Lec:1 - Extraoral,Digital & 3D Imaging

First: Panoramic technique

-the patient is positioned and with the image receptor rotating in front of him,
and the x ray rotate behind the patient. So It takes more time
-only section of the patient is presented by the final radiograph.
Note:
✓ plain films: it is the simple type of x-ray, Object found between x ray source
and image receptor and click the button at least of one second we finish
(no complication) it’s a 2D image
✓ tomography: more advance/more complicated, x ray moves and cell travel

ray machines:
1.Intraoral machine: not recommended to use for extraoral films unless it is the
only choice.
2.Panoramic machine:
3.More advanced specialty extraoral (can make other advanced skull projection or
tomographic projection)
Note: in skull radiograph the patient must be placed in a position that head
doesn’t move thus we use cephalostats (head positioners), why it is important?
✓ making the image reproducible for future if you want to repeat the same
radiograph again.

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- We place the cassette depending on the side of patient. we’re seeking to take a
radiograph of.
- remember that the object near to the film will have a greater resolution.
Second: Transcranial TMJ
-x ray photon passes through the cranium to reach the receptor that found in the
TMJ of the opposite side (cassette is placed about 2 inches above the ear and a ½
an inch behind.)
-plane images in TMJ region
-very difficult to read > a lot of superimposition
-Only gross anatomy can be seen from this radiograph. Very minor changes can’t
be seen

Third: Lateral cephalometric

-the receptor at lateral site with certain distance from mid sagittal plane and x ray
pass parallel to the floor and the mid sagittal plane there is no angulation at all
-identifying trauma and abnormalities, assessing facial growth
and treatment record.
-Aluminum wedge is used in front of soft tissue. This is to
reduce the amount of radiation that exposes the soft tissue,
By the wedge we will be able to see the bony structure along
with the soft tissue.

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Fourth: Postero-anterior skull(PA)
-x ray source can pass behind the patient from (posterior to anterior) to reach
image receptor (that is near from teeth and facial structures)
 We can take it by Intraoral machine but isn't recommended “poor contrast
and can't cover big areas
-This image is good for the identification of trauma, pathology or developmental
abnormalities such as Hemifacial hypertrophy
-the patient’s forehead and nose will be touching the image receptor.

Fifth: waters (sinus view)/occipitomental

-used to evaluate maxillary sinus condition. -the chin touching the cassette and
the nose is 1’’ away.
-Water view is taken by intraoral machine

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Sixth: Submentovertex / zygomatic arch / jug handle view/ basal view
-x ray will pass through submental area toward the head of the patient.
-we can see condyle, magnum foramen, Odontoid process of C2(cervical vertebra
name), used to identify location of condyles and to image zygomatic arch fracture.
-A lot of superimposition
-frankfort-plane is perpendicular to the floor and MSP is parallel with the floor
Note:
✓ If we decrease the exposure the skull will appear whiter > because the x ray
wasn’t enough to pass through the skull and cast what inside so the x ray
will be absorbed by the thick bone)

Seventh: Reverse towns:

-kind of posterior-anterior (PA projection) but with modification on the angle and
it is good to show a condyle and a condylar neck
-The patients touching the cassette with his head and opening his mouth, we call
this position head tipped down mouth open.

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Eight: Caldwell (orbit view)
-Identify trauma, especially to area of orbit (Good to show orbital fraction).
-Very similar to waters view but The tip of the nose and chin are
both touching the cassette.

Waters > PA skull, head tilted up, chin is touching only.

Caldwell > nose and chin are touching.
Standard PA skull > nose and head are touching.
Reverse townes > only forehead is touching, mouth is open.
Lateral ceph > cassette is replaced to the lateral side
All of them with the mid sagittal plane being perpendicular to the floor except
submentovertex.

9- Tomography (Laminography):
-Takes images as slices or layers. It's used to image TMJ
-Images outside these slices are blurred.
-It recurs special machine as panoramic radiography (kind of tomography called
pantomograph)
-Notice that F stays in its place, A and B travel alongside the film and that’s what
we call blurring, so, F is in the fulcrum of rotation.
-linear Tomography: means that the x-ray tube is moving at a linear path.

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-multi-directional

10-Computed Tomography
-X-rays and detectors here will rotate 360-degrees. Complete turn
-CT takes time depending on how thin you want your section to be
➢ the thinner the slices > very high resolution and it will be very sharp but it
takes more time and higher exposure to the pt)
➢ If the slice is bigger, the resolution will be less, and the picture will be
faster, so, less harmful to the patient.
• Collimation is used to restrict the size and shape of x ray beam and to
reduce patient exposure.
• Collimator may have either a circular (round) or rectangular opening.
-The shape of X ray isn’t cone, it is fan beam (because I’m not imaging an area of
patient, I am imaging a slice of patient)
-In CT scan, we have two choices, we can view bones or soft tissue, CT that shows
bone is called “bone window”, and CT that shows soft tissue is called “soft tissue
window”.
1st picture: we can't differentiate between cancellous bone and cortical bone; so
obviously this image wasn’t taken to see bone, the purpose was to examine the
soft tissue so we call it soft tissue window.
2nd picture: Bone window (because the cortical and cancellous different)
(contrast of soft tissue is very poor) Coronal section

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 We can see
nose and nasal
septum, bone,
brain, maxillary
sinus and
sphenoid sinus.

11-Cone Beam CT
-Cone Shape X ray beam (a bigger area will be imaged at a time)
-360 degree rotation around head (you will get more information about patient
structures)
-Scan time around 20 seconds
-Cone beam CT machine is very expensive and very commonly used now.
-From the name we have tomography (rotation)
-Reconstruction at a certain view
-Panoramic > only mesio-distal dimension
-Cone beam CT> mesio-distal and bucco-lingual Dimensions
• very poor contrast in soft tissue compared with CT (because cone beam CT
is mainly to study bone)

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12-Magnetic Resonance (MRI)
-we are able to image soft tissue without contrast agent.
-NO IONIZING RADIATION USED (NO X-RAY, it uses Magnetic fields)
Mechanism: Magnetic fields apply forces on the
hydrogen atoms inside different tissues of our
body—> hydrogen atoms aligned—> magnetics
forces removed—> atoms then realign and release
energy by going back to their initial positions —>
image produced.
-the pt here enter a closed area with a lot of loud
scary noises which cause a problem for claustrophobic pts thus usually the needs
sedations
-In this image we can notice the very high contrast for soft tissue compared with
CT (We can see skin, facia, fat and muscles ) all are different shapes.
-Bone in MRI: (because the bone is tight structure so the hydrogen atoms not will
be free as the soft tissue)
-There is no signal from bone so the resulting image will be black
-Anterior part of the mandible cross section:
➢ White: bone marrow inside the mandible / Black around
the white: cortical Bone
-skull :
➢ Black: cortical bone
➢ Black with shade: Cancellous bone (spongy bone)
-fat: white
-vertibra
➢ black: around cortical bone/dense bone/vertebral body
➢ shade: Cancellous bone
➢ white between them: desk.

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13-Arthrography
-Arthro: associated with joints // graphy: imaging
-radiopaque contrast agent injected into joint
-articular disk will be outlined by this agent
-you can see an indirect image of the disk, while in MRI
it is the best method to look at articulator disk
-biocompatible: will be absorb by the body
-the contrast material injected in the inferior space.

14. Sialography:
• Sialo: salivary gland// graphy: imaging
• There will be an injection of radiopaque contrast agent that will flow
through the canal or duct to go inside cells and glands.
• So if there is obstruction this obstruction will be empty of that contrast.
-White appearance > contrast material (radiopaque) will spread into all structures
of the gland.
-There is construction (mucous or soft tissue construction), because if there is
(sialolith) stones in duct, it will be
radiopaque

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15.Scintigraphy (Radionuclide scan)
• It is similar to nuclear medicine.
• A radioactive pharmaceutical agent will be injected (IV) into the body.
• This agent is tissue specific (the uptake of agents can differ from one tissue
to other)
• is considered as a physiological image (not anatomical)
• Gamma rays are emitted from patient (they are emitted from the patient’s
body due to the radioactive agent that we’ve injected).
• Gamma cameras will detect gamma rays from the body, this will form an
image.
-If the patient was diagnosed with cancer (Lung, Colon, breast, etc..) we should
apply scintigraphy for staging (detecting the cancerous stage, 1,2,3or 4)
➢ More metabolism > more radioactive material uptake > cancer
➢ some areas there is a normal increase in metabolism, thus (increase
uptake) like joints
➢ Bone marrow has more uptake of the radioactive agent (technetium)
➢ Always remember that tissues with high replication rate will absorb more

16.Ultrasound
• No ionizing radiation is used, like MRI (it is safe) High frequency ultrasonic
vibrations are used
• Echoes "‫ "الصدى‬at tissue density differences because of different tissues.
• Echoes are detected by detectors.
• Varying echo intensity causes the appearance of an image.
• Mostly Used for pregnant women.(because it is safe and radiofrequency).
• Used to detect soft tissue thyroid,salivary glands

17.Digital radiography
-digital X-ray sensors are used instead of traditional photographic films.
Advantages include time efficiency through bypassing chemical processing.

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X ray machine
• Low kVp (70), mA (5) ( lower exposure /lower mA)
• Should have accurate timer.
• Small focal spot (small focal spot means that the image will be sharper, So
that there is no shadow around the image(
• DC circuit (Direct current) (constant electric charge) (not alternating
current).
• If there is Underexposure → the image will be Grainy

Image receptor
we have 2 main types of image receptors:
1-Sensors, they are 2 types:
a- CCD > charged coupled device.
b-CMOS > complementary metal oxide semiconductor.
-Real time imaging (Direct) > after the exposure, the imaged will be displayed
directly with no other steps)
-Wired (most common) or wireless by Bluetooth
Advantages Disadvantages
1-“Instant” image 1-Rigid and thick (3 to 8 mm)> Less comfortable.
2-Better resolution 2-Expensive
3-More durable (last long) 3-Most have wire connecting sensor to computer

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2-Plates
• PSP: Photo-stimulable Phosphor.
• Laser scan (Indirect): it means that after exposure,the platewill be takento
the scanner
• Very similar in experience with film (Thin)
• Almost cover the same side or the same area.
• Requires reduced lighting when scanning (the plate could be affected by
light)
• Images erased by exposure to light before reusing plate.
Advantages Disadvantages
1- Patient friendly (thin) 1- Easily damaged
2- More film sizes to choose from 2- More time consuming
3- inexpensive 3- Less resolution
4- image's sharpness is better

Digital Radiography Advantages

➢ Reduced patient exposure (60-90%)
➢ Ability to enhance image
➢ Improved patient education
➢ “Instant” image (CCD, CMOS)
➢ Better workflow (CCD, CMOS)
➢ Environmentally friendly (no lead, silver)
➢ No darkroom errors
➢ Improved archival quality of images
➢ Easier transfer of information

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 Principles of radiographic interpretation
Quality radiographs
• Proper density
achieved by proper exposure setting, technique and
• Proper contrast
processing.
• Good sharpness
-It’s important to avoid any mistake or artifact that could interfere with our
interpretation.
-Retake films if necessary, but we try not to retake them. “to reduce patient
exposure to radiation so only when they are in poor quality ex: overlapped teeth.
Viewing conditions
− No distraction - Subdued lighting
− Variable illumination - Logical sequence
− Alert observer - Magnifying lens
− Mask viewbox

How to recognize abnormalities?

✓ Scanning method: we don’t leave anything, we follow a sequence
✓ Observer motivation (Bias): focus on the tooth that pt complain about.
✓ Familiarity with pattern: which you get it by education and experience.

-Perception: is how to make sense from different stimuli that come to your eyes.
Influenced by your experience, education and culture.
 you shouldn’t follow your perception all the time

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characteristics of lesions to make proper diagnosis
Density: in real life means is it bony or soft tissue lesion, fibrous or fatty, but on
the radiograph it is going to be radiolucent or radiopaque or both (Mixed)
-Shape:
➢ Unilocular means that there is one part of the lesion, the lesion is one
piece either if it is circular, oval or irregular.
➢ Multilocular has many locules but they are connected to each other.
-Borders: are the surface where the lesion starts or where the abnormality
is separated from the normal.
➢ Well defined means that I can say exactly where the lines that
separates normal from abnormal.
➢ diffused which means that there is abnormality but there is no exact
line that determines where does it start.
➢ Circumscribed means that it is confined to a limited area
➢ Corticated means that the border that separates the normal from
abnormal is radiopaque
-Effects on the surrounding tissues: these tissues could be teeth or other
anatomical structures like cortical plates, sinuses or anything surrounding
that lesion can be affected. Effects could be:
• Resorption or Expansion or Displacement
- Size: You can describe the size by giving it extensions like saying it extends
from this structure to this or we can say it is about 2 cm or 15mm by 10mm
 Don’t use big or small
✓ you can make comparison by saying the width of the lesion equals the
mesiodistal width of the crown”

Note: as dentist first of all we should take a full history from the pt > then we do
clinical examination > take x-rays > Integrate clinical/radiographic findings > then
you reach to a Diagnosis/ differential diagnosis.

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 Most common lesions, how they appear on radiograph?!
1-Inflammation 2.Benign Lesion 3-Malignant Lesion

periphery is usually poorly Well-defined, corticated Poorly defined borders because its
defined borders (Smooth, round or growth is fast (Irregular shape)
oval periphery)
Acute ➔radiolucent -Radiolucent, radiopaque or Usually radiolucent but some of
Chronic (low grade long mixed them are radiopaque
standing) ➔ radiolucent, -RL band may surround the
radiopaque, or mixed lesion

-Root resorption or cortical - Expansion, displacement, -Floating” teeth as a result of bone

-perforation (fenestration) resorption destruction (don’t cause
Periodontal ligament space displacement because fast growth
becomes wider. -minimal expansion, and
resorption for the same reason

1-Inflammation
• Most common lesion that affects the jaws because the infection that
causes inflammation comes from teeth.
• 4 Cardinal Signs: redness, swelling, heat and pain
• we might be able to see swelling in CT of soft tissues
• Periapical or along root ➔ most of the time the source is Pulpal
• Alveolar crest/furcation ➔ most of the time the source is Periodontal
• Bone marrow (common in posterior mandible), it’s called Osteomyelitis
• Etiology often evident (you see caries or advanced bone loss)
2.Benign Lesion
• It could be benign tumors or benign cyst or fibro-osseous lesions, benign
odontogenic or non-odontogenic tumors

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 • Usually they occur at Tooth-bearing region because the most common
benign lesions are odontogenic
3-Malignant Lesion
• May occur anywhere; posterior more common

well defined part of the RL, poorly RL, poorly On x-ray a lamina dura will
RL, corticated
lesion, poorly defined part defined, defined, appear as a RO line
periapical, surrounding the root. An intact border, loss of
of the lesion(diffused) , periapical,
resorption, lamina dura is seen as a sign of lamina dura
Not corticated, causing resorption,
`
resorption in root circumscribed healthy periodontium

Mixed, Mixed, well Periapical, Mixed, RL, corticated,

pericoronal, defined border, well defined multilocular,
unilocular, well corticated, border, non- Vitality cause
defined border, unilocular corticated, test?! displacement
corticated unilocular,

RL, poorly
defined, floating RO, expansile,
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RL, Poorly
teeth, Poorly defined,
defined,
discontinuity in resorption
the lower
border
 Nasal fossa
Landmarks of the Maxilla & Mandible
Inferior concha
Landmarks of maxilla: Anterior nasal spine
Incisors Region Nasal septum.

Shadow of the lip

Red > nose

Green > lip
Blue > incisive
foramen

Soft tissue of the

nose

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 Canine Region A+b form inverted Y,
we called it Y line of
Ennis

Red > nasolabial fold appears because

the patient is a little bit older.
Blue > Floor of nasal fossa
White > soft tissue of the nose
Yellow > border of max sinus

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 Recess: cavity inside the wall of sinus
Premolar region (sinus wall wasn’t really smooth, there
was a recess) more RL

zygomatic process of maxilla

(malar process or buttress bone).
U or j shape

Nasal
floor

Septum
+ recess

Pneumatization

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 -Hamular process is a process coming down
Molar region from the medial plate of pterygoid bone.

Supernumerary
teeth

Coronoid

tuberosity,
hamular process,
pterygoid plates

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 Mental fossa represent a depression on the
labial aspect, may be mistaken for pathology ..
Landmarks of mandible: that’s why you should follow the lamina dura
and periodontal ligament space to make sure
Incisor Region that they are intact.

Notice here that Lamina dura

is lost and periodontal space
is widened. And this
represent chronic apical
periodontisits, the teeth are
nutrient canals. Seen on older
non-vital due to trauma
person with thin bone + They
increase in advanced peridontitis.
when we have inflammation we
will have increased vascularization

Canine Region

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Premolar Region: A= mylohyoid ridge/internal oblique
C= submandibular gland fossa

Mental foramen usually located on

the premolar area

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Molar Region:

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 Lec:3 - Radiology of Dental Caries + PDL disease
-Caries: The breakdown of tooth structure > due to the presence of acidogenic
bacteria (Acid-producing Bacteria) > that breaks down carbohydrates to form
acids > then these acids demineralize the tooth. bacteria are found in the
white/pale-yellow plaque that builds up on tooth surface.
-The diagnosis of caries is made through a combination of Clinical examination
&Radiographs.
Bite-Wing Radiography:
-the patient “bite” on a small “wing” of paper attached to a film
packet.
-it includes the crowns of max and mand teeth, interproximal
areas, and areas of crestal bone on the same image.
-used to detect interproximal caries that are not clinically evident + assess existing
restorations, and, examine the crestal bone levels between teeth.
-The most susceptible zone for interproximal caries is just beneath the contact
point.
-we need 40-50% demineralization to appear on the radiograph
-the actual depth of penetration a carious lesion is deeper than it appears on
radiographs
• because we have masking from buccal and lingual surface
• In anterior teeth it’s easier to see lesions because there is less tooth
structure buccally and lingually to mask the lesion
Factors Affecting Appearance of Caries on Radiographs:
• Buccolingual thickness of tooth.
• Limitations of two-dimensional film.
• X-ray beam angulation (horizontal and vertical angles): important in
recurrent caries, superimposition of the existing restoration with the
carious lesion (ex: Amalgam).
 • Exposure factors: Caries detection is improved with a lower kVp setting,
which provides a higher contrast. If the overall density of the film is too
light or too dark, the diagnostic potential of the film is limited.
Note: Contrast is how able you are to differentiate between shades
Contrast & Transition:
-On a scale of shades between white & black, the longer the scale (number of
shades); the lower the contrast; and lower the transition.
• we need shorter scales in radiographs
• we need low kVp, thus high contrast and we need optimum density so the
radiograph won’t be too light or too dark.

Transillumination
-interproximal caries can often be diagnosed using transillumination (a procedure
of directing a bright light through the contact areas of teeth and then noticing the
shadow of caries if found). We can combine it with radiograph.
First: Classification of Proximal Caries:
Stage I: The incipient caries: Stage II: The Stage III: The Stage IV: The severe caries:
moderate caries: advanced caries:
-up to half thickness of the more than half -from DEJ to half -more than half way through
enamel, usually not restored way through the way through dentine
unless pt is high caries risk. enamel dentine -we must assume that the pulp is
involved and try to check the
-needs an expert eye and a vitality and response of the tooth
good viewing condition (in a before deciding the treatment
dark room) plan whether it’s going to be
restoration or root canal
treatment.
Second: Occlusal Caries:
-Must penetrate into dentin to be seen on radiographs (must be large). It’s
diagnosed by clinical examination and might be seen as thin radiolucent line or
cup-shaped zone underlying occlusal enamel.
Third: Buccal & Lingual Caries:
-Should be identified from clinical examination.
-It’s sometimes seen as well-defined circular area in middle of tooth, although it is
not very radiolucent and its depth can’t be determined radiographically.
-My clue is the DEJ, since it’s intact especially at the area of the lesion, so the
occlusal enamel is intact and this lesion can’t be an occlusal
one.
Pink circle: buccal caries, it’s not occlusal because the DEJ in its
site is intact.
Blue circle: severe interproximal caries
➢ to know from radiographs if the lesion is Buccal or
Lingual, I must have two radiographs and then use the SLOB technique
example:
-first thing to do is to know the direction of X-ray source movement.
-Here it mesial shift, notice the direction of the lesion movement, it has also
moved mesially, so it’s a lingual lesion.
Fourth: Root Caries:
-Saucer-like cratering on the roots of the teeth, involving the cementum which is
less mineralized and it’s also easier to demineralize. Usually found on older
individuals with prominent recession and/or periodontitis. May have xerostomia
due to medications.
-Confused with cervical burnout

Cervical Burnout:
-is an apparent radiolucency found just below the CE junction on the root due to
anatomical variation,
➢ ex: concavity on mesial and/or distal surfaces posteriorly or
➢ In the anterior teeth that appears as a collar on the tooth crown
-X-Rays pass through the concavity where there is less tooth structure to
attenuate, so the intensity of x rays reaching the film will be high, and it will
appear more radiolucent
✓ this radiolucency usually disappears when another film of the region is
examined.
✓ Caries does not occur on the root of the tooth unless there is loss of
alveolar bone and gingival tissue due to
recession or periodontitis
Fifth: Recurrent Caries:
-found underneath restorations/ at the margins of restorations
-caused by a combination of: poor oral hygiene, failure to remove
all of the caries during cavity preparation, a defective restoration

Mach-Band:
-It’s an Optical illusion
-giving appearance of increased radiolucency at the junction of differing tissue
densities, such as enamel and dentin. And If you block off the enamel with a
fingernail, the radiolucency will disappear, If the radiolucency persists, it may be
caries.
Sixth: Rampant Caries:
-Extensive and rapidly progressing caries usually found in
children and teens with poor diet affects almost all the
teeth and their surfaces.

Seventh: Radiation Caries:

-it means using radiotherapy in treatment of some diseases like cancer. This type
of tx use very high radiation that affects the salivary glands causing permanent
damage to them, resulting in xerostomia
-These patients before receiving the radiation, they should have confrontation
with regard to their teeth:
✓ Their teeth should be restored before they receive the radiation
✓ Any teeth with poor prognosis should be extracted
✓ Very strict oral hygiene instructions such applying fluoride control

Periodontal disease:
-The second most common disease of affecting teeth or the oral cavity is
periodontal disease. Which mean loss of periodontal ligament attachment and
alveolar bony support
-gingivites vs periodontitis
-Junctional epithelium migrates apical to the CEJ and there will be loss of bone
between the teeth and this will be showing in the radiograph.
Normal pdl on x-ray
-We have 3 structures: -lamina dura, -pdl space, -interdental bone
(alveolar crest)
Note: Shape of Alveolar crest determined by the width of contact
point
➢ In the anterior incisor the contact point will be contact area
> this will lead to a smaller interdental bone reaching
upward “pointed interdental bone.”
➢ In posterior teeth the contact region between the
teeth is a point so you have more bone interdentally
“interdental bone is table or horizontal part.”
-The interdental bone should reach a certain point with
regard of the cemento-enamel junction > a normal bone
should be from (0 to 2 mm) apical to the CEJ.
-we measure from a line connecting the two CEJ.
-periodontal radiograph > Bitewings best for diagnosis, or periapical paralleling
-Higher kVp recommended (long scale, low contrast), compare images from
different visits using same technique
The limitation in radiograph
1. 2D image
2. Superimposition of the bone and the tooth structure
3. Relationship of hard to soft tissues not evident
4. Presence or absence of periodontal pockets, because pockets appear on
the radiograph and they can mask or mimic periodontal disease.
5. Early bone loss (<3mm) is not evident.
6. Early furcation involvement is not evident.

Evidence of Periodontal Disease

1-early sign of periodontal disease is a Loss of Cortical Bone + bone marrow
spaces are getting wider/number of trabeculations getting less.
2-Horizontal bone loss: distance between CEJ’s and the bone level is more than
2mm. in case of severe periodontal bone loss > make vertical bitewing
3-Vertical Bone Loss (Angular Bone Loss): The bone is being resorbed more
toward one tooth than the adjacent tooth, and in this condition that line which
connected the 2 CEJ’s is directed in a vertical bone loss

Predisposing Conditions:
1-Tipping of Teeth
2-Open contact: food stagnation.
3-Plunger (condenser) Cusps: Cusps on the opposing jaw that are causing food
during eating to be condensed or pushed into the contact area
making it a susceptible area for caries and periodontal disease.
4-Poor Contours of Restorations and Overhanging Margins
5-Gross Carious Lesions
6-Calculus: mineralized tissue or plaque or remnant of the food that get
mineralized causing a structure on the tooth that makes that surface rough.
• Again, the causing factor of the periodontal disease is plaque, calculus will
help plaque to accumulate more.

Modifying Conditions
1-Crown to Root Ratio (C:R): how much of the tooth is outside
compared to the inside of bone and gingiva.
• C:R normally 1:2 in anterior teeth, while in posterior teeth
about 2:3
• When we have a bone loss there will be bigger ratio, the
crown ratio increases and this will affect the anchorage of
the tooth.
2-Shape of Roots: Could be conical or cylindrical
• cylindrical one has more anchorage
3-Proximity of Roots: when they are too close this will affect the periodontal
disease
4-Position of Maxillary Sinus:
5-Third Molar Extractions: Before doing the extraction, you should look at the
adjacent tooth and see if it will be affected periodontally.
Differential Interpretation
-Periodontal abscess kind of periodontal disease appear as well defined
radiolucent area.
-Periodontal disease stimulating periapical disease

-Systemic Diseases Simulating or Exacerbating Periodontal Disease

• The diabetes mellitus: they are more susceptible to periodontal disease
• Papillon-Lefèvre Syndrome: rare autosomal recessive disorder, there is a
palmoplantar keratoderma and they have precocious aggressive
periodontitis at a younger age + They have premature loss of deciduous
and permanent dentition
 Lec4: Inflammation of The Jaws and Periosteal Reactions
The jaws are different from other bones because teeth create direct pathway for
agents or processes:
- Physical agents: stone, trauma or someone bites something very hard that
will create injury in the pulp.
- Chemical agents: restoration, sealing agent or a liner that is used in that
cavity.
- Microorganisms: bacteria that cause the caries.

-Caries affects the teeth and lead > pulpitis, which could be reversible or
irreversible. If it is irreversible it will lead > necrosis of the pulp > (osteitis or
osteomyelitis) > patient will start having tenderness to biting > on x-ray you only
see widening of periodontal ligament space but no changes in the bone that
needs time and will occur later.
Osteomyelitis:
-can lead to sclerosis or/and rarefaction (bone resorption). If this spread more to
peripheral of cortical bone this will induce periosteal tissue to induce more bone
formation which is called periostitis.
-This periosteal tissue, if it’s adjacent to mucous membrane (like the condition in
maxilla we have maxillary sinus that is line by mucous tissue and periosteum
separating it from alveolar process) this is called mucositis.
• Rarefaction and sclerosis in case of osteomyelitis may lead to sequestrum
that is the hallmark in osteomyelitis.
• Mucositis and periostitis might cause something called involucrum which is
the extra tissue of bone forming underneath this periostitis.
Osteitis:
-A localized inflammation of the bone which can lead to rarefaction, sclerosis,
periostitis and mucositis. can also result in root resorption, and it might cause
extra cementum formation which is called Hypercementosis.
-Untreated osteitis which is the localized form can progress into osteomyelitis.
-the pathogenicity of the bacterial microorganism, immune response, tissue
vascularity and time, can alter the balance and favor of either the bone formation
or resorption.
Illustration:
Mechanism again??
I. We have only rarefaction in this picture which represents removal of
trabecular bone
II. If this is a long persisting inflammation and the host response is increased
and the microorganism have a low-grade infection, this will allow the
surrounding bone to lay down more bone, this is called “sclerosis.”
III. With time this amount of sclerosis increases replacing the area of
rarefaction.
IV. here we have rarefaction and some amount of sclerosis + root resorption.
V. the tissue of the root has responded by laying down more cementum
described as hypercementosis
VI. If you have maxillary sinus also, you can have periostitis and mucositis
VII. if it reaches the inferior border of the mandible in this example this will
induce the osteoblasts present on periosteum to form new layer of bone
and this is called periosteal reaction more layers giving the appearance
“Onion peel appearance.”
VIII. death and necrosis of the bone producing dead tissue of bone that will
appear radiopaque within radiolucent part of the bone and this is called
sequestrum.
IX. So, osteomyelitis with periostitis might spread more causing more layers
and this is called proliferative osteomyelitis
Radiographic terms:
1-Rarefying osteitis (not for diagnosis): describe periapical lesion that’s caused by
inflammation, Rarefying = rarefaction > which means loss of bone mineralization.
rarefying osteitis can hold the diagnosis of some lesions:
✓ periapical abscess, periapical granuloma and radicular cyst.
✓ In all the cases, we assume the tooth is not vital.
Ex:destructed lateral (radiolucent area), (Lamina Dura is lost & periodontal
ligament can’t be seen due to this)

2-Sclerosing osteitis: It occurs if the inflammation was long standing if MO was

low grade and this presents around the periphery of rarefying osteitis or by itself.

3-Osteomyelitis: bone infection, posterior body of the mandible is the most

common site. It may cause:
• Rarefaction→ Rarefying osteitis (loss of bone)
• Sclerosis: radiopacity at the apex of the tooth (Sclerosing
osteitis/condensing osteitis)
• Sequestrum→ Sequestra, dead bone separated from vital bone
• Periostitis→ Involucrum
• Mucositis→ swelling, soft tissue mass thickening.
 Note: -Chronic systemic diseases especially that cause immune suppression like
DM and patient who have decreased vascularity in the jaws and sickle cell disease
patient have persistent Infection agent and high chance to spread.
-one of the most common differential diagnosis for osteomyelitis is malignant
neoplasm
Cases:

hallmark feature of osteomyelitis

is the present of sequestration=
formation of separate dead bony We can see the
islands periosteal formation
this is swelling is due to
it is less radiopaque, because it periosteal reaction,
lost its blood supply compare it
with normal bone

here the patient has

symptoms of spread of
osteomyelitis and fever.
Its poorly defined

CT is very important in detecting

the spread of osteomyelitis and
seeing the internal structures of
bone and abnormal bone and
sequestration

onion peel appearance

with periostitis because
there is one line of
bone forming, when it
is a tissue it is called
involucrum when it is
only line it is called
onion peel
 spread osteomyelitis with
sequestration, as it is spread
this will weaken the
bone,result fracture,
pathological fraction

more localized osteomyelitis,

increased sclerotic
appearance” chronic case” is
not healing and this is due to
remanence of sequestration
that has to be removed

malignant neoplasia invading the jaw bones from adjacent soft tissue space or growing
within bone maybe difficult actually to differentiate it from acute phase osteomyelitis. The
malignant neoplasm maybe has become secondary infected, this patient will have clinical
symptoms as osteomyelitis

It’s histopathology or the biopsy that has to differentiate these conditions

This is an axial CT section showing periosteal reaction, rarefaction, sequestration and

osteomyelitis

❖ Chemical insult:
-Inflammation could occur because of chemical insult
-Many of the imaging features in osteomyelitis can overlap with changes to bone
as a consequence of other factors “not necessary infection or microorganism”.
We need clinical history. and without clinical history it is difficult to know the
cause of the osteomyelitis
❖ radio-osteonecrosis/osteoradionecrosis
-patients receiving radiation as a part of their treatment of oral cancer (radiation
therapy)
-Many of the late effects of radiation injury will involve the bone, it arises actually
as a consequence of the damage of the vasculature (causing less blood supply,
less healing, more chance bony necrosis and damage).
-The most common side effect of radiation for oral cancer is the damage of
salivary gland

❖ Medication induce osteonecrosis

-bisphosphonate and rankle ligand inheritors.
-patients with osteoporosis or hypercalcemia of malignancy or metastatic disease
and multiple myeloma. Will take these drugs to inhibit osteoclast function and
bone resorption and maintaining the amount of the bone there,
-patient before receiving this medication they should go to a dentist and treat
their teeth, because after receive it they should not have invasive procedures
scaling and root planning, extraction because the bone will be expose and it will
not heal again and this will spread and cause MRONJ

This patient has sequestration, spread rarefaction

and sclerosis in the jaw.

These are difficult to know if this is due to MO,

medication or radiation. you have clinical or
history from patient or medical record

-We check all teeth anything that is hopeless or has poor prognosis must be
extracted, any caries has to be treated, very strict oral hygiene should be given to
those patient and then will be referred to receive bisphosphonate and they
should have also regular checkups
Note: -CT is very helpful and MRI also is being used to differentiate soft tissue
neoplasia from inflammatory. The malignant tumors in radiographs are
differential diagnosis for osteomyelitis so sometimes it’s good to have CT to
differentiate the neoplasia from inflammation.
Periostitis: it is a periosteal tissue reaction to inflammation and there are
different possible reactions and causes to cause this periostitis.
➢ Periapical inflammation
➢ periodontal disease
➢ pericoronitis
➢ hematogenous spread: If we don’t have seen any clinical key or cause
➢ orthodontics bands
➢ Trauma (fracture of the jaw)

Inflammation which is in very enclose relationship to the maxillary sinus has some
appearances that are very distinctive , halo effect :
A. Periostitis
We have rarefying osteitis and it’s getting increased and causing resorption and
deposition at the floor of the maxillary sinus so the sinus borders will be at
different location.
B. Periostitis with mucositis
Maxillary sinus is lined by mucosa, if this mucosal tissue is inflamed locally this is
called mucositis
C. Mucositis
Here the inflammatory product has reached mucous membrane and caused
inflammation of the membrane without causing periostitis, and you can see only a
localized swelling of the mucous membrane. It is limited to the maxilla
Mucous retention pseudocyst
-Accumulation of mucous causing dome shape swelling, the teeth tested vital. it is
not related to inflammation or infection

-other conditions that can cause also periosteal reaction this include cysts and
benign tumors and malignant tumors.
In malignant tumors you have specific appearance of that periosteal reaction
that are called (1-codman triangle, 2-sunray spicules/sunburst spicules)
➢ codman triangle.We have extensive and faster growth of the malignant
tumor in comparison to the benign (slow/gradually). The malignant occurs
very fast and we will have separation of the periosteaum from the bone
making this appearance” codman triangle

➢ When we have one layer of periosteal reaction: osteomyelitis.

➢ When it's multiple: periostitis and osteomyelitis
➢ Healing at this stage is called involucrum. appear as a thicker layer.
➢ We have periosteal reaction in thalassemia
➢ sarcoma will have the codman triangle and sunrays appearance
Resorption of Teeth
It is the removal of tooth structure by osteoclasts, referred to as odontoclasts
when they are resorbing tooth structure.
1. External Resorption
2. External-Internal Resorption
3. Internal Resorption

1. External Resorption: The resorption that occurs from the outer surface of a
tooth. most commonly it involves the root surface but may also involve the crown
especially if it is unerupted.
We have two types of resorption: physiologic or pathologic!?
Causes of pathological external resorption
A. Unerupted Teeth
common site for external resorption in general is the apical area
and cervical area but for unerupted teeth it will mostly occur in
the crown.

B. Chronic Inflammation, Inflammation can result in teeth resorption

especially roots.
 C. Idiopathic: there is no specific cause, no history of anything that causes
resorption. Note the tooth is vital

D. Orthodontic Movement:
when it causes aggressive fast movement It can cause root resorption.
E. Space Occupying Lesion
➢ Cysts: these cysts as they grow they are occupying the normal bone and
sometimes they cause displacement in teeth or may cause resorption of
teeth.
➢ Benign Tumors: same thing here, they will grow and occupy bone and teeth
 F. Endocrine: sometimes endocrine diseases cause resorption of teeth. Like
hyperparathyroidism
2. External Internal Resorption
Here we have external tooth resorption that has started on the buccal or lingual
surface and it’s chewing inside. How to differentiate it from internal resorption? If
you can trace the pulp canal with normal width all along > this is external

3. Internal Resorption
Occurs from the pulpal surface (not from outside), and is usually associated with
large carious lesions or restorations. described as ballooning in the canal and the
canal is no more uniformed
➢ Tx: RCT OR extraction
T differentiate between internal and external resorption:
✓ look to the pulp canal , it is intact or ballooning
✓ slop technique
 Lec5: ORAL & PERIORAL CYSTS
-cysts are considered as benign lesions that affect the jaws. (Their occurrence is
less common than inflammatory lesions). derived from the tissues of developing
teeth.*( odontogenic cysts)
-A true cyst is defined as: pathologic cavity filled with fluid, lined by epithelium
and surrounded by a definite connective tissue wall.
 pseudocysts are not lined by epithelium
- are clinically firm to bony hard swellings, usually they are not painful, unless they
are associated with non-vital pulp or if they were secondarily infected.
Mechanism:
 cyst has developed in the jaw by the proliferation of the cells that left
there.
 As the proliferation gets bigger in size, the center part of those cells will get
deprived of nutrients and vascularization, so they will become necrotic.
 Necrosis will increase the osmolarity, fluids will be attracted from the
vascularization (outside the epithelium) into the lumen giving it the hydrolic
appearance and this will produce a cavity. *( water-filled balloon
appearance.)
 Proliferation will continue until it reaches a certain size
 When it becomes adjacent to another structure; either the border of the
cyst will be altered, or the adjacent structure will be displaced.
Importance of diagnostic images for cysts?
-To describe its extent within bone.
-To determine extent of extraosseous involvement
-To determine best site for biopsy
Ways of imaging:
1. Intraoral images: Easy and good option Used mostly to detect subtle (very
small and early occurring) changes occurring around teeth.
 2. Panoramic imaging: can provide overall assessment of osseous structures
of the jaws and peripheries of the jaws’ involvement like changes to
borders of maxillary sinus.
3. CBCT or MDCT: demonstrate 3D involvement of bone
4. MDCT and MRI: show involvement of adjacent tissues
describing a cyst
 Location: it could be in any location.
 Periphery: cysts tend to have smooth, well-defined & corticated peripheries
 Internal structure: most cysts are radiolucent; because they are filled with
fluid, and it could be mixed (septa or calcification)
 Effect on surrounding structures: cyst will displace the cortices especially
the buccal one; because it’s easier to be displaced, expanded (thinner than
the lingual cortex)> will have some fenestrations windows
 Effect on adjacent teeth: displacement of teeth or resorption of near roots

Different types of cysts that affect the jaws:

1-Radicular Cyst (inflammatory cyst):
 the most common type of cysts affecting the jaws
 results when rests of epithelial cells in periodontal ligament are stimulated
by inflammatory products from a non-vital tooth (caries, large restoration,
trauma)
  you have non-vital tooth then the inflammation will reach the apex with
time > will result in radiolucency we call it periapical rarefying osteitis
which can result in abscess, granuloma but if itcorticated and more than
1cm it will be a cyst.
-When cysts developed in the posterior maxilla, they have a special appearance;
because of the image superimposition of the maxillary sinus.

(2nd PM) is the epicenter of the growing RL

lesion
Notice that the lamina dura is destructed at
the apical third + widening of the periodontal
ligament space

2-Follicular Cyst OR Dentigerous cyst

-Forms around the crown of an unerupted tooth from the proliferation of the
reduced enamel epithelium.
-The eruption cyst is a soft tissue counterpart of a dentigerous cyst, the cyst is
around an erupting tooth, so it will be soft tissue cyst instead of bony cyst
 Under histopathologic examination it’s the same of the non-erupted one
General notes about the dentigerous cyst:
 Second most type of cysts that affect the jaws after the radicular cysts
 Usually affects adolescents, 20-40 years old
 Most common sites teeth that are usually impacted: mandibular third
molars → maxillary canines → maxillary third molars
 Unilocular radiolucency (one area/locule): oval or round, well-defined
because it’s a slow growing cyst, often corticated (unless it gets secondarily
infected, it will expand & cortex will be lost)
 Displaces associated tooth (inferiorly) –causes resorption
  A key feature to diagnose those cysts is that they tend to develop from CEJ
not coronal or apical to it.

this is a big dentigerous cyst

displacing the third molar inside
the sinus but it still well-defined
and the cortex still continous

Note: Dentigerous cysts’ treatment usually is the removal of the tooth and the
cyst itself If the lesion is big, instead of removing the whole cyst (which will leave
a very weak mandible) a technique called marsupialization
 Open the cavity to remove the tooth, then fill it with certain medicines
that will induce secondary intention healing and bone formation until it
gets smaller
- cysts have less tendency to reoccur, but some cysts have high incidence of
reoccurance
differential diagnoses for lesions developing pericoronal?
1-Hyperplastic follicles > It’s not that big (the cyst is bigger)
 Normal follicles follow the shape of tooth crown & they are around 2mm
away from the tooth
  while dentigerous cysts have hydrolic appearance (no respect for crown
shape)
2-Amyloplastic fibroma, 3-Odontogenic keratocyst, 4-Simple bone cyst,
5-Ameloblastoma
Odontogenic Keratocyst (OKC):
 Its epithelial lining is derived from dental lamina and is distinctive for its
thin, keratinized epithelium.
 When keratin sloughs from surface of epithelium, a collection of viscous or
cheesy material can be found in cyst's lumen. (Which gives it a cheesy
histopathologic appearance)
 appear as RL cavities within the bone, they tend to grow but not by the
osmotic pressure instead, they have innate growth potential
 most common site is posterior body of the mandible. Usually they tend to
grow Intralumenal growth which is the growth in an anteroposterior
direction instead of causing mandibular expansion that’s why they are
incidentally found.
 90% of cases happen distal to mandibular canines, and half of these cases
happen in mandibular ramus. Another site that’s used to be common in
maxilla is between LI & C, and this lesion is used to be called
Globulomaxillary Cyst (now there is no such a thing,)
 some parts of the lining epithelium tend to proliferate more than the other
parts, so this localized growth of epithelium will make this bud like
appearance or multilocular appearance cysts. This will give rise sometimes
to satellite (away) microcysts, which then might enlarge independently
 that’s why this type of cysts has a high incidence of reoccurrence

Unicystic odontogenic keratocyst

When you have a cyst in the posterior mandible not involved with the crowns or
the roots of teeth, the first thing that should come to your mind is odontogenic
keratocyst
A differential diagnosis: Amyloblastoma (a benign tumor), Dentigerous cys,
Odontogenic myxoma
Nevoid Basal Cell Carcinoma Syndrome/(Gorlin-Glotz Syndrome)
 patients have multiple nevi of basal cell carcinoma of skin
 Palmar and plantar pitting
 bifid ribs and vertebrae might have some fusions
 Polydactyly
 Shorten metacarpals
 Hypertelorism
 Temporal and tempo-parietal area might have buffing
 Pronated mandible
 Skull RG might show Falx Cerebri calcification
 Asymmetry
 multiple odontogenic keratocysts

Residual Cyst
-Develops after incomplete removal of epithelium associated with a previous cyst.
It could be a 1. Radicular Cyst 2. Dentigerous Cyst.
it is not related to a tooth.

Buccal Bifurcation Cyst/ paradental cyst / infected buccal cyst

-not a common, etiology of the cyst is still unknown; Probably it is derived from
epithelial cell rests of Malassez in bifurcation of multirooted teeth,
-The histopathological characteristics of the lining in this cyst is not distinctive and
also it overlaps with other odontogenic cysts,
-The 1st and 2nd molars are more common than 3rd molar.
-The teeth most of the time are not affected as the vitality is intact, they don’t
have any carious lesion and the pulp is not involved and this also helps you to
exclude radicular cyst.

Lateral Periodontal Cyst

-It is associated with a periodontium tissue or periodontal ligament space.
-Lateral to canine and premolar area.
-Thought to arise from epithelial rests in periodontium lateral to the tooth root.
-differential diagnosis include small OKC, neurofibroma ,neuroblastoma and also
rarefying osteitis
-Sometimes radiographically it appears that there is a resorption in lamina dura
and that makes it difficult to distinguish from radicular cyst but if you see an
intact lamina dura that means it is not a radicular cyst
because the source is not from the accessory canal.

Calcifying Odontogenic Cyst (Gorlin cyst)

-spectrum of appearances because they start as
radiolucent cavity in the jaw with the characteristics of a
cyst and in some instances a solid neoplasm (doesn’t have a hydraulic
appearance).
-most common location of this lesion is mesial to the 1st molar
-Homogeneous radiolucency or “salt and pepper”calcifications.
-differential diagnosis including ameloblastoma and OKC , ameloblastic-fibro-
odontoma (it has radiopaque flexes), calcifying epithelial odontogenic tumor,
--They might also develop around impacted crowns but those radiopaque flexes
will determine that this is not a dentigerous cyst

 not radicular because we don’t have a tooth,

 it’s not dentigerous because we don’t have an impacted
tooth,
 it’s not an OKC because OKC doesn’t cause that amount of
expansion and doesn’t have radiopaque flex.

The non-odontogenic cyst

Cyst that arise from epithelial inclusion or entrapments in the lines of closure of
developing facial process during embryonic period of life
Incisive Canal Cyst (Nasopalatine Duct Cyst)
-Most common non odontogenic cyst
-Midline anterior maxilla (very specific location).
-Persistence of epithelial remnants
-Stimulus – trauma, infections, not-known, and this will stimulate its proliferation
and developing of that cystic cavity. Clinically it occurs in the palatal side.
-differential diagnosis is the canal itself or the foramen itself and your reference
here to know if it’s the foramen or a cyst is to compare it with the width of the
central incisor, when it’s width is 10mm or more you should think that there is a
cyst developing here, when it’s less than that size then it’s a foramen.
-sometimes because its involving a pulp or the apices of the teeth, the first thing
that should come to your mind is including or excluding rarefying osteitis which
include radicular cyst
 Examine the teeth carefully and make a radiograph and see if the lamina
dura is intact and if there is a loss I have to double check the vitality of
these teeth
 Pseudo Cysts and Noncysts
-They are not lined by epithelium.
Mucous Retention Pseudocyst, could be also called: Mucous Retention Cyst ,
Serous Retention Cyst , Mucosal Cyst
-The incidence of this pseudocyst is 2.6% patients,radiographically and they have
no clinical impact.
-Some patients have big and recurrent pseudocysts and complain from some
congestions in their sinuses, it is due to a blockage of the goblet cells That
produce mucus, those goblet cell get blocked sometimes due to certain
environmental factors, this blockage in the goblet cell will make the mucus that’s
produced by it accumulate.
-has a dome shape
-important also to differentiate it from radicular cysts developing in maxillary
teeth, as we said in the radicular cyst the teeth will be affected while here in the
pseudocyst the sinus will be affected and has nothing to do with the teeth and
has no radiopaque border which tells us it’s a soft tissue swelling.
Simple Bone Cyst: Traumatic Bone Cyst ,Hemorrhagic Bone Cyst ,Solitary Bone
Cyst ,Unicameral Bone Cyst ,Idiopathic Bone Cyst.
-they arise from a local disturbance in the normal osteoblasts /osteoclastic
differentiation and coordination.
-Most of time they don’t have any effect on teeth and don’t displace teeth,
instead they will actually scallop between teeth
-Margin vary from well to ill defined but non-corticated
-have higher association with what is called bone dysplasia like cemento-osseous
dysplasia.
-have incidence to occur in females more than males(4:1) in the 5th decade of life.

Mandibular Lingual Bone Depression/Salivary Gland, Inclusion Defect, Stafne

Defect
-it is a depression in the lingual surface or inferior surface of the mandible, they
are developmental in origin and their border is the cortex of the mandible, the
peak incidence is in the 4th and 5th decade of life, it is not a congenital anomaly.
-Sharply circumscribed radiolucency beneath the level ofthe inferior alveolar
canal
 Radiology of benign tumors (I)

-Neoplasms → are formed by cell proliferation that has lost the normal mechanism that control its proliferation
(unlimited). found incidentally in the jaw .

Features of benign tumors:

• it grows in an unlimited, aggressive manner,
• Well defined.
• does not invade surrounding tissues,
• Corticated.
• does not metastasize
• Space occupying.
• Displacement of teeth (bodily + tipping) • resemble the tissue of origin histologically
• Directional resorption of teeth.
• Displacement of anatomical structures
>Displacement of periosteum: cause endosteal resorption and periosteal bone formation
• Radiolucent but sometimes there will be fragments of trabeculae & calcification
• Unilocular or multilocular with septation (could be curved or straight)
Classify:

Epithelium Mixed Mesenchymal

Odontogenic 1-Ameloblastoma (the most common). 1-odontoma 1-odontogenic myxoma
tumors 2-Adenomatoid odontogenic tumor. 2-ameloblastic fibroma 2-bening cementoblastoma
3-Calcifying epithelial odontogenic tumor 3-ameloblastic 3-central odontogenic fibroma
odontoma
Odontogenic 1-neurofibroma 1-osteoma
tumors 2- 2-gardner syndrome
3-hemangioma 4-osteoblastoma & osteoid
 Often Hamartomas (not actually a neoplasm) are included in the category of benign tumors. However, hamartomas
are overgrowths of disorganized normal tissue that have a limited growth potential

Ex: Odontoma , hemangioma , adenomatoid odonotgenic tumor , lymphangioma

Clinical features Periphery and Shape Internal structure

-gradual onset and grow slowly -borders appear round or oval -RL or RO or MIXED
-painless, do not metastasize relatively smooth, sometimes well
-Not life threatening unless they interfere with vital defined, sometimes ill-defined if it is -uniocular or multicoular
organ infected, but usually corticated.
-detected clinically by enlargement of the jaws or -Malignant lesions are completely
during a routine radiographic examination -sometimes results in a radiolucent radiolucent
-common in the post.mand band of soft tissue or capsule at the
periphery

Effects On Surrounding Structure Effects on Adjacent Teeth Notes

-displacement of teeth or bony cortices -root resorption more commonly is - cone beam CT (CBCT) > centrally within
-if the growth is slow, adjacent structures may associated with benign processes. the bone
respond by remodeling around the enlarging mass -MRI > soft tissue involvement.
-displacement of ID canal or max sinus
 odontogenic epithelial tumors

Benin
odontogenic Clinical features Radiographic findings
tumors

➢ Locally invasive/aggressive, derived from remnants of dental - radiolucent to mixed with coarse and
lamina (most common) curved septa + cortication
Ameloblastoma ➢ Male, average age 40, more in mand + 60% in molar-ramus area - Unicystic or multicystic (soap
➢ Slow growing with Gradual facial deformity & bone expansion bubble/honnycoap)
➢ Egg-shell crackling (advanced stage) -Root resorption or tooth displacement
➢ High recurrence rate in older pt -Expansion or perforation of the bone
➢ -Benign, locally invasive but less than ameloblastoma
➢ -Very rare, male, 10-90 (mean 40) ➢ may be well or poorly defined
➢ -Post.Mandible (premolar-molar-ramus), 50% associated with ➢ Varying amount of RO bodies due to
CEOT crown of unerupted tooth classification
“Pindborg tumor ➢ -displace the tooth or prevent its eruption, and may cause ➢ unilocular, or multilocular.
resorption of tooth roots
➢ -located within bone and produce a mineralized substance
➢ -High recurrence rate
➢ Uncommon 3%, non-aggressive tumor ➢ Well-defined RL , corticated
➢ found in child or adolescent. 10-20 years ANT.maxilla , Females ➢ Frequently envelopes crown of
Adenomatoid ➢ Slow enlarging swelling unerupted tooth especially maxillary
.O.T ➢ Can be central (in the bone) or peripheral (in the soft tissue), can canine
be follicular (pericoronal, associated with the crown of an ➢ displace rather than cause resorption
embedded tooth) or extrafollicular (with no embedded tooth) of adjacent teeth
➢ Later develops calcified “floccules” as
content. salt & pepper appearance
D.D: dentigerous cyst, Odontogenic keratocyst. odontogenic myxoma

-Both OKC and odontogenic myxoma extend anteroposterior (tunneling) instead

of buccal expansion while ameloblastoma extends buccaly
 CEOT : large lesion of left mandible
coronal CT from same case of shows a honeycomb-like
large lesion in right maxilla with distribution of calcifications. The
marked expansion and cortical borders are corticated (well-
destruction defined). There is displacement of
an unerupted tooth

D.D:

• ameloblatsic fibroodontoma ,
• calcifying odontogenic Cyst
• adenomatoid odontogenic tumor
 Adenomatoid .O.T

nusual large multilocular mixed

lucency/opacity in midline of
mandible. Note content of
calcific flocules

D.D: anything that has calcification, and it is well defined, corticated in

anterior maxilla and mandible:

• calcifying odontogenic cyst and

• calcifying epithelial odontogenic tumor.
 Mixed odontogentic tumors

Benin
odontogenic Clinical features Radio
tumors

• it’s tooth like material surrounding the crown of impacted -largely radiopaque.
tooth and it’s capsulated -well defined and may be smooth or
• most common mixed odontogenic tumor irregular, have a cortical border with soft
• before age of 20 capsule
• can interfere with the normal eruption
-note:
-Most odontomas (70%) are associated with abnormalities, such as Ameloblastic fibro-odontoma most of the
impaction, malpositioning, diastema, aplasia, malformation lesion is radiolucent with few enamel and
Odontoma dentine
hamartoma 1-Complex odontoma (non-descript mass of dental tissue) > 70%
Posterior mandible, disorganized, can't be differentiated Odontoma is radiopaque with areas of
enamel
• it is small , don’t cause expansion , incidentally found.

2- Compound odontoma (multiple well-formed teeth) twice as

common as complex, 62%anterior maxilla, well-differentiated

• more common in permanent teeth

• Compound odontoma seldom cause bony expansion

Complex odontoma

Compound odontoma
 Mixed odontogentic tumors

Benin
odontogenic Clinical features Radiographic findings
tumors
➢ Not invasive ➢ unilocular, or multilocula RL
➢ Young age group, occur between 5 and 20 years of age, during ➢ well-delineated and corticated.
the period of tooth formation ➢ cause displacement of teeth apically or
Ameloblastic ➢ associated with an unerupted or impacted tooth inhibit eruption.
fibroma ➢ POST.mandible ➢ Expansion without perforation
➢ Expansion of the cortical plate without perforation

➢ Rare tumor ➢ Well-defined unilocular or multi RL

Ameloblastic ➢ consists of segment of enamel & dentine with variable amount of RO material
Fibro-odontoma ➢ Small lesion appears as enlarged follicle with small RO May associated with crown of
➢ Most often associated with impacted tooth , POST.MAND unerupted teeth

ameloblastoma, ameloblastic fibroma and ameloblastic fibro-odontoma : how to differentiate?

1-If the pt over 40 > ameloblastoma , if the pt under 20 > either AF or AFO , how to differentiate?

2-If we see on the x-ray enamel and dentine like-structure > AFO, if not > AF

ameloblastic fibroma > amelo blastic fibro-odontoma (dentine& enamel)> complex odontoma
Ameloblastic fibroma
 Ameloblastic Fibro-odontoma

Most important features: radiopaque foci,

1-ameloblastic fibroma >

2amelo blastic fibro-odontoma (dentine& enamel)>

3-complex odontoma
 Mesenchymal tumors

Benin
odontogenic Central Odontogenic Fibroma Myxoma Cementoblastoma
tumors
• Rare neoplasm • females of young age (10-30) • A slow-growing neoplasm composed
• All age groups (11-39) • maxilla=mand principally of cementum surrounds
• Has female predilection • Locally invasive + High the tooth itself (tooth remains vital)
• May or may not be Recurrence rate • It’s painful
symptomatic • grows anteroposteriorly • M>F
Clinical features • have one or more, thin • usually before 25 y
straight septas and at right • usually solitary
angle to each other.They
like the honeycomb’).
➢ Well-defined ➢ Unilocular or Multilocular RL ➢ Is well defined RO with a RL halo
➢ Small lesion is “soap-bubble or tennis racket surrounding the calcified mass,
unilocular, large lesion is appearance ➢ Mixed RL & RO lesion
multilocular ➢ Root displacement rather ➢ May have wheel pattern
radio ➢ -Expansion of the jaw than resorption ➢ cause root resorption, or expansion of
without perforation of ➢ Well defined with cortical the cortex of the mand.
the cortical plate margin
➢ Tooth displacement ➢ Scalloping of lesion between
with root resorption roots
reported
 dentigerous cyst or ameloblastic fibroma or unicystic or unilocular
ameloblastoma or OKC (all of this right initially) + odontogenic
fibroma should be included in this list +central giant cell lesion or
odontogenic myxoma specially when the have septation

✓ It is a central odontogenic fibroma but we can’t know from

this radiograph alone.

Peripheral odontogenic fibroma

We have a lesion that is developing outside the bone

(peripheral)+ there is a radiopacity at the center of lesion
Expansion (buccaly) + there is
some perforations

“honeycomb” multilocularity,
finely septated

lateral-oblique view of an
extensive multilocular
(“honeycomb”) radiolucency
shows little jaw expansion. The
mandibular canal is displaced
downward (arrow). The third
molar is displaced into the ramus.
This is a lesion that causes displacement (there is no
resorption) there are straight septations (not as coarse as
in ameloblastoma)

The differential diagnosis must include first the myxoma

(because of straight septations and absence of resorption
of teeth) but of course ameloblastoma should be in the
list as it is the most common odontogenic tumor in the
jaw
D.D

-Periapical Sclerosing osteitis However PSO is involved with non-vital teeth and it is not a
lesion, just an area of increased density

-Enostosis Is never surrounded by soft tissue capsule

-Hypercementosis : It is not painful + Will not result in root resorption, expand bone

-periapical cemento osseous dysplasia There will be radiolucency surrounding the root and
those lesions doesn’t cause root resorption
 non-Odontogenic Tumors:

non-
Odontogenic Clinical features Radiographic findings
Tumors

❖ Central giant cell granuloma -Irregular or multilocular radiolucency

➢ common benign reactive lesion. (so it is not a true neoplasm) without cortication.
➢ 50% detected at a young age < 20 years. 60% in females. -Displacement and resorption of adjacent
➢ Maxilla affected in one-third, if it happened in mand it will be on teeth are common.
premolar molar region -sometimes “salt and pepper “ calcification
may appear
Giant cell lesion thin, wispy septa
(granuloma/tumor)
❖ Peripheral giant cell granuloma
➢ occurs in fat tissue and may cause some changes in the bone.
➢ patient will come with soft tissue tumor. caused displacement and it also
➢ swelling in the gingival margin and it may cause ulceration, might cause resorption of the crest of the
bleeding, discomfort, and sometimes they are painful. bone
➢ pyogenic granuloma has the same clinical features but it is more
common in pregnant ladies
-after 21 years (that is the difference between it and GCG) -radiographic appearance similar to GCG so
True giant cell -rare in jaws it has a thin wispy septa
-posterior to first permanent molars (in GCG more common anterior to
tumor 1st molar)
-painful
 So young patient with a lesion causing tooth resorption →
central giant cell lesion

Peripheral giant cell granuloma

 non-Odontogenic Tumors: ectodermal

non-
Odontogenic Clinical features Radiographic findings
Tumors

- proliferations of Schwann cells in a disorderly pattern -RL AND can be unilocular or multilocular
-Age: any but usually young -usually very well defined and may be
Neurofibroma -solitary or multiple lesions “ Neurofibromatosis” occurring in both jaws, corticated.
MIXED tumor can occur anywhere -fusiform enlargement of the canal.
-Pain + Paresthesia -no effects on the teeth.
-Von Reckinghausens’s disease : Autosomal dominant multiple
neurofibromas of the skin and mucosa, and associated café au lait
pigmentation
-high potential for malignant changes
 non-Odontogenic Tumors: Mesodermal

non-
Odontogenic Clinical features Radio
Tumors
-are benign tumors that consist of compact bone or cancellous bone or -Central lesion : well defined RO lesion
combination
-more common on (frontal>ethmoid>maxillary>sphenoid) -Periosteal : asymmetry extending outward
-uncommon in the jaws
-many so-called osteoma probably reactive or “burned-out or
leftover fibrous dysplasia -multiple osteoma of jaw > gardner syndrome
Osteomas -asymptomatic , older than 40 years. ( multiple polyp of large intestine )
-normally covering mucosa & freely movable, sometimes it may be
sessile or pedunculated
➢ Pedunculated = with a neck
➢ Sessile= without a neck

- osseous neoplasm of bone, uncommon in the jaws -central RL with peripheral RO or central RO
- smaller than 1.5-2 cm with RL hallo . bull’s-eye appearance or target
osteoid osteoma -On the spine of a young person. appearance
-Painful
-male > female, age is 17 years, -It increases bone activity.

Benign intraosseous lesions with similar clinical, radiographic, and histopathologic features consisting of
well-demarcated, round intraosseous swellings

Osteoblastoma & cementoblastoma: >2cm.

•Osteoid osteoma: 0.5-2cm.

cancellous bone osteoma
Gardner syndrome :

-multiple osteomas, -supernumerary and impacted teeth, -cutaneous sebaceous cysts, -subcutaneous fibromas,

-multiple GI polyps that can undergo malignant transformation, -multiple DBIs (enostosis), -epidermoid cysts &

-subcutaneous desmoid tumors, Odontomas …. has a cotton wool appearance

 non-Odontogenic Tumors: Mesodermal

Clinical features Radiographic findings

-proliferation of blood vessels “endothelial vascular cells” - variable appearance

-hamartoma -Ill-defined irregular shape, occasionally
1-central (intraosseous) “multilocular” or “honeycombed.” Or “moth-
➢ type is most often found in the vertebrae, skull and rarely in eaten” bone pattern
the jaws -ID canal increase in width > serpiginous
➢ no phleboliths shape
➢ asymptomatic so it can be Incidentally found
Hemangioma: ➢ hypoplastic teeth (smaller in size) -When the hemangioma involves soft tissue,
➢ -female , first decade the formation of phlebolith (small areas of
calcifcation or concretions found in a vein
2-Extraosseous Hemangioma, occurs in soft tissue ( it is Common ) with slow blood flow)

➢ phleboliths developed due to blood clotting and thrombus -target like appearance which
➢ The lesion may cause loosening and migration of teeth or is the radiopaque circles with radiolucency
rebound mobility (f tooth is pressed It returns back to its inside
original position)
angiography as we inject a radiopaqe contrast in a vein and it will go to that lesion
inside the bone and that tell us that this lesion is totally vascular which mean we
have hemangioma here and this is very important in diagnosis because any tempts
to removal or interrupting this lesion or even a biopsy will induce a life threaten
bleeding to the patient

-no more practiced, because now we have MRI which is a better

Melanotic Neuroectodermal Tumor of Infancy

rare

in the first year of life usually from age 1-6 months ‫مميز اشي اكتر‬

rapid onset and alarming local growth rate.

typical premaxillary position

bone destruction and displacement of teeth because this tumor is space occupying
well-circumscribed radiolucency but not necessarily well defined

bone is destroyed as the tumor advances

 24/11/2020

7 part 1

Ghaidaa aljamal

RADIOLOGY OF MALIGNANT TUMORS

Hamza Al-Sleati

Hamza Al-Sleati
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 RADIOLOGY OF MALIGNANT TUMORS

Introduction
Las time, we discussed the radiology of benign tumors and we knew that benign neoplasms are the
result of uncontrolled proliferation of cells , and that what makes the swelling of these neoplasms.
While in malignant tumors or neoplasms, malignant means the Tending to become progressively
worse, and resulting in death, the cells that proliferate in these tumors are abnormal (poorly
differentiated , different from the origin, tend to reach sites away from the tumor origin or primary
tumor ), unlike the benign neoplasms which are normal cells, also the malignant tumors infiltrate and
disturb the function of normal tissues and may result in death.

• There are two main categories of malignant tumors affecting the jaws, they are:
- Carcinoma: A malignant neoplasm made up of epithelial cells (such as mucosa in the mouth
as buccal mucosa, and lining of the maxillary sinus)
- Sarcoma: A malignant neoplasm usually arising from connective tissue cells underneath the
epithelium ( the cell of origin could be: cartilage, bone , fibrous tissue).

• Our role in detecting these tumors through radiology:

- If there is clinical suspicion for a malignancy in the maxillary or mandibular regions, plain
radiography is inadequate. You kay suspect the presence of these malignancies through plain
radiographs or clinically.
- CBCT is also insufficient as the adjacent soft tissues are poorly demonstrated (not shown),
which may be important to rule out malignancy in that area
- Multidetector computed tomography (MDCT) is often the imaging modality of choice, often
with intravenous contrast. These contrast materials will be deposit more in the malignant
tissues , this will be helpful in detecting them.
- Magnetic resonance imaging (MRI) is also essential, because it shows the soft tissues
adjacent to the malignancy.
- Single-photon emission computed tomography (physiologic combined with anatomic imaging )
and positron emission tomography/computed tomography may be required

Characteristics of malignant lesions affecting the jaws

- Poorly defined, Because those tumors grow fast in comparison to cysts and benign tumors. It
will be growing without control that’s why you will not have a definitive line between the normal
and the abnormal
- Non-corticated, because it grows fast, there will be no chance for the normal bone to respond
by laying a cortex around those lesions .
- Space occupying. In some cases they will spread through the bone and will not cause
displacements of tissues or teeth
- Non-resorption of teeth. Even if it happens, it is not directly from the center of the growth,
while in cysts and benign tumors there were some resorption of teeth and it was at the growth
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 center that was touching the teeth in contrast to what happens in malignant lesions in which
the resorption in areas that doesn’t appear to be touched by the lesion.
- Destruction of anatomical structures, instead of being displaced like what happens in cysts
and benign lesions.

This one (the left) is well defined although it is not corticated,

some malignant tumors have a well defined borders but not
corticated.
This one (right) is an ill-defined tumor, and the small white
lines represents the normal trabeculation that was here, and
you can see that there is no obvious border.

it is not actually a space occupying lesion (it doesn’t cause

displacement of teeth), but you can say that it has replaced
bone here so it has occupied the space of that bone without
displacement of teeth.

this photo is the same as the previous one but from another
view.

As we said it rarely cause tooth resorption, but if it happens it is

called non-directional resorption, it causes resorption from a site
other than the epicenter

And here it causes destruction of normal structures.

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 - If the growth of the tumor reaches the periosteum the lines the jaws or the maxillary sinus
between it and the alveolar process, this will lead to the Destruction of the periosteum rather
that displacing it, and there will be remnants remained at the edge of the destruction, this will
lead to periosteal reaction and periosteal bone formation with an appearance that is indicating
a malignant tumor.
- Internal structure of the tumor within the bone consists of trabeculae & calcification
- Could be “Unilocular” or “multilocular”

this is an illustration of a growing tumor within the bone, it

has reached the periosteum and caused destruction the
cortex of the periosteum (there will be no bone formation
to replace it) , so there is no cortical border here in
contrast to what we saw with benign tumors where the
periosteum and the cortex will be maintained

some remnants of the osteoblasts at the edges of the destructed

periosteum will have some bone formation that looks like a
triangle and it is called codman triangle.
This is seen especially in osteosarcoma and chondrosarcoma.

there is another periosteal reaction when it is destructed that is

called sunray spicules or sunbusrt apperance. This can
develpo with some matastatic tumors
You can notice the presence of codman triangle too

some lesions are not totally radiolucent, we may have some

trabeculations, and sometimes you may have abnormal bone
formation in sarcomas.

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sometimes you may have a granular appearnce in the lesion

here you have a combination between granular and

trabeculation.

it could be unilocular (the upper half) or multi-locular (the lower half),

but this multi-locularity is different from that seen in benign tumors and
cysts (like OKC) which have corticated locules, you will have like
septums which result from the trabecular bone in these lesions.

while in malignant lesions, you will not see such things, you will not
see any cortication at the edges.

you can see a well defined, corticated, hydraulic

lesion which could be a cyst or benign neoplasm.
If it doesn’t have a hydraulic appearance, then it is
more likely to be a benign neoplasm rather than a
cyst, although some cysts doesn’t have a uniform
hydraulic appearance (like OKC).
If you see an ill-defined lesion, you should about a
malignant neoplasm.

5|Page
Carcinoma
• The clinical appearance of carcinomas affecting the jaws would be:
- Ulceration ,the patient complains of an ulcer that doesn’t heal, and it has been there
(persistent) for a long time,
- Not usually a tumor mass, it can cause a swelling but usually a carcinoma is an ulcer, it
causes a swelling if it has been secondarily infected then it can cause an elevation and feels
like a tumor
- Early bony involvement may appear as a focal erosion of cortex, (ulceration happens in
the mucosa that covers the bone (such as lingual or buccal mucosa), not like the tongue
except if it’s root is very big and close to the lingual side of the mandible, then it will cause
erosion),

Carcinomas could be:

- Primary carcinoma (from epithelium of the oral cavity)
- Secondary (metastatic) carcinoma (from distant organ)

Primary squamous cell carcinoma

when it is a primary carcinoma, it is from the mucosa lining the bone, it will cause erosion of the
cortex, then the lesion goes into the trabecular part of the bone and becomes larger and larger. This
stage might be neglected by the patients
Note: oral cancers is common in people with bad oral
hygiene such as smokers, alcoholics and old patients.

Also the lesion can start in the mucosa lining the maxillary sinus, it
can appear as a tumor realtive to the air surrounding the lesion

Here it started to invade the bone and destructing the lamina dura.

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Here it continued to cause bone destruction. This destruction has
spread from the sinus towards the oral cavity, we can now that
from the small sheet of normal bone remaining between the teeth,

Here there is no signs or erosion or invasion from the sides,

despite that you should not suspect that it is metastatic.
Remember that the bone is a three dimensional structure and
the radiograph has only two dimensions, so maybe the
invasion is from the dimension that you don’t see (as the
lingual or the buccal side). as you see in the picture, it can
have some radioopacities left from the destructed bone.

Here is an example of primary carcinoma affecting the alveolar

process of an edentulous area, you can see that the mucosa is
a little bit swollen (so clinical there is an affected mucosa).
When we took a radiograph of this persistent ulceration, we
can see that it has made an erosion the alveolar crest, so we
can suspect the presence of carcinoma especially when there
is lymphadenopathy in the surrounding lymph nodes, also from
other clinical features like weight loss.

This radiograph is for the same previous lesion but from another
angle, you can see that the teeth has not been displaced by the
growth of the tumor, also without resorption of the tooth, only bone
destruction surrounding the teeth.

the absence of displacement of teeth is a feature of carcinomas

affecting the jaws called teeth standing in space, the teeth are
held in place by the carcinamous materials growing between the
teeth.

7|Page
here we have a periapical radiograph of the left maxillary area,
there is a lesion extending from the mesial surface of the
canine, the lesion has destructed the bone between the teeth
and we can notice the absence of periodontal tissues, but the
teeth are still in place (standing in space)

this radiograph is for the same patient and you can see the
extension of the destruction

this radiograph for another case from the right maxilla, even
the bone that left is almost destructed and ill-defined and
non-corticated, you can notice the bone surrounding the
teeth is lost, only the tips are left with bone.

this is a lateral oblique radiograph of the mandible, teeth are

absent but you have some roots remaining, if you look at the
top surface of the edentulous crest , you can see that is it
eroded and destructed, this is found in malignancy

8|Page
This is a panoramic radiograph for the same patient, if we
compare the right side with the left side, you can notice the
features of malignancy such irregular destructed bone with
some soft tissue swellings, you can notice the presence of
some teeth especially anterior teeth.

these are periapical radiographsn of the anterior right side

of the mandible of another case, we can notice that the
teeth are left in space with ill-defined, irregular destructed
mandible, which are findings in carcinaoms affecting the
mandible

This is a CBCT image (peri-sagittal section – the right

one) showing the buccal and lingual sides of the premolar
tooth, we can see the destruction of bone (also in the
upper surface of alveolar canal), also we can notice that
the invasion is not from the lingual or the buccal side, it
has invaded from the occlusal surface (notice the left
picture which is oblique coronal section of the same area)
.

this is a cropped PA radiograph showing an entulous patient, if

you compare the left side with the right side, you can see that in
the right side the crest of the mandible is intact, while on the left
it is lost and the bone is destructed, so it is most likely a
carcinoma

9|Page
 this is another radiograph
for the same patient, the
tumor has been resected,
but there is some tumor
left here (the red arrows)

the remaining lesion has grown and caused destruction of the

another portion of the mandible . those carcinomas are very bad with
very poor prognosis, that’s why the treatment should be done by the
resection of the tumor followed by radiation therapy, the teeth before
the radiation have to be cleared and the ones with bad prognosis
have to be removed, because radiation therapy increases the
chance of radio-necrosis, also the vascularization to the jaws and
the salivary glands will be affected by the radiation therapy which
might lead to xerostomia which will increase the caries risk and pulp
necrosis of the remaining teeth, and eventually causing periapical inflammation and sometimes
osteomyelitis due to the radiation.

Note: the morbidity of oral caners is really bad, with very bad quality of life because of defects in the
structures of the mouth affecting the speech, swallowing, eating, etc

This is another example of teeth floating in space, and the line

shows us where the bone was supposed to be before the
destruction

10 | P a g e
Another example of teeth standing is space, in the circle you can see
that the nasal floor has been destructed, also with the alveolar bone
anterior nasal spine and part of the nasal septum.

this is a lateral oblique radiograph of another case of an edentulous

mandible, we can see a big ill-defined erosion

There is a rare case of carcinoma called glandular carcinoma, it

arises from the epithelium forming the salivary glands, sometimes
from remnants from the embryo in the bone, the appearance is
described as being multilocular well-defined radiolucent lesion,
these lesions are common in the posterior mandible.

you can see here a glandular carcinoma in the posterior

mandible extending to the anterior mandible where the
sublingual glands are present.
When these lesions are in the posterior mandible, they
should be mentioned in the differential diagnoses of the
radiolucency with other lesions such as OKC and
ameloblastoma.

11 | P a g e
These radiographs show multilocular
lesion in the anterior mandible, glandular
carcinoma will be part of the differential
diagnoses

These are radiographs of the same patient ,

you can notice the multilocularity

notice the multilocular lesion here, sometimes it is corticated, it

looks benign , but the first thing that will come to your mind when
you see multilocular lesion in the angle of the mandible
(especially if doesn’t cause expansion) is OKC or
amelobastoma, but also you should suspect glandular
carcinoma.

this is a coronal CT section (bone window) showing the right

side of the mandible in the ramus area that is affected by
multilocular lesion that is causing destruction of the lingual
and the buccal side of the mandible, this is glandular
carcinoma.

12 | P a g e
carcinoma can arise also in the mucosa (epithelial lining) of the
sinuses, and then causes destruction of the bone from inside the
sinus toward the alveolar process.

You can see here that the lseion has spread from within the
sinus to the outer surface of the alveolus causing it’s destruction,
it causes lysis of the bone supporting the teeth and will leave
them standing in space.The centre (origin) is from the sinus not
from the oral cavity or alveolar ridge. This lesion might appear
radio-opaque in the sinus compared to the air filled sinus, this is
helpful in the diagnosis of these lesions

this is the same image. Notice that the alveolar ridge is intact, so
the sinus is the center.

This is an Occipitomental view (Water’s view).The normal sinus

should be radiolucent because it’s filled with air with intact
borders (the left one) The abnormal sinus (right side) is swollen
and is getting bigger and has caused destruction in the walls of
the sinus, there is occupation and radio calcifications of the
sinus, it even caused destruction to the inferior orbital rim and
part of the zygomatic bone, so when this destruction appears,
suspect malignancies in the sinus (carcinoma).

13 | P a g e
this is cropped water’s view for another case of an edentulous
patient. The normal sinus with intact walls is the right one, The left
side is abnormal, and it’s totally obliterated with soft tissues (not
filled with air). The normal border of the sinus is visibly absent
(destructed), and it has caused destruction of the buccal side and
mesial wall of the sinus. When this destruction is seen, suspect
malignancies.

this is a CT image. Left image: soft tissue window

Right image: bone window
Appreciate that there is a mass within the sinus that
causes destruction of the border especially the medial
one, so this is a carcinoma.

this is a PA skull. Not only the maxillary sinus is affected,

other sinuses are affected too, the normal border of the frontal
is not corticated, it is slightly destructed . But here there is a
lesion causing destruction (carcinoma).

This radiograph for the same patient, Here you can see the
destruction of the border of the sinus is moving toward the vertex
of the skull.

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 lateral image of skull. Normally, the skull bone is composed of
inner cortical plate and outer cortical plate, with a spongy bone
layer called diploe between them. Here, the outer cortical plate and
the diploe are destructed due to carcinoma from the frontal sinus.

Secondary Squamous Cell Carcinoma

This carcinoma comes from a distant organ either through the blood (hematogenous spread) or
through the lymph ( lymphatic spread) or perineural spread, it is rare for these lesions to metastasize
to the jaws, an example is breast cancer or prostate cancer, which are osteoplastic in nature (it
causes destruction of bone more commonly than bone formation).
The secondary carcinoma of the jaw might give us a clue about the primary carcinoma that the
patient might not be aware of, so it might help in identifying the primary cancer.
as mentioned, occasionally the first sign of cancer is somewhere else in the body, meaning that the
features in the mandible and maxilla include metastasis of primary cancer in the body while the
patient and doctor are unaware of this cancer.
Because they are metastatic, which means they don’t arise
form tissues of the oral cavity, they come from lymphatic
spread or hematogenous spread , they will appear as
multiple lesions (radiolucent areas) in one or two areas of
the jaws, when we see this, we must suspect the presence
of a secondary tumor. Unfortunately, those lesions if they were not caught early, they will grow bigger
and unite to form one big lesion, and it becomes to tell that this a metastatic lesion in this stage
because it has lost it’s multiplicity.
those patients don’t have any ulcerations in the mouth, they might have pain because metastasis to
the bone causes pain, those lesions must be referred to the oncologist to make an investigation by
doing bone scans which will give us idea about the lesion.

this is a cropped panoramic radiograph that shows multiple

radiolucent lesions. The patient didn’t have any clinical findings
intra-orally so it is a metastatic tumor. Inflammation (especially
osteomyelitis) was suspected due to the infection of the tooth
because it appears similar radiographically.

15 | P a g e
because inflammation was suspected, the dentist has extracted the
tooth.

this extraction in addition to others with the presence of a

tumor, has weakened the mandible and resulted in
pathological fracture.

this is another case where the lesion has

metastasized to the left side of the mandible and
causes pathological fracture.

here you can notice the signs of fracture in he left side of the mandible, also there is a radilucent
lesion in the right side, so there are two lesions in two
different sides (locations) , this is common to see in
secondary tumors unlike primary tumors which will be in
a certain location and it might expand from that location.
Note: it is more common to have metastatic tumors in
the mandible than the maxilla.

this is a tomographic view of the mandible, you can see that there
destruction of the anterior ramus, this is a case of secondary
carcinoma.

16 | P a g e
Sarcomas
• Sarcomas are malignant neoplasms that arise from connective tissues rather than epithelium.
• A mass is often found
• Bone production is possible

Osteosarcoma
• The most common sarcoma that affects the jaws, but still is rare to be seen
• Classic, parosteal osteosarcoma, periosteal ~
• Rare in the jaws
• Peak age 20-30 but a wider range of 10-70
• Males>Females, Mandible>Maxilla
• In the beginning, you will have a Ragged, ill-defined (radiolucent, radiopaque or mixed) lesion
• Destruction of cortex
• Sun ray spicules
• Codman triangles
• Garrington sign (asymmetrical widening of the PDL space)
Note: The last three are because of destructed periosteum

If you look at the canines and incisors in these radiographs, you

can see that there is widening in the PDL from the mesial side ,
this is called garrington sign. If there is a swelling in this area, there
will be a high suspension of osteosarcoma.

this lesion might grow and cause disfigurement of the face and periosteal
reactions like sun ray spicules, also there is destruction of the outer cortex of
the mandible.

17 | P a g e
this is another lesion in an older patient affecting the left
side of the mandible, we can see radioapaque
structures (malignant bone formation ) foring within the
tumor tat are ill-defined and causes displacment the the
molar tooth due to the growth of the tumor

this is an axial CT (soft tissue window), we can appreciate the

periosteal reactions and abnormal bone growth within this soft tissue
swelling.

Chondrosarcoma
• Peak age third to fourth decade, in jaws third to fifth decade
• Males=Females (affected equally)
• Maxilla=Mandible
• Anterior maxilla mostly if it affects the maxilla, where you have remnants of cartilage
(chondritic) materials
• Posterior mandible(coronoid, condylar), symphysis-located in tha mandible, those places also
have remnant of cartilage materials.
Radiographically:
• Flocculent calcification, you will abnormal cartilage and bone formation
• Destructive, space occupying lesion
• Mixed radiolucent radiopaque lesion
• Garrington sign
• Sun –ray appearance

Clinically you will have a swelling that hasn’t caused any destruction
of the mucosa yet.

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when we took a water’s view, we can see that there is destruction in the
maxilla, we can’t see the normal borders, even the medial wall of the
sinus has been destructed, also displacement of the nasal septum.

this is the flocculent appearance; you can see bone destruction and
sunray spicules.

Note: it is very hard to differentiate between chondrosarcoma and

osteosarcoma radiographically and sometimes histopathologically.

Hematological malignancies

Myeloma
• Monoclonal proliferation of B cells
• Multiple myeloma, Solitary (one lesion) Plasmacytoma
• Age 50-70
• Clinical features : Bone pain (because there is infiltration of the bone with B-cells), anemia
(because bone marrow is replaced by abnormal B cells), pathologic fracture, weight loss,
abnormal bleeding (because it affects platelets function and formation in the bone marrow)
• Other bones are involved, rarely limited to one site
• Multiple punched out lesions in the skull, jaws in mandible >maxilla
• Areas of scattered bone destruction separated by normal bone
• Periapical radiolucency
• Nasopharyngeal soft tissue density mass as first sign of a plasmacytoma

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this is a PA skull view, showing multiple, all around punched out
radiolucent lesions that are well defined but not corticated.

Here you can see multiple radiolucent lesion with

destruction of the diploe of the skull.

You can see here multiple lesions in the jaw, sometimes it looks
like metastatic lesions

These are lesions affecting the long bones, these lesions will cause
destruction of bone when they get bigger.

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Leukemia
• Acute or chronic leukemia
• Age varies with the type
• Radiologic changes occur in 50-70% of children and 10% in adults
• Loss of teeth
• Loss of lamina dura, with destruction of PDL tissues sometimes especially in deciduous teeth
• Radiolucency of crest of periodontal bone, normally it is trabeculated
• Single noncystic radiolucency of alveolar bone
• Cortical outline of follicle wall absent
• Multipe radiolucencies

This is an example of a patient who has luekemia, you can

see the radilocency of the periodontal crest, we can see
multiple radilucencies under the teeth, the lamina dura is lost
also.

this is another case of a child with

deciduous dentition where he has lost the
follicular wall of the second molar.

This consdition resulted in the early loss of the tooth.

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Tumor like lesions
Another hematological malignany
• Idiopathic histiocytosis
- Another names: Langerhans’s cell disease, Langerhans Histocytosis, Histocytosis X
- A group of lesions affecting the reticuloendothelial cells and characterized by the proliferation
of Langerhans cells or their precursers

LCH (Langerhans cells histiocytosis )

- Single focus or disseminated form involving multiple organs
- Head and neck lesions common, 10% of all LCH have oral lesions
- Older children and young adults
- Dull steady pain, bony swelling soft tissue mass, gingivitis
- Loosening and sloughing of teeth (mimicking sever periodontal disease)
- Mandible>maxilla

We can see the radiolucent lesions due to the

infiltration of the Langerhans or histocytes
cells.

You can also have radiolucent lesions in the skull, when we suspect
these lesions we must refer them to the physicians.

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 24/11/2020

7 part 2

Ghaidaa aljamal

The Radiology of Dysplastic Diseases

Hamza Al-Sleati

Hamza Al-Sleati
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 The Radiology of Dysplastic Diseases
(The Radiology of Fibro-Osseous Diseases)
Introduction
• Fibro –osseous lesions (FOL) are characterized by replacement of normal bone by collagenous ,
fibrous connective tissue with an admixture of mineralized product including osteoid , mature bone
and in some lesions cementum –like material (especially in the lesions that are close to the apices
of teeth where you have cementum).
• Because of histologic similarities among these diverse group of lesions , that includes
developmental , reactive or dysplastic diseases and neoplasms ,the identification of the
majority of FOLs is made upon clinical and radiological features.

Classification

Notes:
- We have talked about some of these lesions when we took benign lesions, Whether they are
odontogenic or non-odontogenic .
- We have already talked about ossifying fibroma and giant cell tumor.
- We will talk about jaw lesions in hyperparathyroidism in endocrine diseases lecture
- aneurysmal bone cyst is very rare.
- Fibro-osseous lesions of periodontal origin are really common, the diagnoses of them is solely
depending on radiographs without the need take a biopsy
- We have talked about cementifying fibroma before.
The disease processes that may be included in the differential diagnosis of a FLOs are:
• Paget’s disease of bone
• Osteosarcoma
• Osteoblastoma
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 • Osteoid oseoma
• Cementoblastoma
• Central odontogenic fibroma
• Renal osteodystrophy
• Central giant cell granuloma
• Brown tumor of hyperparathyroidism
• Aneurysmal bone cyst
• Cherubism
Note: you can favor one above the other depending on the radiographic appearance.

Fibrous Dysplasia

You can see that it is within the fibrous tissue, in the beginning the
normal bone is replaced by fibrous tissue, and there abnormal bone
(osteoid) within the fibrous tissue, it is called dysplasia because it
has dysplastic bone formation, and called fibrous because it is
within a fibrous tissue that replaces the normal bone.

• It is a Benign genetically based sporadic (not hereditary) condition of bone where there is
abnormal remodelling with presence of dysplastic fibrous tissue and varying amounts of immature
bone.
- most common in younger patients (prepubescent)
- no sex predilection in general*
- osteosarcomatous change is unusual
• types:
- Monostotic Fibrous Dysplasia (70% of cases)
- Polyostotic Fibrous Dysplasia (30% of cases)
o Jaffe type (less severe type)
o Albright type (more severe type)
- Growth of lesion usually ceases at the end of skeletal growth, because as we mentioned they
are common in the young patients (around puberty). Those lesions are better not to be
interrupted and it is better not to do a biopsy because the clinical and radiographic features are
often sufficient, and sometimes surgical intervention results in an over-growth of the lesion
especially in younger patients. After the skeletal growth stops, we can correct the appearance
of the lesion, those lesions as they grow in the jaws cause disfigurement, the affected side will
be bigger, and the patient will complain from asymmetry , we need assure them and tell them
that it is something benign, we can monitor the growth of the lesion every 6 months.

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Monostotic Fibrous Dysplasia
• involves one bone, When we diagnose fibrous dysplasia, we have to make sure it is monostatic by
investigating other sites of the body and you may refer the patient to an orthopedic to check the
presence of the lesions in other bones.
• no extraskeletal involvement, except, perhaps, skin pigmentation
• most frequent sites: ribs, femur, tibia, maxilla, mandible
note: it is more common in the maxilla than the mandible.

Fibrous Dysplasia in Jaws:

- maxilla: mandible is said to be 2:1
- bone lesion growth usually ends with somatic Growth

Radiologic Features:
- relative radiolucency depends upon age of the lesion, there will be more dysplastic bone
formation with time.
- usually unilocular, may have septa
- radiopaque appearances:
o ground glass on extraoral views,
o thumb-print, cotton wool, orange peel, cyst-like and multilocular’ appearances, are also seen
on intraoral views
Note: on intraoral radiographs you will see more details because of the higher resolution.
- continuous with surrounding bone (on plain films) (diffused lesions without well defined borders)
- situated within bone (starts from medulla inside the bone which is formed from trabecular bone),
not appositional (from outside), but it grows towards outside.
- cortex is thinned (but still intact), displaced (due to the remodeling), but usually continuous
- Expansion is an important feature (that’s why they complain of asymmetry), unless small, when
they are small, they are incidentally found.

You can see that the pattern of the lesion (abnormal bone formation) looks
like a finger-print, it caused displacement of these teeth (lateral incisor and
canine). These features are very typical for fibrous dysplasia.

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we said that the maxilla is affected more commonly
than the mandible, but in this case the mandible is
affected. The right side of the radiograph is not
affected, you can see the normal trabeculation and
bone marrow of the bone, you can see the grounded
glass or orange peel appearance. Also you can
notice that the lamina dura is affected. It is altered
and not distinct around the root.

this is an occlusal view of the same patient.

this is a small radiolucent lesion that was detected

incidentally, between 3 and 4 teeth, it is well
circumscribed but not well defined, it mimics other
lesions, what we de is that we will follow it up and see if
any changes happen.

This is another case where you have a radioopaque lesion here, the PDL
space is intact (so we exclude inflammation), the lamina dura is not really
distinct but is is intact and it is not as radioopaque os other areas of the
same tooth.

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This is another case of a young patient, you can see that
there is a radiopacity here between 6 and 7, this lesion has
caused growth of the cortex, maybe he wasn’t aware of the
asymmetry in his face and he had this lesion long time ago.
You can see that the right side of the maxilla (even the
vault of the palate) has swollen, it will be hard on palpation
because it is filled with bone in contrast to cystic lesions.
you can also see the cotton wall appearance on this cropped panoramic radiograph.

this is a coronal CT scan of the mandible,

we can check the symmetry of the ramus
area, the right one is normal with thick
cortical border, normal trabeculations and
bone marrow spaces in contrast to the left
abnormal ramus.

This is an oblique sagittal view of the mandible, remember

when we said that those lesions are diffused on plain films,
but on tomographic films it is easy to see the margins of
those lesions, it is growing and causing expansion of the
lower border of the mandible (with a little turning) and
causing displacement of the inferior alveolar canal,
because it is benign it caused displacement (upwards)
rather than destruction

Those photos were not explained by the doctor

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Polyostotic Fibrous Dysplasia
• involves multiple bones
• most frequently involved bones: femur, skull, tibia
• increased skin pigmentation (café-au-lait spots) -coffee in milk -
• skin and bone lesions usually unilateral
• may cause fractures and severe deformities (especially if they are affecting the weight bearing
bones such as femur and tibia )
• bone lesion growth usually ends with somatic growth (as the monostatic lesions)
- Jaffe type (less severe type): polystatic fibrous dysplasia affecting multiple bones with skin
pigmentation.

- Albright type (more severe type)

o various endocrine disturbances (that is why it is more severe):
▪ precocious puberty (they reach puberty before the expected age)
▪ goiter (affecting the thyroid glands)
▪ hyperthyroidism
▪ hyperparathyroidism
▪ Cushing’s syndrome
▪ acromegaly
o not common
o more in maxilla than mandible
o more posterior than anterior
o unilateral involvement (this is important to differentiate it from paget disease of bon)
o craniofacial (such as sphenoid and ethmoid bones with their many foramina) involvement leads to
anosmia, deafness or blindness, because of the pressure on the nerves exiting these foramina

Cherubism (Familial Fibrous Dysplasia)

The name came from yhe word cherubs, which are chlidren(like angels) whci
are seen churchs in the romainian era, these children’s eyes are looking
upward to the sky or heaven. those lesion especially that they grow in the
maxilla (increasing the size of the maxilla) will cause retraction of the lower
eyelids which exposes the sclera of the eye, so they look like they are looking
to heaven
• rare
• inherited (AD) (autosomal dominant)
• limited to jaws, fullness like cherub (it doesn’t affect other bones)
• develops in early childhood, And stops later and it may regress by itself, but sometimes surgery is
required for the cosmetic or orthodontic reasons.
• bilateral involvement of mandible (while fibrous dysplasia is unilateral)
• sometimes followed by bilateral involvement of the maxilla
• unilateral cases have been reported

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Radiologic Features:
• bilateral radiolucent cyst-like lesions (well defined and corticated)
• begins in third molar-ramus area
• extends posteriorly and anteriorly
• occasionally extends into condyle
• the maxilla usually affected after the mandible
• causes enlargement of jaws as they grow
• cortex remains intact but thin
• encroach upon maxillary sinuses
• displacement of developing teeth (may cause problems with these teeth failing to erupt)
• early exfoliation of deciduous teeth (if they cause displacement toward the surface of the jaw)

in this panoramic radiographs you can see those well defined

cystic lesions in the mandible and the maxilla, this is due to
cherubism. lesions in the maxilla may not be obvious here.

these radiographs (cone beam CT on the right) are

for the same case, you can see the enlargement of
the mandibular jaw here, and the maxillary are
obvious unlike in the panoramic radiograph (on the
left) due to extreme superimposition and the
shadows.

Differential Interpretation (diagnosis) include:

- nevoid basal cell carcinoma syndrome (gorlin syndrome)
- bilateral dentigerous cysts
- Cherubism is very rare rare, You may not see it in you life, but gorlin syndrome is more
common

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Ramon Syndrome
- This syndrome includes: (Cherubism, Gingival Fibromatosis, Epilepsy, Mental deficiency,
Hypertrichosis, Stunted Growth)

Paget Disease of Bone

• Another names (synonyms): Osteitis Deformans, Osteodystrophia Deformans
• affects up to 3% of individuals of Anglo-Saxon (central Europe, UK, Australia, new Zealand) a
origin over the age of 40 years but is rare in Arabs (less than 10 reported cases)
• Common in
- Central Europe
- United Kingdom
- Australia
- New Zealand
• Less common in
- Scandanavia
- United States

• A specific isoenzyme of alkaline phosphatase is high in these patients. (And that’s what leads to
osteolytic activity of the bone) > The concentration of hydroxyproline in the urine is increased.
• Calcitonin from the parafollicular cells of the thyroid gland is important in treatment.
• Pagetoid bone may undergo change into osteosarcoma., especially when they are subjected to
radiotherapy

Radiologic Features
o changes in the skull and pelvis are important (part of the diagnosis of this disease)
o cotton-wool appearance of bone
o osteoporosis circumscripta (areas of osteoporosis, not the whole bone)
o linear pattern in the bone
o sinuses are not diminished in size (it spreads in the bone around the sinus, not in the sinus)
o radiopaque appearances:
- ground glass on extraoral views
- orange peel on intraoral views (they have the texture of orange)

o hypercementosis of teeth (bilateral, in contrast to fibrous dysplasia)

o multiple periapical cemento-osseous dysplasia
o osteosarcomatous change is possible

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this is a skull view, and you can see that there is increased
radiopacity here

Here you can see the cotton-wool appearance of the lesion.

This s another skull view, you can see that the skull is not radilucent
anymore, and you can see the heterogenous cotton-wool apperance

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in this case we don’t see increased adioopacity, but I can see that
there is a circumscribed area of radiolucency which is called
osteoposrosis circumscribta

This patient has more areas of osteoposrosis circumscribta

We can see here also in this PA view of the skull the osteoposrosis
circumscribta

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here also we can see the circumscribed areas of radiolucencies
(osteoposrosis circumscribta)

another case here, the frontal sinus is normal, as we said the sinuses
are not affected from those lesions

In this case the maxilla is affected, the maxilla has grown in size
here, and here you can see the cotton-wool appearance
those patients don’t usually wear dentures, few of them lose the
teeth (but we can do teeth implantation for them)
the ones that wear dentures complain that the denture doesn’t fit
their maxilla anymore because of those growing lesions

this is another case with osteposrosis circumscribta

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when you take bone scan for those lesions (in neuclear medicine) you
can see increased activity because of the osteolytic and osteoblastic
activity at the same time

another case with the same charectrsitics

mentioned

When we see intraoral radiographs of those patients, we can

notice the prensence of hyper-cementosis (with abnormal root
shape)
Note: hypercemetosis can also happen in periapical
inflammation.

This is another case where you have a cotton wall

appearance, maybe orange peel, with some
hypercemetosis of roots.

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in this cone beam CT radiograph (axial section), you can see that
the lamina dura is affected and the PDL is not normal, tha mandible
has also expanded bilaterally.

Periapical Cemento- Osseous Dysplasia

• Synonyms: Periapical Cemental Dysplasia, Periapical Fibrous Dysplasia, Periapical Osteofibrosis
Cementoma
• It is common, unlike paget disease

We can see cemento-osseous dysplastic tissue within the

fibrous area, that has occupied an area of normal bone.

• Age: 38.2 (20-68) (in the fourth decade usually)

• Sex predilection: 94% female
• Racial predilection:
- 76% negroid
- 23% caucasoid
- 1% mongoloid
Note: in our area it is more common than Caucasoid but less common that negroid.
• Lesions:
- 33% solitary (1 tooth)
- 66% multiple (2+ teeth)
• Location:
- 91% mandible
- 64% anterior mandible

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Radiologic Features
• anterior mandible commonly
• 1 or more teeth
• with tooth or residual (what remains of the tooth after extraction)
• no root resorption or displacement
• lamina dura lost or intact, when it is lost we have to include inflammatory lesions.
• radiolucent (Stage I), those lesions starts by resorbing bone
• mixed radiolucent-radiopaque (Stage II), some cemento-osseus formation.
• radiopaque (Stage III), but not necessarily all radiopaque.
• asymmetrical hypercementosis

this is the early stage of the lesion, we can see the

radiolucencies around the roots of anterior teeth, the first
thing that should come to your mind is inflammatory lesion
(such as rarefying osteitis ) which is more common. But we
know that rarefying osteitis is the result of pulp necrosis
(which is usually caused by caries or PDL disease). When
these teeth were tested they were vital, so we must exclude
ilflammatory lesions, the only thing that we must do is follow-
up within 6 months. in 6 months you may see changes such
as increased radioopacity.

here you can see that there is increased radiolucency, with

some radioopacities

this is a clearer radiograph of the lesion, we can see

that multiple teeth are affected (which is more common),
ane the teeth were tested vital with mild abnormality in
the PDL.

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this lesion here is affecting one tooth only with mixed appearance , we
have a mild periodontal diease, so we may supect iflammation, but the
teeth were tested vital.

Another case with the same features.

Although this tooth here has lost some vertical bone loss with severe
periodontal disease (with other teeth affected), this doesn’t mean that
this tooth should test vital, even if it was not vital, we call this lesion
periapical cemento-osseous dysplasia because other teeth are
affected

It may appear like asymmetrical hypercemetosis with multiple

teeth affected.

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Another case that is in stage 3 with increased radiopacity

This one is caused by residuals from tooth extraction

Florid Cemento- Osseous Dysplasia

• Synonyms: Florid Osseous Dysplasia, Chronic Sclerosing Osteomyelitis, Gigantiform
Cementoma
• This is similar to the previous lesion, but here we have at least two quadrants affected
symmetrically (the same side).
Note: the word florid is taken from the word flower, indicating that it is wide-spread lesion.
• Age: 38.2 (20-68)
• Sex predilection: 94% female
• Racial predilection:
- 76% negroid
- 23% caucasoid
- 1% mongoloid
• in at least 2 quadrants, symmetrically
• maybe in all four quadrants
• radiolucent (Stage I)
• mixed radiolucent-radiopaque (Stage II)
• radiopaque (Stage III)

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here the same appearance as periapcial type, but here we have
lesions in the right and left maxilla.

Here we have residual florid type leion

another panoramic radiograph showing the mentioned features

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Focal Cemento- Osseous Dysplasia
• Synonyms: Focal Osseous Dysplasia Gigantiform Cementoma
• Age: 38.2 (20-68)
• Sex predilection: 94% female
• Racial predilection:
- 76% negroid
- 23% caucasoid
- 1% mongoloid
• in 1 quadrant
• radiolucent (Stage I)
• mixed radiolucent-radiopaque (Stage II)
• radiopaque (Stage III)

Sometime cemento-osseous lesions create difficulty in the diagnosis especially in the early stage with
the difficulty in ruling out rarefying osteitis, but as we said we can do vitality test. When the lesion is
mixed, it might be confused with scelerosing osteitis, but also we can do the vitality test. While in
stage 3, the diffrential diagnosis will include Alveolo-Osseous Induction Effect Induction Effect,
Sclerosing Osteitis, Osteosclerosis, Enostosis Who Knows?
note: if the teeth were tested vital, there will be no need for RCT, you will just leave them without
treatment, you will only monitor them by radiographs every 6 or 12 months, but sometimes you have
to remove those lesions especially if they are residual when we want to do teeth implantations
because it will lead to implant failure

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