Differential diagnosis and management of radiolucent lesions


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Differential diagnosis and management of radiolucent lesions

  2. 2. Differential Diagnosis:  PERIAPICAL RADIOLUCENCIES: 1. Granuloma 2. Radicular cyst 3. Apical Scar 4. Odontogenic and Nonodontogenic Cysts 5. Odontogenic and NonodontogenicTumors 6. MalignantTumors
  3. 3.  PERICORONAL RADIOLUCENCIES 1. Follicular space 2. Dentigerous cyst 3. Unicystic ameloblastoma 4. Odontogenic keratocyst 5. Ameloblastoma 6. Ameloblastic fibroma
  4. 4. Giant cell lesions  Central giant cell granuloma  Giant cells tumor  Brown tumor of hyperparathyroidism Fibro-osseous lesions:  Fibrous dysplasia- Monostotic & Polystotic.  Cemento-osseous lesions- Florid, Apical and Focal.  Ossifyng fibroma  Desmoplastic fibroma  Chondromyxoid fibroma
  5. 5. Odontogenic tumors:  Ameloblastoma  Odontogenic adenomatoid tumor  Calcified epithelial odontogenic tumor(Pindborg tumor)  Ameloblastic fibroma
  6. 6. Management:  Therapeutic goal of any ablative surgical procedure is to remove the entire lesion and leave no cells that could proliferate and cause recurrence of the lesion.  Surgical therapy for oral lesions involves the following methods: 1- Enucleation 2-Marsupialization 3- Combination of the above 4- Curettage 5- Resection
  7. 7. Enucleatoin:  Definition: o The removal of a tumor or other body entire without rupture, as one shell out of the kernel of a nut.  Principle: o Enucleation allows the cystic cavity to be covered by a mucoperiosteal flap and the space fills with blood clot, which will eventually organize and form normal bone.
  8. 8.  Indications: o Treatment of choice for the removal of cysts of the jaws in one piece without fragmentation.  Contraindications: o Dentigerous cyst o Young patients with erupting teeth o Proximity to vital structure
  9. 9.  Advantages: o Entire pathology is removed. o Pathological examination of the entire cyst can be undertaken. o Chances of recurrence are reduced.  Disadvantages: o Normal tissue may be jeopardized. o Fracture of the jaw could occur. o Devitalization of the tissue could result.
  10. 10. Marsupialization:  An operation in which the sac of the tumor is opened and emptied of its contents then the edges are stitched to the edges of external incision, which is kept open while inferior of the cyst suppurates and granulation occurs.  To make it simple it refers to creating a surgical window in the wall of a cyst and evacuation of the cystic contents.The process decreases intracystic pressure and promotes shrinkage of the cyst and bone fill.
  11. 11. Marsupialization - Technique  Initial Incision circular, extending into cystic cavity  Osseous window-Bur.  Removal of window of cyst lining  Evacuate contents  Irrigation  Perimeter of the cystic lining is sutured to oral mucosa/ Pack the cavity with strip of gauze
  12. 12.  Indications: o Amount of tissue injury- Proximity of a cyst to a vital structure could produce damage by enucleation. o Undertaken if surgical access is limited. o As it is simple and less stressful so its recommended for debilitated patients. o Also if size of the cyst is very large marsupialization is preferred because enucleation can cause jaw fracture.
  13. 13.  Advantages: o Simple procedure to perform. o Spares vital structures. o Even quite large cysts can be dealt with local anesthesia. o Prevent pathological fractures. o Prevent oronasal, oroantral fistulas.  Disadvantages: o Pathology is left in situ. o Need for regular postop care. o Secondary surgery may be needed.
  14. 14. Which one is better?  Enucleation is definitely a better alternate than marsupulization because of complete removal of pathologic cystic lining.  Marsupulization could be preferred in cases with increased morbidity and mortality. Employed in cases of large cysts, proximity to vital structures and young patients with a dentigerous cyst.  While enucleation should be used in cysts having high recurrence potential.
  15. 15. Enucleation after Marsupialization:  Enucleation is frequently done after marsupialization. Enucleation is undertaken when objectives of the marsupialization procedure are accomplished.  This combined approach reduces morbidity and accelerates complete healing.
  16. 16. Enucleation with Curettage:  Means that after enucleation a curette or bur is used to remove 1 to 2mm of the bone around the entire periphery of the cystic cavity. Its done to remove any remaining epithelial cells that could result in a recurrence.  Use is indicated for removing an odontogenic keratocyst due to its aggressive nature or a cyst that is known to recur after complete removal.
  17. 17. Resection:  Removal of a tumor by incising through uninvolved tissue around the tumor, thus delivering the tumor without direct contact during instrumentation.  Marginal resection- Resection of a tumor without disruption of the continuity of bone.
  18. 18.  Partial resection- Resection of a tumor by removing a full thickness portion of the jaw.  Total resection- Resection of a tumor by removal of the involved bone.  Composite resection-With bone, adjacent soft tissues, and contagious lymph node channels(used commonly for malignant tumors)  Resection is indicated when the lesion is determined to be aggressive or removal by curettage or enucleation is difficult .