1. Radiographic Features of Periapical Lesions

2. A periapical lesion is a lesion located around the apex of a tooth.
It cannot be evaluated clinically alone, the use of dental radiographs is important.
Radiographically :It appears either radiolucent or radiopaque.

3. Pulpitis
Acute chronic
Apical peiodontitis
Periapical abscess
Periapical granuloma
Periodontal cyst
Osteomyelitis
Periosteitis
Cellulitis
Abscess
Focal Diffuse

5. A:PA granuloma / cyst B:PA granuloma

6. A: Acute apical periodontitis B: PA lesion in 5 & early apical changes in 6

7. PA lesion
PA lesion

8. White arrow :PA granuloma/cyst . Black arrow : sclerosing ostetitis

10. Periapical Radiolucency
A. Periapical Abscess:
. Acute Periapical Abscess: No radiographical changes is seen, but some time the early radiographic changes shows widening of the apical periodontal ligament.
. Chronic Periapical Abscess: long standing, low grade, pus-producing process. It may develop from an acute abscess or a periapical granuloma. It is usually asymptomatic because the pus drains through the bone or the periodontal ligament.
Clinically : a gumboil (sinus) may be seen in the apical region of the tooth at the site of drainage.
Radiographically: appears as a round or ovoid apical radiolucency with poorly defined margins, the lamina dura is absent in the site of lesion.

11. B. Periapical granuloma:
It is a localized mass of chronic inflamed granulation tissue at the apex of a non vital tooth, due to pulp death & necrosis. A periapical granuloma may give rise to a periapical cyst or abscess. It's asymptomatic but has a previous history of prolong sensitivity to heat & cold.
Radiographically: widened periodontal ligament space at the root apex, with time the widened periodontal space enlarged & appears as round or ovoid radiolucency with absent lamina dura .

12. C. Periapical Cyst (Radicular Cyst): is developed over a prolonged period of time, it is takes place within a periapical granuloma. The tooth is non vital & necrotic. Periapical cyst form 50-70% of the cystic lesions in the oral region. Radicular cyst is asymptomatic, unless secondary infection is occurring.
Radiographically:appears as a well localized, round or ovoid radiolucency with the demarcated outline.
Treatment: either by the surgical curettage or extraction of the offending tooth.

13. Periapical Radiopacities
A-Condensing Osteitis :
It is a response of bone to some form of injury (low-grade infection or excessive physical stress).
Is a well-defined radiopacity that is seen below the apex of a non-vital tooth with history of long standing pulpitis.
Apical opacity represents a proliferation of periapical bone due to a low grade inflammation or mild irritation.
It may vary in size & shape & dose not appear to be attached to the root apex, most commonly occur in the mandibular molar region.
Associated tooth have a large carious lesion or large restoration, this lesion may disappear after proper endodontic therapy.

14. Condensing Osteitis

15. B-Sclerosing bone:
Is a well-defined radiopacity that is seen below the apices of the vital, non-carious teeth.
The lesion not attached to the tooth & varies in size & shape.
The margins may appear smooth or irregular & diffuse, the borders are continuous with adjacent normal bone & no radiolucent line is seen.
It's asymptomatic & discovered by routine dental radiography.

16. White arrow: no PA response Black arrow: PA radiolucency
Red arrows: sclerotic bone.

17. C-Hypercementosis: Is the deposition of cementum on root surface.
Causes idiopathic or resulted from supra-eruption, inflammation or trauma.
Radiographically: is visible as an excess amount of cementum along all or part of a root surface. The apical area is affected & appears enlarged & bulbous, it separated from periapical bone by a normal periodontal ligament space & surrounding lamina dura is normal.
The tooth is vital, asymptomatic; no treatment is required & discovered by routine radiograph.
Complications: interfere with extractions, also result in pulpal necrosis by blocking blood supply via the apical foramen.

18. Hypercementosis