Differential Diagnosis of Maxillofacial Radiology by liaoqinmei

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									                                 Differential Diagnosis of Maxillofacial Radiology

Radiographs: Decay is the most common pathology you will see on radiographs
    Bitewing:
         o Decay
         o Interproximal bone levels
    Periapical:
         o Evaluate periapical areas
    Pano: Great for the BIG picture
         o Cysts
         o Wisdom teeth position

Bone: Matrix of collagen (protein) impregnated w/ mineral (calcium hydroxyapatite)
    Cortical: Solid impregnated w/ blood vessels
    Cancellous (spongy or trabecular): Complex porous network

Normal Bone:
    Mandible:
         o Anterior: Coarse and large trabecular pattern
         o Posterior: Variable; large and sparse trabeculation
    Maxillary: Finer trabecular spaces

Pano: A flattened image of a curved surface
    Midline structures may project as single or double images
    Types of images:
          o Real Images:
                  Single: Image interpreted once
                  Double: Image interpreted twice (i.e. spine)
          o Ghost images: Object located between the x-ray source and the center of rotation (i.e. earrings)

Landmarks:
   1.    Condyles
   2.    Nasal Septum
   3.    Lower Border of the Orbit
   4.    Lower Border of Zygomatic Bone
   5.    Zygomatic Arch
   6.    Lower Border of Maxillary Sinus
   7.    Inferior Concha
   8.    Hard palate
   9.    Mandibular canal
   10.   Pterygoid Plates
   11.   Mental Foramen
   12.   Hyoid
   13.   Articular Eminence
   14.   Mylohyoid Line
   15.   Maxillary Tuberosity
   16.   Glossopalatal space
   17.   Genial Tubercles
   18.   Submandibular Fossa
   19.   Stafne Bone Cavity
   20.   Cervical Vertebra
   21.   Pterygomaxillary fissure
   22.   Ear Lobe
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   Neck Structures:
      1. Thyroid cartilage
      2. Epiglottis



                                         Inflammatory Lesions

• Pericoronitis
 • Osteomyelitis
• Periapical sclerosing osteitis
• Periapical abcess and granuloma
• Periapical cysts

                                          Cysts and Cyst-Like

• Dentigerous cysts
• Odontogentic keratocysts
• Lateral periodontal cyst
• Calcifying odontogenic cyst (Gorlin cyst)
• Nasopalatine duct cyst
• Dermoid cyst
• Pseudocysts
     Simple bone cyst
     Static bone cyst

                                              Benign Neoplasms

• Torus palatinus
•Torus mandibularis
•Dense bone islands
•Odontogenic epithelial tumors
    Ameloblastomas
    Calcifying epithelial odontogenic tumor
•Odontogenic mixed tumors
    Odontomas
    Adenomatoid odontogenic tumor
    Ameloblastic fibro-odontoma
•Odontogenic ectomesenchyme
    Myxoma
    Benign cementoblastoma
• Mesodermal
    Osteomas

                                         Malignant Neoplasms

• Osteosarcoma
• Chondrosarcoma

                                                     2
• Fibrosarcoma
• Multiple myeloma
• Lymphoma
• Leukemia

                                              Metabolic Diseases
• Hyper/hypoparathyroidism
• Hyper/hypopituitarim
• Cushing’s syndrome
• Osteoporosis
• Rickets
• Osteomalacia
• Hypophosphatasia
• Kidney diseases

                                                   Trauma

• Mandibular fractures
• Luxation
• Avulsion
• Root fractures
                                               Bone Dysplasia

• Fibrous dysplasia
• Cemento osseous dysplasia
• Florid, Pa, and Focal osseous dysplasia
• Cemento ossifying fibroma
• Central cell granuloma
• Aneurysmal bone cyst
• Cherubism
• Paget’s disease of bone



                                                    Radiolucencies

   1.   Periapical lesions of pulpal origin
   2.   Periapical radiolucencies of non-pulpal origin
   3.   Pericoronal radioluncencies
   4.   Circumscribed radiolucencies
   5.   Multiple radiolucencies
   6.   Ill defined radiolucencies
   7.   Generalized rarefactions

                                1. Uniocular PA Lesions of Pulpal Origin
                                         1.    • Periapical granuloma
                                         2.    • Radicular cyst
                                         3.    • Apical abscess
                                         4.    • Osteomyelitis
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   1. Periapical Granuloma: Most common type of pathologic radiolucency of the jaws (ill-defined)
         a. Chronic apical periodontitis
         b. Non-Vital
         c. Not painful to percussion
         d. Necrotic pulp
         e. Can become cystic
   2. Radicular/PA Cyst: Most common cyst in the body
         a. Proliferation of epithelium after presence of the PA ganuloma
         b. Non-vital pulp/necrotic
         c. Liquid-filled cavity lined w/ epi
         d. Well-defined; well corticated (if longstanding)
   3. Acute PA Abcess: Acute inflamm. process containing neutrophils and necrotic debris (pus)
         a. Associated w/ tooth w/ deep carious lesion
         b. Little radiographic change in acute situation (change occurs in chronic)
         c. Pupal necrosis
         d. Painful to percussion
         e. Parulis may be present
         f. Untreated may develop into:
                 i. Osteomyelitis
                ii. Ludwig’s angina (Mandibular tooth)
               iii. Cavernous sinus thrombosis (Max tooth)
   4. Osteomyelitis: Infection of Bone marrow
         a. Most common source is a PA abcess
         b. Common in mandible
         c. Rapid onset
         d. Pain and swelling of adjacent tissues
         e. Early acute stages are often not identifiable


Side Note:
                                                  Surgical Defect
                  An area that fails to fill in w/ osseous tissue after root resection procedures

      Composed of dense fibrous tissue
      Situated at apex of pulp-less tooth
      Well-defined borders and remains a constant size
      Asymptomatic

Differential DX:
     PA Granuloma
     Radicular Cyst
     Apical Abscess



                                2. Unilocular PA Radiolucencies of Non-Pulpal Origin
                              1. Cementoma: PA cemental dysplasia (1st stage)
                              2. Periodontitis           4
                              3. Traumatic solitary or simple bone cyst
                              4. Aneurysmal bone cyst
                              5. Eosinophilic granuloma: Assoc. w/ Langerhan’s cell disease
   Cementoma (PA cemento-osseous dysplasia): 1st Stage
        a. Reactive proliferation to unknown factors
        b. Common is middle-aged black women
        c. Round, mono-locular, multiple teeth
        d. Vital teeth; not painful
        e. Stages:
                i. Early: Circumscribed radiolucencies at ends of mandibular anterior teeth
               ii. Intermediate: Radiopacity w/ in apical radiolucencies
              iii. Late: Densely radiopaque outlined w/ radiolucent line

   Traumatic Solitary Bone Cyst: Bone cavity not lined by epithelium, but lined by CT
        a. Asymptomatic
        b. Found in mandible, premolar/molar region
        c. Monolocular, well-defined, and moderately corticated
        d. Scalloping between roots of adjacent teeth
        **Lesion removes bones around teeth, but leaves teeth alone (UNLIKE OKT)

   Eosinophilic Granuloma (Langerhan Cell Disease): Immunodeficiency causing neoplastic histiocytes
         a. Usually in adolescents and young adults
         b. Localized or multiple lesions
         c. Punched out lesion around roots of teeth
         d. Asymptomatic and vital
         e. Destruction of periodontal bone (loose teeth)

                                             3. Pericoronal Radiolucencies

                                  1. Common unilocular
                                         a. Dental follicle
                                         b. Pericoronitis
                                         c. Dentigerous cyst
                                  2. Common multilocular
                                         a. Odontogenic keratocyst (gorlin syndrome)
                                         b. Ameloblastoma
                                  3. Uncommon unilocular
                                         a. Adenomatoid odontogenic tumor (AOT)
                                  4. Uncommon unilocular with calcified tissue
                                         a. Calcifying odontogenic cyst- Gorlin cyst


Dental Follicle: Dental sac w/ enclosed developing tooth
    Normal, not pathologic
    Defined radiolucency around crown of developing tooth
    Differential DX: Follicular Cyst

Pericornitis: Infection of soft tissue surrounding crown of partially erupted tooth
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    Mandibular 3rd molars
    Sclerosing margin seen in chronic cases

Dentigerous Cyst (Follicular Cyst): Most common odontogenic cyst (Unique because around crown only)
    Originates from REE of dental follicle around crown of unerupted tooth
    Fluid accumulates between remnants of enamel organ and tooth crown
    Mandibular 3rd molars, Max canine, and Max 3rd molars
    Unilocular radiolucency, well-defined, circling crown of unerupted tooth
    Eruption Cyst: Dentigerous cyst in children
    Differential DX:
          o Ameloblastoma: Change in the lining
          o Adenomatoid Odontogenic Tumor (AOT)
          o Calcifying Odontogenic Cyst
          o Odontogenic Keratocyst

Amelobastoma: Benign odontogenic neoplasm associated w/ unerupted displaced tooth
   Develops from rests of Malassez, HERS, REE
   Mandibular posteriors
   Soap bubble appearance
   May cause root resorption

Odontogenic Keratocyst (Gorlin Syndrome/ Basal Cell Nevus): Around unerupted mandibular molars
   Derives from dental lamina
   Displaces unerupted tooth
   Lined by keratinizing epithelium
   Causes cortical expansion
   Differential DX:
         o Ameloblastoma

Adenomatoid Odontogenic Tumor (AOT): Surrounds entire unerupted tooth
    Benign neoplasm of tooth forming epithelium
    Rare; young pts
    Anterior Maxilla (Usually canines)
    Circumscribed radiolucent lesion w/ corticated margins

Calcifying Odontogenic Cyst (Gorlin’s Cyst): Non-aggressive cyst lesion characterized by ghost cells
    Epithelial odontogenic origin
    Anterior portion of bone
    Mixtures of calcifications

                                     Periodontal Radiolucent Lesions
                                                                           I’m not sure where these
    Most common are periodontal lesions due to alvelolar bone less        radiolucent lesions fall on
    Chronic Periodontitis                                                 Dr. Pilgrim’s list of
    Combines Perio-Endo: Progression of Periodontal infection             radiolucent lesions……they
        o Non-vital                                                        just kind of appear after her
        o Endo may not be successful                                       pericoronal radiolucencies
                                                                           (sorry).
                                      Interradicular Radiolucencies
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 Radiolucencies in Alveolar Bone may represent:
     o Inflammation
     o Developmental Cysts
     o Neoplasms of Odontogenic Origin




                                     1)   Lateral Periodontal Cyst
                                     2)   Globulomaxillary Cyst
                                     3)   Nasopalatine Duct Cyst
                                     4)   Lateral Radicular Cyst
                                     5)   Giant Cell Granulomas

   1) Lateral Periodontal Cyst: Developmental odontogenic cyst that arises from dental lamina or REE
         a. Common along lateral surface of vital root (Mandibular premolar/canine region)
         b. Asymptomatic
         c. Unilocular, round or oval, well-defined radiolucency

   2) Globulomaxillary Cyst: Radiolucent lesion between Max lateral incisor and canine teeth
         a. Unilocular, pear-like shaped, well-defined radiolucency
         b. May cause divergence of roots in adjacent teeth
         c. Differential DX:
                 i. Radicular Cyst
                ii. ADenomatoid Odontogenic Tumor (AOT)
               iii. Giant cell granuloma

   3) Nasopalatine Duct Cyst: Most common Non-odontogenic cyst
         a. Arises from epi remnants of nasopalatine duct or incisive canal
         b. Midline, anterior Max.
         c. Adjacent teeth displaced
         d. May cause palatal expansion

   4) Lateral Radicular Cyst/Granuloma: Accessory canal opens to lateral root surface
         a. Non-vital pulps
         b. Circumscribed radiolucent lesion displaced laterally along root surface

                                       4. Circumscribed Radiolucencies

                           1.   Bone marrow spaces
                           2.   Tooth crypt
                           3.   Residual cyst
                           4.   Stafne’s bone cavity (lingual salivary gland depression)


   1. Bone Marrow Spaces: Variations of normal anatomy that mimic cyst-like radiolucent lesions
         a. Mandibular molar/premolar region
         b. Differential DX:
                                                   7
               i. PA Granuloma
              ii. Radicular Cyst

2. Tooth Crypt: Bi-lateral, solitary radiolucency of approximate crown of developing tooth
      a. May be seen from birth to late adolescence

3. Residual Cyst: Radicular cyst remaining after tooth extraction
      a. Asymptomatic
      b. Well-defined, unilocular radiolucency

4. Stafne’s Bone Cavity/Static Bone Cyst: Radiolucency situated betwn Mand. Canal and lower
   border

                                   5. Multiple Radiolucencies

                                    1.   Multiple Cysts of the jaw
                                    2.   Multiple myeloma
                                    3.   Langerhans cell histiocytosis
                                    4.   Metastatic Tumors
1. Multiple Cysts of the Jaw: Multiple radicular cysts PA granulomas, or OKC’s
   a. Many may develop with basal cell nevus syndrome (Gorlin’s Syndrome)
   b. Differential DX:
           i. PA Granuloma
          ii. Radicular Cyst
         iii. OKC

2. Multiple Myeloma: Multifocal cancer of plasma cells
   a. Most common malignancy of bone in adults
   b. Punched-out, Swiss-cheese skull
   c. Painful, swelling, paraesthesia

3. Metastatic Tumors: Metastatic lesions in jaws caused by primary lesions below clavicle
   a. Mandible and Max Sinus
   b. Well-defined but not corticated
   c. Coalesce to form large, ill-defined radiolucencies
   d. Painful, swelling, paraesthesia                                Again, this was not listed
                                                                     on Dr. Pilgrim’s original
                                 Multilocular Radiolucencies         list for radiolucencies, so
                                                                     it is just another random
                              1. OKC                                 one I didn’t know what to
                              2. Ameloblastoma                       do with (sorry).
                              3. Aneurysmal Bone Cyst
                              4. Central Giant Cell Granuloma


4. Aneurysmal Bone Cyst: Not a true Cyst
   a. Reactive process
   b. Young people
                                                 8
   c. Soap-bubble appearance
   d. Bony expansion with displacement of adjacent teeth
   e. Blood can be aspirated from the lesion!!!!

5. Central Giant Cell Granuloma: Reactive granulomatous proliferation w/ giant cells (osteoclats)
   a. May be reparative response to inflammation within bone
   b. Young adults
   c. Mandible (anterior region)
   d. Can cause absorption of adjacent roots
   e. Honeycomb appearance!!!!



                               6. Ill-Defined Radiolucencies
                                          (Cancers)

                             1. Chronic osteomyelitis
                             2. Osteoradionecrosis
                             3. Fibrous dysplasia
                             4. Metastatic tumors
                             5. Eosinophilic granuloma
                             6. Squamous cell carcinoma
                             7. Malignant salivary gland tumors
                             8. Osteogenic sarcoma
                             9. Chondrosarcoma
                             10. Ewing sarcoma
                             11. Malignant lymphoma

1. Chronic Osteomyelitis: Inflammation of bone marrow arising from dental infection
   a. Acute phase: No radiographic signs for 8-10 days
   b. Moth-eaten radiolucency
   c. Untreated will lead to bone destruction

2. Osteoradionecrosis: Bone necrosis due to radiation damage
   a. Mandible
   b. Moth-eaten radiolucency
   c. Similar radiograph w/ bisphosphonate therapy

3. Fibrous Dysplasia: Replacement of bone w/ fibrous tissue
   a. Monostotic or Polystotic
   b. Maxilla (or jaw in general)
   c. Painless, slow, progressive enlargement of bone
   d. Ground-glass or orange peel appearance !!!!

4. Metastatis Tumors: Lesions in jaw originating from primary lesions below clavicle
   a. Mandible and Max Sinus
   b. Pain, swelling, paraesthesia


                                             9
       Squamous Cell Carcinoma: Most common primary oral malignant tumor
          o Invade underlying bone                                                 From this point on,
          o Moth-eaten appearance                                                  Dr. Pilgrim strays
          o Destruct alveolar ridge along w/ soft tissue mass                      from her original
          o Displace adjacent teeth                                                list…….

                                      PA/Pericoronal Mixed Lesions

                                    1.   Cementoma
                                    2.   Odontoma
                                    3.   Adenomatoid Odontogenic Tumors
                                    4.   Calcifying Odontogenic Cyst (Gorlin’s)
                                    5.   Cementoblastoma


Odontoma: Common Lesion
   Types:
        o Complex: Composed of haphazardly arranged dental hard and soft tissues
        o Compound: Composed of many denticles (Harmatoma: Overgrowth of normal tiss)
   Young patients
   Asymptomatic
   Failure of tooth eruption may be first indication of Odontoma

Cementoblastoma: Benign neoplasm of cementoblasts that develops at root’s apex
   Circumscribed radiopaque lesion confluent w/ cementum on root (early lesion radiolucent)
   Mandibular tooth
   Vital

                                     Diffuse and Generalized Lesions

                                            1.   Chronic Osteomyelitis
                                            2.   Osteonecrosis
                                            3.   Fibrous Dysplasia
                                            4.   Paget Disease

Paget Disease: Metabolic bone disease
    Multiple radiopaque masses that look like cotton balls
    Maxilla
    May cause movement of teeth
    Often confused w/ Fibrous Dysplasia!!!!

                                              PA Radiopacities

                                              1.   Cementoma (3rd stage)
                                              2.   Cementoblastoma
                                              3.   Hypercementosis
                                              4.   Tori and Exostoses
                                              5.   Condensing Osteitis
                                              6.   Foreign Bodies

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       1. Cementoma (3rd stage): Apices of several lower incisors
          a. Middle aged black women
          b. Vital
          c. PA ligament space intact

       2. Cementoblastoma: Uncommon benign neoplasm of cementum
          a. Slow Growth
          b. Tends to expand overlying cortical plates

       3. Hypercementosis: Deposit of cementum around apical portion of root
          a. Asymptomatic
          b. Thickening and blunting of roots
          c. No tx necessary (not a big deal)

       4. Tori and Exostoses: Slow growing bony protuberances
          a. Torus palatinus
          b. Torus Mandibularis
                 i. Bi-lateral common

       5. Condensing Osteitis: Radiopaque lesion at apex of tooth w/ chronic pulpitis
          a. Asymptomatic
          b. Nonvital
          c. Endo Tx

       6. Foreign Bodies: Filling materials and fragments of dental instruments

                                             Focal Radiopacities

                                      1.   Idiopathic Osteosclerosis
                                      2.   Osteoma and Exostosis
                                      3.   Fibrous Dysplasia
                                      4.   Odontoma
                                      5.   Soft tissue calcification
                                      6.   Foreign bodies
                                      7.   Root remnants
                                      8.   Socket sclerosis

Idiopathic Osteosclerosis: Area of dense bone islands in the mandible
        Differential DX:
              o Osteoma
              o Exostoses
              o Conensing osteitis
              o Root remnants
              o Odontoma

Osteoma and Exostosis: Benign lesion of bone
       Types:
            o Compact
                                                      11
            o Cancellous
        Mandible and Frontal Sinus
        Painless; usually incidental finding

Soft Tissue Calcification: Radiopaque calcifications within overlying soft tissues
        Salivary calculi
        Calcified lymph nodes
        Calcified tonsils
        Phleboliths
        Calcified atheromatic plaques in arteries
        Antroliths

Foreign Bodies: Pathognomonic *See earlier slide

Socket Sclerosis: Osteosclerosis that develops in socket after tooth removal

Dense Bone Island: Absense of radiographic rim
    Asymptomatic
    Peri-radicular bone on Mandible
    No TX
    Looks like condensing osteitis

                                Radiopaque Lesions not Associated w/ Teeth


                                   1. Florid Cemento-Osseous Dysplasia
                                   2. Focal Cemento-Osseous Dysplasia

       1. Florid Cemento Osseous Dysplasia: Benign condition involving multiple quads of the jaws
          a. Bilaterally positioned in edentulous areas
          b. Cloud like masses which vary in size and shape

       2. Focal Cemento Osseous Dysplasia: Posterior mandible
          a. Solitary radiolucent to radiopaque lesion
          b. Females
          c. Vital
          d. Differential DX:
                 i. Central cementifying or ossifying fibroma



                                    Dr. Pilgrim’s Mash of Last Thoughts

    Most common source of infection leading to osteomyelitis in the jaws is a periapical abcess
    Odontogenic cysts occur above the mandibular canal
    Primordial cysts are often odontogenic keratocysts
    Cysts can cause resorption of teeth
    Cysts also can expand the mandible, usually in a smooth, curved manner, and change the
      buccal or lingual cortical plate into a thin cortical boundary
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 Cysts may displace the inferior alveolar nerve canal in an inferior direction or invaginate into the
   maxillary antrum
      o But the odontogenic cyst did not develop initially below the mandibular canal
 Radicular cysts are most common cyst of the jaw
 A round shape, well-defined cortical border, and a size greater than 2 cm in diameter are more
   characteristic of a radicular cyst rather than an apical granuloma
 A simple bone cyst is a cavity within bone that is lined with connective tissue.
 Squamous cell carcinoma originating in bone is presumed to arise from odontogenic epithelium




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