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Mixed radiolucent –radiopaque lesions associated with teeth /endodontic courses

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Mixed radiolucent –radiopaque lesions associated with teeth /endodontic courses

  1. 1. I N D I A N D E N TA L A C A D E M Y L E A D E R I N C O N T I N U I N G D E N TA L E D U C AT I O N Mixed radiolucent –radiopaque lesions associated with teeth www.indiandentalacademy.com
  2. 2. Periapical mixed lesions  Calcifying crown of developing tooth  Tooth root with rarefying osteitis  Rarefying and condensing osteitis  Periapical cemento osseous dysplasia(intermediate stage)  Cemento ossifying fibroma  Rarities  Calcifying odontogenic cyst  Cemento blastoma(intermediate stage)  Foreign bodies  Generalised(florid cemento osseous dysplasia,pagets disease)  Odontoma (intermediate stage )  Osteomyelitis(chronic) www.indiandentalacademy.com
  3. 3. Pericoronal mixed lesions  Odontoma(intermeditae stage )  Adenamatoid odontogenic tumour  Calcifying odontogenic cyst  Amelobalstic fibro odontoma  Calcifying epithelial odontogenic tumour  Rarities  Ameloblastic fibro dentinoma  Calcifying hyperplastic dental follicles  Central odontogenic fibroma  Cystic odontoma  Eruption sequestrum  Post surgical healing www.indiandentalacademy.com
  4. 4. www.indiandentalacademy.com
  5. 5. Periapical mixed lesions  Calcifying crown of developing tooth-  The radiographic appearance of crypts containing tooth germs in early stage of development-cyst like radiolucencies.  The cusp tips of developing tooth is first to calcify.  When sufficient mineral is deposited in the matrix of cusp tips of dev. Teeth to make them radiographically appear as radiolucency with radiopaque foci. www.indiandentalacademy.com
  6. 6. Calcifying crowns of developing teeth www.indiandentalacademy.com
  7. 7.  Before calcification the permanent tooth buds may appear in the periapical regions of deciduous teeth after calcification it may be appear as periapical radiolucencies with radiopaque foci .  Diagnosis-  Age-<20yrs  By comparing developing teeth contralaterally to confirm the calcifying crowns  Periodic radiographs www.indiandentalacademy.com
  8. 8. Tooth root with rarifying osteitis  Retained root and root tips are abnormal radiopacities commonly found in edentulous area of the jaws’  80% posterior region  The root canal of the retained teeth are continuous with the oral cavity at its coronal end which may become channel for infection resulting rarefying osteitis at peri apex, producing mixed radiolucent – radiopaque jaw lesion. www.indiandentalacademy.com
  9. 9. Clinical features  Asymptomatic  Intermittent slight pain or swelling  When pt resistance reduced acute infection may produce fluctuant , painful , smooth surfaced mass (abscess)  Diagnosis-  Retained root-shape of the root with linear radiolucent shadow of the root canal ,a portion of pdl space , and surrounding lamina dura . www.indiandentalacademy.com
  10. 10. Root tip with rarefying osteitis www.indiandentalacademy.com
  11. 11. Differential diagnosis  Intermediate stage cementoosseous dysplasia  Pcod-mandibular incisors,multiple  Odontoma-(age-20yrs)  Chronic osteomyelitis( h/o trauma, mandible,pain ,swelling)  Metastatic osteoblastic carcinoma(medical history of primary malignancy)  Osteogenic sarcoma  Chondro sarcoma www.indiandentalacademy.com
  12. 12. Retained root tip with rarefying osteitis Osteosacoma Chondrosarcoma Metastatic osteoblastoma Small welldefined smoothly outlined dense radioopaque image surrounded by ill defined ragged radiolucency in tooth bearing areas of jaws. Mixed radiopaque radiolucenecy with irregular ,illdefined , ragged borders Management- extraction of retained infected root tip www.indiandentalacademy.com
  13. 13. Rarefying and condensing osteitis  Osteitis-inflammation of bone  Rarefying osteitis-rarefaction of bone it includes acute abscess, chronic abscess and apical granuloma.  Features of rarefying osteitis-  Loss of normal density of bone  Changes in density,thickness, and continuity of trabeculae  Alteration of lamina dura www.indiandentalacademy.com
  14. 14.  Condensing osteitis-  In the presnece of inflammation of bone instead of rarefaction bone is laid down this is known as sclerosing osteitis. www.indiandentalacademy.com
  15. 15. Rarefying osteitis and condensing osteitis  It occurs at the apex of non vital tooth or retained root.  Chronic infection acts as irritating factor (causing resorption of bone )and a stimulating factor (producing dense bone)  When there is chronic infection a well defined radiopacity is seen circumscribing the radiolucency around the root end. www.indiandentalacademy.com
  16. 16. Periapical rarefying and condensing osteitis www.indiandentalacademy.com
  17. 17. Periapical cemento osseous dysplasia (intermediate stage )  It is a reactive phenomenon that arises from elements with in the periodontal ligament  These lesions are sub divided into  2groups- 1.Mandibular incisor region(pcod)  2.Premolar molar region(fcod) www.indiandentalacademy.com
  18. 18. Features  Initial PCOD –osteolytic-periapical radiolucency - Cyst like radiolucency  Intermediate stage PCOD- mixed radiolucent- radiopaque .  Later PCOD-complete radiopacity.  In radiograph the intermediate stage of PCOD appears as smoothly contoured radiolucent border surrounded by radiopacity . www.indiandentalacademy.com
  19. 19. PCOD (intermediate stage) www.indiandentalacademy.com
  20. 20. Differential diagnosis  Rarefying osteitis in combination with condensing osteitis  Chronic osteomyelitis  Fibrous dysplasia  Calcifying crowns  Cementoossifying fibroma  Post surgical calcifying bone defect  Odontoma(intermediate stage )  Juxtaposed pericoronal mixed lesions  Osteogenic sarcoma  Chondrosarcoma  Metastatic osteoblastic carcinoma www.indiandentalacademy.com
  21. 21. Pcod Malignant metastatic osteoblatic carcinoma Osteosarcoma Chondrosarcoma Mixed radiolucent- radiopaque lesions- smooth well defined borders No root resorption Mixed radiolucent –radiopaque lesions-irregular and illdefined borders Root resorption pcod odontoma Periapical region Present above the crown of unerupted tooth sometimes between the teeth www.indiandentalacademy.com
  22. 22.  Post surgical bone defect is differentiated from PCOD by the h/o recent enucleation  Calcifying crowns-<20yrs  By examing contra lateral side of jaw.  Rarefying and condensing osteitis-vitality of teeth www.indiandentalacademy.com
  23. 23. Fibrous dysplasia Pcod Maxilla 1st and 2nd decades of life M=f Elongated fusiform jaw expansion Radiographically poorly defined Mandible >30yrS Females Nodular or dome shaped jaw expansion. Radiographically well defined borders www.indiandentalacademy.com
  24. 24. PCOD CEMENTO OSSIFYING FIBROMA •Common lesion •Lower incisors •Females •>30yrs •Diameter>1cm •Occasionally produces clinically expansion •Multiple lesions •Un common lesion •Premolar-molar area of mandible •Less in females •<30yrs •Diameter-2-4cm •Frequently produces clinically expansion •Single lesion www.indiandentalacademy.com
  25. 25. Cemento ossifying fibroma  These are uncommon neoplastic processes that originate from elements in the periodontal ligament  Features-  These occurs as periapical lesions that are round and well marginated.  Mostly occurs in mandible premolar-molar region  Age <30yrs  They occurs as solitary lesions  Size-2-4cm  Expansion of jaws clinically www.indiandentalacademy.com
  26. 26. Differential dignosis  Pcod-intermediate stage  Tooth root with rarefying osteitis  Calcifying crowns  Rarefying and condensing osteitis  Management- enucleation www.indiandentalacademy.com
  27. 27. Cemento ossifying fibroma www.indiandentalacademy.com
  28. 28. Raritis COMPOUND ODONTOMA www.indiandentalacademy.com
  29. 29. Calcifying odontogenic cyst www.indiandentalacademy.com
  30. 30. cementoblastoma www.indiandentalacademy.com
  31. 31. Pericoronal mixed lesions  It is usually associated with impacted 3rd molars  Incidence-0.81%-4.6% www.indiandentalacademy.com
  32. 32. Odontoma (intermediate stage)  It is a benign lesion containing all the various component tissues of teeth.  It results from a budding of extra odontogenic epithelial cells from the dental lamina.  This clusters of cells forms a large mass of tooth tissue that may be deposited in an abnormal arrangement but consists of normal enamel ,dentin , cementum and pulp. www.indiandentalacademy.com
  33. 33.  Compound odontoma-more common  It comprises of odontogenic tissues laid down in normal relationship and the resulting structure morphologically resembles teeth.  When the teeth components are less organised and tooth like structures are not formed –complex odontoma  Some tumours are combination of both types- compound-complex lesions www.indiandentalacademy.com
  34. 34. Features  Delayed eruption of permanent teeth  Compound variety-maxilla incisor –canine area No gender predilction  Complex variety- mandible -1st and 2nd molar areas-females  Early and intermediate stage –younger age group  Late stage-2nd and 3rd decades  Non aggressive  Diameter-1-3cm  It is situated between the crown of an un erupted teeth and the crest of the ridge www.indiandentalacademy.com
  35. 35. Radiographic features  Early stage –radiolucent  Intermediate stage(compound odontoma)-well defined radiolucent lesion containing varying number of radiopaque(washer like)cross sections of developing teeth and longitudinal ,hollow radiopaque shadows of developing teeth  Complex odontoma-well defined radiolucency with many radiopaque foci that vary greatly in size ,shape , and prominence www.indiandentalacademy.com
  36. 36. Compound odontoma www.indiandentalacademy.com
  37. 37. Compound complex odontoma www.indiandentalacademy.com
  38. 38. Compound odontoma www.indiandentalacademy.com
  39. 39. Differential diagnosis  Complex odontoma-  fibrosseous lesions of PDLO  Calcifying odontogenic cyst(aspiration –thick granular yellow fluid )  Adenamatiod odontogenic tumour(int. stage)(ant maxilla)  Calcifying epithelial odontogenic tumour(age-40yrs) www.indiandentalacademy.com
  40. 40.  Post surgical calcifying bone defect(h/o surgery)  Fibrous dysplasia(mottled /smoky pattern poorly defined borders)  Rarefying osteitis with condensing osteitis  Chronic osteomyelitis www.indiandentalacademy.com
  41. 41. Complex odontoma Chronic osteomyelitis rarefying and condensing osteitis Rule out by no h/o pain ,tenderness,inflammation,drianage,regi onal lymphadenopathy Periodic radiographs Management-surgical enucleation www.indiandentalacademy.com
  42. 42. Adenamatoid odontogenic tumours  AOT are uncommon non aggressive tumors of odontogenic epithelium associated with unerupted tooth.  Central-follicular type extra follicular type  Peripheral tumor www.indiandentalacademy.com
  43. 43. Features  It is a slow growing lesion  Age 10-30 yrs  Site-anterior maxilla (canine)  Females  Delayed eruption of permanent teeth or regional swelling of jaws www.indiandentalacademy.com
  44. 44. Radiographic features  Pericoronal cyst like radiolucency  Mature stage-sharply defined radiopaque foci with in radiolucency  Differential diagnosis-  Odontoma  Coc  Ceot  Management- surgical enucleation www.indiandentalacademy.com
  45. 45. Adenamatoid odontogenic tumour www.indiandentalacademy.com
  46. 46. Calcifying odontogenic cyst  Keratinizing and /or calcifying epithelial odontogenic cyst Gorlin cyst Cystic Keratinizing tumor.  First explained by Gorlin et al in 1962.  In the latest WHO publication on odontogenic tumors, COC was classified as a benign odontogenic tumor and was renamed calcifying cystic odontogenic tumors. www.indiandentalacademy.com
  47. 47.  Age: 10 to 24 years. Common in children and young adults.  Sex – female .  Site - maxilla is more commonly affected.  Lesions occurring before the age of 41 affects maxilla and in older age mandible is more commonly affected Features www.indiandentalacademy.com
  48. 48.  Unerupted teeth  Swelling - frequent complaint.  Usually not associated with pain.  Intra-osseous lesions produce a hard bony expansion .  Cyst may perforate the cortical plate and extend into the soft tissues  Extra osseous lesions tend to be pink to red, circumscribed elevated masses measuring up to 4cm in diameter  Features www.indiandentalacademy.com
  49. 49. Radiographic features  Location : mostly in maxilla ant. to 1st molar  Shape and outline: A circumscribed, smooth, well defined unilocular and may be multilocular radiolucent lesion. It is often corticated.  Internal structure : radiolucent Small foci of calcifications (salt & pepper) Irregular calcified bodies of varying sizes Solid amorphous material (odontome) Cyst like radiolucency with radiopaque foci www.indiandentalacademy.com
  50. 50. Calcifying odontogenic cyst www.indiandentalacademy.com
  51. 51. Differential diagnosis  Odontoma  Calcifying epithelial odontogenic tumour  Adenamatoid odontogenic tumour  Management-surgical enucleation www.indiandentalacademy.com
  52. 52. Ameloblastic fibro odontoma  Benign mixed odontogenic tumours that contains cords and nests of odontogenic epithelium  Some consider them as immature complex odontoma  Features-  Age -2nd decade  M>f  Mandible-premolar –molar region www.indiandentalacademy.com
  53. 53. Ameloblastic fibroodontoma www.indiandentalacademy.com
  54. 54.  It is located pericoronal to an imbedded tooth  And initially completely radiolucent ,but it acquires increasingly radiopaque focis the dental hard tissue with in it become mineralised. Differential diagnosis-  Intermediate stage odontoma  Coc  Aot  Ceot  Management-surgical enucleation www.indiandentalacademy.com
  55. 55. Calcifying epithelial odotogenic tumour Synonym: pindborg tumor It is uncommon,benign odontogenic neoplasm that is exclusively epithelial in origin. Rare tumour  M=f  Age 40yrs  Mandible-molar  50%-associated with unerupted teeth. www.indiandentalacademy.com
  56. 56. Radiographic appearances  1.Pericoronal radiolucency  2.Pericoronal radiolucency with radiopaque foci  3.Mixed radiolucent –radiopaque lesion not associated with unerupted teeth  4. Driven snow appearance.  5.Dense radiopacity. www.indiandentalacademy.com
  57. 57. www.indiandentalacademy.com
  58. 58. Differential diagnosis  Odontoma  Aot  Coc  Management- surgical resection www.indiandentalacademy.com
  59. 59. RARITIES  Cystic odontoma www.indiandentalacademy.com
  60. 60. CONCLUSION www.indiandentalacademy.com
  61. 61. Mixed radiolucent-radiopaque periapical lesions Entity Gender Age Jaw Region Distinguishing features Calcifying crowns M=f <20y rs Tooth bearing areas Compare with appearances in contralateral and opposite arches Tooth root with rarefying osteitis M=f 10- 60yrs 80% posterior Position of tooth root on preextraction radiograph Rarefying and condensing osteitis M=f 2o- 60yrs mandible Premolar - molar Calcifying post surgical bone defect m mandible History of surgery www.indiandentalacademy.com
  62. 62. Entity Gend er Age Jaw Region Distinguishing features Pcod Cementoo ssifying Fibroma F F >30y rs 2os ,30s Mandible Mandible Anteriors Premolar Molar Vital Teeth,circular,<1cm, welldefined With Radiolucent Rim,multiple Circular,2- 5cm,wellmarginated ,Solitary www.indiandentalacademy.com
  63. 63. Mixed radiolucent-radiopaque pericoronal lesions Entity Gend er Age Jaw Region Distinguishing features Odontoma compound M=f 5-20 maxilla Incisor, canine Radiolucent ,smooth contours with well defined radiopaque washers with in Odontoma complex f 5-20 mandib le molars Radiolucent ,smooth contours ,patternless radiopacities with in unerupted Adenamati od odontogeni c tumour f 16.5 maxilla Anterior canines Pericoronal radiolucencies-75%,small raduopaque foci www.indiandentalacademy.com
  64. 64. Entity Gender Age Jaw Region Disstingui shing features Cacifying odontogenic cyst M=f <30yrs Maxilla=ma ndible 75%anterio to ist molar Viscous yellow aspirate Ameloblastic fibro odontoma M 5-20yrs Mandible= maxilla Premolar- molar Calcifying epithelial odontogenic tumour M=f 40yrs Mandible Mandibular pm and m Maxillary molar Assoc with unerupted teeth www.indiandentalacademy.com
  65. 65. references  1.Differential dignosisof oral andmaxilofacial lesions-paul w.Goaz -5th edition  2.Oral radiology –whiteand pharoah -5th edition  3.Oralpathology-shafers-6th edition www.indiandentalacademy.com
  66. 66. Thank you www.indiandentalacademy.com

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