Clinical Cases Gurminder Sidhu BDS, DDS, MS, Diplomate of ABOMR Director of Radiology services Dept. of Dental Practice

CASE 1 30 year old female presented for regular dental check up. On Radiographic examination You find…

CASE 1 On the anterior mandibular periapical radiograph there is a well defined radiolucent area with sclerotic borders present at the root apices of mandibular central and lateral incisors. It is well defined and localized. Is not causing the displacement or resorption of adjacent teeth. There is no gross carious lesion or sign of trauma in the area. The appearance is consistent with periapical cemento-osseous dysplasia. Teeth associated were vital on clinical exam.

CASE 1 Can have three stages radiolucent, mixed or completely radiopaque. Common in middle aged women specially Afro-American. Associated teeth are vital. Periapical Cemento-osseous dysplasia.

Periapical Cemento-osseous dysplasia. Mixed radiolucent and radiopaque stage with simple bone cyst arising within the lesions of cemento-osseous dysplasia.

CASE 2 Patient presented with pain in the lower left posterior area. On the left posterior periapical radiograph there is a radiolucent area associated with the root of mandibular left second premolar. The area is well defined, corticated. No displacement of adjacent teeth or resorption of the root is seen. The associated tooth has a big carious lesion and horizontal bone loss. The C:R ration is 1:1. Evidence of calculus in the general area is seen. Whenever there is a radiolucent area in the periapical area the first question which needs to be answered is “Is it associated with the tooth?” Evaluate the periodontal ligament space and lamina dura around the tooth. If there is loss of lamina dura around the apex of the tooth it would suggest that the radiolucency is associated with the tooth. Usually a large restoration or carious lesion would be evident. This type of radiolucency is called rarefying osteitis ( meaning resorption of bone in periapical area due inflammation). Rarefying osteitis is a broad term and can include abscess, granuloma or a cyst. Abscess is acute, granuloma is chronic and radicular cyst arises when cell rest of malessez is involved. These three are histopathological diagnosis. Radicular cyst can at time be diagnosed off the radiograph when the periapical radiolucency has corticated border and hydraulic shape. Rarefying osteitis has irregular border and gradually merge into adjacent normal bone.

CASE 2 The appearance is consistent with radicular cyst. Whenever there is a radiolucent area in the periapical area the first question which needs to be answered is “Is it associated with the tooth?” Evaluate the periodontal ligament space and lamina dura around the tooth. If there is loss of lamina dura around the apex of the tooth it would suggest that the radiolucency is associated with the tooth. Usually a large restoration or carious lesion would be evident. This type of radiolucency is called rarefying osteitis ( meaning resorption of bone in periapical area due inflammation). Rarefying osteitis is a broad term and can include abscess, granuloma or a cyst. Abscess is acute, granuloma is chronic and radicular cyst arises when cell rest of malessez is involved. These three are histopathological diagnosis. Radicular cyst can at time be diagnosed off the radiograph when the periapical radiolucency has corticated border and hydraulic shape. Rarefying osteitis has irregular border and gradually merge into adjacent normal bone.

CASE 2 The radiolucent area associated with periapical region of mandibular left second molar is irregular and the appearance is consistent with rarifying osteitis. This is the probable cause for pain. Whenever there is a radiolucent area in the periapical area the first question which needs to be answered is “Is it associated with the tooth?” Evaluate the periodontal ligament space and lamina dura around the tooth. If there is loss of lamina dura around the apex of the tooth it would suggest that the radiolucency is associated with the tooth. Usually a large restoration or carious lesion would be evident. This type of radiolucency is called rarefying osteitis ( meaning resorption of bone in periapical area due inflammation). Rarefying osteitis is a broad term and can include abscess, granuloma or a cyst. Abscess is acute, granuloma is chronic and radicular cyst arises when cell rest of malessez is involved. These three are histopathological diagnosis. Radicular cyst can at time be diagnosed of the radiograph when the periapical radiolucency has corticated border and hydraulic shape. Rarefying osteitis has irregular border and gradually merge into adjacent normal bone.

Radicular cyst Rarefying osteitis Rarefying osteitis Rarefying osteitis has ill defined border. The radiolucency gradually merges with surrounding normal bone. When there is a corticated border around the radiolucency associated with a non vital tooth it is most likely a radicular cyst. When radiolucent area is small it is safe to call it a rarefying osteitis which would include cyst, abscess and granuloma. Rarefying osteitis

Case 3 Patient presented for the replacement of #19. On the left posterior Accuitomo image there is a radiolucent area associated with the mid root region of mandibular left second premolar. The area is irregular. No displacement of adjacent teeth or resorption of the root is seen. No pulp canal is evident. Rarefying osteitis.

CASE 4 86 year old patient with a history of prostate cancer presents for routine dental exam. A well defined radiolucent area with thick corticated border is noted on the posterior right mandible below the inferior alveolar canal. Well described lesions can narrow down the diagnosis. Any lesion with epicenter below the inferior alveolar canal is not likely to be odontogenic in origin. So cyst and neoplasm of odontogenic origin can be ruled out. Any lesion with thick corticated borders are more likely to be anatomic variation. This is classic appearance of stafne bone defect.

Anatomy Mylohyoid ridge Submandibular salivary gland fossa Mylohyoid ridge and submandibular salivary gland fossa. Submandibular salivary gland fossa

CASE 5 Patient presented for routine dental exam. On mandibular right premolar periapical radiograph there is a well defined, corticated and unilocular radiolucent area in between the roots of canine and 1st premolar. The periodontal ligament space is intact on canine and premolar. The lesion is not causing expansion, displacement or resorption of the adjacent teeth Lateral periodontal cyst are usually well defined, round or oval and well corticated. Differential diagnosis can include a small OKC and radicular cyst at the foramen of a lateral pulp canal. Radicular cyst can be excluded if the tooth is vital. Lateral periodontal cyst can occur in cluster and appears as multilocular radiolucency, in that case it is called botryoid odontogenic cyst.

Lateral periodontal cyst It is a lateral periodontal cyst. Well define and corticated radiolucency in the location of mandibular premolar canine area. Not causing resorption or displacement of adjacent teeth. Lateral periodontal cyst

Case 6 Patient presented for routine dental exam. On mandibular left canine periapical radiograph there is a well defined, corticated and unilocular radiolucent area in between the roots of lateral incisor and canine. The periodontal ligament space is intact on these teeth. Slight displacement of the adjacent teeth is noted. The lesion is not causing expansion or resorption of the adjacent teeth

CASE 7 Well-corticated pericoronal radiolucency which exceeds 3 mm when measured from edge of crown to periphery of lesion (central and lateral types). Teeth most frequently affected – mandibular third molars, maxillary canines, mandibular premolars and maxillary third molars in that order. Highest incidence – 2nd and 3rd decades. Aspiration – straw colored thin liquid 48 year old patient presented with slow growing (past 6 months) facial swelling of right side. Pt. does not complain of pain or discomfort. On radiographic examination there is a well defined and corticated radiolucent area associated with the crown of mandibular right 3rd molar. The radiolucent area extends from the apices of 1st molar to neck of coronoid and condylar process. It has caused thinning of the lower border of the mandible. 3rd molar has been displaced apically.

coronoid process or to the inferior border of the mandible. Dentigerous cyst: The epicenter of dentigerous cyst is coronal to the crown of the involved tooth. The cyst is attached at CEJ but when it enlarges the tooth appears to be within the cyst. Dentigerous cyst is completely radiolucent and is well defined and corticated. It can resorb and displace adjacent teeth. Usually displace the associated tooth in an apical direction. 3rd molars may be displaced to the condylar or coronoid process or to the inferior border of the mandible. It is slow growing and usually expands the outer cortex. Differential diagnosis can include a hyperplastic follicle, which can be excluded if there is any expansion or displacement of the tooth. If the follicular space is larger than 5mm a dentigerous cyst is more likely. Other lesions to be considered are OKC, ameloblastic fibroma and cystic ameloblastoma.

Enlarged follicle Normal follicular space on panoramic films measure 3.0 mm, on intraoral films 2.5 mm. Canines usually have larger follicle compared to other teeth.

CASE 8

CASE 9 On clinical exam of a 38 year old male a small well defined swelling posterior to the palatine papilla is noted. On radiographic exam there is a well defined and corticated radiolucent area in the region of incisive foramen. Nasopalatine duct cyst usually contains remnants of nasopalatine duct and hence the name. Nasopalatine duct is the primitive organ for smell and contains nasopalatine vessels. Embryonic remnants of nasopalatine duct can undergo proliferation and cystic degeneration. Occurs during fourth - sixth decades. Three times more common in men. Radiographically root displacement and resorption of adjacent teeth can be seen. It is radiolucent and when nasal spine is superimposed on the cyst it appears in the shape of a heart. The differential diagnosis should include an incisive foramen, but if the size is greater than 10mm it is most likely a cyst and clinical examination would reveal expansion. A radicular cyst associated with central incisor can have similar appearance but if the tooth is vital it can be excluded.

CASE 10 On clinical exam of a 32 year old male a small well defined swelling posterior to the palatine papilla is noted. On radiographic exam there is a well defined and corticated radiolucent area in the region of incisive foramen.

In certain cases like this it is important to get 3D imaging to make appropriate diagnosis. It is a radicular cyst associated with #8. It is clearly demarcated from the incisive foramen.

CASE 11 7 year old child is brought to your clinic by his mother with the chief complain “lower right back tooth is missing”. On radiographic examination a well defined, corticated radiolucent area is noted coronal to mandibular first molar area. The tooth is displaced apically and lower border of the mandible is thinned. Ameloblastic fibroma is a benign mixed neoplasm. Simultaneous proliferation of both epithelial and mesenchymal tissue without formation of enamel or dentin. Occurs in much younger age group than ameloblastoma (usually average age of 16). Usual location – premolar-molar region. Uncommon neoplasm of odontogenic origin. It usually occurs in relation with an unerupted tooth or it may arise in an area where the tooth has failed to erupt. Differentiating it from dentigerous cyst or hyperplastic follicle can be difficult in some cases but dentigerous cyst most commonly occur at later age group and is more commonly associated with 3rd molars. It may be multilocular but it is uncommon and in cases where it presents like that the septa are very fine. Not aggressive like ameloblastoma, rarely recurs when treated by simple curettage.

CASE 12 On routine examination of 11 year old patient a well defined corticated radiolucent lesion is noted. The lesion shows some radiopacities and is present associated with 3rd molar. The tooth is apically displaced. Ameloblastic fibro odontoma is a mixed tumor with characteristics of ameloblastic fibroma but with scattered collection of enamel and dentin. Posterior jaws; mandible-maxilla. Young adults. Usually asymptomatic. Uniloculated or multiloculated. Well circumscribed, corticated border. Mixed radiolucency / radiopacity. Treatment is conservative, simple curettage. Recurrences are rare.

Differentiation from an ameloblastic fibroma can be difficult if no radiopacities are apparent. Also differentiating from developing odontoma can be challenging. A complex odontoma has one mass of disorganized hard tissue whereas ameloblastic fibro odontoma has multiple small scattered radiopacities.

CASE 13 On routine dental exam a well defined, corticated radiolucent lesion is noted in the mandibular left posterior area in the region of 2nd molar. The margins are scalloped and it is causing displacement of 2nd molar. OKC is derived from the dental lamina. Unlike other cyst which grow by osmotic pressure, the epithelium in OKC has growth potential Frequent location 3rd mandibular molar area (80%). Mandible to maxilla ratio is 2:1. Recurrence rate approximately 60%. Single or multiple. When multiple evaluate patient for basal cell nevus syndrome. OKC represents between 1.5 and 11% of all jaw cysts. Peak incidence in the 2nd and 3rd decade of life. Male to female ratio is 2:1. Clinical features : Asymptomatic. Paresthesia may be present in some patients. Secondary fractures when the cyst is large Radiographic features : Most OKCs are unilocular. Well defined cortex. Scalloping of the border. Multilocular cyst located in the third mandibular molar area may be confused radiographically with an ameloblastoma. Occasionally OKC may mimic a dentigerous cyst

Epicenter is located superior to IA nerve Epicenter is located superior to IA nerve. It has a propensity to grow along the bone with minimal expansion. OKC can cause root resorption and displacement but to lesser degree compared to dentigerous cyst and ameloblastomas. D/D: If OKC is present on the coronal aspect of an unerupted tooth differentiating from dentigerous cyst may be difficult. Dentigerous cyst is attached at the CEJ and cause greater expansion and displacement of teeth. If the internal structure of OKC is multilocular differentiating it from ameloblastoma, odontogenic myxoma and simple bone cyst and giant cell lesion should be done. Ameloblastoma usually cause more expansion. Odontogenic myxoma will have straight septation as opposed to OKC which has curved septa. OKC

OKC

Axial CT The Encyclopedia of Medical Imaging Volume VI:2

CASE 15 45 year old male presents with the chief concern of “I want an implant in lower right area for the missing tooth” On radiographic evaluation a multilocular, well defined, well corticated radiolucent area is noted extending from the apical area of # 30 to # 27. Displacement of the root of # 27 is noted. On clinical exam there is a hard swelling in this area and overlying tissue appears normal. Ameloblastoma is true neoplasm of odontogenic epithelium – arises from dental lamina or its derivatives (the enamel organ, epithelial rests or dentigerous cysts). Aggressive neoplasm. Most pts are in the age range of 20 – 50 years. Grow slowly and are usually asymptomatic. Cause extensive root resorption and tooth displacement. Unicystic type can cause extreme expansion.

Ameloblastoma 10% 3% 2% 60% 15% 10%

Can present as unilocular, multilocular (coarse septa) Soap bubble or Honeycomb. D/D – small unilocular lesions present coronal to an unerupted tooth may be difficult to distinguish from dentigerous cyst. If internal septations are present then OKC, giant cell granuloma, odontogenic myxoma. OKC generally do not cause so much expansion and tend to grow along the bone. Odontogenic myxomas usually will have at least one straight septa as opposed to curved septa seen in ameloblastoma. Giant cell lesions occur anterior to first molar and in younger age group and have granular and ill defined septa. Ameloblastoma

Recurrent ameloblastoma has characteristic appearance of multiple small cystlike structures with very coarse sclerotic cortical margins. Ameloblastoma

Ameloblastoma forms in wall of DENTIGEROUS CYST Ameloblastoma forms in wall of DENTIGEROUS CYST. (15%-30% of all ameloblastoma form in the wall of dentigerous cyst) Greatest frequency: under 30 years of age Posterior mandible, 3rd molar region. Delayed eruption of tooth, swelling, asymmetry. Mural Ameloblastoma

CASE 16 18 year old female presents with the chief complain of swelling and tenderness in anterior maxilla. Central Giant cell granuloma: usually occur before 21 years and are of unknown nature. Epicenter is located anterior to first permanent molars. Usually painless except for when secondarily infected. Radiographically presents as well defined, corticated, multilocular radiolucent, with “salt and pepper “ calcification and thin, wispy septa. Resorption of teeth very common. Lamina dura of the teeth in the region is usually missing. High propensity for expansion. D/D: AMELOBLASTOMA. Useful differentiating characteristics: ameloblastomas occur posteriorly and in old age group compared to central giant cell granuloma. Odonogenic myxoma: older age group and has at least one straight septa. Brown tumor of hyperparathyroidism may be difficult to differentiate radiographically but lab test can be done to diagnose hyperparathyroidism

CASE 17 Odontogenic myxoma: 10-50 years (15-35, mean 30). maxilla:mandible 1:3. may be infiltrative and aggressive. High recurrence rate of 25% due to lack of encapsulation of the tumor. Lesions are well defined, multilocular, corticated and will have at least one straight septa. Tennis racket type of appearance. Cortical expansion. Root displacement rather than resorption 38 year old male presents with the chief complain of swelling in anterior mandible.

CASE 18 Cherubism is rare inherited developmental abnormality. Radiographic features include bilateral and often both jaws giant cell granuloma type lesions. The epicenter is in the posterior area in both mandible and maxilla. The periphery is well defined. Multilocular pattern and the septa are thin. The teeth are displaced anteriorly as the epicenter is in the posterior region. The lesions grow anteriorly and may at times extend till midline. 5 year old child is brought to your office by his mother. On clinical exam there is bilateral painless enlargement of the face. Enlargement of submandibular lymph nodes.

Basal cell nevus syndrome Cherubism can have the differential diagnosis of multiple giant cell granuloma. Giant cell lesions occur anterior to first molar while cherubism lesions have the epicenter in the posterior aspect. Another lesion to consider is basal cell nevus syndrome which has multiple OKC’s. More expansion is noted in cherubism and the lesions have bilateral symmetry.

CASE 19 Chief complaint: 19-year-old male presented with a 3-month history of an enlarging lower left jaw mass. Physical examination revealed a firm, non-tender, fixed mass located in the body of the left mandible posteriorly and extending up in the ramus. The overlying skin appeared normal and mobile. Oral cavity examination showed a firm expansion of the left madibular vestibule. Odontogenic myxoma.

CASE 20 60 year old male presents with rapidly increasing swelling in the upper right quadrant. On radiographic evaluation there is ill defined radiolucent area present in the region canine and premolar. No cortication or reaction in surrounding bone is seen. Burkitt’s lymphoma: Affect more males than females. Grows rapidly. Cause deformity of the facial bones. Extra nodal disease is norm in Burkitt’s lymphoma. Cause pain and paresthesia. Radiolucent. Does not induce any reaction to the surrounding bone. Not corticated radiolucencies which later may coalesce into larger, expansile radiolucencies. Lamina dura and cortical boundaries are destroyed. D/D: Osteolytic osteosarcoma and Non Hodgkin’s lymphoma. Although Non Hodgkin’s lymphoma occur later in life.

CASE 21 Osteosarcoma of the jaw is rare and accounts for 7% of all osteosarcomas. Males are affected twice as commonly as females. Highest incidence in fourth decade. Mandible more commonly involved compared to maxilla. More common in posterior area. The lesion may cross the midline. Ill defined borders, radiolucent with no peripheral bone reaction or encapsulation. If lesion involves periosteum directly sunray spicule appearance is noted. Can be entirely radiolucent, mixed or completely radiopaque. Widening of PDL is seen in osteosarcoma but can be associated with other malignancies. D/D If no internal structure is present fibrosarcoma and metastatic carcinoma may appear similar. If osseous structure is visible chondrosarcoma should be considered. Physical exam and lab test can help differentiate metastatic from primary. 35 year old male presented with rapidly growing swelling in mandibular posterior area. On clinical exam the teeth in the area are loose and overlying mucosa is erythematous with small area of ulceration. Pt. complains of pain in the area.

CASE 22 60 year old male presents with C/C of pain in left posterior area in mandible. Metastatic lesions in jaw usually arise from sites below the clavicles. Usually the primary is already known. Most often the tumor is a type of carcinoma. Common primary sites are breast, kidney, lung, colon, rectum, prostate, thyroid. Mandible is favored over maxilla. Radiographic features: posterior area more commonly involved, maxillary sinus next most common sight followed by anterior hard palate and mandibular condyle. Maybe bilateral. Maybe located in PDL. Usually well demarcated but without cortication. May have ill-defined and invasive margins. Both prostate and breast lesions may stimulate bone formation of the adjacent bone. Initially as small areas of osseous destruction which may later coalesce. Generally radiolucent. Sclerotic in breast and prostate lesions. Can stimulate periosteal reaction. Effaces lamina dura and increase the width of PDL. Resorption of teeth is rare. D/D most cases primary malignancies is known. Has to be differentiated from multiple myeloma which has better defined margins. Lesions starting in PDL may simulate rarefying osteitis. Malignant lesions usually cause uneven widening of PDL.

Case 23 Patient presented for the replacement of #19. On the left posterior Accuitomo image there is a radiolucent area associated with the mid root region of mandibular left second premolar. The area is irregular. No displacement of adjacent teeth or resorption of the root is seen. No pulp canal is evident. Rarefying osteitis.

CASE 24 Pt. presents in emergency clinic with the chief concern of loose upper tooth. On radiographic examination there is an ill defined enlargement of PDL unilaterally. Periphery shows infiltrative border. No reaction in surrounding bone is noted. On evaluating medical history it is noted that pt. is undergoing treatment for leukemia. Leukemia is malignancy of bone marrow. C/F: Chronic leukemia usually has no symptoms. On the other end pts. With acute leukemia usually complain of weakness and bone pain. Oral symptoms are usually absent but if present include loose teeth, petechiae, ulceration and boggy and enlarged gingiva. Radiographic features: Usually bilateral. Ill defined, patchy radiolucent area. DOES NOT CAUSE EXPANSION. Developing teeth or teeth in the crypt are displaced in an occlusal direction. Premature loss of teeth. Lamina dura and cortical boundaries are effaced. D/D Lymphoma or metabolic conditions with generalized rarefaction of bone can be exclude with blood testing.

CASE 25 23 year old pt. presents with swelling, dull pain, gingivitis. History of multiple extractions over the last 6 months. Teeth have become progressively loose then been extracted. Langerhan’s cell histiocytosis (LCH) RESULTS FROM ABNORMAL PROLIFERATION OF Langerhan cells . 3 clinical types:1. Eosinophilic granuloma (EG) (solitary lesion), 2. Hand-Schuller-Christian Disease (chronic disseminated) , 3. Letterer-Siwe disease (acute disseminated). 10% of all pts. Will have oral symptoms. EG appears in skeleton (ribs, pelvis, long bones, skull and jaws). Occurs in older children and young adults. Forms quickly and can cause dull pain. On clinical exam overlying mucosa may shows ulceration. Letterer-Siwe disease (acute disseminated) occurs in infants under 3 years of age. Radiographic features are similar to malignant disease. Mandible more common than maxilla. Posterior more common than anterior. Punched out lesions without cortication. Alveolar lesions usually start in the midroot region of the tooth. Lesion does not displace teeth or cause root resorption. D/D would be periodontal disease, differentiation can be made based on epicenter of the lesion. In periodontal disease the epicenter is at the alveolar crest and extends apically down to the root surface. In LCH epicenter is midroot region. Differentiation of a squamous cell carcinoma can be difficult but LCH is usually well defined.

CASE 26 54 year old male presents with the chief complaint of loose teeth. On radiographic examination there is a radiolucent area present in the mandibular right premolar-molar area. Squamous cell carcinoma arising in Bone: Arise from intraosseous remnants of odontogenic epithelium. More common in men {4 – 8th decade}. More common in mandible {molar region}. Only arise in tooth bearing part of the jaw. Radiolucent Ill defined borders. Can cause pathologic fractures. Destruct the antral/ nasal floor, cortical border of inferior alveolar canal. Effacement of lamina dura. Teeth “floating in space” SQCC: Teeth floating in space appearance as the bone around the teeth is invaded. Also notice the ill defined margins and invasion and thinning of the lower border of the mandible.

CASE 27 Characterized by intense fibrosis Induration, loss of skin contours, wrinkles and immobility; starting usually in the fingers Diagnostic criteria according to the American Rheumatism Association are: Either scarring of the skin in the extremities, or 2 of the following symptoms in the same patient; sclerodactily, edematous lesions of the fingers, loss of sensitivity in the fingertips or bilateral basilar pulmonary fibrosis on chest radiograph Sclerodactily - Stiffness and tightening of the skin of the fingers, with atrophy of the soft tissues and osteoporosis of the distal phalanges of the hands and feet. Annual incidence – 19 cases per 1 million 30-50 years of age. F:M = 3:1, peaks before menopause. Risk for blacks slightly greater. ORAL MANIFESTATIONS: Xerostomia, candidosis. Microstomia & xerostomia result in elevated plaque index, gingival recession. Width of PDL significantly increased, possible cause of increased tooth mobility 45 year old female presents with the chief complain that her teeth are progressively becoming loose. On radiographic evaluation there is generalized widening of PDL.

CASE 28 58 year old female complains of pain of 2 years duration. Pain is not relieved by any pain medication. Intra-oral examination WNL. OSTEO

Osteomyelitis

Osteomyelitis The axial section on the left shows sequestrum (area of necrotic bone) The axial image on the right shows periosteal reaction.

CASE 29 82 year old patient with a history of breast cancer presents for routine dental exam. A well defined radiolucent area with thick corticated border is noted in the anterior left mandible. STAFNE DEFECT.

CASE 29 STAFNE DEFECT

STAFNE DEFECT