Multilocular radiolucencies /endodontic courses

Multilocular
radiolucencies
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INDIAN DENTAL ACADEMY
Leader in continuing Dental Education

 Multilocular r/l are produced by multiple,
adjacent frequently coalescing and
overlapping pathologic compartments in bone.
 More commonly in the mandible.
 Unilocular lesions that may perforate one or
more areas –may giving multilocular r/l.
 ML lesion may contains two or more septa
partially separated by septa of bone.

Types:
o Soap bubble:
several small circular compartments for
lesions that vary in size, appear to be overlap.
o Honey comb:
compartments are small and uniform in a size.
o Tennis racket:
angular compartments
straight septa.

Anatomic structures
Maxillary sinus
Bone marrow spaces

Maxillary sinus
 Although septa appear to separate the
sinuses into distinct compartments, this
is seldom the case because the septa are
usually of limited extent.

Maxillary sinus
showing multilocular
pattern

Maxillary sinus showing septa
that divide it into separate
compartments giving multilocular
appearance

Bone marrow spaces
The cancellous bone lies between cortical plates in
both jaws.
It is composed of thin ro plates and rods
surrounding many rl pockets of marrow.

The trabecular pattern in the
posterior mandible is quite
variable, generally showing
large marrow spaces and sparse
trabeculation,
The trabecular pattern in the
anterior mandible is characterized
by coarser trabecular plates and
larger marrow spaces (arrow) than
in the anterior maxilla.

Pathologic:
 Multilocular cyst
 Ameloblastoma
 CGCG
 Hyperparathyroidism
 Cherubism
 Odontogenic myxoma
 OKC
 Anuresmal bone cyst
 Metastatic tumours
 Vascular malformations
 Central haemangiomas
 Rarities:
 AV malformation
 CEOT
 Burkitt’s lymphoma
 Chondroma
 Chondro sarcoma
 Fibrous dysplasia
 Langerhans cell disease
 Immature odotoma
 Osteomyelitis
 neurilemmoma

Multilocular cyst
 Man post area
 Soap bubble variety
Radicular cyst, OKC, Primordial cyst, dentigerous
cyst.
C/F: 15 yrs of age.
Small cysts asymptomatic.
Large cysts: displacement
Aspiration:
usually thin straw colour fluid
OKC- thick granular yellow fluid

 Botryoid odontogenic tumour:
multilocular grape bunch appeareance.
variant of lateral periodontal cyst.

Multiple OKCs associated with nevoid basal
cell carcinoma syndrome

Multilocular OKC
1.Crrpped occlusal view
2.Cropped panoramic view

Ameloblastoma
 11-13 %of all odontogenic tumours
 True neoplasm of odontogenic epithelium.
 Unicystic ,nonfunctional, intermittent in growth,
anatomically benign, clinically persistent.
c/f:
 Migration,tipping, mobility of tooth.
 Parasthesia of lip
 Erosion of bone, invading into soft tissue.
 Common in mandible 3rd molar region.

r/g findings:
Divide into 4 types:
1)simplest but not most frequent resembles
dental cyst.
there is an area of bone destruction with has
well defined and corticated borders with out
any evidence of bone or other solid structure
with in the lumen.

2)area of bone destruction having smooth curved margins
which are well defined and corticated.
 situated with in cavity is an arrangement of coarse
trabeculae.(more cmn)
3)Less comn than 2nd and more comn than 1st.(multilocular
cyst)
 shows multiple cystic cavities which vary greatly in no
and size.
 Two or more cavities in continuty may be present with
septa separating them.
 Loss of continuty in some portion of wall.
 Mostly-honey comb pattern, septa are well developed and
coarse.
 Rarely-one large cavity, one or more daughter cyst
adjacent –resembles multiple myeloma.www.indiandentalacademy.com

4)Solid variety of tumour.
normal bone is replaced by honey comb appearance
with relatively small and fairly uniform size cavities.
margins separating normal bone are denser.
walls of cavities are coarse and margins are
lobulated.

Soap bubble appearance
Honey comb appearance
Various multilocuar r/g features of
ameloblastoma

1.Cropped views
showing multilocular
variants of
ameloblastoma

Cropped view showing multilocular
variety of ameloblastoma

Cropped r/g showing multilocular ameloblastoma

Desmplastic ameloblastoma
 anterior region of jaws
 r/g lly shows mixed r/l r/o pattern
 Similar to fibro osseous lesions.
Other variants:
malignant ameloblastoma
ameloblastic carcinoma

(PA view) shows a diffuse,
radiodense lesion with a
honeycomb appearance in
the anterior mandible on
the right, with lingual
displacement of the
adjacent teeth and possible
extension across the
symphysis.
Case report: Desmoplastic ameloblastoma
Indian J Radiol Imaging. 2008 February; 18(1): 53–55

axial CT of the mandible with
bone window settings, shows an
expansile, solid, mixed
radiodense-radioopaque lesion
with poorly defined margins on
the right anteriorly, with
destruction of the cortices and
extension into the soft tissues .

CGCG
it is an on neoplastic bone disease reactive to
some unknown stimulus.
c/f:
before 30 yrs, female predilection.
Mandibular ant region than maxilla.
anterior to 1st molar.
Not commonly crossing the midline.
h/o trauma seldom found.

r/g findings:
1.Area of bone destruction-r/g darkness similar to
cyst (grey instead of dark).
due to presence of bone in tumour, bone is not
apparent.
Outer and inner cortical plates are expanded and
destroyed.
Dif b/n expansion of bone by cyst and tumour:
cyst-smooth expansion (hydraulic phenomenon)
Tumour-slightly undulating or irregular bony
covering.

Multilocular r/l:
internal structure:
no visible trabeculae.
one or more faint wispy or more substantial
trabeculae.
Some are straight, some or wavy(soap bubble
pattern)

A giant cell
granuloma in the
anterior
mandible with no
evidence of
internal structure.
lesion in the anterior
maxilla with a very fine
granular pattern

portion of a panoramic film showing wispy, ill-defined
internal septa-CGCG

Cropped occlusal r/g showing
expansion of cortical plates

d/d
 Ameloblastoma
 Aneurysmal bone cyst-
location, aspiration
 Odontogenic myxoma-
honey comb pattern,
associated with missing tooth, impacted
tooth.
 Traumatic bone cyst

 CGCG
more common in ant
region
Cmn in younger age
group.
Lighter, wispy septa.
More prone for-
unilocularity.
 Ameloblastoma
Common in man post
region
More than 30 yrs of age.
Hard, curved arch like
septa.
More-multilocular
lesion.

Gaint cell lesion of
hyperparathyroidism
 Most common in sec type.
 Uniloular or multilocular r/l.
 Poorly demarcated borders b/c rarefying
surrounding bone.

Brown tumour of
hyperparathyroidism

Cherubism
Autosomal dominant disorder .
c/f:
 2-6 yrs.
 Painless,firm,bilateral enlargment of
lower face.
 Enlargement in face produces cherrub
like appearance.
 At puberty lesion may begin to regress.

r/g findings:
 Lesion is bilateral affects the both jaws.
 Mand post region
 Epicenter in mandible is-post aspect
maxilla-maxillary tuberosity
 Lesion grows an ant direction
 Periphery usually well defined and corticated.
 Multilocular pattern-fine granular bone and
wispy trabeculae.
 Enlargement of jaws.
 Teeth displaced in ant direction.

d/d
 CGCG
 Fibrous dysplasia
 Multiple OKC

r/g of cherubism 4 lesions in max
and man with internal ill defined
septa

multilocular bone lesions of the angle and
ascending ramus of the mandible and coronoid
process- JOURNAL OF ORAL MAXILLOFACIAL
RESEARCH –a case reportwww.indiandentalacademy.com

Panoramic radiograph shows expansive
multiloculated cystic lesions distributed in the
mandible and maxilla with loss and medial
displacement of the deciduous teeth. -
Pol J Radiol, 2012; 77(3): 53-57www.indiandentalacademy.com

Odontogenic myxoma
 Infiltrative benign tumor.(3-6%)
 It is mesenchymal and myxomatous
component is gelatenous in nature.
c/f:
 Slowly enlarging, painless expansion of jaw.
 Loosening, migration of tooth.
 25-35 yrs, female predilection.
 Root resorption.
 Man post region.

r/g findings:
 Unicystic
 Multilocular
 Peri-coronal(less often)
 Mixed r/l r/o(rare)
Unicystic-
small,common in anterior region.
Multilocular-
Posterior region
The internal septa are curved and straight giving the
tumor multilocular appeareance
A straight thin etched septa is a characteristic Feature-
tennis Racket Like Or Stepladder Like.
Scalloping between the roots of adjacent teeth

r/g of odontogenic
myxoma-straight
internal septa
producing a tennis
racket appearance

Radiograph showing honeycomb or
tennis racquet appearance a case
report

Radiograph of an odontogenic myxoma of
the mandible showing a honeycomb
multilocularity.

d/d
CGCG- more ant location
Ameloblastoma- older age group
Cherubism- younger age, bilateral
Hyperparathyroidism- h/o kidney disease,
serum chemistry.
Metastatic carcinoma- older age, primary
tumour.

Aneurysmal bone cyst
 It is a false cyst.
 Etiology is unclear.
 Reactive lesion of bone.
 Exaggerated localized proliferative response to
vascular tissue.
c/f:
mandible post region.
persons under 20 yrs of age,female predilection
expansion of cortical plates, rapid growth, biny
swelling(buccal or lingual).
Develops in association with other primary lesions –
fibrous dysplasia, CGCG, Osteosarcoma

r/g findings:
 Periphery is usually well defined, shape is
circular(hydraulic).
 Unilocular or multilocular
 Multilocular-wispy, ill defined septa
 Septa positioned right angles to outer expanded
border.
 Expansion of cortical plates.
 Mouth eaten appearance.
 A characteristic radiographic feature of ABC is the
“ballooning” distension of periosteum with a thin
outline of reactive, subperiosteal bone.

d/d
CGCG
Ameloblastoma
Cherubism

ABC in the angle of the mandible.illdefined
septa in the internal structure

Panoramic radiograph
showing a well-defined
unilocular lesion at the right
angle of the mandible.
Journal of Oral Science, Vol.
53, No. 4, 529-532, 2011
Panoramic radiograph showing a
regular radiopaque lesion at the righ
angle of the mandible with bony
expansion in the inferior direction
r/g of same pt.

well-defined expansile lytic
soft tissue lesion at the right
angle and ramus of the
mandible with thinning
of the bony cortex.
Axial CT scan showing a well-
defined nonenhancing
expansile lesion at the right
angle and ramus of the
mandible with thinning of the
bony cortex

An axial CT scan using a soft tissue
algorithm demonstrating the presence
of an ABC of the left mandibular
condyle. expansion and the wispy ill-
defined septa (arrows).

Metastatic tumours to the jaw
 1-3%of all metastasis.
 Women-from breast, adrenal gland, genital
organ, thyroid gland.
 Man-lung, prostate, kidney, adrenal gland

c/f:
 50-70 yrs of life
 Female predilection
 Oral neoplasm may be 1st sign of malignancy-
30%of cases.
 Enlarging tumours erode rapidly through
cortical plates.

r/g findings:
1.A solitary well defined cyst like r/l- tumors are
slow growing, well differentiated,pt was
successfully treated.
2.A solitary poorly defined r/l-localized, rapiidly
growing tumour.
3.multiple, separate, poorly defined r/l- several foci
of malignant nests are present and growing
separately.
4.multiple,punched out r/l- several nests of slow
growing tumour are located close to each other in
bone.

5.r/o patterns with any of foregoing r/l appearances-
tumours induced osteoblastic activity or produced
osteosclerosis in bone.
6.Irregular salt and pepper appearance-
involves large segment of jaws, widely disseminated
as multiple nests.
Nests appear small r/l(pepper)
They induce sclerotic areas about themselves and
sprinkled overall image with r/o foci.(salt)
7.A relatively dense, solitary, r/o area-
Prostate or breast malignancy demonstrstes
osteoblastic activity-resembles condensing osteitis.

Metastatic tumour in the maxillary
anterior region

Metastatic tumour in mandibular post region

Central haemangioma
 hemangioma is a proliferation of blood
vessels creating a mass that resembles
neoplasm.
 rarely develops in jaws.
 may be developmental or traumatic in
origin.

C/F:
 females
 1st decade
 slow,non tender, expansion of jaws
 may or may not be painfull
 bony hard
 loosening or migration of teeth
 bleeding from gingiva
 teeth may show rebound mobility
 ON ASPIRATION PRODUCES ARTERIAL BLOOD

r/g findings:
o Mostly-multilocular(honey comb pattern)
o Coarse, linear trabeculae that appear to
radiates from centre of lesion, small angular
locules of varying size may seen.
o Cyst like radiolucency with hyperostotic
border.
o Sun-ray like appearance, spoke wheel type.

 Mand post region, body, with in the IAC.
 The formation of linear spicules of bone emanating
from the surface of bone(sunray like)
haemangioma breaks the outer cortex and
displsces periosteum.
 When residual bone is trapped around blood
vessels may result in ML appearance.
 Coarse,dense, well defined trabeculae.
 Honey comb pattern-small circular r/l spaces
represent BV.

 IAC involved may result in whole canal inc in width
shape changed into serpingenous creating ML
appearance.
 Roots resorbed and displaced.
 mandibular and mental foramen may enlarged.
 Involved bone is enlarged.
 Developing teeth may be larger abd erupt earlier
when intimate relation with haemangioma.

a.Areas of coarse trsbeculations.
b/honey comb pattern
c.Multiple round locules
d.Parallel tubelike trabeculations
e.Inferiorly displaced mandibular
canal.
Dentomaxillofacial
Radiology (2005) 34, 120-125
Various r/g
appearances of CH
produced in same
patient

Cropped panoramic radiograph of a 65-year-old
female, demonstrating multilocular (spoke-like)
radiolucency with welldefined
borders in the right incisor area of mandible

vascular lesion. A, radiolucency in the mandible below
the developing first premolars (arrows). B, An occlusal
radiograph shows expansion of the mandible
with loss of the buccal cortical border.

Central muco epidermoid carcinoma
producing a multi locular appearance

Panoramic
view of AV
malformation
of mandible-
moth eaten
appearance
Axial CT and
Coronal CT section
demonstrating
widespread
destruction and
thinning of cortical
plates.

Fibrous dysplasia
 Fibrous dysplasia results from a localized change
in normal bone metabolism that results in the
replacement of all the components of cancellous
bone by fibrous tissue containing varying
amounts of abnormal-appearing bone.
 2types:
mono ostotic-more commonly on jaws
maxilla is more commonly affected.
ribs,tibia,mandible are next common sites.
poly ostotic-children under 10 yrs of age.

c/f
 Monostotic fibrous dysplasia often is discovered as
an incidental radiographic finding.
 Patients with jaw involvement first may c/o
unilateral facial swelling or an enlarging
deformity of the alveolar process.
 Pain and pathologic fractures are rare.

r/g findings
The affected bone is enlarged, may due to
bone formation with in the bone.
r/g appearance may divided into 3 groups:
1. predominance of fibrous tissue
2.predominance of bone formation
3.equal mixture of fibrous tissue and
bone.

1.Fibrous tissue predominance:
inc r/l with out evidence of bone formation.
most likely resembles a cyst.
Cyst like shadows which extends along the jaw
with out division into loculi.
2.Bone formation predominance:
stippled appearance(orange peel or ground glass
appearance).
granular appearance
dense structure less homogenous density
Some times-thumb print pattern on mandible.

 Max post region, lesions are unilateral
 The periphery of lesions mostly ill defined, with a
gradual blending of normal trabecular bone into an
abnormal trabecular pattern.
 The internal density is more radiopaque in the
maxilla.
 Early lesions are more r/l.
 The abnormal trabeculae usually are shorter,
thinner, irregularly shaped, and more numerous
than normal trabeculae.
 Cortical boundaries such as the floor of the antrum
may be changed into the abnormal bone pattern

 distinct lamina dura disappears because this
bone also is changed into the abnormal bone
pattern
 PDL may appear to be very narrow
 displace the inferior alveolar nerve canal in a
superior direction.

Cropped r/g showing unilateral
fibrous dysplasia of maxilla and
mandible

r/g pictures of early stages of fibrous
dysplasia-total r/l internal structure

REFERENCES:
 Principles practice oral radiologic interpretation
H.m worth
 Oral radiology principles and interpretation 5th
edition white & pharaoh
 Differential diagnosis of orol and maxillofacial
lesions 5th edition norman.k and wood,paul w.goaz

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