DD of pericoronal RL.pptx

DIFFERENTIAL DIAGNOSIS

1. DIFFERENTIAL DIAGNOSIS of PERICORONAL RADIOLUCENCIES Dr.BHANUPRAKASH .

2. CONTENTS: INTRODUCTION PERICORONAL RADIOLUCENCIES ENTITIES PRODUCING PERICORONAL RADIOLUCENCIES DESCRIPTION OF EACH IN DETAIL

3. INTRODUCTION: Variations in the density of a structure exert a profound influence on the image. Greater the density of a structure within the subject,greater the attenuation of the x-ray beam directed through that area. Dense objects(strong absorbers) cause radiographic image to be light-----RADIOPAQUE. Objects with low density(weak absorbers) allow most of the photons to pass through and they cast a dark area on the film-------RADIOLUCENCY

4. ENTITIES PRODUCING PERICORONAL RADIOLUCENCIES:

5. PERICORONAL RADIOLUCENCIES WITHOUT OPACITIES

6. 1)NORMAL FOLLICULAR SPACE: The crowns of the unerupted teeth are normally surrounded by a dental follicle--- a soft tissue remnant of enamel organ referred as REE(Reduced Enamel Epithelium) RADIOGRAPHIC FEATURES: Dental follicle appears as a radiolucent halo with a thin outer radiopaque border. The halo varies in thickness coz of : ---varying thickness of follicles. Or ---accumulation of fluid between REE and crown of the tooth.

7. VARIATIONS: Longstanding impacted teeth show meagre follicular spaces. Unerupted max.canines show enlarged follicular spaces –when eruption is delayed. Some children have generalised enlargement or hyperplasia of the follicular spaces. (as reported in -- Rough Hyperplastic AI & -- Lowe syndrome)

8. GUIDELINES TO DISTINGUISH BETWEEN NORMAL & ABNORMAL FOLLICLE: If an assymptomatic follicular radiolucency becomes approximating 2.5mm in dia & surrounding cortical plate is poorly defined---disease is strongly suggested. If pericoronal space reaches 2.5mm …this is a presumptive evidence that fluid is collecting within the follicle -----pathosis is present in 8O% of the cases.

9. MANAGEMENT: It is advisable to radiographically examine enlarged / enlarging follicles every 6 months. If eruption is delayed ; dentigerous cyst or any other pericoronal pathology must be considered and surgical intervention is indicated.

10. 2)DENTIGEROUS CYST: FOLLICULAR CYST(most common developmental odontogenic cyst) Most common pericoronal radiolucency caused by the accumulation of fluid between REE & crown of an unerupted tooth. CLINICAL FEATURES: Always assosiated with crowns of unerupted /embedded/impacted teeth. Frequently affected sites:(in order) - mand.3 rd molar - max.canine - mand.premolars - max.3 rd molars

11. Multiple dentigerous cysts are seen in: - Cleido -cranial dysplasia - Maratoux-Lamy syndrome -Basal cell nevus syndrome. Expansion of bone with subsequent facial assymetry , displacement of teeth, root resorption of adj teeth are all possible sequele . RADIOGRAPHIC FEATURES: Location: Seen as radiolucency surrounding the crowns of unerupted teeth.(suspected when follicular space is >5mm) 3 varieties: -central -lateral & -circumferential

12. Periphery: Well defined cortex. If infection is present cortex may be missing. Internal structure: Completely radiolucent except for the crown of the impacted tooth. Effects on surrounding structures: May displace or resorb adj teeth Expansion of outer cortical boundary of the involved jaw.

13. Dentigerous cyst surrounding the crown of 3 rd molar 3 rd molar has been displaced to the inferior cortex

14. DIFFERENTIAL DIAGNOSIS: HYPERPLASTIC FOLLICLE: No evidence of tooth displacement /expansion of involved bone. The region should be re-examined in 4-6 mo to recognize influence on surrounding structures characteristic of cysts. ODONTOGENIC KERATOCYST: May attach further apically on the root instead of at CEJ. less likely to resorb teeth. AOT & COT: can surround the crown &root of the involved tooth. evidence of internal radiopaque structure. RADICULAR CYST (at the apex of primary tooth appears to surround the crown of the developing permanent tooth.): Evidence of extensive caries / large restorations in a primary tooth would indicate radicular cyst.

15. MANAGEMENT: Smaller cysts ---Complete enucleation Larger cysts ---- Marsupialization Recurrance is uncommon.

16. 3)ODONTOGENIC KERATOCYST: A cyst derived from the remnants of dental lamina with the biologic behavior similar to that of a benign neoplasm. Distinctive lining of 6-10 cells thickness. Basal cell layer of palisaded cells Surface of corrugated keratin.

17. CLINICAL FEATURES: Wide age ranges Slight male prediliction Mandible>>>maxilla In mandible-- molar ramus area is more common followed by anterior mandible. In maxilla --3 rd molar area followed by cuspid region is more common OKCs usually are assymptomatic. Although 50% of the cases may show----pain , soft tissue swelling&expansion of the bone, drainage & various other neurologic manifestations such as paresthesia of lips….etc

18. RADIOGRAPHIC FEATURES: LOCATION Posterior body of the mandible & ramus are most common sites. Epicenter ----superior to mandibular canal. Has same pericoronal location as dentigerous cyst. PERIPHERY & SHAPE: Show cortical border unless infected secondarily. Smooth round/ovoid shape or may have a scalloped outline.

19. INTERNAL STRUCTURE Mostly radiolucent..presence of internal keratin does’nt increase its opacity. Presence of curved internal septa may give it a multilocular appearance. EFFECTS ON SURROUNDING STRUCTURES OKCs grow along the internal aspect of the jaws,causing minimal expansion.(except for the upper ramus & coronoid process where considerable expansion may occur). May displace / resorb teeth but to a lesser degree. Displace mandibular canal inferiorly. & In the maxilla , cyst can invaginate & occupy the entire antrum .

20. OKC i.r.t to impacted 3 rd molar Note the scalloped distal margin

21. DIFFERENTIAL DIAGNOSIS: DENTIGEROUS CYST Show expansion of the cortical plates Cyst is connected to tooth at the CEJ. AMELOBLASTOMA (scalloped margins & multilocular ) Shows greater propensity for expansion. SIMPLE BONE CYST (scalloped margin & minimal bone expansion) The margins are more delicate & difficult to detect

22. MANAGEMENT: Has a propensity to recur. hence complete removal of the walls of the cyst should be done. Surgical resection may vary and include: --resection --curettage or -- marsupialization } to reduce the size of the large cysts before excision.

23. 4)UNICYSTIC AMELOBLASTOMA: (MURAL) Accounts foe 5% of the all ameloblastomas . Forms in the wall of the dentigerous cyst. CLINICAL FEATURES: Age: common in younger age groups.(<30yrs) Usually assymptomatic. As the lesion enlarges – nontender,hard bony swelling seen due to expansion of the cortical plates. On further enlargement—thinning of cortical plates discloses softer areas on palpation which may be fluctuant cystic spaces. Few areas may be firm representing solid masses of tumor extending through the eroded bone.

24. RADIOGRAPHIC FEATURES: INTERNAL STRUCTURE Pericoronal radiolucency PERIPHERY & SHAPE Localized thinning and haziness of hyperostotic radiopaque rim.

25. MANAGEMENT: Cyst must be enucleated. If the mass has penetrated the basement membrane,then more bone should be removed by curettage. Recurrance is less common compared to that of the conventional ameloblastoma .

26. 5)AMELOBLASTIC FIBROMA: SOFT ODONTOMA Benign mixed odontogenic tumor. Characterised by neoplastic proliferation of epithelium resembling dental lamina & primitive mesenchymal components resembling the dental papilla. Enamel, Dentin, and Cementum are not formed in this tumor.

27. CLINICAL FEATURES: Age –5-20 yrs ; avg ---15yrs. They produce usually a painless, slow growing expansion and displacement of the involved teeth. Although most common symptom is swelling & occlusal pain, the tumor may be discovered on a routine radiograph. May be associated with a missing tooth.

28. RADIOGRAPHIC FEATURES : LOCATION Most common site --- premolar& molar area of the Mandible. Near the crest of the alveolar process/Follicular relationship with the unerupted tooth. May arise in an area where a tooth failed to develop. PERIPHERY Borders are well-defined & often corticated similar to that of a cyst. INTERNAL STRUCTURE Mostly unilocular (totally radiolucent) May be multilocular with indistinct curved septa. EFFECTS ON SURROUNDING STRUCTURES If the lesion is large; there may be expansion with intact cortical plate . May impede the eruption of the associated tooth/ displace it in apical direction.

29. AMELOBLASTIC FIBROMA i.r.t unerupted 3 rd molar

30. DIFFERENTIAL DIAGNOSIS: It is difficult to differentiate this small tumor with follicular relationship to an unerupted tooth from a ---- SMALL DENTIGEROUS CYST / -----A HYPERPLASTIC FOLLICLE. AMELOBLASTOMA The septa are more defined and coarse. Whereas in Amelo.fibroma they are infrequent & often very fine. And it occurs at an early age. ODONTOGENIC MYXOMAS Eventhough multilocular ; few sharp,straight -septa are seen ………which are not characteristic feature of amelo fibroma .

31. TREATMENT: Since the rate of recurrence is low; conservative surgical approach such as: Enucleation &Mechanic curettage of the surrounding bone was found to be successful.

32. 6)PERICORONITIS:(OPERCULITIS) “PERICORONITIS” –Inflammation of the tissues surrounding the crown of partially erupted tooth. Gingiva surrounding the erupted portion of the crown may be inflammed,when food&microbial debris gets accumulated under the soft tissue. It may get secondarily traumatized by the opposing occlusion…& this inflammation may spread to the surrounding bone of the crown of the tooth.

33. CLINICAL FEATURES: Age—young adults during the eruption of 3 rd molars. Pain & swelling are typical complaints.an ulcerated operculum is usually the source of pain. Trismus -common feature when lower 3 rd molar is involved. RADIOGRAPHIC FEATURES: No radiologic signs are seen when the lesion is confined to the soft tissues. In most severe cases the signs may vary from localized rarefaction to & sclerosis to osteomyelitis .

34. LOCATION Bone changes are centered around the follicular space/portion of the crown still embedded in bone or in close proximity to it. PERIPHERY Ill-defined with gradual transition between normal trabecular pattern to sclerotic region. INTERNAL STRUCTURE An area of radiolucency seen adjacent to crown may be seen that enlarges the follicular space. Internal structure of bone adjacent to the pericoronitis is mostly sclerotic with thick trabaculae ……as the lesion spreads it becomes consistent with osteomyelitis . EFFECTS ON SURROUNDING STRUCTURES Sclerosis & rarefaction of surrounding bone. In extensive cases,periosteal new bone formation may be seen at inferior cortex, posterior border of the ramus & coronoid notch of the mandible. ***the soft tissue shadow seen radiographically; that covers the coronal portion of the partially erupted/impacted tooth is called‘FLAME SHAPED RADIOLUCENCY’ ***

35. PERICORONITIS i.r.t partially erupted 3 rd molar Note the sclerotic bone reaction adj to follicular cortex & The periosteal reaction

36. DIFFERENTIAL DIAGNOSIS: Enostoses & Fibrous dysplasia (mixed density/sclerotic lesions that exist adj. to the crown of a partially erupted 3 rd molar.) Absence of the typical c/f of inflammation which are seen in case of pericoronitis can exclude these lesions.

37. MANAGEMENT: Aim of Rx of pericoronitis is removal of partially erupted tooth. In acute phase, when trismus can prevent adequate access, antibiotic therapy & reduction in occlusion of opposing tooth should relieve symptoms until definitive Rx is provided.

38. 7)INFLAMMATORY PARADENTAL CYST (IPC) : INFLAMMATORY COLLATERAL CYST/ CRAIG’S CYST Arises from the inflammatory stimulation of the REE of the dental folliclearound the erupting tooth IPC ---Inflammatory bone destruction with subsequent expansion of the follicle. CLINICAL FEATURES : more common in males Common symptoms for 1 st and 2 nd molars is ------ pain,swelling & pus discharge from periodontal defect. Often a communication from periodontal pocket to the cyst on buccal / distal aspects is seen. In 3 rd molars ---all associated teeth are impacted / partially erupted & H/O 1 or 2 episodes of pericoronitis .

39. RADIOGRAPHIC FEATURES: LOCATION More common in mandible. 3 rd molar(56%) ; 2 nd molar(26%) ; 1 st molar(19%) Buccal / distal to the involved tooth depending on the position of the tooth….rarely surrounds the entire tooth. 3 rd molars--------^distal position 1 st & 2 nd molars-----^ buccal position INTERNAL STRUCTURE Well defined radiolucency buccal /distal to the inv tooth (1-2cm dia ) PERIPHERY AND SHAPE Thin sclerotic rim (sometimes discontinuous). IPCs ---more crescentic /quarter circle shape near crest of the alv ridge. More round / ovoid as it extends in to the bone along the distal root.

40. EFFECTS ON SURROUNDING BONE Acute inflammation—breakdown of sclerotic margin. Chronic low grade inflammation—diffuse sclerotic zone of reactive bone at margins. Therefore in IPC A COMBINATION OF CYSTIC & INFLAMMATORY COMPONENTS are seen at the margins. ** buuccolingual tilting of the crown** Distal displacement of crypt of 2 nd molars.

41. DIFFERENTIAL DIAGNOSIS : DENTIGEROUS CYST In IPC- ---more severe bone destruction seen along the distal root. Can easily enter the cystic cavity by probing distal to the involved tooth. Although sclerotic margin of tooth crypt of displaced tooth may be resorbed;no evidence of increased follicular space. No resorption of involved / adjacent tooth. MANAGEMENT: Cystectomy with tooth extraction

42. PERICORONAL RADIOLUCENCIES WITH OPACITIES

43. 1)CALCIFYING ODONTOGENIC CYST : (COC) GORLINS CYST. Uncommon, slow growing, benign lesions. They occupy a spectrum ranging from.. a cyst to an odontogenic tumor. WHO now catagorises it as a benign tumor. This lesion may manufacture calcified tissue identified as dysplastic dentin….in some instances it may be associated with an odontoma .

44. CLINICAL FEATURES: Age—mean age 36yrs peaks at 10yrs &19yrs. Slow growing, painless swelling of the jaws. Expanding lesion may destroy cortical plate & cystic mass may become palpable as it extends in to soft tissue . RADIOGRAPHIC FEATURES: LOCATION 75% of COCs occur in bone, equal distribution b/w the jaws. 75% of them manifest as pericoronal radiolucencies associated with incisors & cuspids (anterior to 1 st molar)

45. PERIPHERY & SHAPE Can vary from well defined and corticated with a curved,cyst -like shape to an ill-defined and irregular . INTERNAL STRUCTURE It may be completely radiolucent . (or) May show evidence of small foci of calcified material that appear as white flecks. (or) May show even larger amorphous masses . Rarely lesion may appear multilocular . EFFECTS ON SURROUNDING STRUCTURES Impedes the eruption of the tooth it is associated with . (mostly cuspid ) in 20-50% of cases. Displacement of teeth & resorption of roots may occur. Perforation of cortical plates may be seen with enlarging lesions.

46. COC i.r.t Lateral incisor Note well-def corticated border Resorption of part of the root of canine

47. DIFFERENTIAL DIAGNOSIS: when there are no internal calcifications FOLLICULAR CYST —difficult to differentiate. When there are internal calcifications: AOT CEOT AMELOBLASTIC FIBRO ODONTOMA MANAGEMENT: Enucleation & curettage.

48. 2) CALCIFYING EPITHELIAL ODONTOGENIC TUMOR: (CEOT) PINDBORG TUMOR Rare neoplasms usually located within bone & produce mineralised substance within amyloid -like material. Distinctive microscopic appearance --epithelium that resembles str.intermedium of the enamel organ. CLINICAL FEATURES: Age—b/w 2 nd & 5 th decades. Male prediliction . The only symptom usually is jaw expansion. Palpation reveals a hard tumor. 55% of cases are associated with unerupted /impacted teeth

49. RADIOGRAPHIC FEATURES : LOCATION Most of them are seen in mandible , premolar-molar area. 55% --crown of a mature impacted tooth. PERIPHERY Well-defined cyst-like cortex or May be irregular / ill-defined. INTERNAL STRUCTURE Unilocular / Multilocular with numerous scattered radiopaque foci of varying size & density. Small thin radiopaque trabeculae may cross the radiolucency in several directions. EFFECTS ON SURROUNDING STRUCTURES Displace a developing tooth / prevent its eruption. Associated expansion of the jaw with maintenance of cortical boundary may also occur.

50. CEOT: Note the mixed rediolucent – radiopaque lesion associated with an unerupted tooth.

51. DIFFERENTIAL DIAGNOSIS: Lesions with completely radiolucent internal structures may mimic: DENTIGEROUS CYST AMELOBLASTOMA Lesions with radiopaque foci mimic: AMELOBLASTIC FIBRODONTOMA ADENOMATOID ODONTOGENIC TUMOR(AOT) CALCIFYING ODONTOGENIC CYST(COC) * However prominent location of CEOT and the age of the pt will help in D/D.* .

52. MANAGEMENT : Rx is more conservative ie ; Enucleation & curettage. In case of recurrent / persistant tumors: Surgical resection may be required.

53. 3) ADENOMATOID ODONTOGENIC TUMOR : (AOT) ADENOAMELOBLASTOMA Uncommon, non-aggressive tumors of odont.epithelium in variety of patterns mixed with mature C.T stroma . Sometimes may contain Dentinoid –like material hence called mixed tumor follicular type CENTRAL AOT extra follicular type PERIPHERAL 73% of central lesions are --- follicular type associated with crown of an embedded tooth.

54. CLINICAL FEATURES: Age—mostly seen in 2 nd decade. 2:1 Female prediliction . AOT is slow growing, presents as painless swelling/asymmetry . often associated with a missing tooth. RADIOGRAPHIC FEATURES: LOCATION More common in –maxilla Incisor-canine-premolar region ( esp cuspid region) is involved in both the jaws. Tumors often have a follicular relationship with an impacted tooth often it doesn’t attach to CEJ but surrounds greater part of the tooth.

55. PERIPHERY Well-defined corticated/sclerotic border. INTERNAL STRUCTURE Few—completely radiolucent (or) Contain faint radiopaque foci (or) Dense clusters of ill-defined radiopacities (or) Calcifications may be small with well-defined borders (cluster of small pebbles) EFFECTS ON SURROUNDING STRUCTURES May inhibit eruption of involved tooth As tumor enlarges; adj teeth are displaced & some amount of jaw expansion may occur.

56. F: Follicular type : The tumour is located around the crown and often as shown here including part of the root of an unerupted tooth ( envelopmental ). E1- E4: Extrafollicular types. E1: Without relation to tooth structures neither erupted nor unerupted . E2: Inter- radicular ; adjacent roots diverge apically due to tumour expansion. E3: Superimposed at root apex level ( radicular / periapical ). E4: Superimposed at mid-root level. Extraosseous variant: P: Peripheral or epulis type (with slight erosion of bone).

57. DIFFERENTIAL DIAGNOSIS: When this tumor is completely radiolucent has a follicular relationship with the tooth: FOLLICULAR CYST PERICORONAL OKC However if the attachment is more apical than CEJ, a Follicular cyst may be discounted. When it contains foci of radiopacities : AMELOBLASTIC FIBRO ODONTOMA CEOT These occur more commonly in the posterior mandible.

58. MANAGEMENT: Since the tumor is non-invasive & well-encapsulated; Conservative surgical excision is adequate.

59. 4)ODONTOMA: The term ODONTOMA is used to a tumor that is radiographically & histologically characterized by the production of mature enamel, dentin, cementum and pulp tissue. These components are seen in various states of histo & morhodifferentiation Due to its slow and limited growth & well differentiated tooth tissue; it is considered as a ‘HAMARTOMA’ & not a tumor. Since this lesion is composed of more than 1 type of tissue----it is called “COMPOSITE ODONTOMA” COMPOUND .OD COMPOSITE ODONTOMA (multiple well formed teeth/DETICLES) COMPLEX.OD (non descript masses of dental tissue)

60. CLINICAL FEATURES: Common odontogenic tumor; often interferes with the eruption of permanent teeth. No sex prediliction ; most begin to form when the normal dentition is developing.(2 nd decade) ** Odontomas develop and mature when the corresponding teeth are forming & cease development when the associated teeth completes its development.** Rarely associated with the primary teeth. Compound Odontomas are twice as common as the Compound Odontomas . Although Compound variety forms equally b/w men and women, 60% of Complex varieties occur in women.

61. RADIOGRAPHIC FEATURES: LOCATION More of the compound type (62%) occur in anterior maxilla in association with the crown of an unerupted canine. 70% of complex odontomas are found in the mandibular 1 st & 2 nd molar areas. PERIPHERY Well-defined, smooth / irregular. These have a cortical border and immediately inside and adjacent to cortical border is a soft tissue capsule.

62. INTERNAL STRUCTURE The contents of these lesions are largely radiopaque . Compound odontomas ---have a few no: of (even dozens of ) tooth like structures / denticles that look like deformed teeth. Complex odontomas ----contain an irregular mass of calcified tissue. The degree of radiopacity is equivalent to or exceeds that of the adjacent tooth structure. A dilated odontoma has a single calcified structure with a more radiolucent central portion----that has an overall form of a doughnut. EFFECTS ON SURROUNDING STRUCTURES 70% of Odontomas are associated with impaction, malpositioning , diastema , aplasia , malfomation , and devitalization of adj teeth . Large Complex odontomas can cause expansion of the jaw with maintenance of the cortical boundary.

63. COMPOUND ODONTOMAS In the mandible interfering with the eruption of (d) Deciduos molar & (m)1 st molar In the anterior maxilla ;Interfering with eruption of the central incisor In the anterior mandible ;interfering the eruption of the cuspid

64. COMPLEX ODONTOMA DILATED ODONTOMA

65. DIFFERENTIAL DIAGNOSIS: Tooth –like appearance of radiopaque structures within a well-defined lesion ---make it easier to recognise COMPOUND ODONTOMAS. D/D for COMPLEX ODONTOMAS: CEMENTO-OSSIFYING FIBROMA Complex odontomas differ from these by their tendency to associate with the unerupted molar teeth & usually are more radiopaque.And they develop in much younger pt. PERI-APICAL CEMENTAL DYSPLASIA These lesions are multiple and centered on the peri -apical region of teeth. They have wider sclerotic border. Whereas ;Complex od have a well defined sclerotic border & soft tissue capsule is more defined.

66. TREATMENT: Complex & Compound odontomas are usually removed by simple excision . They do not recur and are not locally invasive.

67. 5) AMELOBLASTIC FIBRO-ODONTOMA: It is a mixed tumor with all components of ameloblastic – fibroma but with scattered collections of enamel & dentin. In Ameloblastic fibroma;neoplastic proliferation of the epithelium resembling dental lamina & primitive mesenchymal components resembling the dental papilla. ( enamel,dentin & cementum are not formed in this tumor ) Some consider them to be the early stage of ODONTOMAS. However Amelo.fibro odontomas do not occur early enough compared to Odontomas to be considered as precursor.

68. CLINICAL FEATURES: This tumor appears during the same age as odontomas & amel.fibromas No sex prediliction Often associated with the tooth that has failed to erupt. Occasionally occupies the position of a missing tooth.

69. RADIOGRAPHIC FEATURES: LOCATION Most cases occur in the posterior aspect of the mandible Epicenter usually occlusal to the developing tooth/ towards alveolar crest. PERIPHERY Usually well-defined & sometimes corticated. INTERNAL STRUCTURE Is mixed with majority of the lesion radiolucent. Smaller lesions---enlarged follicles with ona /two discrete radiopacities . These small calcifications have a round shape with a radiopaque enamel-like margin---------similar to that of a dough-nut. Larger lesions have more extensive calcified internal structure.

70. AMELO.FIBRO-ODONTOMA: Well defined radiolucent lesion with few scattered radiopacities . Lesion with larger no: of radopacities

71. DIFFERENTIAL DIAGNOSIS: COMPLEX ODONTOMA(which shares a common location): Has one mass of disorganised tissue in the center. whereas ; Amel.fibro-odontoma has multiple scattered mature small pieces of dental hard tissue. COMPOUND ODONTOMA: Rarely occurs in posterior mandible .& organisation of tooth material in amel.fibro odontoma is not well organised to resemble a tooth; as seen in comp.odontoma MANAGEMENT: Conservative enucleation ia used ;although recurrence has been reported.

72. 6)AMELOBLASTIC ODONTOMA: ODONTO AMELOBLASTOMA. Rare clinical entity. An odontogenic neoplasm characterised by simultaneous occurrence of an Ameloblastoma & an Odontoma . CLINICAL FEATURES: More common in-- children. Common in-- Mandible. Slowly expanding lesion of bone which produces considerable Facial assymetry if left untreated. Considerable destruction of bone occurs . Delays eruption of teeth. Mild pain may be a presenting complaint.

73. RADIOGRAPHIC FEATURES: Central destruction of bone with expansion of cortical plates is prominent. The characteristic feature is the presence within the lesion proper of numerous small radiopaque masses which may / may not resemble teeth. In other instances there is a single irregular radiopaque mass of calcified tissue present. Thus it may be identical with that of composite odontoma of one form or the other.

74. MANAGEMENT: Recurrence is common after conservative curettage / enucleation …..therefore more Radical approach is necessary. Resection of the jaws preserving the areas uninvolved; will certainly result in permanent cure.

75. 7) AMELOBLASTIC FIBRO-DENTINOMA : It is a rare tumor of odontogenic origin. First reported by Field&Ackermann in 1942 Also called immature dentinoma CLINICAL FEATURES: Sex : more common in males Age: 16 yrs Location: primary incisors or permanent first and second molars Facial swelling seen Lesions are painless

76. RADIOGRAPHIC FEATURES : Location: In first decade-maxillary and mandibular anterior region In second decade- madibular molar region Internal structure : Predominantly radiolucent Radiopaque flecks consisting of calcified dentinoid maybe seen within the lesion. Radiopaque mineralised structure is in close proximity to crown. Several radiopaque striae or spicules are seen in the radiopaque material.

77. TREATMENT: Surgical enucleation

78. 8)DENTINOMA: It is rare odontogenic tumor consisting of immature C.T, odontogenic epithelium(that has failed to histo -differentiate) and irregular dentinoid /dysplastic dentin. May be considered as odontoma of only one hard tissue. CLINICAL FEATURES: Age---<36yrs ; avg-26yrs Most common site—in Mandible, above the crown of unerupted 3 rd molar. Most pts are assymptomatic. Swelling is not always a symptom. Associated pain is also variable . Some cases; overlying mucosa may be erythematous .

79. RADIOGRAPHIC FEATURES: Image may be radiopaque mass / several small masses within the radiolucent area as seen in the Odontomas , associated with the crown of unerupted tooth. Homogenous or mottled radiopaque mass of density similar to that of dentin. It is circular or ovoid.

80. Margins of the mass are smooth, lobulated , spiked or combination of these. Remainder of the lesion is surrounded by a thin radiolucent line. In few cases the dentin is so sparse/poorly calcified that it is not apparent on the radiograph. Beyond the thin radiolucent line a thin rim of condensed bone similar to the crypt of developing tooth is seen.

81. DIFFERENTIAL DIAGNOSIS : ODONTOMA It cannot be differentiated from a Dentinoma Since the management is same for both the cases no problem of differentiating both of these……… MANAGEMENT: Although Dentinoma doesn’t metastasize, it may cause local bone destruction & should be treated. *Adequate surgical excision + thorough Curettage* is curative.

82. REFERENCES: STUART C. WHITE AND MICHAEL J.PHAROAH (ORAL RADIOLOGY) WOOD AND GOAZ (DIFFERENTIAL DIAGNOSIS Of oral & maxillofacial lesions) SHAFER’S (ORAL PATHOLOGY) THANK YOU