Radiographic Differential Diagnosis 2008

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Oral Diagnosis II
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Radiographic Differential Diagnosis 2008

  1. 1. Radiographic differentialRadiographic differential diagnosis of common oraldiagnosis of common oral diseasesdiseases Dr. Suresh.C.S. BDS; MDS; MDSc (UK)Dr. Suresh.C.S. BDS; MDS; MDSc (UK) College of Dentistry, KFU,College of Dentistry, KFU, Dammam, KSA.Dammam, KSA.
  2. 2. ClassificationClassification - Anatomical- Radiolucent; Radiopaque.Anatomical- Radiolucent; Radiopaque. - PathologicalPathological - Radiolucent –- Radiolucent – unilocular/multilocularunilocular/multilocular - Radiopaque- Radiopaque - Mixed- Mixed ------ Solitary / Multiple.------ Solitary / Multiple.
  3. 3. Classification-pathologicalClassification-pathological RadiolucentRadiolucent – Contacting tooth– Contacting tooth - Not contacting tooth- Not contacting tooth MixedMixed – Contacting tooth– Contacting tooth - Not contacting tooth- Not contacting tooth RadiopaqueRadiopaque – Contacting tooth– Contacting tooth - Not contacting tooth- Not contacting tooth
  4. 4. Classification-pathologicalClassification-pathological Radiolucent – Contacting toothRadiolucent – Contacting tooth 1. Periapical1. Periapical - Usually sequelae of pulpitis.- Usually sequelae of pulpitis. Periapical granuloma; Radicular cyst; Abcess;Periapical granuloma; Radicular cyst; Abcess; Osteomyelitis, Periapical cementoma.Osteomyelitis, Periapical cementoma. 2.2. PericoronalPericoronal Follicular spaces; Dentigerous cysts; Ameloblastoma;Follicular spaces; Dentigerous cysts; Ameloblastoma; Adeno ameloblastoma.Adeno ameloblastoma.
  5. 5. Periapical-radiolucentPeriapical-radiolucent Periapical granulomaPeriapical granuloma – well circumscribed, rounded– well circumscribed, rounded -around apex. May’ve thin radiopaque border. Tooth may-around apex. May’ve thin radiopaque border. Tooth may have deep caries/restorations. Tooth-non-vital.have deep caries/restorations. Tooth-non-vital.
  6. 6. Periapical-radiolucentPeriapical-radiolucent Radicular cystRadicular cyst –– involve apex of permanent tooth. Untreatedinvolve apex of permanent tooth. Untreated cyst slowly enlarge, expand and thin cortex – crackling soundcyst slowly enlarge, expand and thin cortex – crackling sound (crepitus). If infected, all painful symptoms of an abscess develops.(crepitus). If infected, all painful symptoms of an abscess develops.
  7. 7. Periapical-radiolucentPeriapical-radiolucent chronic & acute Dento alveolar abscesschronic & acute Dento alveolar abscess::  Small/large radiolucencies.Small/large radiolucencies.  May have cortical expansion.May have cortical expansion.  Associated tooth- non is vital.Associated tooth- non is vital.  Teeth with a/c abscess –pain to percussion (high to bite on )Teeth with a/c abscess –pain to percussion (high to bite on ) - PDL abscess originating in deep PDL pocket – PA- PDL abscess originating in deep PDL pocket – PA radiolucency + intra bony Pocket;radiolucency + intra bony Pocket; pulp vital usuallypulp vital usually..
  8. 8. Periapical abscessPeriapical abscess
  9. 9. Periapical-radiolucentPeriapical-radiolucent Osteomyelitis:Osteomyelitis:  Seen rarely in maxilla (due to rich blood supply).Seen rarely in maxilla (due to rich blood supply).  Non vital pulp, sensitive to percussion or associated with acuteNon vital pulp, sensitive to percussion or associated with acute or chronic PA abscess.or chronic PA abscess.  Borders: poorly defined and ragged.Borders: poorly defined and ragged. Sinus tract –Sinus tract –  if present, appears as a radiolucency from the PA radiolucencyif present, appears as a radiolucency from the PA radiolucency through the cortical plate opening on the skin or mucosa.through the cortical plate opening on the skin or mucosa. If sequestrum seen (segment of dead bone) & largeIf sequestrum seen (segment of dead bone) & large enough, it appears radiopaque within a radiolucency.enough, it appears radiopaque within a radiolucency.
  10. 10. Osteomyelitis (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:94-8)
  11. 11. Periapical-radiolucentPeriapical-radiolucent - PACOD (Periapical cementoma):PACOD (Periapical cementoma):  its early stage: round well defined borders,its early stage: round well defined borders, associated with vital tooth.associated with vital tooth.  Usually in mandibular incisors; asymptomatic.Usually in mandibular incisors; asymptomatic.  If it’s a pulpo-periapical lesion: non vital pulp.If it’s a pulpo-periapical lesion: non vital pulp.
  12. 12. Periapical-radiolucentPeriapical-radiolucent Periapical Cemental Dysplasia
  13. 13. Pericoronal - radiolucentPericoronal - radiolucent Follicular spaceFollicular space::  Surrounding crowns of unerupted teeth.Surrounding crowns of unerupted teeth.  Homogenous radiolucent halo with a thin outer radiopaqueHomogenous radiolucent halo with a thin outer radiopaque border, that is continuous with LD.border, that is continuous with LD.  Normal follicular spaces usually decrease in size with age.Normal follicular spaces usually decrease in size with age.
  14. 14. Pericoronal - radiolucentPericoronal - radiolucent Dentigerous cystDentigerous cyst: Mostly: Mostly  mandibular 3mandibular 3rdrd molarmolar  maxillary- Cmaxillary- C  mandibular - premolarmandibular - premolar  maxillary- 3maxillary- 3rdrd MolarMolar AmeloblastomaAmeloblastoma – Infiltrate bone– Infiltrate bone
  15. 15. Pericoronal - radiolucentPericoronal - radiolucent Adeno ameloblastomaAdeno ameloblastoma – (AOT)-– (AOT)-  Benign & non-invasive.Benign & non-invasive.  It differs from ameloblastoma.It differs from ameloblastoma.  AOT-slow growing tumor, doesn’t infiltrate bone.AOT-slow growing tumor, doesn’t infiltrate bone.  Displace teeth but doesn’t cause root resorption.Displace teeth but doesn’t cause root resorption.  Common in anterior maxilla.Common in anterior maxilla.  Expand cortical plate, produces clinical swelling,Expand cortical plate, produces clinical swelling, no soft tissue invasion.no soft tissue invasion.
  16. 16. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth - Inter radicularInter radicular - Solitary cyst – likeSolitary cyst – like - MultilocularMultilocular - Solitary, ragged, poorly defined bordersSolitary, ragged, poorly defined borders - Multiple separateMultiple separate - Generalized rarefactionGeneralized rarefaction
  17. 17. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Inter radicular radiolucenciesInter radicular radiolucencies :: That occur b/w roots ofThat occur b/w roots of teeth.teeth. periodontal pocket:periodontal pocket:  periodontal bone loss (horizontal vertivcal) appear onperiodontal bone loss (horizontal vertivcal) appear on films.films.  Occurs closer to involved tooth contacting its surface.Occurs closer to involved tooth contacting its surface.  Confirmed diagnosis by placing a periodontal probe intoConfirmed diagnosis by placing a periodontal probe into the defect.the defect.
  18. 18. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Furcation involvementFurcation involvement::  Seen in advanced periodontal disease.Seen in advanced periodontal disease.  Produces furcation involvement.Produces furcation involvement.  Usually seen in mandibular molars,Usually seen in mandibular molars, where bifurcation is devoid of bone &where bifurcation is devoid of bone & shows a radiolucency.shows a radiolucency.  Usually a probe can be introd. intoUsually a probe can be introd. into bifurcation area from the B/L aspect.bifurcation area from the B/L aspect.  LD remains intact in furcation in normalLD remains intact in furcation in normal furcationfurcation..
  19. 19. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth  Lateral Radicular cystLateral Radicular cyst::  Associated with non vital pulp.(near to lateral accessoryAssociated with non vital pulp.(near to lateral accessory canal opening).canal opening).  If infected, pain, swelling occur on offending tooth;If infected, pain, swelling occur on offending tooth; sensitive to percussionsensitive to percussion
  20. 20. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Primordial cystPrimordial cyst::  Cyst like radiolucencies,Cyst like radiolucencies,  not contacting tooth.not contacting tooth.  May occur in a region where a toothMay occur in a region where a tooth may’ve failed to develop.may’ve failed to develop. Odontogenic tumorsOdontogenic tumors::  Usually Odontomas.Usually Odontomas.  Freq seen as inter radicularFreq seen as inter radicular radiolucencies.radiolucencies.  In its radiolucent stage: cyst like withIn its radiolucent stage: cyst like with a well defined border.a well defined border. Odontomas
  21. 21. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Globulomaxillary cystGlobulomaxillary cyst::  Asymptomatic.Asymptomatic.  If large, expands cortical plate buccally;If large, expands cortical plate buccally;  if secondary infected, pain.if secondary infected, pain.  Inverted tear shaped radiolucency.Inverted tear shaped radiolucency.
  22. 22. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Incisive canal cystIncisive canal cyst::  Cyst like radiolucency.Cyst like radiolucency.  Maxillary central incisor.Maxillary central incisor.  Often – antr nasal spine is seen over the supr portion of the cyst as aOften – antr nasal spine is seen over the supr portion of the cyst as a radiopaque shadow, thus producing a Heart- shaped radiolucency.radiopaque shadow, thus producing a Heart- shaped radiolucency.
  23. 23. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth MalignancieMalignancies:s:  May begin in inter septal bone and usually present as radiolucencies withMay begin in inter septal bone and usually present as radiolucencies with poorly marginated borders.poorly marginated borders.  If they involve PDL early in their development, charact. pds a band likeIf they involve PDL early in their development, charact. pds a band like widening image of PDL.widening image of PDL. Lateral periodontal cystLateral periodontal cyst::  More in mandibular Canine & premolar.More in mandibular Canine & premolar.  Adjacent teeth’ve vital pulpsAdjacent teeth’ve vital pulps..  Round/oval, well defined, often with sclerotic border.Round/oval, well defined, often with sclerotic border.
  24. 24. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth  Median mandibular cystMedian mandibular cyst: Occurs in symphyseal: Occurs in symphyseal region of L/jaw. If the adj teeth are non-vital, it isregion of L/jaw. If the adj teeth are non-vital, it is usually a radicular cyst.usually a radicular cyst.
  25. 25. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Solitary cyst like:Solitary cyst like: Post extraction socketPost extraction socket: sometimes show cyst like radiolucency after: sometimes show cyst like radiolucency after extraction. H/o extn exists.extraction. H/o extn exists. Residual cystResidual cyst: Is a radicular/ another cyst that has remained after its: Is a radicular/ another cyst that has remained after its associated tooth has been lost. Usually over 20 yrs & more inassociated tooth has been lost. Usually over 20 yrs & more in Maxilla.Maxilla.
  26. 26. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth  Lingual MNDlr bone defect (Stafne’s cyst):Lingual MNDlr bone defect (Stafne’s cyst):  Invagination in the median surface of mandible.Usually 3Invagination in the median surface of mandible.Usually 3rdrd M, angle area.M, angle area.  Located inferior to mandibular canal in 3Located inferior to mandibular canal in 3rdrd molar area.molar area.  Asymptomatic, Unilocular/multilocular, lined by cortexAsymptomatic, Unilocular/multilocular, lined by cortex
  27. 27. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Odontogenic Keratocyst (OKC)Odontogenic Keratocyst (OKC)::  Usually in 2Usually in 2ndnd & 3& 3rdrd decades.decades. Findings suggestive of OKC:Findings suggestive of OKC: 1. Cyst like radiolucency in MNDlr 31. Cyst like radiolucency in MNDlr 3rdrd M region/ ramus.M region/ ramus. 2. A diameter of > 3 cm.2. A diameter of > 3 cm. 3. Unilocular cyst like radiolucency with scalloped margins.3. Unilocular cyst like radiolucency with scalloped margins. 4. Multilocular cyst.4. Multilocular cyst. 5. Odorless, creamy or caseous contents on aspiration.5. Odorless, creamy or caseous contents on aspiration.
  28. 28. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth OKC
  29. 29. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Primordial cyst:Primordial cyst: B/w 10 & 30 yrs. MNDlr 3B/w 10 & 30 yrs. MNDlr 3rdrd M. rarely produces corticalM. rarely produces cortical expansion. Usually in areas where a tooth failed to develop.expansion. Usually in areas where a tooth failed to develop.
  30. 30. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth AmeloblastomaAmeloblastoma::  Asymptomatic initially.Asymptomatic initially.  Expands, perforates cortical plates.Expands, perforates cortical plates.  Feels firm if it is of solid type.Feels firm if it is of solid type.  Cystic type is soft & fluctuant and straw colored fluid canCystic type is soft & fluctuant and straw colored fluid can be aspirated in some cases.be aspirated in some cases.
  31. 31. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Multilocular type:Multilocular type: Terms – Soap bubble, honey comb and tennisTerms – Soap bubble, honey comb and tennis racket – used to describe the variousracket – used to describe the various radiographic images of multilocular lesions.radiographic images of multilocular lesions.
  32. 32. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Soap bubble appearance
  33. 33. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth AmeloblastomaAmeloblastoma: Multilocular type may be of soap bubble/honey comb: Multilocular type may be of soap bubble/honey comb variety.variety.
  34. 34. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Solitary radiolucencies with ragged & poorlySolitary radiolucencies with ragged & poorly defined borders:defined borders: Chronic osteitis & osteomyelitisChronic osteitis & osteomyelitis::  Inflammation of bone caused by pathogenicInflammation of bone caused by pathogenic microorganism,microorganism,  Osteitis: when just alveolar bone is affected.Osteitis: when just alveolar bone is affected.  If basal bone of jaws is involved, this process isIf basal bone of jaws is involved, this process is Osteomyelitis.Osteomyelitis.
  35. 35. Osteomyelitis (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:94-8)
  36. 36. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Multiple separate, well definedMultiple separate, well defined radiolucencies:radiolucencies: - Multiple cysts/granulomasMultiple cysts/granulomas
  37. 37. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Generalized rarefactions of jaw bones:Generalized rarefactions of jaw bones: -Hyperparathyroidism-Hyperparathyroidism:: -Osteoporosis-Osteoporosis::
  38. 38. Radiolucencies- not contacting teethRadiolucencies- not contacting teeth Osteoporosis
  39. 39. Mixed lesions – contacting toothMixed lesions – contacting tooth Mixed lesions assoc: with teeth:Mixed lesions assoc: with teeth: 1.1. Peri apical mixed lesions.Peri apical mixed lesions. 2.2. Pericoronal mixed lesions.Pericoronal mixed lesions. Peri apical mixed lesions:Peri apical mixed lesions: Calcifying crown of developing toothCalcifying crown of developing tooth::
  40. 40. Mixed lesions – contacting toothMixed lesions – contacting tooth Calcifying crowns of -developing teeth
  41. 41. Mixed lesions – contacting toothMixed lesions – contacting tooth Calcified material with in an intermediate stage odontomaCalcified material with in an intermediate stage odontoma
  42. 42. Mixed lesions – contacting toothMixed lesions – contacting tooth Pericoronal mixed lesions:Pericoronal mixed lesions: Odontoma – intermediate stageOdontoma – intermediate stage..
  43. 43. Mixed lesions – not contacting toothMixed lesions – not contacting tooth 1.1. Healing surgical siteHealing surgical site: h/o Surgery.: h/o Surgery. 2.2. chronic Osteomyelitischronic Osteomyelitis::
  44. 44. Osteomyelitis (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:94-8)
  45. 45. RadiopacitiesRadiopacities Contacting toothContacting tooth – Periapical radiopacities– Periapical radiopacities Not contacting toothNot contacting tooth –– - Solitary- Solitary - Multiple separate- Multiple separate - Generalized opacification- Generalized opacification
  46. 46. Radiopacities contacting toothRadiopacities contacting tooth Periapical radiopacities:Periapical radiopacities: 1.1. Condensing or sclerosing osteitisCondensing or sclerosing osteitis:: Sclerosis of bone induced by an inflamm.Sclerosis of bone induced by an inflamm. or infec. that most often occurs as aor infec. that most often occurs as a pulpo periapical lesion. Non-vital teeth.pulpo periapical lesion. Non-vital teeth. Usually in MND – 1Usually in MND – 1stst M & PM.M & PM.
  47. 47. Radiopacities contacting toothRadiopacities contacting tooth 2.2. Mature periapical cemental dysplasiaMature periapical cemental dysplasia
  48. 48. Radiopacities contacting toothRadiopacities contacting tooth Periapical Cemental Dysplasia
  49. 49. Solitary radiopacities not contacting toothSolitary radiopacities not contacting tooth True intra bony radiopacities:True intra bony radiopacities: a.a. Tori.Tori. b.b. Unerupted, impacted & supernumeraryUnerupted, impacted & supernumerary teeth.teeth. c.c. Retained roots.Retained roots. d.d. Focal & diffuse sclerosing osteomyelitisFocal & diffuse sclerosing osteomyelitis
  50. 50. Multiple separate radiopacities not contacting toothMultiple separate radiopacities not contacting tooth 1.1. Tori & exostosesTori & exostoses 2.2. Multiple retained rootsMultiple retained roots Mandibular tori
  51. 51. Multiple separate radiopacities not contacting toothMultiple separate radiopacities not contacting tooth 3. Multiple hypercementosis3. Multiple hypercementosis 4. Multiple embedded/impacted teeth4. Multiple embedded/impacted teeth Hypercementosis
  52. 52. Generalized radiopacitiesGeneralized radiopacities D/d of Gen. radiopacities of jaw bones:D/d of Gen. radiopacities of jaw bones:  OsteopetrosisOsteopetrosis  Normal variations in form & density.Normal variations in form & density.
  53. 53. Generalized radiopacitiesGeneralized radiopacities Dense radiographic images of the jaw bonesDense radiographic images of the jaw bones may be seen in patients who have heavymay be seen in patients who have heavy jaw bones or are over weight.jaw bones or are over weight. ----------------------------------------------

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