the presentation deals with the various mixed radiopaque and radiolucent lesions of jaw. it covers important topics useful in bds curriculum.

2. Seminar on
Mixed radiopaque – radiolucent lesions
- By
Samarth johari

3. Definitions
Radiolucent : It refers to that portion of a
processed radiograph which appears as dark / black. It
is caused due to the passage of maximum photons
through the objects.
Radiopaque : It refers to that portion of
processed radiograph which appears as light / white.
It is caused due to the presence of dense objects in
path of photons that are strong absorbers.

4. Why Mixed????
Some normal anatomic structures and disease
states can produce mixed radiolucent and
radiopaque images on radiographs.
Some pathology may be present as an osteolytic
lesion, which appears as radiolucency in
radiograph.
During it’s development, foci of calcified material
may form within the osteolytic area.

5. When these foci become large and
mineralized, they become radiographically
apparent.
Thus, mixed radiolucent & radiopaque
condition frequently represents an
intermediate stage in development of lesion.

6. Mixed Radiolucent – Radiopaque Lesions
1. Cementoma
2. Calcifying epithelial odontogenic cyst
3. Calcifying epithelial odontogenic tumor
4. Adenomatoid odontogenic tumor

7. 1. CEMENTOMA :
Also known as –
• Periapical cemental dysplasia
• Fibrocementoma
• Sclerosing cementum
• Periapical osteofibrosis
• Periapical fibrosarcoma
• Periapical fibrous dyplasia
• Periapical fibro – osteoma
Defined as –
a reactive fibro–osseous lesion derived from the
odontogenic cells in the periodontal ligament.
Located at –
apex of tooth.

8. Clinical features –
• More common in females, blacks & in middle age.
• Age group : middle age.
• Common in mandibular anterior region.
• Asymptomatic & involved tooth is vital.
• Usually diagnosed during routine checkup.
• Small in size ( <1cm in diameter) but may become
quite large causing expansion of alveolar process.
• Early phase – resorption of normal bone ( radiolucent
phase )
• Developing phase – abnormal bone manufactured
within lesion (mixed radiopaque & radiolucent
phase)
• Late / mature phase – internal structure dominated
by abnormal bone.

9. Radiographic features -
• Location :
–Epicenter lies at apex of tooth.
–Mostly lesion is multiple & bilateral.
• Periphery & shape :
–Well defined periphery.
–Radiolucent border of varying width, surrounded by
varying width of sclerotic bone.
–May be irregular in shape or round or oval shaped
centered over apex of tooth.
• Internal structure :
–Stage 1 – osteolytic stage :
» Radiolucency ( 1cm in diameter ) in periapical region
» More than 1 tooth may be involved.

11. –Stage 2 – cementoblastic stage :
» small areas of calcification develops within
radiolucency.

12. –Stage 3 - Mature stage:
»Individual calcified mass increase in size
»Masses unite with adjacent lesions to form
single large radiopaque mass with thin
radiolucent line in periphery

13. • Effects on surrounding structures :
–Adjacent teeth are not displaced
–No root resorption of adjacent teeth are seen
–Adjacent teeth are vital, with intact PDL space,
lamina dura may be discontinuous
–No expansion of jaw is seen
Differential diagnosis –
• Periapical rarefying osteitis – in early stages,
PCD can not be ruled out radiographically
alone. Thus, final diagnosis is based on vitality
of involved tooth.

14. • Benign cementoblastoma & odontoma –
–Cementoblastoma : solitary, attached to surface of
root which may be partly resorbed.
better defined peripheral soft tissue capsule

15. –Odontoma : starts occlusal to a tooth
prevents eruption
resembles tooth like structure
more uniform in width & better defined than
the periphery of PCD

16. Management -
• Periodic radiographic evaluation (watchful
neglect)
• Surgical enucleation indicated in cases of
expansion of cortical plates.

17. 2. CALCIFYING EPITHELIAL ODONTOGENIC CYST :
Also known as –
Calcifying odontogenic cyst
Gorlin’s cyst
Defined as –
an unusual lesion with features suggestive of a cyst &
characteristics of a solid neoplasm.
Clinical features –
• females > males
• 3/4th of the lesion occurs centrally, 75% occuring
anterior to the 1st molar.
• Affects both jaws equally.
• Slow growing, asymptomatic.
• May cause expansion or destruction of cortical plates.

18. • Adjacent teeth may be displaced.
• May be associated with an odontoma & may have
calcified material identified as dysplastic dentine.
• Aspiration yields a viscous,granular, yellow fluid.
Radiographic features –
• Location :
–Anterior to 1st molar
–Associated with cuspids
& incisors, where it may
manifest as pericoronal
radiolucency
• periphery & shape :
–Vary from well defined & corticated with curved,
cyst like shape to ill defined & irregular.

19. • Internal structure :
–may be completely radiolucent or may show
evidence of small foci of calcified material that
appear as white flecks or small smooth pebbles.
–Multilocular in rare cases.
• Effect on surrounding structures :
–Most commonly associated with cuspid
–Displacement of teeth may be seen
–Root resorption
is present
–Perforation of cortical
plates in enlarged lesions

20. • It may resorb roots of adjacent teeth.
• Radiolucency may contain
small foci of calcified
material seen as white
flecks or smooth pebbles
( radiopacities ). At times
the entire lesion may be
occupied by the calcific body
& thus appear radiopaque.

21. Differential diagnosis –
• Fibrous dysplasia – appears as mottled or has a smoky
defined borders, more common in maxilla.
• Odontoma – surrounded
by a capsule.

22. • AOT – in the intermediate stage of development, AOT
appears like a CEOC.

23. • Cementoblastoma – well defined radiographic
image attached to the root of the tooth.
Management –
• Enucleation with curettage
• Regular follow - up

24. 3. CALCIFYING EPITHELIAL ODONTOGENIC TUMOR :
Also known as –
Pindborg’s tumor
Ameloblastoma of unusual type with calcification
Defined as –
rare tumor of distinctive microscopic appearance that
appears to arise from the reduced enamel epithelium or
dental epithelium.
Clinical features –
• Accounts for 1% odontogenic tumor.
• Males > females
• Age range : 8-92 yrs.
• Mandible > maxilla
• Common in premolar – molar region
• Rarely may have extraosseous location.

25. • Usually asymptomatic.
• May be associated with paresthesia.
• Associated with unerupted teeth.
• Cortical expansion is common.
• Palpation indicates hard swelling with well defined or diffused
border.
• Simulates ameloblastoma, less aggressive but locally invasive.
• Rate of recurrence is high.
Radiographic features –
• Location :
– Mandible > maxilla
– More common in
premolar – molar area
• Periphery :
– Well defined cyst like cortex
– Irregular & ill defined border

26. • Internal structure :
– May be unilocular or multi locular ( HONEYCOMB PATTERN )
– Numerous scattered, radiopaque foci of varying size & density
are seen.
– Small thin, opaque trabaculae cross radiolucency in many
direction ( DRIVEN SNOW APPEARANCE )
• Effects on surrounding :
– May displace developing
Tooth & prevent eruption
– Expansion of jaw with
maintenance of cortical
boundary may occur

27. Differential diagnosis –
• AOT – more common in
anterior maxilla as compared
to CEOT, which is common in
the mandibular premolar – molar
region.
• Calcifying odontogenic cyst –
aspiration yields vicous, granular,
yellow fluid.
• Odontoma – has a capsule.
Management –
Conservative treatment with local ressection with
limited margins.

28. 4. ADENOMATOID ODONTOGENIC TUMOR :
Also known as –
• Adenoameloblastoma
• Ameloblastic adenomatoid tumor
Defined as –
an uncommon, non aggressive tumor of odontogenic
epithelium, with a duct like structure & varying degree of
inductive changes in connective tissue.
Classified as –
• Peripheral adenomatoid odontogenic tumor
• Central adenomatoid odontogenic tumor –
a. follicular type
b. extra follicular type

29. a. follicular type – associated with
embedded tooth
b. extrafollicular type – not associated with
embedded tooth.
Clinical features –
• Females > males
• Age range : 5-50yrs
• Maxilla > mandible
• More common in anterior cuspid region
• Asymptomatic
• Slow growing swelling
• Associated with unerupted tooth
• Expands cortices but is non - invasive

30. Radiographic featurers –
• Location :
–More common in incisor – canine – premolar
region
–May have follicular relationship with impacted
tooth
–Does not attach at CEJ
–Surrounds greater part of tooth

31. • Periphery :
–Well defined corticated, sclerotic border
• Internal structure :
–Completely radiolucent or may contain faint
radiopaque foci
–Occasionally, small calcifications with well defined
borders, like cluster of small pebbles
• Effects on surrounding
structures :
–Displacement of adjacent
Teeth
–Root resorption is rare
–Prevents eruption
–Expansion of jaw may
Appear but outer cortex is
maintained

32. Differential diagnosis –
• CEOC – occurs in older age group, usually in
premolar region.
• CEOT – more common in
posterior mandibular region.

33. • Ameloblastic fibro – odontoma – more common in
posterior mandible region, is multilocular &
radiopacities of enamel & dentine are seen inside
the radiolucency. Whereas, in AOT snow flecks are
seen in periphery.

34. • Odontogenic fibroma or myxoma –
TENNIS RACKET appearance
is seen.
Management –
• Conservative surgical excision with curettage.