibroma9-Central fibroma
10-Traumatic bone cyst10-Traumatic bone cyst
Ill-definedIll-defined
1-Ameloblastoma (late stage)1-Ameloblastoma (late stage)
2-Central myxoma (late stage)2-Central myxoma (late stage)
3-Fibrous dysplasia3-Fibrous dysplasia
4-Cherubism4-Cherubism
150. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 150150
8-8- Multiple but separate RL with well-Multiple but separate RL with well-
defined or punched out marginsdefined or punched out margins
Well-defined marginWell-defined margin
1-Multible myloma.1-Multible myloma.
2-Metastatic carcinoma2-Metastatic carcinoma
3-Histocytosis-X3-Histocytosis-X
4-Cherubism4-Cherubism
Punched out marginsPunched out margins
1-Multible myloma1-Multible myloma
2-Metastatic carcinoma2-Metastatic carcinoma
3-Histocytosis-X3-Histocytosis-X
154. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 154154
2-2-SolitarySolitary R.O lesions notR.O lesions not
contacting teethcontacting teeth
1- All the above item (Periapical R.O)1- All the above item (Periapical R.O)
8-Osteoma8-Osteoma
9-Salivary gland stone9-Salivary gland stone
10-Osteomlitis10-Osteomlitis
11-Remeaning root11-Remeaning root
12-Unerupted tooth12-Unerupted tooth
155. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 155155
3-3-MultipleMultiple separate radio-separate radio-
opacities.opacities.
1-All the first item1-All the first item
8-Paget’s disease8-Paget’s disease
9-Osteogenic sarcoma9-Osteogenic sarcoma
163. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 163163
Odontogenic TumorsOdontogenic Tumors
They develops as neoplasias from the dental
lamina. They are usually benign but several
of them have the tendency towards
malignant transformation.
Because growth occurs only slowly,
asymptomatically and without any changes
in mucosal appearance,
The existence of such lesions in their early
stages is usually detected only by chance, or
after the development of some structural
deformation.
164. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 164164
AmeloblastomaAmeloblastoma
Benign but locally invasive neoplasm.Benign but locally invasive neoplasm.
Arises from epithelial remnants of dentalArises from epithelial remnants of dental
lamina or dental organ.lamina or dental organ.
Cells do not differentiate enough to formCells do not differentiate enough to form
enamel.enamel.
Extreme expansion of bone,Extreme expansion of bone,
Resorption of adjoining roots.Resorption of adjoining roots.
May cause perforation of cortical bone.May cause perforation of cortical bone.
Average age at discovery: 35-40 years.Average age at discovery: 35-40 years.
166. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 166166
Ameloblastoma (Cont.)Ameloblastoma (Cont.)
Occasionally develops in the wall ofOccasionally develops in the wall of
dentigerous cyst (mural Ameloblatoma).dentigerous cyst (mural Ameloblatoma).
80% in mandible. ¾ of these in molar-80% in mandible. ¾ of these in molar-
ramus area.ramus area.
Pain and paresthesia not common.Pain and paresthesia not common.
Extremely high recurrence rate.Extremely high recurrence rate.
167. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 167167
Ameloblastoma (Cont.)Ameloblastoma (Cont.)
Most often a well-corticated multilocularMost often a well-corticated multilocular
radiolucency.radiolucency.
““Honey-comb”, “soap-bubble” or “tennis-racket”Honey-comb”, “soap-bubble” or “tennis-racket”
appearance.appearance.
May be a well-corticated unilocular lesionMay be a well-corticated unilocular lesion
resembling a cyst.resembling a cyst.
HoneyHoney
comb-like smallcomb-like small
ameloblastoma atameloblastoma at
early stage withearly stage with
evidence of rootevidence of root
resorption.resorption.
168. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 168168
Ameloblastoma
Ameloblastoma at the
angle of the mandible.
Expansive form with
oval RL traversed by
few very thin septa
170. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 170170
Ameloblastoma
Large multilocular soap bubble appearance.
Typically located in the molar region, angle of the
mandible and ascending ramus
Thin not penetrated cortical plate.
Impacted or neighboring teeth are displaced with
roots often resorped.
171. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 171171
Ameloblastoma in early stages with lobularAmeloblastoma in early stages with lobular
patternpattern
177. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 177177
Ameloblastic fibromaAmeloblastic fibroma
Appears as a follecularAppears as a follecular
cystic cavitycystic cavity
surrounding a crown ofsurrounding a crown of
a tooth.a tooth.
In early stages appearsIn early stages appears
as a hat upon theas a hat upon the
occlusal surface ofocclusal surface of
affected toothaffected tooth
178. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 178178
Most common site, lower premolar molar region
Well defined RL, may be corticated, unilocular or
sometimes multilocular
Inhibition of eruption of involved tooth or displaced
apically
179. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 179179
More advanced case of ameloblastic fibroma
demonstrates how the follicular sac is opened.
Note also the displacement of the tooth bud of
lower 8 in the ascending ramus.
180. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 180180
Odontogenic myxomaOdontogenic myxoma
It is a benign, mucous-It is a benign, mucous-
containing tumor thatcontaining tumor that
originates from the toothoriginates from the tooth
bud.bud.
It appears as a soapIt appears as a soap
bubble-like appearance.bubble-like appearance.
Cyst like unilocular orCyst like unilocular or
multilocular with mantmultilocular with mant
septa giving tennis racketsepta giving tennis racket
apperancapperanc
It cause toothIt cause tooth
displacementdisplacement
183. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 183183
CementomaCementoma
Usually appears at lowerUsually appears at lower
anterior area.anterior area.
First appears as fibrousFirst appears as fibrous
tissue stage, which maytissue stage, which may
confused with aconfused with a
granuloma (vitality test).granuloma (vitality test).
The second stage isThe second stage is
characterized withcharacterized with
accumulation of calcifiedaccumulation of calcified
materials.materials.
The third stage consists ofThe third stage consists of
radio-opaque materials.radio-opaque materials. Early stageEarly stage
187. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 187187
CementoblastomaCementoblastoma
( True Cementoma )( True Cementoma )
Slow growing neoplasmSlow growing neoplasm
composed of cementum.composed of cementum.
Usually solitary lesionUsually solitary lesion
seen as a growth onseen as a growth on
root of tooth.root of tooth.
Most common inMost common in
mandible, premolar ormandible, premolar or
11stst
molar (80%).molar (80%).
188. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 188188
Cementoblastoma
Appears as a wellAppears as a well
defined RO areadefined RO area
with a thin RL bandwith a thin RL band
around itaround it
May cause externalMay cause external
root resorptionroot resorption
189. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 189189
Cementoblastoma
It not removed after
tooth extraction
Remarks the RL
related to canine and
second premolar, it is
another
cementoblastoma in
the fibrous stage.
190. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 190190
Cementoblastoma
Another case
remaining after tooth
extraction.
It surrounded by the
radiographic signs of
chronic inflammation.
Periapical cemental
dysplasia related to 4
tooth
191. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 191191
Odontoma
Most common sites
Tumor characterized by
production of enamel, dentin, cementum
and pulp tissue
198. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 198198
Compound Composite OdontomaCompound Composite Odontoma
Composed of enamelComposed of enamel
and dentin.and dentin.
Enamel and dentinEnamel and dentin
are laid down in anare laid down in an
orderly fashion soorderly fashion so
that the mass hasthat the mass has
some similarity tosome similarity to
normal teeth.normal teeth.
Appears like a bunchAppears like a bunch
of small teeth.of small teeth.
200. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 200200
Osteoma
Central Osteoma at the mental area
Symptomless lesion
Mandible is more
affected post area
Compact bone
205. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 205205
Central HemangiomaCentral Hemangioma
Tumor characterized byTumor characterized by
proliferation of bloodproliferation of blood
vessels.vessels.
Central hemangiomas ofCentral hemangiomas of
jaws uncommon.jaws uncommon.
50% occur in children50% occur in children
and teens.and teens.
More common in femalesMore common in females
and mandible.and mandible.
Well-defined or ill-Well-defined or ill-
defined, unilocular ordefined, unilocular or
multilocular radiolucency.multilocular radiolucency.
206. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 206206
Central Hemangioma (Cont.)Central Hemangioma (Cont.)
May cause expansion of bone andMay cause expansion of bone and
resorption of teeth.resorption of teeth.
Early treatment is desirable in orderEarly treatment is desirable in order
to avoid profuse bleeding due toto avoid profuse bleeding due to
accidental trauma. Aspiration prior toaccidental trauma. Aspiration prior to
surgical procedure is advised.surgical procedure is advised.
210. Benign tumorsBenign tumors
Growth of new tissues resemble tGrowth of new tissues resemble t
the originthe origin
Growth by direct extensionGrowth by direct extension
Insidious onsetInsidious onset
Rl + RO, Well defined bordersRl + RO, Well defined borders
Tooth displacement, or rootTooth displacement, or root
resorptionresorption
Expansion or thinning of corticalExpansion or thinning of cortical
bonebone
No metastasisNo metastasis
Not life thearatingNot life thearating
03/15/1603/15/16 Ossama El-ShallOssama El-Shall 210210
Malignant tumorsMalignant tumors
Growth a newGrowth a new
tissue with anaplasiatissue with anaplasia
Growth byGrowth by
infiltration and destructioninfiltration and destruction
Sudden onsetSudden onset
Totally RL, IllTotally RL, Ill
defined bordersdefined borders
Punched outPunched out
bordersborders
Destruction ofDestruction of
alveolar bone, teeth floating oralveolar bone, teeth floating or
displaced occlusallydisplaced occlusally
Erosion andErosion and
destruction of cortical bonedestruction of cortical bone
211. Radiographic features of malignantRadiographic features of malignant
tumorstumors
Ill defined, invasive borders.Ill defined, invasive borders.
Bone destructionBone destruction
Destruction of cortical boundary like floor of Max.sinusDestruction of cortical boundary like floor of Max.sinus
Irregular thickening of periodontal membrane spaceIrregular thickening of periodontal membrane space
due to invasion of bonedue to invasion of bone
Displacing the developing teeth in occlusal direction.Displacing the developing teeth in occlusal direction.
Bone destruction around teeth make teeth like floatingBone destruction around teeth make teeth like floating
in spacein space
03/15/1603/15/16 Ossama El-ShallOssama El-Shall 211211
212. Radiographic features of malignant tumorsRadiographic features of malignant tumors
03/15/1603/15/16 Ossama El-ShallOssama El-Shall 212212
213. Clinical features of malignant tumorsClinical features of malignant tumors
Displaced teeth,Displaced teeth,
Looseness of teeth in short timeLooseness of teeth in short time
Ulcers unhealed for more than 3 monthsUlcers unhealed for more than 3 months
Foul odorFoul odor
Fixed lymphadenopathyFixed lymphadenopathy
Exposure of boneExposure of bone
Sever painSever pain
SwellingSwelling
03/15/1603/15/16 Ossama El-ShallOssama El-Shall 213213
214. Classification of malignant tumorsClassification of malignant tumors
CarcinomaCarcinoma, Lateral border of tongue, lip floor of mouth, soft palate, Lateral border of tongue, lip floor of mouth, soft palate
SarcomaSarcoma
OsteosarcomaOsteosarcoma
Hematopoietic systemHematopoietic system
Multiple myelomaMultiple myeloma
03/15/1603/15/16 Ossama El-ShallOssama El-Shall 214214
215. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 215215
Osteosarcoma
This tumor, which affects males twice as
females, exhibit a predilection for the
mandible.
Radiographically, bone destruction as well as
new bone formation (Osteoblastic) and
osteolysis can be observed, along with
perforation of the compact bone with
spicules (sunrays effect), where the lesion
borders on the soft tissues
216. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 216216
Osteosarcoma
Ill defined border, RL Appears as irregular
areas of osteolysis and new osteoblastic
bone formation at the extraction site of
lower 6.
217. Radiographic appearanceRadiographic appearance
Appears ill defined RL Or combined Rl +Appears ill defined RL Or combined Rl +
RO, area with no peripheral sclerosisRO, area with no peripheral sclerosis
If it involve periosteum, it give Sunray orIf it involve periosteum, it give Sunray or
Hair-on-end speculate appearance, due toHair-on-end speculate appearance, due to
radiating mineralized speculateradiating mineralized speculate
Widening of periodontal membrane spaceWidening of periodontal membrane space
Loss of lamina duraLoss of lamina dura
Floating teethFloating teeth
03/15/1603/15/16 Ossama El-ShallOssama El-Shall 217217
218. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 218218
Mixed form of ostiosarcoma: In addition
to areas of new bone formation, osteolysis
and destruction of the compact bone can be
observed. Note the areas of spicules
(arrows) and spontaneous fracture (arrow)
222. Multiple mylomaMultiple myloma
03/15/1603/15/16 Ossama El-ShallOssama El-Shall 222222
Malignant fatal neoplasm of plasma cells
Long bone more then jaws (2%)
Mandible more than maxilla
Well defined RL area not corticated, appears punched out
Teeth may appears floating
224. 03/15/1603/15/16 Ossama El-ShallOssama El-Shall 224224
Thank you all for listening
Dr. Ossama El-Shall
Chairman of Oral Medicine & Periodontology
department, Faculty of Dental Medicine for
girls, Al-Azhar University, Cairo, Egypt.
E-mail address: oelshall@hotmail.com
