3 radioraphic anatomy&interpretation part ii

05/19/1605/19/16 Ossama El-ShallOssama El-Shall 11
Dental RadiographicDental Radiographic anatomy &
Interpretation
Part II
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

Radiographically, lesions may classifiedRadiographically, lesions may classified
into:into:
I-I- Radiolucent lesionsRadiolucent lesions
II-II- Radioopaque lesionsRadioopaque lesions
III-III- Combination of RL + RO. lesions.Combination of RL + RO. lesions.

Radiolucent lesionsRadiolucent lesions

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

1-1- Radiolucent lesions related toRadiolucent lesions related to
tooth apex:tooth apex:
A- Periapical cystA- Periapical cyst
B- Periapical granulomaB- Periapical granuloma
C- Periapical abscessC- Periapical abscess
D- Periapical periodontitisD- Periapical periodontitis
E- Periapical cementoma. (early stage)E- Periapical cementoma. (early stage)
F- Periapical scarF- Periapical scar

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.

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.

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.

5-5-RL lesions lateral to midline ofRL lesions lateral to midline of
maxilla.maxilla.
1- Globulomaxillary cyst1- Globulomaxillary cyst
2- Residual cyst2- Residual cyst

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

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 (late2-Central myxoma (late
stage)stage)
3-Fibrous dysplasia3-Fibrous dysplasia

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
Punched out marginsPunched out margins
1-Multible myloma1-Multible myloma
2-Metastatic carcinoma2-Metastatic carcinoma
3-Histocytosis-X3-Histocytosis-X

Radio-opaque lesionsRadio-opaque lesions

Radio-opaque lesionsRadio-opaque lesions
1-1-Periapical solitary radio-opaque lesionsPeriapical solitary radio-opaque lesions
2-2-Solitary R.O lesions not contacting teethSolitary R.O lesions not contacting teeth
3-3-Multiple separate radio-opacities.Multiple separate radio-opacities.
4-4-Generalized radio-opacities.Generalized radio-opacities.

1-1-Periapical solitary radio-opaquePeriapical solitary radio-opaque
lesionslesions
1-Condesing osteitis1-Condesing osteitis
2-Sclerosing bone2-Sclerosing bone
3-Periapical cementoma (late stage)3-Periapical cementoma (late stage)
4-Odontoma4-Odontoma
5-supernumerary unerupted tooth5-supernumerary unerupted tooth
6-Hypercementosis6-Hypercementosis
7-forign body.7-forign body.

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

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

4-4-Generalized radio-opacitiesGeneralized radio-opacities
2-osteopetrosis2-osteopetrosis

Combined RL & RO lesionsCombined RL & RO lesions

Combined RL & RO lesionsCombined RL & RO lesions
1-1-Mixed Periapical lesionsMixed Periapical lesions
2-2-Mixed lesions not necessarilyMixed lesions not necessarily
contacting a tooth.contacting a tooth.
3-3-Pericoronal mixed lesions.Pericoronal mixed lesions.

1-1-Mixed Periapical lesionsMixed Periapical lesions
1-Cementoma1-Cementoma
2-Sclerosing osteitis2-Sclerosing osteitis
4-Ossifying or cementifying fibroma4-Ossifying or cementifying fibroma

2-2-Mixed lesions not necessarilyMixed lesions not necessarily
contacting a tooth.contacting a tooth.
1-Ostemylitis1-Ostemylitis
2-F.D2-F.D
4-Ossifying or cementifying fibroma4-Ossifying or cementifying fibroma
5-Sarcoma5-Sarcoma
6-calcifying cyst6-calcifying cyst
8-Cementoma8-Cementoma

3-3-Pericoronal mixed lesions.Pericoronal mixed lesions.
2-Calcifying Odontogenic tumor2-Calcifying Odontogenic tumor
3-calcifying cyst3-calcifying cyst
4-Odontogenic fibroma4-Odontogenic fibroma

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.

Periapical inflammatory lesions.Periapical inflammatory lesions.
Ill defined RL area, widening of PM space,
loss of LD

Periapical Inflamatory LesionsPeriapical Inflamatory Lesions
Bone destruction around apexBone destruction around apex
of tooth, mostly secondary toof tooth, mostly secondary to
pulp exposure due to cariespulp exposure due to caries
or trauma.or trauma.
Bacterial invasion of pulpBacterial invasion of pulp
produces toxic metabolitesproduces toxic metabolites
which escape to thewhich escape to the
periapical bone through apicalperiapical bone through apical
foramen and causeforamen and cause
inflammation. The followinginflammation. The following
may occur:may occur:

Periapical Inflamatory LesionsPeriapical Inflamatory Lesions
Periapical granuloma:Periapical granuloma:
Localized mass ofLocalized mass of
chronic granulation tissuechronic granulation tissue
containing PMN’s,containing PMN’s,
lymphocytes, plasmalymphocytes, plasma
cells.cells.

Periapical GranulomaPeriapical Granuloma
Radiographically,Radiographically,
widening of PDL orwidening of PDL or
variable size ofvariable size of
periapicalperiapical
radiolucency mayradiolucency may
be presentbe present

Periapical GranulomaPeriapical Granuloma

Periapical Granuloma??Periapical Granuloma??

Apical periodontitis.Apical periodontitis.

05/19/1605/19/16 Ossama El-ShallOssama El-Shall

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 liningCysts can be true or pseudo according its lining
tissues: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

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-Primordial cysts (Before formation of hard toothPrimordial cysts (Before formation of hard tooth
structures)structures)
4-4-Keratocysts.Keratocysts.
5-5-DentigerousDentigerous cystcyst
-Follicular cyst-Follicular cyst
- Eruption cysts.- Eruption cysts.
- Coronal cysts.- Coronal cysts.
-Lateral cysts.-Lateral cysts.
6-6-Residual cysts of all typesResidual cysts of all types..

II- Non-odontogenic cysts.II- Non-odontogenic cysts.
Fissural cystsFissural cysts
1- Median palatine cyst.1- Median palatine cyst.
2- Nasoalveolar cyst2- Nasoalveolar cyst
3- Globulomaxillary cyst3- Globulomaxillary cyst
4- Median mandibular4- Median mandibular
cyst.cyst.
Non-fissural cystsNon-fissural cysts
1- Nasopalatine cysts1- Nasopalatine cysts
2- Median alveolar cyst2- Median alveolar cyst

PseudocystsPseudocysts
(not lining with epithelial)(not lining with epithelial)
Solitary bone cyst.Solitary bone cyst.
Aneurysmal bone cyst.Aneurysmal bone cyst.
Latent bone cyst.Latent bone cyst.

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.

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

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.

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

Typical manifestationTypical manifestation
of radiclar cystof radiclar cyst
Infected radiclar cystInfected radiclar cyst

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

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.

Radicular residual cyst
Notes the relation to
max. sinus

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.

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.

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 multilocularmultilocular well-defined RL lesion withwell-defined RL lesion with
an ability for root divergence and cortical expansion.an ability for root divergence and cortical expansion.

Odontogenic Keratocyst (OKC)Odontogenic Keratocyst (OKC)
Can cause severe bone destruction.Can cause severe bone destruction.
Can displace teeth and cause root resorption.Can displace teeth and cause root resorption.
Should be followed for recurrence for 5-10 years.Should be followed for recurrence for 5-10 years.

Odontogenic Keratocyst (OKC)Odontogenic Keratocyst (OKC)

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.

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.

Lateral Dentigerous cyst on lower third
molar

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.

Enlarged Dentigerous cystEnlarged Dentigerous cyst

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

Nonodontogenic cystsNonodontogenic cysts
Nasopalatine cyst
Median palatal cystMedian palatal cyst
Globulomaxillary cystGlobulomaxillary cyst

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

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.

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

Nasopalatine cyst

Differential diagnosis of periapical inflammatoryDifferential diagnosis of periapical inflammatory
lesionlesion
Periapical cemental dysplasiaPeriapical cemental dysplasia
Periapical scarPeriapical scar
Traumatic bone cystTraumatic bone cyst
Central giant cell granulomaCentral giant cell granuloma

Failure apicectomy successful apicectomy

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

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

FactorsFactors predisposingpredisposing toto
osteomyelitisosteomyelitis
LOCAL
FACTORS
(decreased
vascularity/vitality of
bone)
Trauma.
Radiation
injury.
Paget’s
disease.
Osteoporosis.
Major vessel
disease.
SYSTEMIC
FACTORS
(impaired host defense)
Immunedeficie
ncy states.
Immunosuppr
ession
Diabetes
mellitus.
Malnutrition.
Extremes of
age.

types of osteomyelitistypes of osteomyelitis

SUPPURATIVE
OSTEOMYELITIS

ONSET OF
DISEASE 4 WEEKS
Acute suppurative
osteomyelitis
Chronic suppurative
osteomyelitis
Onset of disease:
Deep bacterial invasion into medullary & cortical bone
Suppurative osteomyelitisSuppurative osteomyelitis

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.

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

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.

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.

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

CHRONIC SUPPURATIVE
OSTEOMYELITIS
CAL FEATURES
Swelling
Intermittent Pain
Sinus formation
Purulent discharge
Sequestrum formation
Tooth loss
Pathologic fracture

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.

CHRONIC SUPPURATIVE
OSTEOMYELITIS
Sequestra

FOCAL SCLEROSING OSTEOMYELITIS

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.

FOCAL SCLEROSING OSTEOMYELITISFOCAL SCLEROSING OSTEOMYELITIS
CLINICAL FEATURES
Children & young adults are affected.

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.
Increased areas of
radiodensity
surrounding
apices of nonvital
mandibular first
molar

DIFFUSE SCLEROSING OSTEOMYELITIS

It is an ill-defined, highly
controversial type of osteomyelitis.
Bone metabolism tipped toward
increased bone formation.

RADIOLOGY
Increased radiodensity may be seen
surrounding areas of lesion.
Diffuse area of
increased
radiodensity
of Rt. Side of
mandible

DIFFUSE SCLEROSING
OSTEOMYELITIS

Proliferative periosteitis
“ Periostitis ossificans”
“Garee’s osteomyelitis”.

Proliferative periosteitis
Also known as “ Periostitis ossificans” &
“Garee’s osteomyelitis”.
It represents a periosteal reaction to the
presence of inflammation.

““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

PROLIFERATIVEPROLIFERATIVE PERIOSTITIS
RADIOLOGY
Radiopaque
laminations of bone
roughly parallel each other
& underlying cortical
surface.
Laminations
may vary from 1-12 in

PROLIFERATIVE PERIOSTITIS

OsteoradionecrosisOsteoradionecrosis
-It is the inflammatory condition occurs in bone after the
bone has been exposed to therapeutic dose of radiation
- Infection or trauma are necessary
- mandible more affected

OsteoradionecrosisOsteoradionecrosis

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.

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.

Most common sites of
ameloblastoma
80%
20%

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.

Ameloblastoma (Cont.)Ameloblastoma (Cont.)
Most often a well-corticatedMost often a well-corticated
multilocular radiolucency.multilocular radiolucency.
““Honey-comb”, “soap-bubble” or “tennis-Honey-comb”, “soap-bubble” or “tennis-
racket” appearance.racket” appearance.
May be a well-corticated unilocularMay be a well-corticated unilocular
lesion resembling a cyst.lesion resembling a cyst.

Ameloblastoma
Ameloblastoma at the
angle of the mandible.
Expansive form with
oval RL traversed by
few very thin septa

Ameloblastoma
Soap-like form of
ameloblastoma of the
molar region.

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.

Large ameloblastoma in the right ascending
ramus of the mandible

Honeycomb-like small ameloblastoma atHoneycomb-like small ameloblastoma at
early stage with evidence of root resorption.early stage with evidence of root resorption.

Ameloblastic fibromaAmeloblastic fibroma
Appears as a follecularAppears as a follecular
cystic cavitycystic cavity
surrounding a crownsurrounding a crown
of a tooth.of 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

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.

Odontogenic myxomaOdontogenic myxoma
It is a benign, mucous-It is a benign, mucous-
containing tumor thatcontaining tumor that
originates from theoriginates from the
tooth bud.tooth bud.
It appears as a soapIt appears as a soap
bubble-likebubble-like
appearance.appearance.

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

R.LR.L R.L+R.OR.L+R.O

Periapical
cemental dysplasia

CementoblastomaCementoblastoma
( True Cementoma )( True Cementoma )
Slow growingSlow growing
neoplasm composedneoplasm composed
of cementum.of cementum.
Usually solitaryUsually solitary
lesion seen as alesion seen as a
growth on root ofgrowth on root of
tooth. Most commontooth. Most common
in mandible,in mandible,
premolar or 1premolar or 1stst
molarmolar
(80%).(80%).

Cementoblastoma
It not removed after
tooth extraction
Remarks the RL
related to canine and
second premolar, it is
another
cementoblastoma in
the fibrous stage.

Cementoblastoma
Another case
remaining after tooth
extraction.
It surrounded by the
radiographic signs of
chronic inflammation.
Periapical cemental
dysplasia related to 4
tooth

Odontoma
Most common sites

OdontomaOdontoma
Complex typeComplex type

OdontomaOdontoma
Intermediate typeIntermediate type

Compound Composite OdontomaCompound Composite Odontoma

Non-Odontogenic Tumors,
Granulomatous and
Osteofibrous lesions of the jaws.

Central giant cell granuloma.
Ossifying fibroma
Fibrous dysplasia.
Osteoma.
Osteoblastoma.
Exostosis & Enostosis.
Osteoporosis.
Osteogenesis imperfecta.
Eosinophilic granuloma.
Hemangioma.

Central giant cell granuloma
Or Central Reparative Giant cell Granuloma,
this type of granuloma grows expansively
within the bone and occurs more frequently
in female under age of 25 than in males.
It characterized by asymptomatic swelling of
the affected jaw that is manifested by facial
asymmetry

Radiographically appears as isolated or
multilocular radiolucences that are sharply
demarcated & exhibit soap-bubble like
structures with lobulated margin. It may
cause thinning of cortical plate
DD:
1- Ameloblastoma. It difficult to differentiate.
2- Eosinopilic granuloma.
3- Odontogenic cyst.
4- Aneurysmal & solitary bone cyst.

Most common sites of central giant cell
granuloma (dark) and peripheral giant cell
granuloma (Light)

Central Giant Cell Granuloma
With its characteristic appearance of soap-bubble
appearance which can confused as ameloblastoma
Note that the Periapical view cannot provide an
overview of the lesion extension

The impacted ankylosed
canine and displacement
of the teeth may indicate
a signs of follicular cyst.
The fine septa and soap-
bubble like contour
resemble Ameloblastoma
Central Giant Cell Granuloma

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.

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.

Malignant tumors
Sarcoma
Carcinoma.
Metastasis.

Sarcoma
This tumor, which affects males twice as
females, exhibit a predilection for the
mandible.
Radiographically, bone destruction as well as
new bone formation and osteolysis can be
observed, along with perforation of the
compact bone with spicules (sunrays
effect), where the lesion borders on the
soft tissues

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

3 radioraphic anatomy&interpretation part ii

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