these are group of case reports collected from the published case reports , showing almost all types of inflammatory lesions of the jaws presented with different imaging modalities including conventional , CT , and MRI images
2. the inflammatory process is:
response of the body that aims to destroy the
injurious stimulus and repair the damaged
tissue
according to the source of the
infection which initiate the
inflammatory condition in the jaws ,
the inflammatory jaw lesions are
either:
3. Necrotic pulp when the lesion is
just confined around the root it is called
Periapical inflammatory lesion
Infection from the overlying
soft tissues Periodontal
lesions and Pericoronitis.
Infections spreads to bone
marrow Osteomyelitis
4. Radiation induced bone
changes ORN of the jaws
Chemicals induced bone
changes osteo-chemo-necrosis
of the jaws
5.
6. 27-year-old male patient
chief complaint :
swelling in the upper
front right region of the
mouth 1 month ago. He
had a history of trauma to
right upper anterior
region 12 years back
7. Clinical examination
Intraoral swelling in the
palatal region with respect
to right 1,2,3,4and a sinus
opening with respect to the
apex on buccal aspect of
right 2, 3, on palpation the
swelling was soft and
painful, the right 1,2,3 were
tender on percussion and
non vital
11. revealed fibrous
connective tissue which
was inflamed, dense
aggregate of chronic
inflammatory cells,
dilated and congested
blood vessels and
hemorrhagic foci, many
Russell bodies, and few
giant cells. No evidence
of epithelium was present
Periapical Granuloma
14. 34-year-old male
chief complaint discharging pus in the buccal
sulcus in anterior region.
The patient gave history of a childhood accident
with anterior tooth fracture, then root canal
treatment and crown fabrication for the affected
tooth
15. Clinical examination
a sinus discharging pus in the buccal
sulcus opposite to upper left central
incisor on palpation a mild firm
swelling was detected, mild pain on
percussion
16. Radiographic
examination
The periapical
radiograph showed an
adequate root canal
filling resulting in
periapical RL, that is
moderately defined,
with sclerosis of the
surrounding bone
21. 32 years old man
Chief complaint pus oozing in the lower
right posterior last molar making unpleasant
taste in the mouth, and foul odour, this
condition is persistent since 10 years or
more, with absence of the symptoms on
antibiotic taking , and then the condition re
appear again every while
However, no pain or trismus were found
22. Clinical examination
purple-blue color of the
gingiva covering the
occlusal surface and the
presence of a purulent
green fluid exuding from
under this gingiva, no pain
on palpation was elected ,
and no swelling was found
25. Tentative diagnosis
Chronic
pericoronitis
It was reached by exclusion of
other possible conditions, and
confirmed by the positive
response to the antibiotic
therapy, and complete resolve
after extraction of the wisdom
tooth
26. It deserve noting that when pericoronitis
left untreated it may lead to spread of
infection to either to:
The adjacent bone marrow spaces
causing Osteomylitis
Adjacent potential soft tissue spaces
(most commonly buccal space and sub
maseteric space) may cause just
inflammation in which and may lead to
abscess formation
27. 24 years old man
Chief complaint
Pain in the lower left posterior area, the
pain was radiating to the ears and
throat, the patient also complained
from trismus, and swelling in the
affected region
28. Clinical examination
On examination partially erupted
lower left wisdom was found,
The operculum covering it was
inflamed, and errythmatous and
it was painful on palpation
The submandibular lymph nods
were palabable and movable,
and the facial swelling was
noticeable and fluctuant on
palpation
31. Tentative diagnosis
Acute pericoronitis
It was reached by exclusion of
other possible conditions, and
confirmed by the positive
response to the antibiotic
therapy
And complete resolve after
extraction of the wisdom tooth
32.
33. I.Acute suppurative osteomyelitis
(rarefactional osteomyelitis)
II. Chronic suppurative osteomyelitis
(sclerosing osteomyelitis)
III. Chronic focal sclerosing osteomyelitis
IV. Chronic diffuse sclerosing osteomyelitis
V. Chronic osteomyelitis with proliferative
periostitis (Garre's Osteomylitiss)
VI. Specific osteomyelitis
1. Tuberculous osteomyelitis
2. Syphilitic osteomyelitis
3. Actinomycotic osteomyelitis
34. Osteomylitis in SAPHO syndrome
Chronic Recurrent Multifocal
Osteomyelitis (CRMO)
Both were not mentioned in any of the
classifications proposed for jaw
osteomylitis
35. 31 years old man
Chief complain: pain, trismus, and swelling in
mandibular right third molar region
No serious medical condition in medical HX
Clinical examination extra-oral examination revealed
a right facial swelling with a areas of fluctuation indicating
para-mandibular abscess
Intra oral examination revealed pericoronal inflammation in
the right and left lower wisdoms, with decayed erupted
part of the lower right wisdom
36.
37. Based on clinical and radiographic
findings a tentative diagnosis was
assumed of
Combined periapical, and
pericoronal infection with soft
tissue extension in to the
adjacent Para mandibular space
38. The treatment for the patient was
initiated 2 April 2002 with a 6-days
course of (I.V) penicillin 10 mega
once/day , and after 2 days of the
treatment the 4 wisdoms and the md lt
1st molar were removed surgically
under GA
On the day 8 after antibiotic the
patient complaint of pain and
increased swelling , a panoramic
radiograph and contrast enhanced CT
were made for the patient
39.
40. On day 12 abscess was formed in para
mandibular area with increased
swelling and fluctuant sensation on
palpation, so bacterial culture was
made and specific antibiotic for the
causative bacteria was given together
with extra-oral draing
On day 40 the abscess reoccur, so
panoramic radiograph was made,
followed by CT examination , microbial
culture and antibiotic giving together
with extra oral drainage
42. In the week starting from day 43-day
50 the patient was given 3 sessions of
hyperbaric oxygen
In the day 60 the facial swelling
reoccur, so CT ,and MRI examination
were made for the patient
43.
44. In the day 65 histological examination
of a biopsy from the lesion showed
that the lesion is
Secondary diffuse chronic
Osteomylitis
45. Finally partial resection of the
mandible with exarticulation
was performed and after that
the condition of the patient
was improved with
disappearance of the
symptoms
46. 47-year-old man
Chief complain dull pain in the cheek
and the buccal gingiva of the right
mandibular molar region for 2 weeks. He
complained of paralysis in the lower lip
from the day before admission
47. Clinical examination
On extra-oral examination mild facial
swelling on the affected site was
noticed, the swelling was soft on
palpation
On intra-oral examination no abnormal
finding could be detected only a
restored lower second molar was seen
Blood analysis showed increase ESR
50. The tentative diagnosis was
Acute Osteomylitis
Based on that the patient was given
broad spectrum antibiotic therapy
and all the symptoms disappeared,
the blood analysis was normal,
which confirm the diagnosis
51. 9-years old boy with a Chief complaint of
swelling of the left lower part of the face
and trismus
He gave a history of 5-month of
recurrent swelling of the left lower face
After extraction of the left lower second
deciduous molar, he underwent
administration of multiple courses of
antibiotics and curettage of the
mandibular lesion twice but these
treatments were not effective
52. Clinical examination
low-grade fever, left mandibular
swelling and trismus were found, but
his teeth and gingiva appeared normal
Blood analysis showed elevated levels
of ESR, and alkaline phosphatas
55. The histological findings of the
Biopsy leaded to a diagnosis of
Osteomyelitis
but microbiological culture of bone
fragments was negative
56. Because of severe enlargement and
deformity of the mandible with
intermingled sclerotic and osteolytic
lesions extending from the left
condyle to the right angle,
decortication of the mandible along
with hyperbaric oxygen therapy and
irrigation-perfusion treatment with
antibiotics, was performed
57. 2 years latter the patient came
complaining that the previous
treatments resulted in the transient
disappearance of symptoms, they
recurred repeatedly at variable
intervals, again the Histopathological
examination revealed the same result
as the previous biopsy, and
microbiological culture was negative
again, another CT examination for him
was made
58.
59. These findings led to the diagnosis of
Chronic diffuse
sclerosing
osteomyelitis
60. Another trial of treatment was conducted
using Bisphosphnat (pamidronate) I.V
infusion two doses were given separated
by 3 months and the conspicuous
improvement was brought about both
clinically and radiographically.
osteolytic changes of the mandible were
decreased, and reappearance of the
lamina dura and alveolar bone with
normal density were observed
61.
62.
63. however 3 months later, he noticed painful
swelling of the right upper arm
Bone scintigraphy was made which showed
slight uptake in the mandible and high
uptake in the right humerus
Open biopsy of the humerus revealed
Non-suppurative osteomyelitis,
At this point the diagnosis was
established of
Chronic recurrent multifocal
osteomyelitis (CRMO)
64. 45 years old female
Chief complaint multiple pus discharging
sinuses associated with pain in the upper
jaw
65. Clinical examination
there was generalized
mobility of all the
maxillary teeth,
associated with bone
exposure in the left
molar region on the
buccal aspect
Also multiple pus
discharging sinuses
were seen
69. Histopathologiy
An incisional biopsy and a culture test
were made, the diagnosis was
chronic suppurative
osteomyelitis
Culture showed the growth of
Staphylococcus organisms
70. the patient was kept
on antibiotic
coverage for 2
weeks, which
drastically improved
the condition
surgery was planned
under general
anesthesia to remove
the lesion totally as
the final treatment
71. 34 years old female was referred to the
department of oral and maxillofacial surgery by
her dental practitioner for extra examination of
the left maxillary sinus, as RO mass was found in
it in routine panoramic examination
The patient had no symptom in any teeth
Clinical examination
IO examination didn’t reveal any obvious decayed
tooth
EO examination didn’t show any swelling or
tenderness
72. The panoramic radiograph showed a focal RO
mass in the left maxillary sinus above the apex
of upper left 2nd molar, with diffuse sclerotic
change around the molar teeth
73. For more detailed examination, CT scan was made
It revealed high density mass lesion with an internal
low density area in the left maxillary sinus floor,
close to the apex of left upper 2nd molar
75. The decision was made to remove the lesion
completely than histopathological examination
of it will be made
76. Histopathological findings
Based on the histopathological findings the
lesion proved to be
Chronic focal sclerosing
osteomylitis
77. A 12-year-old male patient
Chief complaint of swelling on the
posterior region of the left mandible
Clinical examination the patient
report diffuse pain on palpation in the
affected area and lymphadenopathy,
though without evidence of
suppuration, the first molar in affected
area was badly decayed.
83. Histopathological examination
bone biopsy was performed and the
material was sent for histological
evaluation, the histological findings
together with the clinical, and
radiographic presentation confirmed
the diagnosis of
Garre’s osteomylitis
84. A 68-year-old woman was admitted to the
clinic in August 2010 with a 14-month history
of pain in the left side of the mandible.
One month after treatment of a chronic
apical lesion of the mandibular left canine in
October 2007, she developed pain in the left
side of the mandible. Mandibular
osteomyelitis was diagnosed by radiographic
and laboratory findings May 2008.
85. When she was 66 years old, psoriasis
developed on her dorsal, palmar, and
plantar skin.
There was no trismus or paresthesia of the
left side of the lower lip and chin on her first
visit to our clinic.
Clinical examination
Oral examination showed tooth loss from
the left first premolar to the left third molar
and no evidence of either mucosal or bone
lesions.
90. By correlating the skin lesion, the
radiographic findings of the patient,
and the bone scintigram, a
presumptive diagnosis was proposed
which is
SAPHO syndrome
91. After 4 months she experienced pain and
trismus. However, radiographic examination
showed development of inflammation in the
soft tissue around the left mandibular
condyle and resorption of condylar bone
93. After consultation with her physician, we
prescribed oral risedronate hydrate (2.5 mg
daily).
The patient showed no mandibular
symptoms 12 months after starting
conservative therapy
94. A 53 year-old, edentulous, African-American
woman came with a chief complaint of
swelling, pain, and purulent discharge involving
the region of the left lower mandible, The
drainage was described as white, thick, and with
bad odors
The pt complaint started 5 months ago, She was
treated with a chlorhexidine oral rinse and a two-week
course of oral levofloxacin but did not
improve
Then a biopsy performed approximately two
months after the onset of symptoms revealed
dead bone but no specific diagnosis
95. Two months later, the patient noted a
bone fragment erupting from the same
pus-draining ulcer, then the ulceration
and draing continued till the time of
presentation
She gave a history of longstanding
FCOD a condition shared with her
mother
She denied fevers, chills, night sweats
or other constitutional symptoms
96. Clinical examination
poorly-fitting mandibular denture was removed
and the alveolar tissues revealed slight
swelling along the anterior border of the
ramus with an area of exposed bone
measuring approximately 1 cm along the
external oblique ridge laterally
There was soft tissue edema and congestion in
this area.
No lymphadenopathy was found
98. CT scan image showing hypertrophic, sclerotic and
heterogeneous changes of FCOD within the mandible
(open arrow). There is a large lytic lesion in the body
of the left mandible with loss of bone at its lateral
aspect and central sclerosis consistent with infection
(solid arrow).
100. Histopathological, and
microbiological examination
the patient underwent debridement with bone
biopsy and cultures of the diseased left
mandibular ramus
bone biopsy revealed that the lesion is
Osteomylitis super imposed on
FCOD
Whereas the culture yielded
Actinomyces species along with a mixture of
oral anaerobic bacteria
101. Now based on clinical, radiographic,
histopathological, and microbiological
findings a final diagnosis was reached of
Actinomyces osteomyelitis
complicating FCOD
102. The patient was managed by
intravenous ertapenem one gram daily
for eight weeks
An additional 10 months of oral
therapy were instituted with
amoxicillin/clavulanic acid 675 mg
twice daily.
She responded well to antimicrobial
treatment with complete healing of her
operative site, and to date denies any
further pain, swelling, or drainage.
103.
104. 38 Y -female patient
Chief complaint : pain in the lower right
posterior jaw, the pain was insidious in
onset, continuous in nature, and radiated to
the right ear, The patient had restricted
mouth opening, And intermittent discharge
from the right ear over the past 5 years
The patient had a history of surgery and
radiotherapy in the same region for a low
grade mucoepidermoid carcinoma
105. clinical examination
• Bilatteral restriction in TMJ
motion
RT submandibular L.N was
palpable, enlarged, soft in
consistency, tender, and freely
movable
The skin over the angle of the
mandible had a desquamated
shiny appearance
Purulent discharge was noticed
in relation to the right external
auditory meatus.
the masseter and
sternomastoid muscles were
fibrosed
108. Based on the clinical findings,
radiological features, and history of
radiotherapy to the head and neck
region, a provisional diagnosis of
Osteoradionecrosis
N.B Examination by an otolaryngologist
revealed granulation of the tympanic
membrane exposing the tympanic plate and
necrosis of the overlying skin which was
the cause of pus discharge from the ear.
109. A 67-year-old woman with metastatic
breast cancer treated with pamidronate
and later zoledronate presented with
a chief complaint of pain and non-healing
extraction socket
Clinical examinnation didn’t reveal
any extra oral abnormal finding, no
swelling was found and the LN was
normal
113. Histopathological findings
the curettage specimen stained with
hematoxylin- eosin demonstrates
Ostenecrosis with inflammatory
cell infiltration
The lesion proved to be
Bisphosphonates induced
Osteonecrosis of jaws
114. NB : although suppurative
osteomyelitis (SO), bisphosphonate
induced osteonecrosis (BIONJ), and
osteoradionecrosis of the jaws (ORNJ)
all share a common finding of necrotic
bone with empty osteocytic lacunae,
Haversian and Volkmann canals, but
each showed a distinctive
histopathologic pattern indicating a
different disease mechanism and
treatment options
115. 61-year-old African American female was
diagnosed with left breast cancer with
multiple bone and liver metastases in April
2009, she was treated with chemotherapy
and intravenous bisphosphonate therapy
On a follow up bone scan multiple bone
metastasis were found, and a foci of
increased radiotracer activity in the left
mandibular angle was noticed,
Radiological interpretation suggested that
this focus most likely represented either
severe dental disease or a metastatic focus.
117. Few months later, the patient developed
severe pain in her mandible, dental
evaluation led to a tooth extraction
However, following the extraction, the
patient’s jaw pain progressed with
worsened swelling of the left lower jaw
The patient underwent CT examination for
the lower jaw , followed by new bone scan
118. The CT scan
demonstrates
thickening of the
mandibular body
This was thought to
represent metastatic
disease.
119. Technetium 99m
Bone scintigraphy
demonstrated
expansion of the
mandibular lesion
(thought to be
metastatic disease).
and slight
progression of the
multiple other skeletal
metastases.
120. referral was made to radiation
oncology due to worsening jaw pain
unresponsive to narcotic medications
and imaging findings suggestive of
ametastasis
She underwent RT to her jaw lesion
However, after the RT, the patient’s jaw
pain continued to worsen.
Despite negative blood and bone
cultures, she received courses of
cephalexin and clindamycin, for a
presumed jaw infection with no
improvement
121. Repeat CT scan of the mandible showed
changes along the external and internal surface
of the mandible with production of new bone
along the body extending to the mandibular
angle
122. Since there was no therapeutic response, a
bone biopsy of the mandibular lesion was
obtained , it revealed :
no evidence of metastatic disease
Instead necrotic bone with non viable
osteoclast was dtected
123. In light of the pathology , bone scan and CT
findings together with lack of clinical
response, the diagnosis was now felt to be
most consistent with
Bisphosphonates induced
Osteonecrosis of jaws
Hinweis der Redaktion
IOP showing well defined RL related to upeer central lateral and acanine,
The case underwent root canal ttt followed by surgical removal of the lesion with lesion enoculation and apicectomy, the biobsy was taken
Periapical radiograph of upper left central incisor showing an area of radiolucency around the root with well defined margins. There is an inadequate root filling in the same tooth.
T1 axial image showing shows a distinct circular area of slightly lower signal than surrounding marrow around the root apex of the upper left central incisor. There is no cortical bone on the labial aspect of the root surface, which is at the level of the discharging sinus as ascertained clinically. There is a thick black line of low signal on the
palatal aspect that indicates sclerosis and thickening of the palatal cortex of the dentoalveolar ridge, probably
in response to the chronic infection, STIR) sequenceshows a mottled grey appearance of mixed signal from the
same area, indicating high water content in the lesion. This heterogeneity, and the moderate signal on T1
weighted imaging, is not typical of a simple cyst but of chronic infection
and expansion of the buccal coronal follicular space (arrow). (b) Coronal CT image obtained with soft-tissue window settings in the same patient shows an adjacent abscess in the masticator space (arrows). Streak artifact from dental amalgam extends through the abscess.
Panoramic radiograph showing pericoronitis in the 4 wisdoms
On panorama no thing abnormal except the dry socket of the lower lt six
CT showing Swelling in the maseter and latteral pterygoid muscles without abcess
The ramous and condylar process showed moth eaten appearance due to of normal trabecular pattern
CT shows partial bony resorbtion of the condylar head, periosteal new bone formation on the latteral cortex of the ramus, contrast enhanced MRI show contrast enhanced soft tissue swellung
Panoramic tomography and computed tomographic image did not show any change of the cancellous and cortical bone in the right mandibular molar region
On the next day, MRI examination was done. C, The T1-weighted image showed a low SI area in the molar to ramus region of
the right mandible (arrow). D, The STIR image showed an extremely high SI area in the same region (arrow).
(CT) revealed widespread periosteal bone formation and cortical bone resorption from the left mandibular ramus to the right premolar region, together with thickening of the overlying soft tissues.
Axial CT scans before the first pamidronate infusion showing advanced osteolytic changes in the sclerotic lesions extending to the bilateral condylar processes of the mandible (arrowheads)
Orthopantomogram (OPG) was advised, which showed areas of bone loss in the maxilla around the teeth from first molar of one side to the first molar of the other side
CT scan [Figure 4] of the patient revealed osteolytic destruction of the maxilla on both sides of the midline.
Hyperplastic lymph node
showing a ground-glass appearance (yellow arrows) from the left premolar to the mandibular ramus region and enlarged canals of the left mandible (red arrow).
showed enlarged canals of the left mandible and increased density of cancellous bone, which seemed to be reactive bone remodeling
T2-weighted imagesThe left side of the ascending ramus of the mandible shows heterogeneous intermediate-to-high signal intensity
showing extremely intense tracer uptake in the left side of the mandible, the sternum, and the sternocostal and sternoclavicular joints
CT and MRI at 4-month follow-up after the first visit: (A) plain CT showing diffuse cortical bone resorption of the left condyle of the mandible; (B) MRI, with the left condyle of the mandible in part showing low-high signal intensity on a T1-weighted image; (C) MRI, with soft tissue around the left side of the ascending
ramus of the mandible showing heterogeneous high-signal intensity on a fatsuppressed T2-weighted image.
6 Bone scintigram 6 months after administration of antibiotics. Note: Radioisotope uptake in the left mandible is unchanged, while radioisotope uptake in the sternum and in the sternocostal and sternoclavicular joints is increased, compared with the images of the first visit.
An intraoral examination could not be performed due to restricted mouth opening
Orthopantamogram showing patchy radiopaque-radiolucent areas in the region of right body and ramus of the mandible. There was discontinuity in the right lower border of the mandible near the angle region. A retained root stump was also observed in the same region (B) Right lateral oblique view shrowing extension of lesion into the ramus.
showed fluid in the right mandible within the marrow and multiple cortical breaks There was diffuse infiltrative edema in the right masticator space. T1 Axial magnetic resonance imaging section showing (A) fluid within marrow with multiple cortical breaks, T2 marrow edema around right condylar head
The orthopantomogram demonstrates the nonhealing extraction socket in the right posterior mandible (*) with sclerosis in the adjacent body and ramus of the mandible (arrow) and generalized thickening of the lamina dura in the mandible (arrowhead) and maxilla, Axial CT demonstrates the osseous sclerosis, as well as narrowing the mandibular canal (*), thin periosteal new bone anteriorly (arrow) and generalized thickening of the lamina dura
in the mandible (arrowhead
Tc99m-HDP bone scan demonstrates increased radiotracer uptake in the right hemimandible corresponding with the area of sclerosis,
howed diffuse thickening of the body of the right mandible and
the entire left mandible to the condyle (Fig 4). Lytic lesions appeared
throughout the mandible except for the right ramus and
condyle.
