牙放seminar第一組 2.1.1-1 Periapical granuloma 2.1.2-4 Nasopalatine duct cyst 2.1.1-2 Radicular cyst 2.1.2-5 Eosinophilic granuloma 2.1.1-3 Surgical defect 2.2-1 Dental follicle 2.1.1-4 Periapical abscess 2.2-2 Pericoronitis 2.1.1-5 Osteomyelitis 2.2-3 Paradental cyst 2.1.2-1 Cementoma 2.2-4 Dentigerous cyst 2.1.2-2 Periodontitis 2.2-5 Muralameloblastoma 2.1.2-3 Trauma bone cyst 2.2-6 Adenomatoid Odontogenic Tumor

2.1.1-1 these are well-defined round radiolucences surround both root apexes and bifurcation of the tooth #36, measuring not more than 2cm in diameter. The radiolucence between the roots may develop alveolar bone resorption

Periapical Granuloma Clinical features: asymptomatic pain and sensitivity can develop 病理特徵: Periapical Granuloma 的 granulation tissue 是由三個東西組成 : - 發炎組織 : lymphocyte 、PMN、plasma cell -血管 -Fibrous tissue : 在發炎組織和血管的外面 看不到epithelium lining , 沒有表皮包圍 , 只有granulation tissue 。

2.1.1-2 there is a well-defined unilocular round shaped circumrooted radiolucence with a corticated margin over the tooth #23 between the adjacent teeth. The radiopaque border is continuous with the lamina dura of the associated tooth.

Radicular cyst 外圍是non-keratinized stratified squamous epithelium 有rete process增生 hyaline body foamy cells fibrous wall會有 heavy deposits of cholesterol crystals

Periapical granuloma 和 Radicular cyst的不同點 : periapical granuloma 比cyst常見 periapical cyst 比較常發生在 upper jaw bone. X-ray 片上可以看到完整的lamina dura Granuloma 沒有治療就會演發成radicular cyst Radicular cyst發生在nonvital tooth

2.1.1-3

Surgical Defect 病灶不會擴大，所以應該也不會對其他牙齒或者組織造成任何影響 這是根尖切除術之後，手術的地方骨頭組織再生失敗造成的 骨頭組織被fibrous tissue所取代，很常發生在apical的地方 在X光片下，是well-defined, radiolucence的 牙齒自己本身也不會有任何症狀，除非是照X光片，否則是不會被察覺的 根尖切除術的術後結果；有可能會pain, hemorrhage, swelling, ecchymosis, paresthesia, maxillary sinus perforation。

2.1.1-4 There is ill-defined unilocular shaped radiolucence without a corticated margin on periapcial area of tooth 14, and with a periodontal pocket on the distal side. This maybe a combination syndrome of both endo. and perio. with progression, the abscess may extend through the medullary spaces away from the apical area resulting in osteomyelitis, or it may perforate the cortex and spread diffusely through the overlying soft tissue

Apical absess arise as the initial periapical pathosis or from an acute exacerbation (phoenix abscess) of a chronic periapical inflammatory lesion. In the early stage, the periapical periodontal ligament fibers may exhibit acute inflammation but no frank abscess formation. best termed acute apical periodontitis.

Clinical Features painful tender swelling of varying size and position tenderness to pressure in buccal sulcus    fever and malaise    erythema and possibly draining sinus, intraoral or extra-oral    unresponsive to thermal and electrical stimuli   positive percussion test

Differential diagnosis Periapical granuloma: 根尖處牙周膜肥厚(raiolucency) Well-defined with a corticated radiopaque line or zone of sclerotic bone. Radicular cyst: 與periapical granuloma類似，無法以radiolucency區別。 Osteomyelitis: poor-defined “moth-eaten” radiolucency

2.1.1-5

Osteomyelitis, periapical 好發位置在posterior body of mandible，上顎是很少見的 其重要的特徵就是會有sequestra的產生。 分為 acute以及chronic

2.1.2-1 There is a well-defined monolocular round shaped radiolucence without a corticated margin at the apical area of both mandibular central incisors(tooth24,25)extending from the mesial aspect of tooth 26 to the periapical area of tooth 24,measuring approximately 1 cm in diameter .the adjacent teeth are typically vital and not resorbed with an intact periapical ligament space.

Cemetoma , periapical cemento-osseous dysplasia , stage 1 Middle-aged adults (typically black women ) Monolocular , often multiple Early stage : radiolucent ,not corticated Intermediate stage : radiopacity within the apical radiolucencies Late stage : densely radiopaque but surrounded by a thin radiolucent line Traumatic ( solitary ) bone cyst Radicular cyst Periapical granuloma

2.1.2-2 There is a continuous irregular radiolucence with a poor defined margin along the apical area of the right maxillary posterior teeth (tooth 2,3,4and 5),and a well-defined round shaped radiolucence without a corticated margin at the periapical area of tooth 4 ,with a superior margin at the apex os the root and a inferior margin near the midle one-third of the root,measuring approximately 1 cm in diameter.Severe bone destruction can be observed around the roots of the teeth.

Periodontitis Localized severe bone destruction around the roots of the teeth Endo-perio lesion Eosinophilic granuloma Traumatic (solitary ) bone cyst Periapical granuloma Radicular cyst

2.1.2-3 There is a well-defined monolocular scalloped-shape radiolucence with a cortical margin between the root of the 35 and 37 extending from the distal of 35 to the root tip of 37 squeezing along the root outline，measuring approximately 4 × 2 cm in diameter. The involved teeth from 35 to 37 are still alive with lamina dura.

Trauma bone cyst well-defined (corticated) radiolucence asymptomatic under 20 years old 60% male common in the mandibular premolar and molar areas margin along the root， not push vital teeth scallop(several teeth) empty or fluid filled cavity

lateral periodontal cyst Same-- male prefer asymptomatic corticated round radiolucency along the lateral root surface in alveolar bone Different-- old ages often in mandibular premolar-canine-lateral incicor area(rarely in molars) some are botryoid round lucency(botryoid odontogenic cyst)

aneurysmal bone cyst(ABC) same— well defined unilocular radiolucency different— large blood-filled spaces often described as "soap bubble" teeth moved and roots resorption

odontogenic keratocyst(OKC) Same— scalloping asymptomatic different– wide age range multiple(about10%) teeth moved and roots resorption

glangular odontogenetic cyst(GOC) same— painless scalloping different— usually anterior mandible middle aged teeth moved and roots resorption

2.1.2-4 There is a well-defined monolocular round shaped radiolucence with a corticated margin at midline of anterior maxilla ,measuring approximately 2x4 cm in diameter.Upper central incisors are separated apart.

Nasopalatine duct cyst (Incisive Canal Cyst) 40~60 years old ; ♂＞♀ site: midline, anterior maxilla Unilocular, round or oval, well-defined, well corticated (unless infected) It may cause palatal expansions smooth cortical border arises from epithelial remnants of the nasopalatine duct

usually present in the midline of the anterior maxilla near the incisive foramen many are inflamed pain, pressure, drainage and swelling can occur

Differential Diagnosis : periapical granuloma    radicular cyst  

2.1.2-5 There is a round monocular radiolucence without corticated margin between tooth44 and tooth47,measurely approximately 3X5 cm in diameter, Destruction of the periodontal bone (loose teeth)without otherwise affecting the teeth (e.g. root resorption).

Eosinophilic Granuloma Benign proliferation of Langerhans cells. Usually adolescents and young adults. Localized or multiple lesions. In the jaws, more than 75% in mandible. Round, monolocular, not corticated. Destruction of the periodontal bone (loose teeth)without otherwise affecting the teeth

Periodontitis  Radicular cyst  Squamous cell carcinoma  Metastatic tumors (ill defined) Malignant salivary gland tumors 

2.2-1 ＊ There is a well-defined, unilocular, round-shaped radiolucence with a well-corticated margin above tooth22,surrouing crown of an impacted tooth, extending from distal aspect of tooth 21 to mesial aspect of tooth 24 and from the half part of the tooth 22’s root to alveolar bone above tooth 22. The height of the radiolucence is about to its width. ☆ Dental follicle !!

Dental follicle 在牙齒成長時期晚期(cap stage+bell stage)的支持組織；牙齒萌發後轉變為periodontium上的纖維組織。 ※ dentigerous cyst： 同：組成都有reduced enamel epithelium 異：後者的reduced enamel epithelium有異常增生的 現象，cyst會聚積液體不斷擴大。 ＊ Dentigerous cyst有構成cyst的三個要素，是一個病理上 的構造；dental follicle只是牙齒發育時期的正常組織。

Dental follicle ※ Upper canine 阻生牙發生原因： ※ Impaction of upper canine-- 全部牙齒發生率 No.1 ※ Upper canine 阻生牙發生原因： 1. 牙弓空間不足，兩側恆齒較早萌發。 2. Lat. Incisor的牙根偏歪。 3. 乳齒的canine因蛀牙太早離開牙弓。 4. 牙胚位置不正確 5. 有dentigerous cyst或是tumor阻礙萌發

2.2-2 This radiograph is part of a panoramic one. There is a radiolucence locating at distal aspect of tooth 38, extending from distal of the tooth 38’s crown to the ramus of mandibular bone, measuring about 1 cm. Its height is approximately the length of tooth 38’s crown. It’s well-defined, surrouned by nearby soft tissue (gingiva) and the crown of tooth 38.

Pericoronitis口病特徵: 位在左側第三臼齒的遠心面外側 成因是因為下顎智齒在長成的時候牙弓已經沒有太多的空間，牙冠生長受到上方牙齦肉的阻礙 reduced enamelepithelium沒有辦法與oral mucosa結合形成junctional epithelium，使牙齦肉與牙齒無法緊密結合

Pericoronitis口病特徵: 智齒的清潔不夠徹底的話，就會導致該處牙齦發炎，並且引起劇烈疼痛 病人有咬合困難的問題 。嚴重一點的話，發炎的牙齦內有pus的產生，引起不適的味覺體驗。 引起的痛覺，可能會轉移到喉嚨，耳朵，口底等處

Differential diagnosis: Paradental cyst: 同:同樣是發生在第三下顎臼齒的遠心面外 側或facial aspect，與部份阻生的牙齒有 關 。 異:它所形成的是cyst，要形成cyst有3要 素，分別是cavity，epithelium，wall。 而pericoronitis並非cyst。

Differential diagnosis: Dentigerous (follicular) cyst : 同:與阻生牙的機率成正比，也易發生於第 三臼齒 。 異:是一種cyst，要形成cyst有3要素，分別 是cavity，epithelium，wall。鈣化好的 牙冠(crown )，被cyst給包住 。發生的 地點除智齒外，也有可能發生在upper canine。

治療: 局限性的 ：用溫的鹽水來漱口，並時時確 保沒有食物在gingival flap內。 急性的：發生了嚴重的疼痛及發炎，就要 採取手術的方式，將智齒拔除或是 切掉gingival flap 。

2.2-3 There is a small well-defined unilocular oval shaped radiolucence with corticated margin in the distal of the tooth 48 extending from distal cervical margin of the tooth 48 down to inferior alveolar canal and up to the 1/4 ramus

Paradentalcyst 病理特徵 好發位置：mandibular third molar的lateral root surface、靠近cervical margin 致病原因：uncertain. involved by pericoronitis (usually lower 3rd molar).

2.2-4 There is a well-defined unilocular oval shaped circumcoronal radiolucence with a corticated border over the submerged tooth 48 extending from retromolar area down to the mandibular angle, measuring approximately 1*2 cm in diameter.

Features of Dentigerous Cyst Most common odontogenic cyst, next to radicular cyst. Etiology X-ray Site P’t ages: usually adolescents, 20~40 years old. Eruption cyst Effects on adjacent tooth Treatment Progonosis Ameloblastic change (neoplastic transformation)

Differential diagnosis Mural ameloblastoma

Differential diagnosis Adenomatoid Odontogenic Tumor (AOT)

Differential diagnosis Ameloblastic fibroma

Differential diagnosis Paradental cyst

2.2-5 There is a well-defined unicystic irregular shaped pericoronal radiolucence without corticated margin associated with an unerupted 38 tooth in the cyst extending from distal aspect of the unerupted tooth 37 up to approximately 2/3 left ramus and from superior border of ramus down to left mandibular angle

Muralameloblastoma 病理特徵 ‧arises most commonly from a dentigerous cyst ‧most common site: Mandible posterior region ‧cause root resorption of the adjacent teeth ‧屬於unicystic ameloblastoma其中一種 tumor會侵入cystic wall(fibrous tissue)，往外增 生，癒後最差

Ameloblastoma 臨床上ameloblastoma分成三大類： conventional / multicystic type ( 86% ) unicystic type ( 13% ) - luminal ameloblastoma - intraluminal ameloblastoma - mural (wall) ameloblastoma Peripheral (extraosseous) type ( 1% )

Ameloblastoma unicystic ameloblastoma 和 conventional ameloblastoma 的比較： conventional ameloblastoma Unicystic ameloblastoma Case比例 about 86% of all cases about 13% of all cases Shape multilocular radiolucence Unicystic radiolucence 發生位置 20% in maxilla 80% in mandible 56% in mandibular molar, ramus region 90% in ramus region 發生年齡 40、50歲的時候診斷出來，發生的平均年齡大約是39、40歲左右 18-20歲 recurrent rate 50-90% 10-20%

2.2-6 There is a well-defined unilocular oval shaped radiolucence with a corticated margin. It extend from apex of tooth 21 to apex of tooth 25 and from 3mm below alveolar crest to nasal spine level,measuring approximately 3 x 3 cm in diameter. It causes tooth 21 and tooth 23 unerupted, tooth 21 malposition (root slants to mesisal) and tooth 24 slanted to distal.

Adenomatoid Odontogenic Tumor (AOT) 良性腫瘤. 發生在年輕人.(70% 2nd decade) 好發區域：上顎前牙(側門齒－犬齒－第一小臼齒) 經常包住一個沒有萌發的牙齒 生長緩慢，無痛，長太大會使骨頭鼓起使臉不對稱 2/3的病例在裡面會有Radiopacities發生 治療：手術切除

Difference Disease Dentigerous cyst Dental follicle Mural Ameloblastoma Full radiolucence的話只能用採樣確認

THE END