Mixed Lesions Imaging

Mixed radiopaque – radiolucent lesions
Definition
Radiolucent :sIt refers to that portion of a
processed radiograph which appears as dark / black. It
is caused due to the passage of maximum photons
through the objects.
Radiopaque : It refers to that portion of

processed radiograph which appears as light / white.
It is caused due to the presence of dense objects in
path of photons that are strong absorbers.
Why
Mixed????
Ø Some normal anatomic structures and disease
states can produce mixed radiolucent and
radiopaque images on radiographs.
Ø Some pathology may be present as an osteolytic

lesion, which appears as radiolucency in
radiograph.
Ø During it’s development, foci of calcified material

may form within the osteolytic area.
ØWhen these foci become large and
mineralized, they become radiographically
apparent.
ØThus, mixed radiolucent & radiopaque

condition frequently represents an
intermediate stage in development of lesion.
Mixed Radiolucent – Radiopaque
Lesions
1. Cementoma
2. Calcifying epithelial odontogenic cyst
3. Calcifying epithelial odontogenic tumor
4. Adenomatoid odontogenic tumor
1.
üCEMENTOM
Also known as –
A : • Periapical cemental dysplasia
• Fibrocementoma
• Sclerosing cementum
• Periapical osteofibrosis
• Periapical fibrosarcoma
• Periapical fibrous dyplasia
• Periapical fibro – osteoma
üDefined as –
a reactive fibro–osseous lesion derived from the
odontogenic cells in the periodontal ligament.
üLocated at –
apex of tooth.
üClinical features –
• More common in females, blacks & in middle age.
• Age group : middle age.
• Common in mandibular anterior region.
• Asymptomatic & involved tooth is vital.
• Usually diagnosed during routine checkup.
• Small in size ( <1cm in diameter) but may become
quite large causing expansion of alveolar process.
• Early phase – resorption of normal bone ( radiolucent
phase )
• Developing phase – abnormal bone manufactured
within lesion (mixed radiopaque & radiolucent
phase)
• Late / mature phase – internal structure dominated
by abnormal bone.
üRadiographic features -
• Location :
– Epicenter liesat apex of tooth.
–Mostly lesion is multiple & bilateral.
• Periphery & shape :
– Well defined periphery.
–Radiolucent border of varying width, surrounded by
varying width of sclerotic bone.
–May be irregular in shape or round or oval shaped
centered over apex of tooth.
• Internal structure :
– Stage 1 – osteolytic stage :
» Radiolucency ( 1cm in diameter ) in periapical
region
–Stage 2 – cementoblastic stage :
» small areas of calcification develops within
radiolucency.
–Stage 3 - Mature stage:
» Individual calcified mass increase insize
» Masses unite with adjacent lesions to form
single large radiopaque mass with thin
radiolucent line in periphery
• Effects on surrounding structures :
– Adjacent teeth are not displaced
– No root resorption of adjacent teeth areseen
– Adjacent teeth are vital, with intact PDL space,
lamina dura may be discontinuous
– No expansion of jaw is seen
üDifferential diagnosis –
• Periapical rarefying osteitis – in early stages,
PCD can not be ruled out radiographically
alone. Thus, final diagnosis is based on
vitality of involved tooth.
• Benign cementoblastoma & odontoma –
– Cementoblastoma : solitary, attached to surface of
root which may be partly resorbed.
better defined peripheral soft tissue capsule
–Odontoma : starts occlusal to a tooth
prevents eruption
resembles tooth like structure
more uniform in width & better defined than
the periphery of PCD
üManagement -
• Periodic radiographic evaluation (watchful
neglect)
• Surgical enucleation indicated in cases of
expansion of cortical plates.
2. CALCIFYING EPITHELIAL
ODONTOGENIC
üAlso known as –CYST :
Calcifying odontogenic cyst
Gorlin’s cyst
üDefined as –
an unusual lesion with features suggestive of a cyst &
characteristics of a solid neoplasm.
ü Clinical features
–
• females > males
• 3/4th of the lesion occurs centrally, 75% occuring
anterior to the 1st molar.
• Affects both jaws equally.
• Slow growing, asymptomatic.
• Adjacent teeth may be displaced.
• May be associated with an odontoma & may have
calcified material identified as dysplastic dentine.
• Aspiration yields a viscous,granular, yellow fluid.
üRadiographic features –
• Location :
– Anterior to 1st molar
–Associated with cuspids
& incisors, where it may
manifest as pericoronal
radiolucency
• periphery & shape :
– Vary from well defined & corticated with curved,
cyst like shape to ill defined & irregular.
– may be completely radiolucent or may show
evidence of small foci of calcified material that
appear as white flecks or small smooth pebbles.
– Multilocular in rare cases.
• Effect on surrounding structures :
– Most commonly associated with cuspid
– Displacement of teeth may be seen
–Root resorption
is present
– Perforation of cortical
plates in enlarged lesions
• It may resorb roots of adjacent teeth.
•Radiolucency may contain
small foci of calcified
material seen as white
flecks or smooth pebbles
( radiopacities ). At times
the entire lesion may be
occupied by the calcific
body & thus appear
radiopaque.
• Fibrous dysplasia – appears as mottled or has a smoky
defined borders, more common in maxilla.
•Odontoma – surrounded
by a capsule.
• AOT – in the intermediate stage of development, AOT
appears like a CEOC.
• Cementoblastoma – well defined radiographic
image attached to the root of the tooth.
üManagement –
• Enucleation with curettage
• Regular follow - up
3. CALCIFYING EPITHELIAL
üAlso known as –TUMOR :
ODONTOGENIC
Pindborg’s tumor
Ameloblastoma of unusual type with calcification
üDefined as –
rare tumor of distinctive microscopic appearance that
appears to arise from the reduced enamel epithelium or
dental epithelium.
• Accounts for 1% odontogenic tumor.
• Males > females
• Age range : 8-92 yrs.
• Mandible > maxilla
• Common in premolar – molar region
• Rarely may have extraosseous location.
• Usually asymptomatic.
• May be associated with paresthesia.
• Associated with unerupted teeth.
• Cortical expansion is common.
• Palpation indicates hard swelling with well defined or diffused
border.
• Simulates ameloblastoma, less aggressive but locally invasive.
• Rate of recurrence is high.
ü Radiographic features –
• Location :
– Mandible > maxilla
–More common in
premolar – molar area
• Periphery :
– Well defined cyst like cortex
– Irregular & ill defined border
– May be unilocular or multi locular ( HONEYCOMB
PATTERN )
– Numerous scattered, radiopaque foci of varying size & density
are seen.
– Small thin, opaque trabaculae cross radiolucency in many
direction ( DRIVEN SNOW APPEARANCE )
• Effects on surrounding :
–May displace developing
Tooth & prevent eruption
–Expansion of jaw with
maintenance of cortical
boundary may occur
•AOT – more common in
anterior maxilla as compared
to CEOT, which is common
in
the mandibular premolar – molar
region.
•Calcifying odontogenic cyst –
aspiration yields vicous, granular,
yellow fluid.
• Odontoma – has a capsule.
üManagement –
Conservative treatment with local ressection with
4. ADENOMATOID ODONTOGENIC
TUMOR :
üAlso known as –
• Adenoameloblastoma
• Ameloblastic adenomatoid tumor
üDefined as –
an uncommon, non aggressive tumor of odontogenic
epithelium, with a duct like structure & varying degree of
inductive changes in connective tissue.
üClassified as –
• Peripheral adenomatoid odontogenic tumor
• Central adenomatoid odontogenic tumor –
a. follicular type
b. extra follicular type
a. follicular type – associated with
embedded tooth
b. extrafollicular type – not associated with
embedded tooth.
• Females > males
• Age range : 5-50yrs
• Maxilla > mandible
• More common in anterior cuspid region
• Asymptomatic
• Slow growing swelling
• Associated with unerupted tooth
• Expands cortices but is non - invasive
üRadiographic featurers –
• Location :
– More common in incisor – canine – premolar
region
– May have follicular relationship with impacted
tooth
– Does not attach at CEJ
– Surrounds greater part of tooth
• Periphery :
– Well defined corticated, sclerotic border
– Completely radiolucent or may contain faint
radiopaque foci
– Occasionally, small calcifications with well
defined borders, like cluster of small pebbles
•Effects on
surrounding
structures :
–Displacement of adjacent
Teeth
– Root resorption is rare
– Prevents eruption
–Expansion of jaw may
Appear but outer cortex is
maintained
• CEOC – occurs in older age group, usually
in premolar region.
•CEOT – more common in

posterior mandibular region.
• Ameloblastic fibro – odontoma – more common in
posterior mandible region, is multilocular &
radiopacities of enamel & dentine are seen inside
the radiolucency. Whereas, in AOT snow flecks are
seen in periphery.
• Odontogenic fibroma or myxoma –
TENNIS RACKET
appearance is seen.
üManagement –
• Conservative surgical excision with curettage.

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Mixed radiopaque – radiolucent lesions

Radiopaque : It refers to that portion of

Ø Some pathology may be present as an osteolytic

Ø During it’s development, foci of calcified material

ØThus, mixed radiolucent & radiopaque

•CEOT – more common in

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