1. 口腔診斷學 陳玉昆副教授 : 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw Multiple Separated Radiopacities 多個分開之 X 光不透過影像

2. Understanding: 1. 多個分開之 X 光不透過影像的鑑別診斷 學 習 目 標學 習 目 標

3. 1.Wood, Goaz. Differential diagnosis of oral lesions. Mosby, 3rd ed., Chapter 27, p. 610-9 2.Kaohsiung Medical University, Department of Oral Pathology 3.Golan I et al. Dentomaxillofacial variability of cleidocranial dysplasia: clinicoradiological presentation and systematic review. Dentomaxillofac Radiol 2003;32:347-54 4.Golan I et al. Early craniofacial signs of cleidocranial dysplasia. Int Pediatr Denti2004;14:49–53 5.Ribeiro ACP et al. Oral cysticercosis: case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:e56-e58 References: 參考資料

4. Multiple Separated Radiopacities (1) Most common lesions 1.Tori and exostoses 2.Multiple retained roots 3.Multiple socket sclerosis 4.Multiple mature cementomas 5.Multiple periapical condensing osteitis 6.Multiple embedded or impacted teeth 7.Cleidocranial dysostosis (dysplasia) Ref. 1

5. Multiple Separated Radiopacities (2) Multiple large tori – occlusal radiography Multiple large exostosis – periapical radiography Refs. 1, 2

6. Multiple Separated Radiopacities (3) Multiple root fragments – readily identified Multiple root fragments – not readily identified Ref. 1

7. Multiple Separated Radiopacities (4) Multiple socket sclerosis 1.May be mistaken for retained roots (both have identical shape) 2. If PDL space not apparent, should be identified as socket sclerosis (except for ankylosed root) 3. Not require definitive treatment 4. Suspect for a GI malabsorption or a renal malady Ref. 1

8. Multiple Separated Radiopacities (5) Multiple cementomas – Note of RL rims – Located in mandibular incisor region – Less frequently in maxilla Ref. 1

9. Multiple Separated Radiopacities (6) Multiple idiopathic osteosclerosis 1.Bilaterally & in multiple separate areas in mandibular molar or premolar region 2. Dense, irregularly shaped RO 3. Vary from 0.5 to ~2.0 cm in diameter 4. Found at the periapices of vital teeth Ref. 1

10. Multiple Separated Radiopacities (6) Multiple periapical condensing osteitis 1.Non-vital or degenerating pulp 2. Found surrounding multiple root fragments Ref. 1

11. Multiple Separated Radiopacities (7) Multiple embedded/impacted teeth (no syndrome) 1.Embedded tooth: fail to erupt due to imbalance in the coordinated forces responsible for the axial movement of teeth 2. Impacted tooth: prevented from erupting by a physical barrier in the path of eruption 3. D.D. from partial anodontia, cretinism (hypothyroidism in young children), cleidocranial dysostosis Ref. 1

12. Multiple Separated Radiopacities (8-1) Cleidocranial dysostosis – 1.Numerous impacted teeth 2.Partially or complete absence of clavicles 3.Skull: enlarged but a shorter than normal P dimension (brachycephaly) 4. Frontoparietal bossing 5. Delayed fontanelle closure (may be open throughout life) 6. Unusual no. of wormian bone: 2 nd centers of ossification suture lines Ref. 1

13. Multiple Separated Radiopacities (8-2) Cleidocranial dysostosis- Dentomaxillofac Radiol 2003;32:347-54 Ref. 3

14. Multiple Separated Radiopacities (8-3) Cleidocranial dysostosis- Dentomaxillofac Radiol 2003;32:347-54 Ref. 3

15. Multiple Separated Radiopacities (8-4) Cleidocranial dysostosis- Int J Pediatric Dent 2004;14:49-53 Ref. 4

16. Multiple Separated Radiopacities (8-4) Cleidocranial dysostosis- Int J Pediatric Dent 2004;14:49-53 Ref. 4

17. Multiple Separated Radiopacities (9-1) Cysticercosis – many small RO foci scattered within the cranium Multiple calcified LN – TB history Ref. 1

18. Multiple Separated Radiopacities (9-2) Cysticercosis – Frequent in developing countries A parasitic infection rarely involves the mouth Ref. 5

19. Multiple Separated Radiopacities (10) Multiple phleboliths Multiple sialoliths Bilateral Ref. 1

20. Multiple Separated Radiopacities (11) Multiple RO - Paget’s disease Ref. 1

21. Summarie s 明白多個分開之 X 光不 透過影像的鑑別診斷。

22. 口腔診斷學 陳玉昆副教授 : 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw Generalized Radiopacities 廣泛性 X 光不透過影像

23. Understanding: 1. 廣泛性 X 光不透過影像的鑑別診斷 學 習 目 標學 習 目 標 Ref. 1

24. 1.Wood, Goaz. Differential diagnosis of oral lesions. Mosby, 3rd ed., Chapter 28, p. 620-630 2.Dutta S et al. Infantile cortical hyperostosis- Indian Pediatric 2005;42:64-6 3.Ramaglia L et al. Gardner’s syndrome – Oral Med Oral Pathol Oral Radiol Endod 2007;103:e30-e34 4.Wong YK & Cheng JCF. Infantile cortical hyperostosis of the mandible. Br J Oral & Maxillofac Surg 2008;46:497-8 References: 參考資料

25. Generalized Radiopacities (1) Most common lesions 1.Florid cemento-osseous dysplasia 2.Paget’s disease (mature stage) 3.Osteopetrosis Rarities 1.Infantile cortical hyperostosis (Caffey disease) 2. Gardner’s syndrome 3. Multiple large exostoses and tori 4. Metastatic carcinoma of prostate Ref. 1

26. Generalized Radiopacities (2) Florid cemento-osseous dysplasia 1.Restricted to jawbones 2.Vast majority of patients > 30y/o 3.A marked predilection for females & blacks 4.Mandible > maxilla 5. Early or mild cases: symptomless & found on routine X-ray check 6. Advanced lesions: painless expansion (may complain constant need for adjustment of prosthesis) Ref. 1

27. Generalized Radiopacities (3) Florid cemento-osseous dysplasia Ref. 1

28. Generalized Radiopacities (4) Paget’s disease Enlarged skull & maxilla Exophthalmos, healing aid Cotton wool D.D. with polyostotic fibrous dysplasia: involves a section of a bone rather than the complete bone, asymmetric enlargement, serum chemistry if present will be slight Commonly involves 5/6 bones at most Ref. 1

29. Generalized Radiopacities (5) Malignant osteopetrosis (Albers-Schonberg disease, marble bone disease) Almost complete obliteration of medullary portions of femurs & tibiae Two main types (Normal serum chemistry levels): 1.Clinically benign dominantly inherited form: develop later in life, less severe, fractures on minor trauma 2.Clinically malignant recessively inherited form: present at birth or in early childhood, severe & debilitating, die <20 y/o, neurologic/hematologic disorders, pathological fx Involve all the skeletal bones Ref. 1

30. Generalized Radiopacities (6-1) Infantile cortical hyperostosis 1.Proliferation of cortices 2.Almost completely obliterated the shadows of the medullary cavities 3.Soft tissue swellings, fever and irritability Ref. 1

31. Generalized Radiopacities (6-2) Infantile cortical hyperostosis- Indian Pediatric 2005;42:64-6 Radionuclide bone scan (posterior view) on day 85 showing involvement of all ribs on the right side, lowest rib on the left and the mandible Plain X-ray of the chest (antero-posterior view) showing cortical hyperostosis of the ribs Ref. 2

32. Generalized Radiopacities (6-2) Infantile cortical hyperostosis Ref. 3

33. Generalized Radiopacities (6-2) Infantile cortical hyperostosis Ref. 3 The child may present with hyperirritability, fever, facial swelling, pain, malaise, erythema, or poor appetite, and non-specific laboratory abnormalities including leukocytosis, thrombocytopenia, and increased erythrocyte sedimentation rate (ESR).

34. Generalized Radiopacities (6-2) Infantile cortical hyperostosis Ref. 3 Treatment with amoxycilln/clavulanic acid (Augmentin) for two weeks resulted in remission. However, symptoms recurred two weeks after discharge. Indometacin was then started orally at 2.3 mg/kg/day divided into three doses a day. The left facial swelling resolved after five days and treatment continued for four weeks. The ESR and C- reactive protein (CRP) concentration level returned to within normal limits. There was no recurrence over a nine-month period with no resultant facial asymmetry.

35. Generalized Radiopacities (7-1) Gardner’s syndrome – multiple osteomas Ref. 1

36. Generalized Radiopacities (7-2) Gardner’s syndrome – Oral Med Oral Pathol Oral Radiol Endod 2007;103:e30-e34 1. A hereditary disorder inherited as autosomal dominant with complete pentrance & variable expression 2. A variant of familial adenomatous polyposis characterized by extracolonic manifestations including osteomas, dental anomalies, and epidermoid cysts Ref. 3

37. Generalized Radiopacities (7-3)

38. Generalized Radiopacities (8) Unusual large & numerous exostoses & tori

39. Systematic approach to differentiate radiopacities 1. Attached or not attached to tooth apices 2. Which tooth/teeth involved? 3. Vitality of the attached tooth 4. Degree of opacities 5. Presence of radiolucent rim (margin) or not 6. Number of opacities (multiple quadrants) 7. Clinical symptom of infection exist? ( 必考 )

40. Summarie s 明白廣泛性 X 光不透過 影像。

41. * 各位同學 要坐上此架飛機, 遨遊. 飛越美國 (Flying over America!) 飛越美國 (Flying over America!) 對準這架飛機，按兩次滑鼠： Left Double Click Your Mouse on this plane