Radiopaque Lesions

RadiopaqueLesions

1. Radiopaque Lesions And Their Interpretation By: Maryam Arbab House Officer Dept Of Radiology

2. CONTENTS Radiopacity definition Anatomic radiopacities of jaws Classification of lesions Abnormalities of the teeth Conditions of variable radiopacity affecting bone Developmental Inflammatory Tumors- Odontogenic N on odontogenic

3. Definition Normal r adiopacity may be defined as the radiographic image of the normal anatomic structures of sufficient density, thickness or both to appear light or white on radiographs

4. Anatomic R adiopacities O f Jaws Radiopacities common to both jaws: Teeth Bone Cancellous bone Cortical plates Lamina dura Alveolar process

5. Radiopacities Peculiar To Maxilla The commonly seen radiopacities of maxilla from anterior region to posterior region 1. Nasal septum and boundaries of the nasal fossae: The nasal septum may be seen on films of the central incisors. It is positioned superiorly to the apices of these teeth. Appear as a wide vertical radiopaque shadow and frequently deviates slightly from the midline.

6. Nasal fossae are lined with compact cortical bone There floors may be seen extending bilaterally from the inferior limit of the septum They appear as linear radiopacities that curve superiorly when the lateral walls of the fossae are approached 2. Anterior nasal spine: It’s a projection of the maxilla at the lower borders of the nasal fossae It is seen as a small white, v-shaped, opaque shadow below the nasal septum

7. Nasal Septum

8. 3. Walls and floor of the maxillary sinus: Walls of maxillary sinus appear as white lines on the radiographs of the maxillary teeth Outline of sinus extends from area of canine to the tuberosity Floor of the sinus lies above the apices of maxillary teeth but varies widely as to extent and contour It is scalloped as it dips between roots to varying depths or it may be smoothly curved or flat especially in the edentulous jaws.

9. 4. Zygomatic process of maxilla and zygomatic bone: It is seen as U shaped radiopaque shadow above the roots of max. 1 st molar. The inferior border of the zygomatic bone may appear on the superior aspect of maxillary molar as a dense, more or less horizontal extending from the zygomatic process posteriorly .

10. 5. Maxillary tuberosity: It’s a rounded projection of cancellous bone outlined by a thin layer of compact bone. Cancellous bone may extend into the tuberosity causing this structure to appear on radiograph as a thin shell of cortical bone. 6. Pterygoid plates and pterygoid hamulus: Lateral pterygoid plate is wider than the medial plate and rarely seen on radiographs of max. 3 rd molar region. Pterygoid hamular process varies in length, thickness and density, and its tips may be seen lying above or below the level of alveolar crest on periapical films.

11. 7. Coronoid process: It’s a mandibular structure that often appears on radiographs of max.3 rd molar region. Is cone shaped with its apex pointing upward and forward with varying contours and positions. Sometime it’s radiopaque shadow has been mistaken for a root fragment in the maxilla.

12. Radiopacities Peculiar To Mandible 1. External oblique ridge: It’s a continuation of anterior border of ramus clearly seen as radiopaque line passing across the molar region 2. Mylohyoid ridge: It originates on the medial portion of ramus over the lingual surface of mandible It is clearly seen in its posterior portion crossing retromolar and molar region inferior to and running approx. parallel to the external oblique ridge

13. 3. Mental ridge: The term mental ridge is a misnomer Two bilateral radiopaque lines occasionally run anteriorly and superiorly from low in the premolar area toward the midline where they meet. 4. G enial tubercles:

14. Classification C ommon lesions that present variable radiopacities in the jaws: Abnormalities of the teeth Unerupted and misplaced teeth including supernumeraries Odontomes- Compound - Complex Root remnants H ypercementosis

15. Conditions Of Variable R adiopacities A ffecting T he B one Developmental: exostoses including tori- mandibular or palatal Inflammatory: 1. Low grade chronic infection 2 . Sclerosing osteitis 3 . Osteomyelitis Tumors: A: Odontogenic: CEOT AOT Calcifying cystic odontogenic tumors Cementoblastoma Odontomes- Compound Complex

16. B: Non odontogenic- Benign: O steoma Chondroma Malignant: Osteosarcoma O steogenic sec. metastasis Bone related lesions Osseous dysplasias : Periapical osseous dysplasia Focal osseous dysplasia Florid osseous dysplasia Familial gigantiform Cementoma

17. Other lesions : Ossifying fibroma Fibrous dysplasia Bone diseases: P aget’s disease of bone O steopetrosis Superimposed Soft T issue C alcifications: Salivary calculi Calcified lymph nodes Calcified lymph nodes Phleboliths Calcified acne scars Foreign Bodies: Infra-bony Within the soft tissues On or overlying the skin

18. Typical Radiographic F eatures O f A bnormalities O f T he T eeth Unerupted or misplaced teeth including supernumeraries

19. Odontomes It’s a benign tumour of odontogenic origin. Specifically, it’s a dental hamartoma.

20. 1. Compound odontome This odontome is made up of several small tooth like denticles. The miniature tooth shapes are of dental tissue radiodensity,with surrounding radiolucent line. 2. Complex odontome This odontome is made up of an irregular confused mass of dental tissue bearing no resemblance in shape to a tooth. The enamal content provides the dense radiopacity suggestive of dental tissue and the mass is surrounded by radiolucent line.

21. Root R emnants Deciduous and permanent root remnants remaining in the alveolar bone, following attempted extraction, are common. The site shape and density make radiographic identification relatively simple. Additional diagnostic feature include the surrounding radiolucent line of periodontal ligament shadow and sometime evidence of root canal.

22. HYPERCEMENTOSIS Also known as “excessive formation of cementum on the surface of root of the tooth”. Etiology unknown but sometimes assoc. with development of periapical inflammatory conditions, pcod, systemic diseases such as paget’s disease acromegaly or gigantism.

23. Features: Completely asymptomatic. Premolars and molars are affected. Can be confined to small region of root or whole root may be involved. In multi-rooted teeth one or two or all roots may show hypercementosis. Teeth are usually vital and not sensitive to percussion.

24. Differential Diagnosis: Condensing osteitis. Periapical idiopathic osteosclerosis. Developmental anomalies such as fused roots and dilaceration. Management D o not require special treatment.

25. Tori and Exostosis Situated in the periphery of jaws and vary greatly in size shape and location. They are slow growing benign bony protuberences . Appear symmetrically as nodular or bosselated lesion that have smooth contours and covered with normal mucosa. Hard on palpation and are attached by a broad bony base to the underlying jaw. Growth occurs mainly in 1 st 30 years of life. Common in females. Developmental Condition

26. Specific exostosis develop in particular sites and are often bilateral. Torus mandibularis- L ingual aspects of the mandible, in premolar/molar region. Torus palatinus- E ither side of the midline towards the posterior part of the hard palate.

27. Inflammatory Condition Condensing or S clerosing osteitis 1) It is a sclerosing of bone induced by an inflammation or infection that occur pulpo apical lesion. 2) In this proliferation of bone tissue occurs ( opposite from rarefying osteitis in which bone resorption occurs). 3) Highly concentrated products of infection are thought to act as irritants and produce resorption where as diluted irritants induce bone proliferation as seen in this case.

28. Features: Almost invariably painless and do not produce expansion of the cortex. Covering mucosa is normal in appearance. Sinuses are not present. Approx.85% of this occurs the mandible of whites, 1 st molar is the predominant site. In blacks approx. 71.6% of focal bony sclerotic area are in mandible. Female to male ratio is 3:2 , majrity found in mandible. 50% cases are under 30 yrs of age.

29. Pulps of involved teeth are non-vital although the sclerosing may have commenced before the complete pulp become non-vital. If carious molars are treated with IPC some of these lesions disappear and pulps remain vital. Radiographic images may vary greatly in number size shape contours and discreteness of margins. Since the process is low grade there is usually no pain, swelling, drainage, or associated lymph adenitis.

30. Differential diagnosis: Periapical idiopathic osteosclerosis. Periapical cementoosseous dysplasia (PCOD) . Focal cementooseous dysplasia (FCOD). Hypercementosis. Management Extraction of affected tooth or root canal treatment.

31. PERIAPICAL IDIOPATHIC OSTEOSCLEROSIS Relatively common finding on full mouth radiographs of dentulous patients over 12 years of age. It second most frequently seen periapical radiopacity. Term idiopathic means the cause of the lesion is not readily apparent or understood.

32. Features: Mostly located in the peri apex of mand. 1 st premolar and canine. Female : male ratio is 2:1 More often in black females. Associated teeth are invariably healthy, have vital pulps, and are asymptomatic. No associated pain, cortical change, softness, expansion, drainage or lymphadenitis. Overlying alveolar mucosa appears normal. Its radiopacity vary from few mm. to 2cm in diameter.

33. Shape may range from round to very irregular or sometimes triangular configuration is observed. Degree of density may vary from slight accentuation of the trabecular pattern to a dense homogenous radiopaque mass. Borders may b well defined or vague and well contoured or ragged. Differential Diagnosis: H ypercementosis, abnormally dense alv. Bone induced by heavy occlusal stress.

34. Management Endodontic treatment or extraction

35. TUMORS 1. Calcifying Epithelial O dontogenic T umor Also known as CEOT or P indborg tumor. Defined by WHO as a locally invasive epithelial odontogenic neoplasm, characterized histologically by amyloid material that may become calcified. Age : 20-60 yrs old adults. Frequency : rare- approx. 1% of all odontogenic tumours. Site : molar/premolar region of mandible maxilla occasionally.

36. Shape: unilocular or multilocular usually round often associated with impacted tooth especially 38 48 Outline: variable definition , frequently scalloped, variable cortication Radiodensity: radiolucent in early stages, then numerous scattered radiopacities usually become evident within the lesion, often most prominent around the crown of any associated unerupted tooth. - this appearance is sometimes described as DRIVEN SNOW Effects: adjacent teeth sometime displaced or resorbed. Expansion of cortical bone

37. 2. Ameloblastic Fibro-odontoma These are rare, unilocular or multilocular odontogenic tumors. Resemble closely ameloblastic fibromas. Also affects children. However they are often associ . With an unerupted tooth. Usually contain enamel, dentin either as multiple, small opacities or as a solid mass.

38. 3. Adenomatoid O dontogenic T umor Described by WHO as being composed of epithelium embedded in a mature connective tissue stroma and characterized by slow but progressive growth. Age : variable but 90% develop before age of 30 with most diagnosed in 2 nd decade of life. Frequency: rare-approx.2-7% of all odontogenic tumours. Site: anterior maxilla-incisor/canine region occasionally anterior mandible.

39. Shape: Unilocular, usually round or oval often surrounds an entire unerupted tooth Outline: Smooth and well defined well corticated Radiodensity: I nitially radiolucent, but small opacities (snowflakes) within central radiolucency may be seen peripherally as the lesion matures. Effects: Adjacent teeth displaced, rarely resorbed. Assoc. tooth is often unerupted. Buccal/palatal expansion.

40. 4. Calcifying Cystic O dontogenic T umour ( C alcifying O dontogenic C yst) Also known as gorlin’s cyst. WHO described it as benign cystic neoplasm of odontogenic origin characterized histopathologically by ameloblastoma like epithelium with ghost cells that may calcify. Age: Variable reported in patients between 5 to 92 yrs of age Frequency: R are Site: Mandible or maxilla-anterior or premolar region 1/3 rd assoc. with unerupted tooth or odontome.

41. Size: Usually small upto 4cm in dia. Shape: Variable but usually unilocular. Outline: Smooth well defined well corticated. Radiodensity: Initially radiolucent but in more advanced stages contains a variable amount of calcified radiopaque material of tooth like density. Effects: Adjacent teeth usually displaced, causing root divergence, or resorbed. - bony expansion

42. 5. Cementoblastoma Classified by WHO as an odontogenic tumour which is characterized by the formation of cementum-like tissue in cementum with the root of a tooth. Age: Reported in patients b/w 8 and 44 yrs old with mean age 20. Frequency: rare Site: Apex of mandibular 1 st permanent molar, occasionally premolars. Exceptionally assoc. with the primary dentition Size: Variable,but upto2-3cm in dia.

43. Shape: Round or irregular, sometimes sometimes described as resembling a golf ball attached to tooth root Outline: Well defined Radiodensity: Radiopaque but often surrounded by a thin radiolucent line owing to an outer zone of osteoid - often surrounded by a diffuse area of sclerotic bone Effects: Attached to the tooth root which is usually obscured as a result of resorption and fusion to the tooth -if large may cause localized expansion of the cortical plates.

44. 6. Osteoma ( Benign ) Osteoma of the jaws may be located in the medullary bone (enosteal osteoma) or arise on the surface of the bone as a pedunculated mass (periosteal osteoma) . Usually detected in young adults and are typically asymptomatic, solitary lesions. Multiple jaw osteomas are a feature of rare inherited condition Gardner’s syndrome. They are of two types 1. Compact - consisting of dense lamellae of bone 2. Cancellous -consisting of trabeculae of bone

45. 7. Osteosarcoma ( Malignant ) Rare, rapidly destructive, malignant tumour of bone from a radiological viewpoint, there are three main types: Osteolytic: N o neoplastic bone formation. Osteogenic/osteosclerotic: N eoplastic osteoid and bone formed. Mixed lytic and sclerotic patches of neoplastic bone formed. Early features: N on specific, poorly defined radiolucent area around one or more teeth. Widening of periodontal ligament space.

46. Later features Osteolytic lesion Unilocular, ragged area of radiolucency. Poorly defined, moth eaten outline. So called spiking resorption and/or loosening of assoc.teeth. Osteogenic and mixed lesion Poorly defined radiolucent area. Variable internal radiopacity with obliteration of the normal trabular pattern. Perforation and expansion of the cortical margins by stretching the periosteum, producing the classical, but sunray or sunburst appearance.

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