Practical Oral Radiology 2

Ahmed A.Abdelazim

Total: 5 marks1- Benign tumors

2-Malignant tumors

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Odontogenic Tumors• They develops as neoplasias from the dental

lamina. They are usually benign but several of them have the tendency towards malignant transformation.

• Because growth occurs only slowly, asymptomatically and without any changes in mucosal appearance,

• The existence of such lesions in their early stages is usually detected only by chance, or after the development of some structural deformation.

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Ameloblastoma• Benign but locally invasive neoplasm.• Arises from epithelial remnants of

dental lamina or dental organ.• Cells do not differentiate enough to

form enamel.• Extreme expansion of bone, • Resorption of adjoining roots. • May cause perforation of cortical bone.• Average age at discovery: 35-40 years.

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Most common sites of ameloblastoma

80%

20%

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Ameloblastoma (Cont.)• Occasionally develops in the wall of

dentigerous cyst (mural Ameloblatoma).

• 80% in mandible. ¾ of these in molar-ramus area.

• Pain and paresthesia not common.• Extremely high recurrence rate.

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Ameloblastoma (Cont.)• Most often a well-corticated multilocular

radiolucency. • “Honey-comb”, “soap-bubble” or “tennis-

racket” appearance.• May be a well-corticated unilocular lesion

resembling a cyst.Honeycomb-like small

ameloblastoma at early stage with evidence of root resorption.

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Ameloblastoma• Ameloblastoma at the

angle of the mandible.• Expansive form with

oval RL traversed by few very thin septa

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Ameloblastoma

• Soap-like form of ameloblastoma of the molar region.

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Ameloblastoma Large multilocular soap bubble appearance. Typically located in the molar region, angle of the

mandible and ascending ramus Thin not penetrated cortical plate. Impacted or neighboring teeth are displaced with

roots often resorped.

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• Ameloblastoma in early stages with lobular pattern

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Ameloblastoma

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• Large ameloblastoma in the right ascending ramus of the mandible

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Ameloblastoma

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Ameloblastoma

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Ameloblastic fibroma

• Appears as a follecular cystic cavity surrounding a crown of a tooth.

• In early stages appears as a hat upon the occlusal surface of affected tooth

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• More advanced case of ameloblastic fibroma demonstrates how the follicular sac is opened.

• Note also the displacement of the tooth bud of lower 8 in the ascending ramus

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Odontogenic myxoma

• It is a benign, mucous-containing tumor that originates from the tooth bud.

• It appears as a soap bubble-like appearance.

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Cementoma• Usually appears at lower

anterior area.• First appears as fibrous

tissue stage, which may confused with a granuloma (vitality test).

• The second stage is characterized with accumulation of calcified materials.

• The third stage consists of radio-opaque materials.

Early stage

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R.L R.L+R.O

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Periapical cemental dysplasia

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Periapical Cemental Dysplasia

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Cementoblastoma( True Cementoma )

• Slow growing neoplasm composed of cementum.

• Usually solitary lesion seen as a growth on root of tooth.

• Most common in mandible, premolar or 1st molar (80%).

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Cementoblastoma• Appears as a well

defined RO area with a thin RL band around it

• May cause external root resorption

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Cementoblastoma

• It not removed after tooth extraction

• Remarks the RL related to canine and second premolar, it is another cementoblastoma in the fibrous stage.

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Cementoblastoma

• Another case remaining after tooth extraction.

• It surrounded by the radiographic signs of chronic inflammation.

• Periapical cemental dysplasia related to 4 tooth

Ossama El-Shall

Odontoma

• Most common sites

Tumor characterized by production of enamel, dentin, cementum and pulp tissue

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Odontoma

Complex type

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Odontoma

Intermediate type

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Odontoma

Intermediate type

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Odontoma

Compound type

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Compound odontoma in maxillary tubrosity

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Complex odontoma in maxillary tubrosity

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Compound Composite Odontoma

• Composed of enamel and dentin.

• Enamel and dentin are laid down in an orderly fashion so that the mass has some similarity to normal teeth.

• Appears like a bunch of small teeth.

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Compound Composite Odontoma

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Central Osteoma anterior to remaining roots of lower 7

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Peripheral osteoma located in maxillary sinus

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Peripheral osteoma in right angle of the mandible

It may confused with calcified lymph noads

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Osteoma

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Central Hemangioma• Tumor characterized

by proliferation of blood vessels.

• Central hemangiomas of jaws uncommon.

• 50% occur in children and teens.

• More common in females and mandible.

• Well-defined or ill-defined, unilocular or multilocular radiolucency.

05/02/2023 Ossama El-Shall 41

Central Hemangioma (Cont.)

• May cause expansion of bone and resorption of teeth.

• Early treatment is desirable in order to avoid profuse bleeding due to accidental trauma. Aspiration prior to surgical procedure is advised.

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Central Hemangioma (Cont.)

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Central Hemangioma (Cont.)

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Malignant tumors

• Sarcoma• Carcinoma.• Metastasis.

Benign tumors• Growth by direct extension• Insidious onset• Well defined borders• Rl + RO• Tooth displacement, or

root resorption• Expansion or thinning of

cortical bone

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Malignant tumorsGrowth by infeltration and

distructionSudden onsetIll defined bordersPunched out bordersTotally RLDestruction of alveolar

bone, teeth floating or displaced occlusally

Erosion and destruction of cortical bone

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SarcomaThis tumor, which affects males twice

as females, exhibit a predilection for the mandible.

Radiographically, bone destruction as well as new bone formation and osteolysis can be observed, along with perforation of the compact bone with spicules (sunrays effect), where the lesion borders on the soft tissues

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Mixed form of ostiosarcoma: In addition to areas of new bone formation, osteolysis and destruction of the compact bone can be observed. Note the areas of spicules (arrows)

1-Benign Tumors

• Ameloblastoma • CEOT• AOT

• Odontoma• Ameloblastic fibro-

odontoma• Ameloblastic fibroma• COC

• Odontogenic Myxoma• Odontogenic Fibroma• Cementoblastoma

1. Od. Epithelium

2. Od. Epithelium+ CT Mesenchyme

3. Od. CT Mesenchyme

Odontogenic Tumors

Ameloblastoma

Ameloblastoma

1- AmeloblastomaMultilocular (Soap bubble> honey comb))

origin (dental lamina and dental organ)

• 40 y (Middle age)• Males • Mand. Molar Ramus area• Sever expansion +Perforation• Root Resorption• Teeth Displacement• Negative aspiration

Unicystic (Rare) Inter radicular (Uncommon)

Solitary Periapical Pericoronal

Mural ameloblastoma

Mural (Unicystic) Ameloblastoma

Mural ameloblastoma

The shape of the septa

AmeloblastomaThick- Coarse & Curved

Well defined in mandible but tend to be ill defined in maxilla

Multicystic Am.

2- Calcifying epithelial odontogenic tumor (CEOT) = Pindborg tumor

CEOTUnilocular or Multiocular + RO Foci

• 40 y.• Males • Mand. Molar Ramus area• Mostly Related to impacted/ unerupted tooth (50%)• Calcific foci are numerous closely located to the crown

(snow driven appearance)• Sever expansion (less than ameloblastoma) +

maintenance of cortical boundaries• Teeth Displacement

Rare tumor

CEOT

3- Adenomatoid odonotgenic tumor (AOT)

Radiolucent area surrounding impacted tooth

AOT

• Wide age range: around 16 years Females > Males

• Mainly anterior maxilla • ⅔ Mixed (RL +RO):

RL surrounds more than the crown: not at CEJRO: Dense clusters OR Faint foci (Snow flecks appearance)

AOT in mandible

2- Mixed Odontogenic Tumors

1- Odontoma

2- Ameloblastic fibroma

3- Ameloblastic fibro-odontoma

1- OdontomaOdontomas are developmental malformation ( hamartoma) of dental tissue, it is not neoplasm

Very important - very common – children

Two main Types

Compound = normal arrangement of dental tissuesComplex = abnormal mass of Calcification

1- Odontoma

Complex odontomas

Compound odontomas

Odontoma

• 2nd decade (young age )• Complex: ♀ Compound ♀=♂ Mand. Molar Max. Ant.• Maturtion:RL…Mixed…..RO • Surrounded by RL rim• Discovered while searching for the cause of

unerupted permanent or retained deciduous• Easily identified upon Shape & Density• It’s the most common odontogenic tumor

Odontomas

The compound type shows apparent tooth shapes while the complex type appears as uniform opaque mass with no apparent tooth shapes present

Compound Complex

2-Ameloblastic Fibroma

• 2nd decade• ♀ = ♂• Mand. Molar - premolar • Discovered while searching for the cause of unerupted tooth or because of the facial

swelling & Occ. pain they cause• Identified upon:

-Outwards growth from the follicle-Grows towards the alveolar process

• Hat cap like RL

Ameloblastic fibroma

Ameloblastic fibroma

3-Am. Fibro-Odontoma

• 2nd decade• ♀ = ♂• Mand. Molar - premolar • Discovered while searching for the cause of unerupted tooth• Identified upon:

-Outwards growth from the follicle-Grows towards the alveolar process-RO: discrete foci 1 – 2 if small lesion extensive calcification if large

40 y, ♂, Not as an outward growthRL

Fibroma or fibro-odontoma ?

3- Mesenchymal Tumors1-Odontogenic Myxomas2-Benign Cementoblastoma3-Central Odontogenic Fibroma

1- Odontogenic myxoma

Od. Myxoma Multilocular (Soap bubble > Tennis-racket)

Pericoronal to unerupted tooth or from a tooth that failed to develop

• 2nd- 3rd decade, ♀ • Mand. > Max. Molar – premolar. • Discovered while searching for the cause of unerupted tooth• Identified upon:

-Grows along the bone, lees likely to expand-Grows around teeth causing scalloping, loosening, displacement of teeth but rarely resorption

Multilocular

• Radiography:• Typically appears as multi

locular radiolucent area with well defined scalloped margin or soap bubble.

A lateral radiograph of a surgical specimen of a myxoma

An occlusal view shows buccal expansion

2- Cementoblatoma

• ♂ >♀• No race predilection• Wide age range

• Vital teeth, Painful• Mand. Premolars & 1st molars• Fused with the roots• Roots resorbed or obscured

Cementoma orPeriapical cemental dysplasia ?

Periapical cemental dysplasia

Tori - Exostosis - Enostosis

Known from clinical examination by:•Their location, •Lobulated shape,• Adherent normally appearing mucosa •Asymptomatic

•Accidentally discovered•Intra-bony

Osteoma

• ♂ >♀, 40 y & above• Asymptomatic until interferes with function• Overlying mucosa is normal and freely mobile.• Mand. > Max. & Paranasal sinuses

frontoethmoidal • Well-defined, RO (Compact),

Internal RL core (Cancellous)

A panoramic radiograph shows an osteoma in the right mandibular angle region

Osteoma

Cherubism

2- Malignant Tumors

Well defined borders

106Clinical photograph shows leukoplakia that transformed to gingival cancer

Intraoral panoramic view shows diffuse bone destruction

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Primary intra-osseous Carcinoma

Osteosarcoma

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Effects on surrounding structures:i-Early :widening of the

periodontal membrane• Loss of cortices and lamina dura. • Floating or hanging teeth

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ii-Late : • poorly defined osteolytic,

osteoblastic • mixed pattern of

involvement

Naglaa S. El Kilani

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Naglaa S. El Kilani

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“Sunray” Periosteal Reaction • Osteosarcoma • Chondrosarcoma • Ewing’s Sarcoma

D-Ewing’s sarcoma-It is a rare highly malignant tumor of long bones and is relatively rare in the jaws.-The arise in the medullary portion of bone and spread to the endosteal and later periosteal surfaces.

Metastatic tumors

Metastatic tumors

Metastatic tumors

Multiple Myeloma

Naglaa S. El Kilani

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Naglaa S. El Kilani

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Punched Out” Skill Lesions • Multiple Myeloma • Langerhans Cell Histiocytosis • Metastatic Carcinoma • Neuroblastoma

Describe? D.D?

• Solitary ill defined radiolucent area related to lower right molars and causing invasion of the IAC.

What is the view? Describe? D.D?• Inflammatory1. Chronic osteomyelitis 2. Osteoradionecrosis • Neoplastic 1. Squamous cell

carcinoma 2. Metastatic tumors to

the jaws 3. Osteosarcoma and

chondrosarcoma

Describe? D.D?• What is the D.D? Solitary irregular periapical

radiolucent area related to upper left lateral and causing extensive interproximal bone loss of the adjacent tooth.

D.D:• Chronic alveolar abscess• Chronic osteomyelitis• Osteoradionecrosis• Squamous cell carcinoma• Metastatic tumors to the jaws• Osteosarcoma and

chondrosarcoma• Fibrous dysplasia (early stage)

What is D.D?

Multiple punched out radiolucent areas: Myeloma

Case study• A 20-year old male patient

reported to the Department of Oral Medicine, with chief complaint of swelling in the lower half of the left side of and inability to chew food at the same side.

• What is the D.D?