Professional Documents
Culture Documents
Carte
Carte
Dento-maxillo-facial
Imaging
Cuprins
Scientific reviewers:
Prof. Dr. FLOAREA FILDAN - U.M.F. "Iuliu Haieganu" Cluj-Napoca
Prof. Dr. CONSTANTIN ZAHARIA - U.M.F. "Carol Davila" Bucharest
Cover: ing. Sorin Popescu
Made with funding from CNCSIS grant no. 1204/2006
CONTENTS
1. INTRODUCTION .............................................................................. 5
1.1 The numbering of the teeth ............................................................. 7
1.2. Developmental anomalies of maxillofacial region .......................... 8
2. DENTAL DECAY AND ITS COMPLICATIONS ......................... 33
2.1. Interproximal caries ..................................................................... 35
2.2. Occlusal caries ............................................................................. 37
2.3. Caries on buccal and lingual surfaces ........................................... 38
2.4. Root caries................................................................................... 39
2.5. Cavities in included teeth ............................................................. 40
2.6. Rampant caries ............................................................................ 40
2.7. Dental recurrent / secondary caries .............................................. 41
2.8. Radiographic evaluation of tooth decay and the proper treatment of
simple cavities .................................................................................... 41
3. MARGINAL PERIODONTAL DISEASES .................................... 63
3.1. Definition .................................................................................... 63
3. 2. Anatomical aspects ..................................................................... 63
3.3. Radiographical examination......................................................... 64
3.4. Classification of periodontal lesions............................................. 66
3.5. Radiographic aspects encountered in gingivitis ............................ 66
3.6. Radiographic aspects seen in periodontitis ................................... 67
3.7. Evaluation of the treatment ......................................................... 74
4. DENTO MAXILLO FACIAL TRAUMA .................................... 77
4.1. Introduction ................................................................................. 77
4.2. Classification ............................................................................... 77
4.3. Mandibular fractures.................................................................... 80
5. JAW AND CERVICO FACIAL SOFT TISSUE CYSTS .......... 105
5.1. Periapical tissues cysts ............................................................... 107
5.2. Odontogenic cysts ..................................................................... 111
5.3. Non odontogenic cysts ............................................................... 116
5.4. Cysts of unknown origin ............................................................ 126
5.5. Cysts of the soft cervico-facial parts .......................................... 127
INTRODUCTION
Dento-maxillo-facial imaging is an important area of medical
imaging which has known continuous development for more than three
decades.
Based on conventional radiology, based on dental radiographs of
the skull, in various incidents, the tomography plane and sialographies,
they started to use the phase of whole exploration technique of intraoral
panoramic outbreak subsequently abandoned and in particular that the
extraoral outbreak has already become a classic in its turn, having
orthopantomography as a generic name (OPT).
This stage of development has increased the dental patients
addressability to radiology laboratories and determined the dentists to use
OPT as a first instance method for the overall assessment of dental
maxillo-facial complex status.
The second stage of development in the field of imaging was
related to the possibility of obtaining images of the human body by
processes other than X-rays (ultrasonic, electromagnetic waves). New
methods have allowed the use of such means as including diagnostic
method for dental-maxillo-facial lesions (ultrasound and magnetic
resonance imaging).
Introducing the use of the computer in dental practice - used for
processing and storing sectional images obtained with the new methods of
diagnosis CT, MRI, Seldinger angiography in recent years dental digital
radiography and Cone Beam CT - have reduced the radiation dose and
the necessary time to explore advanced imaging with the ability to view
images on the computer monitor, remote transmission, simulating surgical
technique and a protocol default optimum treatment, all aimed at
improving the quality of medical care.
This book addresses the main groups of dento-maxillo-facial
injuries which have been organized into eleven chapters, briefly
presenting the advantages and disadvantages of conventional and modern
radioimaging methods used, their diagnosis, and their imaging exemplify
common and particular aspects encountered in daily medical practice.
The presentation of this paper was ment combining the imaging
clinical characteristics, sometimes even the anatomo-pathological ones, to
highlight the importance of issuing a diagnosis based on an amount of
information from different medical examinations based on the cooperation
between all medical specialties.
Introduction
Chapter 1
5 .4 .3 .2 .1 .1 .2 .3.
8
Fig. 1.4. Anodontitis to 1.5, 2.5, 3.5, 4.4, 4.5, accompanied by rotation of
the upper lateral incisors and a cuneiform aspect of the central upper teeth.
O.P.T. Patient of 10 years. Neuro-sensory severe hearing loss patient
experiences severe mental deficiency (IQ = 34). (Collection Dr. Petcu E).
10
Fig. 1.5. Total anodontitis. O.P.T. 11 year old patient with total anodontitis
(milk and permanent teeth), a manifestation in dental maxillofacial area of
a severe ectodermal dysplasia. (Collection Dr. Zetu I).
1.2.1.1.2 Anomalies in excess
They are also called polydontitis and hyperdontitis and can be with and
without topographic preference:
polydontitis with topographic preference:
* supernumerary incisors or molars, commonly tiny (fig.1.6., b, c);
*meziotooth is a tiny tooth, supernumerary, located between the upper
central incisors (fig.1.7., b, c),
unregulated polydontitis:
*odontoms are dental malformations of the dental tissue (hamartomas)
Clinical: accidentally discovered in the jaw or mandible, without
preference for one sex,
Imaging: they appear on dental radiographs, or X-rays ,OPT in jaw scroll
incidence as radio opaque, well defined, showing a small clear space
around.
11
c
a
Fig. 1.6 .Lateral incisor as supernumerary a) OPT, patient 8 years old.
b) nannous supernumerary molar, root remnants included over 26,
c) supernumerary lateral incisor overlapping apex region 11,
retroalveolar dental radiography.
a
b
c
Fig. 1.7. Meziondens. a) Image of a meziodens in the jaw;
b), c) a dental meziodens radiography in children of 6 and 12 years old.
(Collection Dr. Zetu I).
We can meet in our daily practice:
The compound odontoma that appears as a dense mass, composed of
numerous dental micro dysmorphic elements surrounded by a radiolucent
fibrous capsule (fig.1.8., B);
The complex odontoma is a dense, a heterogenous formation, composed
of atypical dental tissue, without being able to individualize a tooth
already formed, relatively circumscribed (fig.1.9), which is sometimes
very difficult to differentiate from an ameloblastic odontoma or a
cementifiant fibroma; confirmation was made after the anatomo
pathological examination.
12
a
b
Fig. 1.8.Compound odontoma. a) occlusal radiography DISTO-front
eccentric superior patient of 14, small compound odontoma that prevents
a normal canine eruption 23. b) incidence of left mandible scroll,
compound odontoma near the apex 32 and 34, 33 included between 34
and 35.
a
b
Fig. 1.9. Complex odontoma between 35 and 36 tooth apex, panoramic
X-ray) confirmed pathological and operated by preserving distal crown
and root at 36, after surgery aspect, panoramic radiograph b).
We can also meet:
canine or supplementary premolar on jaw or mandible;
polydontitis of a number of syndromes. The condition of this type is
the cleido-cranial dysplasia or Pierre-Marie and Sainton disease. Imaging
aspects can be viewed on:
OPT under the form of dental overcrowding, supernumerary teeth,
including dysmorphic, with persistence of milk teeth adult arcades,
In the skull radiographs profile and frontal brachycephalism appears,
13
Fig. 1.10. Upper canines included because of the lack of space in the
mesiala) and disto version b) crown.
14
Fig. 1.11. Upper canine included in the mesio-coronal, version CT Dental axial
Exam), b), d), e), with 2D reconstruction, panoramic c)
and oblique-transverse or paraxial f).
15
b
c
Fig. 1.13. Cherubism. 19 year old patient diagnosed with cherubism
at 12. a) OPT, b) Scroll mandible, c) frontal profile
(Prof. Gh. Timosca collection).
Fig. 1.14. Right canine ectopic in right maxillary sinus, left canine
included, skull radiography in the Blondeau incidence.
b
a
Fig. 1.16. Macrodontitis a)Photographic aspect in a child with 11 giant, b)
dental radiography with macrodontitis to 11, probably by fusion with
meziodens. ( Surgery Clinic OMF, Iai collection)
c
b
a
Fig. 1.17. Microdontitis. a) superior frontal periapical radiography with 21
nannous b) periapical radiograph with 18 nannous included, positioned
distal to maxillary c) periapical radiograph of 35 nanous
(Surgery Clinic OMF, Iai collection).
1.2.1.4. Abnormally shaped
This occurs quite frequently by aberrant ameloblastic group with atypical
tooth formation as a whole or only in the crown or root. Thus we find:
Dental fusion may be partial or total.
18
c
Fig. 1.18. Merger lower incisors 41, 42 a) X-ray retroalveolar, c) OPT
and lower incisors 31, 32, retroalveolar radiography b). (Dr. A.E. Petcu
collection).
Gemination or duplication is a dental anomaly that may be common in
upper incisors, as partial or complete.
In radiological partial duplication a more voluminous crown appears, with
a notch on the occlusal groove that continues with a vertical downward
along the area of the union of the crowns (fig.1.19). Tooth root may have a
bifida, a common crown, a pulp chamber and root canal under division.
19
b
a
Fig. 1.19. Gemination of the central incisor 11 a) X-ray retroalveolar
and b) photograph of central incisors
(Dr. A. E. Petcu collection).
concrescence is the union of two dental buds, the roots through root
cementum, sometimes resulting in a divergent orientation of the teeth
(fig.1.20).
a
b
Fig. 1.20. Concrescence of upper molars 2 and 3),
radiograph or photograph b) of extracted molars
( Surgery Clinic OMF Iasi collection).
Dens in dente or enamel-dentin invagination usually occurs in upper
lateral incisors, and corresponds to a unilateral invagination of enamel in
dentine which appears radiographically as a "candle flame" in a
dysmorphic tooth (fig.1.21).
20
b
a
Fig. 1.21. Dens in dente, the central incisor lateral 11 and 12,
retroalveolar radiographs ( Dr. C. Bucur collection)
Taurodontism is an abnormality common in Eskimos, who have an
exaggerated elongation of the pulp chamber with apparent shortening of
roots and root canals, making a point of "no waist tooth" (fig.1.22).
21
d
e
Fig. 1.23. Corono-root laceration of 21, post-traumatic
with pulp necrosis, pre-treatment scan) and post-treatment b) molar root
physiological rizaliz 84 c) pathological root resorption 43, 44, 45 due to
a ameloblastoma d) root in tooth root resorption produced by a 84
follicular cyst e).
22
d
f
e
Fig. 1.24. Apical resection in the roots of premolar 24),
abnormal cusp (spur) to central incisor 11 b) molar root curving
leading to incomplete fillings of lower 3 and 2 c), d), two upper
premolar apex angulation, e) enamel pearl on the crown molar distal
edge of 27 f) (retroalveolar dental radiographs).
1.2.1.5. Abnormalities of tooth structure
Tooth structure can be changed due to:
genetic defects:
*imperfect amelogenesis
*imperfect dentinogenesis
* regional odontodisplasia.
*dentin dysplasia,
acquired defects :
* congenital syphilis,
* vitamin deficiency, irradiation, etc..
The imperfect amelogenesis is a genetic abnormality of tooth structure that
may occur in three forms:
hipomaturity of the enamel with defects in growth and final
maturation of enamel crystals that make it appear much smoother and less
opaque for the photographic visibility as a partial defect (fig.1.25.a),
presented radiographically as a tooth with a low radio opacity of a portion
of the crown (fig.1.25. b);
23
a
b
c
Fig. 1.25. Imperfect amelogenesis in right central incisor clinical visible)
and radiographically as a radiolucency b).Imperfect dentinogenesis
retroalveolar radiography in mandible premolars, with dysmorphic
crowns and early obliteration of root canals c).
24
Fig. 1.26. Odontodisplasia. Child of 9 years old with low radio opacity
anterior teeth in quadrant I and II, with no enamel, delineation, dentin
and pulp chamber array. (Collection of Pedodontics Clinic, Iai).
1.2.2. Abnormalities of the development of the massive facial skeleton
These abnormalities include:
abnormalities of the jaw or mandible,
Other rare anomalies of development or syndromes.
1.2.2.1. Mandible and maxilla abnormalities
The most common abnormalities seen in mandible are:
micrognathia (fig.1.27 a)
macrognathia (prognathism) (fig.1.27 b)
condyle hyperplasia (fig.1.28 a)
condyle hypoplasia (fig.1.28 b)
bifid condyle,
coronoid process hyperplasia.
The most common abnormalities of the jaw are:
unilateral or bilateral cleft lip,
cleft lip and palate (fig.1.29)
cleft of the palate,
cherubism (fig.1.30).
localized bone defects:
*exostosis: palatine torus / mandible (fig.1.31)
*idiopathic marrow cavity, Stafne's cavity,
25
a
Fig. 1.27. Micrognathia a) and macrognathia b).
(Collection of Orthodontics Clinic, Iai).
a
b
Fig. 1.28. Hyperplasia and hypoplasia of the mandible condyle. Axial
CT in bone window showing right condyle as increased in size,
hyperplasia) and hypoplastic appearance of rarefaction of the trabeculas
and left condyle lowering in diameter b).
26
c
d
Fig. 1.29 Nasopharyngeal left cleft palate highlighted defective between
central incisors, next to the interincisive suture, retro-alveolar
radiography), CT in bone window shows dehiscence of the hard palate
and nasal fossa left, visible in coronal reconstructions b ), sagittal c) and
direct axial section d).
b
a
Fig. 1.31. Unilateral and bilateral mandible torus: Occlusal radiograph
showing radio opaque nodular, with net shape and relatively
homogeneous density, located on the lingual of mandible premolars area
above milohioidien muscles.
1.2.2.2. Other rare syndromes and developmental abnormalities
the microsomas of the hemifacies (fig.1.32)
cleido-cranial dysplasia (fig.1.33)
Gorlin syndrome (fig.1.34)
Eagle syndrome,
Crouzon syndrome (fig.1.35)
Apert syndrome (fig.1.36)
Mandibulo-facial disostosis (Treacher Collins) (fig.1.37)
We will show some radiographic aspects of these rare anomalies.
a
b
Fig. 1.32. Microsomia of left hemifacies, front bearing radiography
"rocks in orbit" and profile, highlighting the difference between basilar
edge of the mandible.
28
a
b
Fig. 1.34. Gorlin syndrome, radiograph of skull face and profile.
29
a
b
Fig. 1.35. Crouzon syndrome, radiograph presents incidence "rocks in
orbit" and profile, highlighting digitiform turibrahicefalia and fingerprints
from the calvaria.
a
b
Fig. 1.36. Apert syndrome, lateral skull radiograph hypoplasia of
maxilla) Hand frontal radiography with phalanges 2,3, 4 units b).
30
31
32
Chapter 2
33
a
b
Fig. 22. Early interproximal caries in enamel (C1) at 24, 25, bitewing
radiograph a) and between 31, 41, periapical radiograph b).
During stage C2 we meet:
A more extensive lesion better noticed clinically than
radiographically;
A triangular radiolucent, based at the tooth surface below the
interproximal contact with the adjacent tooth (fig.2.3);
Generally, under current rules the cavity does not require endodontic
treatment.
35
Fig. 2.3. Interproximal tooth enamel caries (C2) at 14-15, 15-16, bitewing
radiograph a) and 85, as well as voluminous cavity C4 stage 84 with
opening the pulp chamber, radiographic bitewing b).
During stage C3 we meet:
An injury that progressed faster in dentin than in enamel;
A radiolucent side at enamel-dentine junction level;
Caries are treated if they affect more than 0.5 mm of dentin (fig.2.4).
Fig. 2.4. Interproximal tooth enamel (C3) at 23, 25 a) and 25 b) and decay
stage C2 26, 34-35,35-36, 36-37 b) bitewing radiographs.
During C4 stage we meet:
Decay appears as a deep dentin lesion with irregular aspect,
excavated;
The lesion may appear larger radiographic than clinical as a diffuse
radiolucent gradation, peripheral paler, U-shaped horizontally (fi.2.5);
Caries in stage C4 should be treated.
36
a
b
Deep cavity (C4) at 25 and decay stage (C2) at 24, 26, 34, 35, 36, bitewing
radiograph a) Image of a ocluzo-distal deep cavity in 36 obtained with a
video camera, b).
To radiologically see a cavity a significant demineralization of tooth
structure is required, often the clinical lesion being larger than the
radiological one. Thats why early caries can sometimes remain unnoticed
radiologically, especially if they are located interproximal where they are
'burned' by the phenomenon of "burn-out" or "marginal halo" that appears
because X-rays are tangent to the curve of the crown decay.
2.2. Occlusal caries
Grinded surface caries are clinically detected as linear or dotted. These
lesions progress on both sides of the crack, gaining the appearance of a
triangular base to dentin lesions, radiographically not easy to detect when
restricted to enamel, which appears large in the cusps. Cavities can be
extended in dentine without clearly exceeding the enamel dentine.
Radiographic: These cavities appear as linear or band transparency,
enamel-dentine junction located below, which has a rounded shape as an
"U" or a crescent with a heterogeneous transparency, much lower towards
the normal dentin (fig.2.6).
a
b
Occlusal caries present at the first maxillary and mandible molar) and
video camera image of two mandible molar occlusal caries b).
37
c
d
Fig. 2.7. Vestibular cavity in 11, interproximal cavities C4 stage in 11,
21, stage C3in 12) the "burn-out" phenomenon with a clear tape aspect
on the pack of front incisors b) pack cavity at 11 and 21 photographic
aspect c) and the pack cavity in 45 accompanied by significant retraction
of the marginal periodontium d).
Radiographic: a radiolucent round / oval shape may appear with a clear
demarcation between carious enamel and the remained enamel (fig.2.7. a).
Pack decay occurs in the space between the edge of the free edge of
enamel and gums, affecting both cementum and dentin, premolars or
anterior teeth being affected (fig.2.7.c). Sometimes small cervical caries
can be masked during clinical examination by plaque and can be easily
identified radiographically on interproximal surfaces and vestibulo-oral as
semilunar radiolucent ( fig.2.7.d) above the gum ( "black hole" aspect).
38
a
b
Fig. 2.8. Root caries in third apical to 11, with vertical retraction of
39
a
b
Fig. 2.10. Rampant caries of the upper front teeth) in a child and a
teenager b) with multiple cavities, corono-root clogged. (O.P.T).
Radiographic: These cavities occur between interproximal and cervical
areas of the teeth prior to coronary radiotrasparencies with irregular edges
and deep extension in the pulp chamber (Fig. 2.10).
40
b
a
Secondary cavity, mesial in 25 and recurrent in 26 (bitewing radiography)
and recurrent caries in 15 periapical radiograph b).
Recurrent or secondary caries are difficult to assess if radiographic
radiolucent fillings are used, baseless, the only radiological sign is to
identify a limited diffuse area of the cavity wall, blocked in contrast with
the rest of a demarcated area.
2.8. Radiographic evaluation of tooth decay and the proper treatment
of simple cavities
Eric Whaites considers it is important to have a systematic analysis of
bitewing radiographs, and starting from the crown and continuing with the
cervical zone and the root.
Thus, in the crown:
we trace the edge of the enamel;
we draw a line in the enamel-dentine junction edge,
we note any changes in contour, enamel, eg. a possible cavity
we note any change in the density of interproximal enamel, for
example the presence of radiolucent triangular cavity products,
we note any change in the density of dentin:
41
a
b
Fig. 2.12. Overflowing crown restorations with secondary caries
occurrence in 16, 45,) 26 and 34 b) and horizontal retraction of marginal
periodontium b) bitewing radiographs.
Neighbouring of the filling with the pulp chamber, the thickness of
dentin between the pulp chamber and cavity
Root location and basic conformation is to protect the pulp (Fig.
2.12.b);
Changes induced by dental amalgam for reparative dentin radiopaque
aspect, different from normal dentin and possible problems of differential
diagnosis,
Dental caries beneath crown cover, which appear as a small
radiolucent area extending from the edge of the crown, apical, and much
different from the metal intensity of the crown.
The correct analysis adjusts radiolucent or radiopaque filling material
would be much easier if restorative materials should have a radiopacity
equal to or slightly higher than normal enamel for proper differentiation of
recurrent caries.
Filling root requires precise radiological analysis of the number, shape,
direction and length of roots, root canal character and after treatment, the
way the filling was performed. As a root filling material only paste or
gutta-percha cones and paste radiopaque are used. Filling material must
reach:
up to apex,
to 1-2 mm far from the apical foramen,
up to apex when infected channel,
up to 1 mm beyond the apex, where excess means greater pains, bone
resorption and the healing process is prevented.
Radiographic: we can see how root canal was filled (fig.2.13):
complete
incomplete
discontinuous
44
supraclogged,
with cutter or needle fragment tire-nerfs,
the false path (perforation) or interradicular root,
axial root fracture.
Tissue reaction to root canal fillings can be assessed radiographically as:
favourable apical obliteration by failure of forming the cement in the
apical region of the channel,
favourable settlement of
inflammatory focus and trabecular
reconstruction,
unfavourable when the paste comes over apex, with the advent of
aseptic process, apicolisis, lamina dura resorption and alveolar bone
partial absorption,
unfavourable by apical periodontal infection, or lack of sanitation in
the existing infection with the production of apical acute / chronic
periodontis
unfavourable with incomplete root fillings, and in time it can produce
a periapical granuloma.
45
b
a
c
Fig. 2.14. Secondary dentine coating a) looking for denticul b), and as
pulpolit and denticul c).
46
47
sometimes exceeding causal space between the tooth and adjacent teeth
(fig.2.15.b)
easy apical cementolise, sometimes.
d
c
Fig. 2.15. Mesio-occlusal cavity depth in 27 without radiographically
visible periapical process, 24, 25 with corono-radicular reconstruction
and expansion space periapical discrete in 25 ,without destruction of the
lamina dura), loss of lamina dura and diffuse periapical radiolucency in
the mesio-vestibular root of 26 b) incomplete corono- root fillings, in
36, 37 and widening the periapical area of disappearance of lamina dura
with a small round periapical radiolucency c) incomplete fillings at 37
with loss of lamina and widening of periapical space, 38 included with
open apex, intact lamina and normal expansion of periapical space d).
The evolution of this damage can be towards bone subperiosteal abscess
that opens the soft parts. Radiography shows in this case the place of
departure of abscess and the extent of bone lesions (fig.2.15.c).
2.9.2.2. Chronic apical periodontitis
We find two forms of chronic apical periodontitis: fibrous and diffuse
progressive granulomatose.
48
If the healing of the acute periodontitis is not completed, the chronic stage
of injury is settled and chronic arthritis and dental granuloma appear.
2.9.2.2.1. Chronic apical fibrous periodontitis
Radiographic: there is an increased radiolucency around the apex, the
spongy bone with a heterogenous osteoporosis aspect with uneven etching
channels that form the spongy bone. The main feature is the destruction of
lamina dura and the serrated contour of the irregular radiotrasparent area
(Fig. 2.16., B).
2.9.2.2.2. Progressive chronic diffuse apical periodontitis
Radiographic: it shows a radiolucent intense homogeneous zone
surrounding the apex, with regular shape but diffuse lamina dura
destruction and a discrete process of apicolisis (Fig. 2.16.c)
b
c
a
Fig. 2.16. Chronic periodontitis fiber in 45, with transparency around a
residual periapical dental pulp and destruction lamina dura), periapical
transparencies periapical at 43, 44, serrated shape and lamina dura
disruption, chronic apical periodontitis in 41 fistulising diffuse appearance
of radiolucency with irregular shape, uneven intensity, jagged outline and
diffuse b) and chronic apical diffuse periodontitis in 22 c).
2.9.2.2.3.Chronic
granuloma)
granulomatous
apical
periodontitis
(apical
a
b
Fig. 2.17. . Chronic apical periodontitis with a periapical radiolucent
area in the palatal root of the premolar 1) and lower central incisors b) net
shape without condensation around and disrupted lamina dura.
b
a
Fig. 2.18. Granuloma cyst at the side of the palatal root in 15 with
transparency shaped net with dew lizereu around seems to continue with
the lamina), apical resection at apexes 24 which had cystic granuloma b).
2.9.2.2.5. Chronic dental abscess
This infection is characterized by chronic suppuration and the presence
of fistulas.
Radiographic: exhibit the following characteristics:
clear demarcation in chronic forms
diffuse radiolucency, acute forms surrounding a strong irregular,
round or oval, often asymmetrical form, with a significant broadening and
50
c
a
b
Fig. 2.19. Pathological rizaliza in the vestibulo-mesial root of molar 26,
showing a deep cavity in the open pulp chamber and chronic apical
diffuse periodontitis), physiological rizaliz 54 B) in 41 chronic dental
abscess, chronic apical diffuse periodontitis in 42 and 44.
.
Fig. 2.55 Physiological rizaliza differs from the pathological because it
occurs in deciduous teeth, affected or unaffected by decay.
2.9.2.2.7. Hipercementosis
This change is an apico-periapical osteocondensation process, with an
increased function of cementoblast in apical region.
Radiographic: find a change of the root tip in volume and shape that
appears thickened due the apozition of the periapical cementum, giving
the apex an aspect of "club", "stick drummer" or "clapper" (fig.2.20).
Periapical area is sometimes narrow but well defined, with the lamina dura
intact or discontinuous and granulomatous lesions.
51
d
f
e
Fig. 2.20. Hipercementosis in the premolar1 root and in the rest of the
root of the premolar 2, with a "stick drummer aspect, a), molar apices II
hipercementosis " club " aspect b) and " clapper "aspect in the mesial
root of molar I showing chronic apical diffuse periodontitis and deep
occlusal caries c) periapical hipercementosis to 36, d). , 26 s), and 34 f)
2.9.2.2.8. Condensation periapical osteitis
The bone lesion is produced by the osteoclasts pathological hyper
function occupying the areolas of the sponge bone.
Radiographic: it can highlight a radiopaque area, oval or round, which
looks amorphous, without bone hardness and contour with a relatively net
(2.21).
b
a
Fig. 2.21. Osteita condensant periapical, zon radioopac periapical
la rdcina mezial a molarului I, ovalar a) sau rotund b), cu aspect
amorf dar contur net, la rdcina mezial a molarului II care are o carie
ocluzal profund.
52
b
a
Fig. 2.21. Periapical condensed osteitis, a periapical radio opaque area in
the mesial root of molar I, the oval) and round b) amorphous aspect,
but net shape, the mesial root of molar occlusal caries II is profound.
53
g
h
i
Fig. 2.22. Various aspects encountered in endodontic radiograph..
54
a
b
Fig. 2.23. Periapical palatal osteitis in 16 with acute right maxillary
sinusitis, a) X-ray retroalveolar bisectorix technique, b) skull
radiography, Blondeau incidence, with full and intense opacification of
the right maxillary sinus.
55
b
a
Fig. 2.24. OPT. a) Oral sinusal communication left side, maxillary
sinusitis, b) Presurgical aspect.
CT and CT dental program made with fine sections, millimeter and
paraxial reconstruction (Fig. 2.25) and panoramic (Fig. 2.25 c, d, e, f)
allow a precise exhibition of the teeth and the periapical processes that
cause dental sinusitis.
56
f
e
Axial CT in bone window shows a cystic intrasinusal lesion in the
palatal root and in the root of the mesio-vestibular molar 16, a), i.e. a
complete opacification of the third lower left maxillary sinus with
filling with radio opaque material, b) , CT in dental panoramic
reconstructions show more cystic lesions with sinus development in 16
c), e), and odontogenic left maxillary sinusitis with intrasinusal radio
opaque material d), f).
Acute and chronic maxillary sinusitis can be complicated by:
extension to the other sinus infection,
osteitis or osteomyelitis of the sinus wall,
orbital cellulitis,
zygomatic fossa abscess or genian,
rear extension to the sphenoid sinus, cavernous sinus with concomitant
damage and major neurological signs.
Chronic sinusitis of dental origin without teeth and sinus communication
that can not be suppressed because the starting point of the disease
outbreaks infection (Fig. 2.26 e).
57
d
Fig. 2.26. Intrasinusal as a periapical
cyst)
aspect
CT
paraxial
reconstructions, b) radiographic
Blondeau incidence, c) acute
maxillary intrasinusal left sinusitis
with radio opaque dental pulp and
left maxillary sinus opacification, CT
appearance, d) showing radiographic
aspect, e) chronic right maxillary
sinusitis radiographic aspect of the
mucosa is thickened by a peripheral
radiopacity "in frame".
58
b
a
Fig. 2.27. . Acute osteomyelitis: a) early after extraction of 46: relatively
well-defined radiolucency associated with apical lesions and preexisting
periodontal lesions (indicated by black arrows), b) Acute osteomyelitis
of the right mandible ascending branch after the extraction of 48: a
moderate radiolucency in a moderate sclerosis area (indicated by black
arrows).
b
a
Fig. 2.28. Osteomyelitis with seizures with the more opaque fragment of
bone surrounded by a transparent halo) after extraction of molar 47 five
weeks ago, b) spontaneous fistulas and demineralization adjacent to
the areas of seizure bone infection 6 weeks old in the dental apex 34.
59
These forms are more rare and difficult to diagnose strictly by imaging.
Differential diagnosis means:
diffuse sclerosing osteomyelitis of the:
*osteosarcoma,
*Paget's disease,
proliferative osteomyelitis (Garre disease):
* Ewing osteosarcoma,
*fibrous dysplasia.
a
b
Fig. 2.30. a) chronic secondary osteomyelitis with necrosis and
sequestration b) Chronic osteomyelitis localized from the beginning with a
reactive sclerosis the dental canal.
61
62
Chapter 3
1 - crown
2 - enamel
3 - dentine
4 - gum
5 - pulp
6 - cement
7 - nerves and
vessels
8 - root
9-alveolar
bone
trabeculae
blood
with
64
c
b
a
Fig. 3.2 a) Scheme: j - enamel-cement junction, the amelo-cement line, b
- septa ridge height line, normal distance between a and b is 2-3 mm
(after Whaites, 2003), minimum horizontal retraction of periodontal
visible on a lateral mandible periapical radiograph in the group b) and
bitewing radiography in the lateral area c).
We consider as periodontal disease an increasing of more than 3 mm
distance between interdental septa ridge line and enamel-cement junction,
which is accompanied by clinical signs of gingival loss of attachment
(Eric Whites, 2003).
Radiographic aspect of a healthy periodontium:
the dental septum in the posterior region has: thin, smooth margins,
well shaped bone trabeculae;
the dental anterior septum presents: sharp edges, thin, bony trabeculas
less obvious due to the small amount of bone between the previous teeth
interdental septum continues with lamina dura of the adjacent teeth,
and the junction between them creates an acute angle.
It is important to know that:
We do not always find radiographically all these characteristics of
healthy periodontium, but their absence from the X-rays is not necessarily
a periodontal lesion,
Their absence may be due to:
*a faulty technique,
*a supraexposing of the dental film, with a "burn-out"effect
normal anatomical variations in alveolar bone density and shape,
After a successful treatment, clinically speaking, the marginal
periodontium looks healthy, but radiographically signs of bone loss can
occur when the disease was active, therefore the visualized
radiographic bone loss is not an indicator of the presence of
inflammation and must be permanently linked with the clinical
examination.
65
-specific
Chronic:
ic,
mative,
Periodontitis:
Acute:
Chronic:
* severe
*with an early onset:
66
67
b
a
c
Fig. 3.3. a) - c) marginal halistereza and trabecular rarefaction, vessel
visualization, marginal triangulation and septum pinch in the incisor
region.
a
b
Fig. 3.4. . a) and b) Marginal triangulation and the decrease of marginal
bone trabeculas density visible in molars- premolars region,
bite-wing radiographs.
b
c
a
Fig. 3.5. a) - c) pinching the septum in the region of the upper jaw
premolar-molar right, in the canine premolars and mandible premolarsmolars, periapical radiographs.
* local secondary factors such as plaque, cavities, no contact points,
overflowing restorations, dental versii (fig.3.6).
68
a
b
c
Fig. 3.6. Retractions due to periodontal plaque and food debris
remaining under the prosthetic), the decay or overflowing fillings b), c).
3.6.2.1. Moderate to severe chronic marginal periodontal disease
These types of lesions are present:
interdental periodontal space widening (fig.3.7)
a
b
c
Fig. 3.7. a) - c) retractions of periodontal with teeth with interdental space
enlargement and irregular layout for a typical horizontal loss of alveolar
bone height, the damage of the posterior teeth.
images of destruction of the alveolar bone (vertical and / or horizontal)
become more visible with the emergence of periodontal pockets (Fig. 3.8),
loss of acute angle shape between the lamina dura and interdental
septum with rounded angles and irregular aspects: the aspect of parodontal
pocket, funnel, sink" in ladder "(fig.3.9)
localized or generalized loss of alveolar bone support (fig.3.9);
69
Fig. 3.8. Parodontal pockets around the apices of some teeth included in
the corono-root reconstruction.
c
a
b
Fig. 3.10. Various bone defects: a)bony lysis with radiolucent aspect of
crater or "funnel" b) interproximal septal defect, c) horizontal
radiolucent bony liza.
70
a
b
c
Fig. 3.11. Degrees of bone loss at pluriradicular teeth furcation.
deep periodontal funnels(around the apex site)
total marginal periodontitis (the root is floating''), when the desmodont
is completely destroyed, lamina dura missing, irregular contour of the
spongy zone).
*bone loss patterns: horizontal and / or vertical (fig.3.12 - 3.14),
71
Fig. 3.15. . Juvenile periodontitis, severe vertical bone loss affecting the
mandible molars and premolars in particular, and the maxilla and
mandible incisors in a young man of 22 years old with important
phenomena of furcation in 26, 36.47, aspect of "funnel" in 45, and
"sink" in 34 and 12.
Fig. 3.16 Juvenile periodontitis, severe vertical bone loss affecting the
mandible molars and premolars especially in a young person of 21 years
old.
73
75
76
Chapter 4
77
79
d
e
f
Fig. 4.1. a) a) coronarian fracture in 21 (retro-dental-alveolar
radiography), b) root fracture 21 (occlusal radiograph), c) dislocations
with extrusion of 41.31 and dislocations with the avulsion of the tooth
32, d) and mandible alveolar fracture with left paramedian fragment
displacement and canine dislocation, e) post immobilization aspect with
radiopaque material, f)fracture of the alveolar rebord with intrusion of
11 and rotation of 12.
81
Fig. 4.2. . Shot comminutive fracture of the left mandible body with the
bullet retained in the mandible horizontal left ram and minimum
overlapping fragments of bone, OPT.
(Prof. D.Goglniceanu collection).
rotation or gap of a higher amplitude (fig.4.4)
* these fractures are sometimes accompanied by rupture of blood
vessels, nerve elongation or rupture and foreign body (bullet, plexiglass,
glass).
these fractures sometimes occur in a pathological bone(fig.4.6).
Radiographic examination requires: OPT pre-and post-surgery (Fig.4.3),
radiographic axial and occlusal film radiography, holistic impact of the
mandible in PA.
82
83
b
a
a) Jaw scroll incidence. Right mandible body fracture without
displacement, b) occlusal radiograph, fracture with displacement of the
right mandible body, with minimal displacement (OMF Surgery Clinic
Collection Iasi).
b
a
Fig. 4.6. a) Left mandible body fracture with fracture path passing
through a small residual cyst and through the dental channel,
radiographic incidence of jaw scroll: b) Comminutive body left fracture
with fracture paths passing between premolars and bulky periapical cyst.
4.3.2.2. Gonion fractures (mandible angle) 17%
These fractures occur in an area of low bone strength and may have a
trajectory:
pre- muscle with secondary bone fragments movement (fig.4.7 -4.8),
muscle mass, without dislocation of the fragments.
The radiographic examination requires: OPT and holistic radiography of
the mandible in incidence before and after immobilization PA.
84
b
a
Fig. 4.7 Displaced fracture in the right gonion, mandible radiographic
incidence scroll: a) with an interest in the 48 molar socket which is in
eruption, with minimum drag fragments b) fracture displacement left
gonion, the immobilization of osteosynthesis material, but significant
displacement of the fragments and the focus of the wisdom tooth root
fracture (OMF Surgery Clinic Collection Iasi).
Fig. 4.8. a) Comminutive mandible angle fracture near the angle of the
right mandible, with the fragment ascension and molar root 48 in outbreak
incidence x-ray of the mandible jaw scroll b) comminutive fracture with
displacement of the left mandible angle, with moderate displacement of
the fragments, radiography skull incidence low face" PA. (Collection
OMF Surgery Clinic Iasi).
4.3.2.3. Median fractures (mediosymphysa)
These fractures are relatively rare in the mandible fractures because the
mentoniera symphysis resistance is an important point of the mandible.
85
Fracture line type of injury is between the two central incisors and get
parasymphysis the basilar edge of the mandible, making sometimes
inverted Y-shaped bifurcation, hence the name "lambda fracture" (fig.4.9 4.10) The radiographic examination requires: OPT, axial radiograph
occlusal film.
a
b
Fig. 4.11. a) Parasymphysa left occlusal fracture, occlusal radiograph
with displacement and overlapping fragments, b) right parasymphysa
fracture, radiographic incidence scroll of the right mandible with
moderate displacement of the fragments and follicular bag of tooth 43 in
the focus of the fracture (OMF Surgery Clinic Collection Iasi).
b
a
Fig. 4.14. Right juxta simphysis fracture with fragments overlapping the
bone fragments produced by projecting a metal piece, CT axial in bone
window, b) soft tissue window, showing fracture and subcutaneous
emphysema adjacent to the fracture.
Fig. 4.18. Left malar fracture and left subcondylar, with amputation of
the left coronoid process, O.P.T.
(Prof. D. Goglniceanu collection).
90
92
c
d
Fig. 4.19. . a) the interpretation of Campbell's lines: COS-superior orbital
curve; COI-inferior orbital curve, CPN-palato-nasal curve, CAD dental
alignment curve b) curves of Ginestet, Le Dinh and R. Race. c), d),
Campbell's lines schematically represented on the skull.
The analyzed elements in both steps are:
any alteration or outline or shape asymmetry in bone,
deformation speed
widening sutures,
* presence of a transparent fracture line,
the fracture lines direction,
the degree of bone fragments separation,
any radiopaque line or shade indicating overlapped fragments,
We must pay a particular attention to radiographs made with X-ray tube
set at 0 degrees to the plane OM, facial fractures from 1/3 are usually
identified:
fronto-zygomatic suture,
93
fronto-nasal suture,
temporo-zygomatic sutures,
lower edges of the orbits,
sides of the antrum,
nasal septum and ethmoid complex,
All these structures are automatically checked if a systematic approach is
followed to view occipito-meatal radiographs(OM).
Step 3
Examination sinus antrum. Comparing both sides and the opacity and / or
fluid levels suggests a hemorrhage in atrum.
a
b
Fig. 4.20. Le Fort II type middle transverse fracture, a) incidence of profile
skull radiography, b) incidence of skull tall face radiography
4.4.2.2. Bone structures analysis of the profile skull radiographs
We will examine several areas (Fig. 4.20 a):
Zone 1 checked areas: frontal sinus, frontal cerebral fossa floor
including blade cribriform, back walls of the middle cerebral fossa,
sphenoid sinus, vertical walls of the pterigo-palatine fossa, the
pterigoidian blades, teeth, posterior and front
Zone 2: front-nasal suture, the lateral edge of the orbit, maxillary
antrum, hard palate, anterior margin of the jaw,
Zone 3: nasal bones, the front wall of the maxillary antrum, nasal
front spina
Particular attention must be paid to:
Frontal:
Any step deformation or destruction of bone contours,
fluid levels in the maxillary antrum,
Back:
94
95
f
e
Fig.4.21 Le Fort I fracture (Guerrini), a) a tall face skull radiograph,
highlighting a bilateral fracture of the side walls and the sinuses clouding
with hemosinus, b) 3D CT reconstruction of the fracture profile
highlighting that isolates infrastructure as a trajectory above the teeth
apices, c) - d). Coronal CT reconstruction of maxillary sinus fracture path
visible to the union of 2/3 of upper third and lower apophyses of the
pterigoid sinuses, e) - f). CT, 3D reconstructions profile SSD and oblique
left.
4.4.3.2. Middle horizontal fracture Le Fort II
This type of fracture makes a low or transmaxilo cranio-facial disjunction
(Fig. 4.22).
96
f
e
Fig. 4.22. . Le Fort II fracture (incomplete bilateral), a) x-ray front in
tall face incidence with transverse fracture path and change lines and
curves Campbelles Ginestet, c), e), CT bone window showing the
fracture of all the walls of the jaw sinus of the great wing of right
sphenoid and zygomatic arch, d), f), CT soft tissue window showing all
the walls of the right maxillary sinus fracture priorbitar emphysema with
gentian hematoma.
4.4.3.3. Upper horizontal fracture Le Fort II
This fracture is a high cranio-facial fracture disjunction fracture,
separating the massive facial from the neurocranium (Fig. 4.23).
a
97
d
e
Fig. 4.23. . Bilateral cranio-facial high fracture-disjunction Le Fort III,
a) X-ray of skull showing high fracture incidence from passing through
the cross bilateral vomer, upper third of the nasal bones, inferior orbital
COI-curve, CPN-palato-nasal curve b) the incidence of profile skull
radiography, c) upper fragment CT MIP reconstruction showing the
transverse fracture with the inter-cranial disjunction, d), e) Axial CT
pneumatocel HAS post-traumatic cerebral edema, ischemia left front,
implying left subfalciforma petechiae.
4.4.3.4. Zigomato-maxillary complex fractures
This fracture can be:
center-facial -nasal bone fracture with orbit-nasal dislocation
latero-facial a fracture with a maxillo-malar disjunction (tripoidal or
fracture or tetrapoidal fracture) and with associated intracranial lesions
(Fig. 4.24).
98
g
h
k
Fig. 4.24. Left zigomato-maxillary complex fracture a) - c), with
displacement and clogging of the malar, or radiopaque foreign bodies,
pellet, k), and Right maxilla-zygomatic complex fracture d) - h) Axial
CT in soft tissue window and bone fractures highlighting comminutive,
overlapping fragments, hemisinusal jaw, post traumatic subarachnoid
hemorrhage and suntentorial cerebral edema, diffuse disappearance of
the tanks d), f).
4.4.3.5. Blow-up fracture of the orbit
They are produced by direct impact with an object too large to enter the
orbit and the impact force is transmitted into the median or lower orbital
bone so that the thin bone floor is fractured determining a herniation of the
orbital content in the ethmoid cells or atrum. (Fig. 4.25).
99
f
e
Fig. 4.25. Blow-up fracture of the right orbital floor with the herniation
of orbital fat: a) axial CT, b) 3D reconstruction, left orbital floor
fracture, c), d) coronal CT; right and left orbital floor fracture of the
papyrus-like blade) f) Axial and coronal CT.
Since in the conventional radiographs bony structures overlap, this type of
fracture is difficult to be highlighted and require sectional exploration , the
examination using computed tomography which allows the analysis in
bone window and soft tissue fracture, intraorbital fat examination, with or
without implying the left low muscle .
100
c
d
Fig. 4.26 Skull base and calvaria irradiated right latero-facial fracture, a),
b) Axial CT in bone window showing maxillary sinus wall fracture right
combinative of the large sphenoid wing, temporal bone, and a small
pneumatocel and subcutaneous emphysema, c) Axial CT soft tissue
window showing the areas of fronto-temporal hemorrhagic contusion
bilateral post-traumatic subarachnoid hemorrhage, d) 3D CT
reconstruction VRT right latero-facial fracture irradiated to calvaria, front
right.
intracranial injury - and sometimes MRI CT (Fig. 4.27),
101
d
c
Fig. 4.28. Fracture dislocation C4-C5 a) and C2-C3, b) changes of the
retrozid, c) Bodily settlement C7 fracture with minimal posterior
displacement of the retrozid, d) parietal hematoma dissecting right
vertebral artery observed in posttraumatic FS T1 MRI sequence .
103
Fig. 4.29. C6-C7 fracture with a herniated disk, post trauma, right
paramedian, sagittal sequence T2 a), sagittal T1 sequence b), C4-C5 with a
hipersignal at the vertebras in sagittal T2 sequence and compressive effect
on the LCR belt c), right vertebra artery parietal disecant hematoma post
trauma noticed in T1sequence FS
104
Chapter 5
nasoalveolar cyst
nasolabial cyst
brachial (lateral) cyst
thyroglossal (median) cyst.
In 2003, E. Whaites believed that the highlighting of a cystic radiolucency
located in the maxillary or mandible requires systematic analysis and the
several steps:
Step 1 - there is considered:
location
size
shape
edges or periphery of the cyst
the relative radiodensity and its internal structure
the effect upon the surrounding structures
how long has the cyst been present, if it is known.
Step 2 there is stated whether the radiolucency is:
of a normal anatomic aspect:
On the mandible level:
mentonier hole
tooth crypt
On the jaw level:
antrium
-palatinal fossa
an artefact: according to the type of scan performed, sometimes
appears:
a radiolucency by overexposure,
air overlapping shadows that appear as a radiolucent cyst,
pathological lesions:
congenital
in progress
gained.
Step 3 according to the injuries acquired one can decide which
category the radiolucency belongs to:
infection localized in the apical tissues:
* acute
*chronic
extensive infections in the jaw:
* osteomyelitis
106
* osteo radionecrosis
injuries
cysts
tumors or pseudo-tumoral lesions
giant cell lesions
cement fibrous-osseous lesions
*idiopatic lesions.
Step 4- there are taken into consideration the classifications of the
lesions in OMS lists
Step 5 - the radiological aspects of radiolucency found with each of the
pathologies described in the table above are compared. Then a list is
produced, with the differential radiological diagnosis of all pathologies
that might fit at the found lesion.
5.1. Periapical tissues cysts
5.1.1. The radicular cyst
It is an inflammatory cyst developed in the epithelial Malassez cells,
which may occur at any age.
Clinical features
epidemiology: high frequency in the maxilla, with a rate of about
70%, especially in adult males, aged between 20 and 50;
location: at the apex of any devitalized tooth, upper lateral incisors
and often in the roots of the lower molars;
dimensions: diameter 1-5cm (the smallest are difficult to be
distinguished from granulomas);
shape: round when monolocular, spherical, elongated when
multilocular;
edges: smooth (Fig. 5.1, 5.2), well-defined, corticalizated if chronic
(except in case of an infection) and continuing with the lamina dura of the
associated tooth.
107
c
Fig. 5.1. Periapical radicular cyst: a)OPT in a 19 year old with a
periapical radiolucency in 22 (which is devitalised), oval, smooth-edged,
well defined and sizes over 1 cm, b) Sketchy representation, shaded cyst
and decay depth of 21, 24 and 11, 47, past obstructions c) OPT in an
adult of 27 years, periapical cyst in the distal molar root of 36, radicular
remains 16, 21, 35, 47, 37 deep cavity with suppurative apical
periodontitis (periapical abscess).
108
e
d
f
Fig. 5.2. Radicular periapical cyst a) retroalveolar X-ray with a
radiolucency with smooth fine edges in 22 which is devitalised, b) Scroll
mandible periapical cyst at 46 which is devitalised and periapical
resorption, c) periapical cyst al. HEx40, d), e) dental CT axial and sagittal
2D reconstruction with periapical cysts in 46, 45, 44 which are in the
form of debris root f) paraxial CT reconstruction showing the reference
of the cysts with inferior dental nerve canal.
Imaging examination
Ways of examination: dental radiographs, OPT, radiographic incidence
in jaw scroll, CT.
Imaging features
smooth, well-defined, uniform radiolucency adjacent to the apex of
the devitalized tooth,
effects:
adjacent teeth are displaced, periapically resorbed, sometimes
cystic formation may cause shift antrum,
cyst may cause buccal expansion,
Pathognomic signs: absent; any periapical cyst needs a pathologist
confirmation.
Differential diagnosis: periapical granuloma, ameloblastoma,
neodontogen epithelial cysts, non epithelial neodontogenous cysts.
109
b
Fig. 5.3. Residual cysts: a) Left scroll
mandible
with
a
radiolucent
formation with smooth edges,
corticalised, adjacent to an empty
socket post - extraction of molar 36,
b) well defined radiolucency after
extraction of right
mandible
horizontal ram, c) CT - sagittal
reconstruction, residual cyst in the
lower dental nerve canal.
Imaging examination
Methods of examination: dental radiographs, ortho-pantomography (OPT),
CT.
Imaging features
smooth, well-defined, uniform radiolucency,
110
c
d
Fig. 5.5. Dentiger mandible cyst: a) radiolucency with fine edges around
45, un erupted and postero-inferior moved, 54 remaining, 44 and 46
distalised; b) radio transparency with fine edges around un erupted 45, 85
and 86 remaining with physiological rizaliz; c) radiolucent soft-edged
border around the un erupted 48 with physiological rizaliza in 85
d)eruptive cyst superficially located around the crown of 48 which has an
eruption in progress.
112
Imaging characteristics
*uniform transparency, well defined, with thin walls, extended round
the crown of a non erupted tooth (fig. 5.5a, b, c,) having the following
effects:
*the non-erupted tooth, moved,
*the adjacent teeth are displaced, 50% absorbed, covered by large
cysts
*oral or median expansion that can be extensive in case of large
cysts causing facial asymmetry and the movement of the antrum (Fig.
5.6).
d
c
Fig. 5.7. Keratocyst multilocular appearance, bearing radiographs in the
scrolled mandible and low horizontal portion located between the
mandible premolar and wisdom molar), b), the lesion has thickened
edges, festooned or vertical ram extension of the mandible around
wisdom teeth, internal and external cortical blowing, Gorlin-Goltz
syndrome, multiple keratocysts around wisdom teeth in the maxilla and
mandible visible on a radiograph mandible scroll c) and skull in "low
face" incidence d). (OMF Surgery Clinic Iasi collection).
114
Imaging characteristics
uniform radiolucency, usually a single lesion, with the following
effects:
*adjacent teeth have minimal displacement (Fig. 5.7.a, b), rarely
resorbed roots
*large area expansion (Fig. 5.8),
*may include the crown, resembling a follicular cyst,
b
Fig. 5.8. Median and paramedian bilateral mandible keratocyst, a) OPT.
presurgery multichystic mandible lesion with bulky medina which has
fine septa, displacing but not lysing dental apexes and inferior dental
canal, deforming the jaw, blowing and uneven the lower edge of the
mandible and its cortex, b) panoramic radiography with an intraoral
focus, the aspect of the cavity and dental apexes post surgery(Prof. D.
Gogalniceanu Collection)
115
116
c
Fig. 5.9. Nazopalate cyst ovoid, well-defined, located between the
central incisors, vital and distalised apex, palatal expansion) occlusal
incidence, b) retroalveolar incidence c) OPT- cyst with a "heart" shape
(Prof. D.Goglniceanu collection).
Imaging examination
Methods of examination: dental radiographs, ortho pantomography (OPT),
CT, MRI.
Imaging Features
Radiographic
uniform radiolucency, but radio-opaque shadows sometimes
overlapping, with the following effects:
*distal adjacent teeth displaced, very slowly resorbed,
*palatal expansion, identified only f the lesion is bulky,
Differentiated diagnosis: median maxillary cyst.
117
118
Imaging Features
Radiographic:
well-defined radiolucency in the maxillary, between the lateral incisor
and canine,
effects: laterally displaces the apexis of the teeth adjacent to the cyst.
Differential diagnosis: radicular cyst, ameloblastoma, tumor with
mieloplaxes.
b
Fig. 5.11. Globulo-maxillary cyst: a) unilocular radiolucency between
lateral incisor and left canine, surrounded by a net pathognomonic
divergence of apexes of the lateral incisor, canine and premolars, but
without decay, b) radiolucency which at first glance resembles a globulomaxillary cyst, but is a radicular cyst developed lateral the right central
incisor apex and lateral incisor apex, which is distally displaced, as well
as canine and first premolar apexes.
c
Fig. 5.12. Well defined radiolucency in a mandible median cyst,
unilocular, median mandible, that drives away the central incisors apexes
and the canines adjacent to the lesion, without resorption ,a), b)., The
mandible median cyst size and the well-defined edges make sometimes
difficult the differentiation of an odontogenic cyst from a neodontogenic
one, the differentiation is made only by histopathological examination c).
120
Imaging examination
Methods of examination:
Effects used for diagnosis: OPT, occlusal radiography, Belot technique,
mentonier radiographs, submentonier film.
Imaging Features
well-defined radiolucency,
which results in a slight shift of dental apexes (fig.5.12).
5.3.1.4. Maxillary median cyst
This cyst is located between upper central incisor roots and probably
develop from the epithelium of the dental burjoni.
Imaging examination
Methods of examination:
Effects used for diagnosis: OPT, periapical and occlusal radiographs using
Belot technique.
Imaging features
well-defined radiolucency, which results in: easy movement of the
dental apexes (fig.5.13).
Differential diagnosis: inter incisor channel, solitary bone cyst,
odontogenic inflammatory cysts.
a
b
Fig. 5.13. Median maxillary cyst, periapical radiograph OPT in a young
man with an interincisor radiolucency, well defined, that moves the
apexes.
121
b
a
Fig. 5.14. Traumatic mandible cyst) incidence of jaw scroll: radiolucency
of the right mandible angle without periapical pathological rizaliz to 47,
b) radiolucency between canine and premolar roots 1, displaced, with
regular edges and multilocular appearance without rizaliz of dental
apexes, post extraction absence of 6 years molar, with normal socket, is
anatomo- apatological diagnosed as traumatic cyst.
122
123
c
Fig. 5.15. Solitary bone cyst: visible near the right angle of incidence of
scrolled mandible, a) and the incidence of low face to the skull, b) in
another patient seen at OPT c) in the body of the mandible under the
molar root residues of 46 and 47.
CT: examination performed native and post-contrast highlights:
a radiolucency, expanding in the mandible, extending distal and
mezial,
the lesion does not destroy the cortical bone (fig.5.16) and
determins the lower movement to the basilar edge of the dental
channel
124
e
f
Fig. 5.16. Left hemimandibular solitary bone cyst CT: axial sections in
bone window a) and tissue b) shows an intracystic fluid density contrast
without destroying the cortical bone; panoramic reconstructions show
mesio-distal and vestibulo-lingual extention of the mandible cyst which
pushes the dental canal; c) and another three periapical cysts developed
in the jaw around the dental apexes 12, 24 and 26, all with root remnants
aspect d) transverse oblique reconstructions, along the dental axis outline
the cyst with fine, regular walls, the net delimitation of the cortical dental
canal and periapical fine rizaliz of the root apex of premolars 34 and 35
which are inside the top edge of the cyst e) and f).
5.3.2.3. Aneurysmal bone cyst
This cyst is located in the abundant spongy tissue bones and jaw. The
cystic cavity contains highly vascularized tissue (dilated arteries and veins
), sometimes a cavity containing blood.
Clinical features
Epidemiology: it is rarely found in adolescents,
Site: body angle of the jaw or occasionally jaw
Size: variable, up to a few cm,
Shape: unilocular or multilocular,
Outline: regular, smooth, moderately defined.
Radiographic:
round radiolucency, clear shapes with thin limestone lizereu with
limestone septa (as in ameloblastoma) that make the radiographic
diagnosis impossible (fig.5.17)
CT: examination performed native and / or post-contrast highlights:
the radiolucency, its contours, the fine limestone lizereu, the relations
with neighboring teeth and allows the measurement of intracystic densities
with Hounsfield scale (+55 to +75 UHU blood), confirming the diagnosis.
MRI: examination performed native and post-contrast highlights:
125
the cyst, confirms the diagnosis and demonstrates the features within
the cyst fluid levels visible in native and post-contrast T1 sequence in T2
and STIR sequence.
Differential diagnosis: ameloblastoma, mieloplaxis tumor, traumatic cyst.
126
Fig. 5.18. Stafnes bone cyst of the right mandible vertical ram.
5.5. Cysts of the soft cervico-facial parts
The anatomical cervico-facial structures can be the site of cystic lesions
frequently of an embryonic origin, but can also occur by cystic
transformation of sebaceous glands (sebaceous cyst) or of accessory
salivary gland (mucoid cyst).
The localized facial and cervical cysts are:
thyroglossal cyst - can be found in any part of vestigial thyroglossal
duct.
Clinic - submentonier, median or supratiroidian tumor;
The diagnosis is established by the CIV CT
brachial cyst - is formed from the remnants of brachial arches.
It is located latero-cervical or submandibular, frequently fistulises. The
diagnosis is established by the CIV CT
salivary retention cyst
It is dependent on small salivary glands, located in different places: on the
lips, sublingual, in the nasopharynx mucous, etc.. The diagnosis is done by
analyzing CT and MRI examinations with civ
The confirmation of the imagistic diagnosis is based on the anatomopathological examination.
5.5.1. Thyroglossal duct cyst
This is the most common congenital malformation of the neck resulting
from a ruptured infected cyst. The lesion is commonly found in children
under 10 years old, often from an infection near the midline of the neck,
around the hyoid.
Clinical features
127
d
e
f
Fig. 5.19. Thyroglossal duct cyst developed antero-lateral left. Axial CT
native and civ, showing cyst developed on the left side of the hyoid bone,
the attachment on the borders of contrast and at the level of the adjacent
fascia.
MRI: it shows a cystic mass, round, fine attachment of peripheral contrast
in non homogeneous hiposignal in sequence T1 and hipersignal intense
but non homogeneous in T2 sequence, showing peripheral contrast when
fistulizes between thyreo-hyoid muscles.
Differential diagnosis: malignant lymph nodes, thyroid adenoma, dermoid
cyst, abscess, hematoma.
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129
a
b
c
Fig. 5.20. Brachial arch 1 cyst developed right laterally, with a moderate
density contrast fluid and peripheral attachment in izosignal T1 and T2
hipersignal.
d
e
f
Fig. 5.21. Brachial arch 2 cyst developed in the posterior lateral angle of
the jaw, with density liquid and a moderate contrast peripheral grip.
b
a
Fig.5.22 . Brachial arch 2 cyst developed in the right lateral posterior
angle of the jaw, with liquid density a) that displaces external the parotid,
as it is shown in CT axial section post sialography
131
d
e
f
Fig. 5.23. Salivary retention cyst in nasopharingean cell membrane with
hiposignal in T1SE native sequence), d), hipersignal homogeneous in T2
FSE sequence b), e), which has a small grip on the border of the cyst,
visible contrast in T1 SE axial sequence f ) and sagittal c).
The lesion most frequently develops in the lips cell membrane both in
women and men, being asymptomatic as long as it is small. (fig.5.24.)
Imaging features
CT exhibits a small hipodens mass, oval-round at the lips cell
membrane level; it has very seldom a large size and could easily be taken
as being a pleomorphus adhenoma of the salivary accessory gland.
MRI presents all the characteristics of the cyst, has a fine grip of
neighbouring contrast in T1 sequence.
c
d
Fig. 5.24. Salivary retention cyst in the upper lip cell membrane, The
external aspect a), vestibular b), intrasurgical c), and the surgical piece d).
(Surgery Clinic of OMF-Iasi collection)
133
134
Chapter 6
136
c
Fig. 6.1 Multichistic mandible ameloblastoma a) the low face incidence
shows a radiotrasparency at the level of the ascending rami of the right
mandible angle and in incidence jaw scroll.
b) shows multiple cystic images with very fine septa, large size, which
thinns but does not destroy the cortical basilar edge, "bubbles" aspect,
multicystic ameloblastoma developed around the included molar 3
arcade and horizontally located.
CT:
variable-sized tissue damage and bounded by complete septa, which
has or hasnt an extension outside the cortical mandible or maxilla;
MRI:
mixt injury, tissue and cystic of varying sizes with intermediate signal
in T1 native sequence, hyper, izosignal in sequence T2 and T1 hipersignal
grip contrast to the solid component.
Complications: infections, pathological fractures, malignant degeneration.
Differential diagnosis: ameloblastic fibroma, squamous odontogenic
tumor,
adenomatous odontogenic tumor, epithelial odontogenic fibroma,
odontogenic calcified cyst, adenoid cystic carcinoma of maxillary sinus
origin.
Prognosis: locally aggressive nature and may recur even in 10 years after
surgery may have a malignant evolution in approximately 2% of cases.
6.1.1.2. Peripheral extraosseous ameloblastoma
This histopathological entity is the homologous of the solid multicystic
intraosseous ameloblastoma.
Features:
epidemiology - represents between 1.3 and 10% of all
ameloblastomas, being more frequent in patients aged between 50 and 70.
site: in the gingival of the maxillary or mandible teeth or alveolar cell
membrane of the edentulous patient; can also be multicentered.
Imaging features:
Radiographic:
Radiolucent and radiopaque composite aspect of the dental ridge may
be accompanied by its depression or erosion (fig.6.3).
CT and MRI:
allow an analysis of injury and ensure the planning of therapy.
Differential diagnosis: peripheral odontogenic fibroma, odontogenic
squamous tumor, odontogenic gingival epithelial hamartom.
Prognosis: a lesion that recur after many years, is locally aggressive and
can become malignant.
138
b
a
Fig. 6.4. Right maxillary ameloblastoma MRI examination; SE axial T1
sequence, a) FS SE axial post contrastT1 sequence highlights the
contrast tumoral grip and its setting its posterior extension into the right
retrozigomatic fat
139
b
a
Fig. 6.5. Unicystic ameloblastom in 36, with teeth apexes moving, front
x-ray visible, a) and panoramic b) net cortical thinning.
CT and MRI:
allow analysis of injury and ensures the planning of treatment.
Differential diagnosis: follicular cyst, residual cyst, post traumatic bone
cyst, essential keratocyst, giant cell granuloma, etc..
Prognosis: a lesion that is sometimes confused with periapical cyst and
recurrent, must be observed for many years.
6.1.1.5. Calcified epithelial odontogenic tumor (Pindborg tumor)
This unusual tumor looks like a ameloblastoma but has amyloid material
that can calcify and it is locally invasive.
Features:
Epidemiology: is 1% of the odontogenic tumors, being more frequent
in patients between 20 and 60 years old
Site: is more common in the mandible posterior region that contains a
tooth sometimes included, can have a extraosseous location in 6% of the
published cases
140
the tumor grows slowly and remains asymptomatic for a long time.
Imaging features:
Radiographic:
initially is presented as a small radiolucency,
in time, it will become multilocular, getting opaque zones of variable
sizes, amorphous, surrounding the crown of an included tooth; these
opacities may look as snowballs (fig.6.6).
CT and MRI:
allow the analysis of injury and ensure the planning of treatment.
Differential diagnosis: intraosseous squamous cell carcinoma, clear cell
odontogenic carcinoma, metastases from renal cell carcinoma or salivary
glands.
142
Imaging features:
Radiographic:
a radiotrasparency, round, oval with scalloped edges that invades the
body and ram, in the upward angle of the mandible (Fig. 6.8) and can
contain an included tooth (similar to ameloblastoma).
CT and MRI:
Assists in identifying multiple lesions, cortical perforations and
extensions from the jaw to the retro-maxilla-zygomatic region.
b
a
Fig. 6.8. Keratocystic odontogenic tumor in a patient of 28 years old )
with low incidence shows a radiolucency at the angle and ascending
rami of the right mandible coronoid process, with a wisdom tooth
leveled and embedded in the tumor, which is in incidence jaw scroll b)
occurs with multiple cystic images with fine septa, large thinning zones
but not destroying the cortical basilar edge.
Differential diagnosis: ameloblastomas, ameloblastic fibroma
Prognosis: a potentially aggressive lesion should be watched closely for
any daughter -cysts or malignant tendency.
6.1.2. Ectomezencyme odontogenic epithelial tumors with or without
hard tissue formation:
6.1.2.1. Ameloblastic fibroma
Odontogenic tumor is of an unusual benign odontogenic epithelial
origin mixed with ectomzenchyme. It does not contain any dental hard
tissue formation and dentin. From a histopathological point of view the
lesion is considered as an ameloblastic fibrodentinoma.
Features:
* Epidemiology: a rarely met tumor that can occur between 1 and 62
years of age,
143
CT and MRI:
Assist in identifying multilocular lesions, mandible cortical
perforations and extensions from ascending mandible rami.
Differential diagnosis: ameloblastoma.
Prognosis: a lesion after curettage and enuclearing sometimes can recur
and become an ameloblastic fibrosarcoma of a malign origin.
6.1.2.2. Ameloblastic fibro-odontoma
This rarely met odontogenic tumor can be unilocular or multilocular and
resembles in radioimagistic terms with the ameloblastic fibroma.
Features:
Epidemiology: the lesion occurs in children aged 8-12 and rarely in
adults,
Site: in the premolars, malar, maxillar and mandible areas
develops slowly, easily infiltrating the bone, but can reach very large
sizes, with facial deformation, tooth movement, occlusion disorders and
dental eruption, with the emergence of pain, in time
144
145
b
a
Fig. 6.10. Compound odontoma with multiple nannous teeth, visible
radiopaque radiographic pre a) and postsurgery b)
b
a
Fig. 6.11. Compound odontoma multiple nannous teeth, visible
radiopaque radiographic in occlusal incidence, a ) and retroalveolar b).
b
a
Fig. 6.112. Complex odontoma visible as a less organized radiopacity,
located left mandible surrounded by a thin radiolucent halo, bordered by a
radiopaque lizereu in incidence), and occlusal jaw scroll b).
146
147
148
c
d
Fig. 6.14. Odontogenic mixoma a) low face incidence with multiple
radiolucent fine bony septa, blowing the right jaw cortex; the incidence
of jaw scroll b, d) and in panoramic incidence c) tumor appears as a
multilocular area with crossed, fine plans, that blow the cortex and
deforms the basilar edge of the jaw, causing moderate rizaliza of the
apexes and neighboring teeth.
CT:
helps in identifying the multilocular lesions and evaluates local
extension.
MRI:
the injury appears as an izosignal or hiposignal in the sequence T1, T2
sequence, homogenous hiposignal and STIR, homogeneous hipersignal
post contrast T1 sequence.
Differential diagnosis: odontogenic fibroma.
Prognosis: that is a locally aggressive lesion, without giving metastases.
149
150
151
d
c
Fig. 6.16. Central osteoma fronto-etmoido-orbital, polycyclic explored
radiographically a) and CT b, c), mandible compact osteoma visible on a
panoramic radiograph with an intraoral focus d).
b
a
Fig. 6.17. Periosteal osteoma mandible in the angle and the right upward
ram.
location:
* at the jaw (nasal apophyses, orbital floor, dental arch)
*at the mandible (the lingual face of the body, basilar edge, gonion)
*at the mandible condyle modifying the bite.
Imaging features:
Radiographic:
A round / oval, opacity may exist, attached to the cortical bone, or
may be sessile or a pedunculated lesion (often intrasinusal).
Differential diagnosis: jaw exostoses, osteoblastomas, osteoid odontoma,
odontoma, condensed osteomyelitis, cementoma.
The establishing of the diagnosis is possible only by histopathological
examination.
152
a
b
Fig. 6.18. Central osteoma at the level of the left mandible angle a) not
to be confused with a bulky cyst on the mandible salivary bunk b).
Gardner syndrome is a condition that includes intestinal polyposis,
multiple osteomas, compound odontomas, skin sebaceous cysts,
subcutaneous fibromas, supernumerary teeth (fig.6.19). the peripheral
osteoma is always present in Gardner syndrome, which has a family
character.
b
a
Fig. 6.19. Gardner syndrome multiple osteomas on the left mandible, a)
jaw scroll, b) low face incidence - X-ray of the skull.
Imaging features:
Radiographic: a small transparent area (less than 2 cm) called the nidus,
round, which has inside some radiopaque foci (less than 1 cm).
6.2.3. Osteoblastoma
It is an aggressive tumor, rarely met and which interests, more
commonly, the alveolar region of the mandible. It is also called giant
osteoid osteoma, being larger than 2 cm.
Features:
Epidemiology: in young people of 20 to 30 years old, rarely in older
age, being more common in men
Site: the spine, long bones and jaw.
Is considered an advanced osteoid osteoma.
Imaging features:
Radiographic: a transparent area with only calcifications or a radio
opaque mass surrounded by a transparent halo and an opaque, marginal
lizereu. Sometimes, there is a periosteal reaction with an aspect of sunrays.
Differential diagnosis jaw exostoses, osteosarcoma, bone cyst aneurysma.
6.2.4. Neurogenic tumors
6.2.4.1. Schwannoma
These tumors originate in the Schwann cells, are localized in 10% of cases
in the mandible.
Features:
Radiographic- a transparent round / oval area, on the path of a nerve,
clearly contoured, sometimes condensed;
prognosis: has a slow growing and depending on location, can
deform the maxillary sinus or the orbit.
6.2.4.2. Neurofibroma
Can be found alone or in Recklinghausen disease.
Features:
Produces a well-defined lesion that enlarges a section of the dental
channel.
Radiographic - osteolytic area (benign) with condensed strokes, located
on a nerve path.
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155
156
a
b
Fig. 6.23. Bone hemangioma of the left mandible explored CT with a
bone window with an axial section to highlight the expansion and
rarefaction of the trabeculas) caused by malformation of blood vessels in
the development of medullary spaces that extend into adjacent soft parts
with an aspect of "flow void" or salt and pepper in axial T2 sequence.
157
158
Chapter 7
159
Features:
Epidemiology: the average age at presentation is 30, but a third of the
patients are younger than 20.
Imaging features:
Imaging appearance is identical to that of the benign ameloblastoma.
Prognosis: after a period of about 10 years, it develops metastatic nodules
in lungs, cervical lymph nodes or extragnatic bones.
7.1.1.2. Ameloblastic carcinoma primary type
It is a rare tumor which demonstrates vague ameloblastomatic issues
identified in extensive areas of squamocellular epidermoid carcinoma.
Features:
Epidemiology: occurs in both sexes in relatively equal percentage;
grows into adulthood, being met at young persons of 30-33 years old;
Site: 2/3 of ameloblastic carcinoma develop mandible and only a third
of cases occur in the jaw.
Imaging features:
Radiographic:
radiopacity with irregular borders with cortical thinning or perforation
and infiltration of adjacent structures.
CT:
multilocular location in mandible, maxilla unique lesion, mixt aspect
combined with cortical destruction, analyzed examination in bone and
parencym window illustrates the contrast grip, extension and distant
metastasis (infratemporal fossa, masticatory space, lymph nodes,
extragnatic lungs and bones).
Differential diagnosis: Primary intraosseous squamous cell carcinoma,
clear cell odontogenic carcinoma, metastatic carcinoma.
Prognosis: has a cautious prognosis due to the aggressive nature of lung
metastases arising in short time.
7.1.1.3. Ameloblastic carcinoma secondary intraosseous type
The malignant lesion arises from preexisting benign ameloblastoamas in
old persons, usually during the seventh age decade.
Features:
Is a benign ameloblastoma evolving along years, with multiple local
recurrences after radiotherapy and rapid bone expansion, with the
160
a
B
c
Fig. 7.1. Secondary intrasinusal ameloblastic carcinoma expanded FIT,
FN and jugal region: a) Axial CT soft tissue in bone window in post
contrast, b) Axial CT in bone window, c) CT civ, sagittal reconstruction
in soft tissues window.
161
Prognosis: tumor development near vital structures (orbit, skull base and
the pterigopalatin fossa) are important for determining prognosis, which
can be several years.
7.1.1.4. Primary intraosseous squamous cell carcinoma
This lesion is a squamous cell carcinoma of the mandible, evolving from
odontogenic epithelial residue. It's called "intraosseous" as it develops in
the central area of the bone. Any ameloblastic differentiation was
identified. The tumor has several subcategories:
a) solid tumor invading the medullary spaces with bone resorption,
b) tumor arising from odontogenic cyst lining,
c) squamous cell carcinoma in combination with other benign epithelial
odontogenic tumors.
When the lesion destroys the cortex and goes into the mucosa, the
diagnosis becomes difficult to differentiate between solid primary
intraosseous squamous cell carcinoma and squamous cell carcinoma that
originates in the oral mucosa.
7.1.1.4.1. Primary intraosseous squamous cell carcinoma - solid
variant
Features:
Epidemiology: the average age of presentation is 52 years old, but a
fifth of cases are patients younger than 34, and one third are older than 65.
It usually occurs in men,
Site: usually in the body and the back of the jaw, rarely in the anterior
portion of the jaw,
Symptoms: Most cases are asymptomatic and discovered incidentally
at achieving dental radiographs or OPT.
Imaging features:
Radiographic:
radiopacity with irregular borders without proper contour with cortical
thinning. Large lesions cause cortical bone expansion and / or destruction.
162
b
a
Fig. 7.2. Solid primary intraosseous squamous cell carcinoma:
radiopacity with irregular borders without proper contour with thinning,
expansion of cortical bone and inferior dental canal movement) and
osteolytic lesion with irregular borders that destroys cortex and goes into
the oral mucosa causing multiple tooth extractions b ).
CT:
The tumor produces osteolysis which leads to jaw bone expansion
with irregular borders, with the aspect of "mouse-eaten"
the inferior dental canal is infiltrated by the lesion and the buccal and
lingual cortical is damaged,
the tumor can be with or without pathological fracture with obvious
contrast grip and extension of the adjacent soft parts.
Differential diagnosis:
benign ameloblastoma
clear cell odontogenic carcinoma,
metastatic carcinoma.
Prognosis: the tumor infiltrates regional and at the distance.
163
Fig. 7.3. Squamous call mandible carcinoma. Patient 57 years old in oral
leukoplakia, pain and recent fracture. a) Axial CT of tumors in tissue
window with a moderate iodofil tumor that destroys bone and extends
intraoral and vestibular b) Bone window axial section, destruction of
cortical mandible anfractuas, c), d) 2D reconstruction of the fracture
that crosses the vestibular part of the section, e), f) paraxial
reconstruction with measurements of tumor formation, with a tumor
extension into the dental channel.
164
165
Late stage lesions may cause extensive expansion of cortical bone and
/ or destruction with the lesion that penetrates soft parts.
Prognosis: 3 molar lesion is associated with favorable prognosis.
7.1.1.5. Clear cell odontogenic carcinoma
Is a carcinoma with a low degree of malignancy, composed of islands of
cells with uniform nuclei and clear cytoplasm. The lesion is very rare, only
36 cases published in the literature in 2007, people over 60 years.
Features:
Epidemiology: about 70% develop in women aged between 17 and 89.
Site: approximately 90% of cases develop in the lower jaw, half in the
anterior and half in the posterior segment.
Symptoms are initially teeth loss and then with paraesthesia.
Imaging features:
Radiographic: various aspects, often with an unilocular expansive
radiolucent lesion, with a poorly defined border, sometimes with irregular
radiopacities, and teeth with pathological rizaliz.
Differential diagnosis: metastatic melanoma, metastatic clear cell renal
carcinoma, calcified epithelial odontogenic tumor.
Prognosis: high rate of recurrence and metastases in regional lymph
nodes, lung, bone and requires monitorising.
7.1.1.6. Odontogenic ghost cell carcinoma
Epithelial odontogenic tumor is a malignant odontogenic tumor with
characteristics of calcified and / or dentinogenic ghost cell tumor.
The lesion is very rare, only 19 cases published in the literature in 2007,
persons aged 23-72.
Features:
Epidemiology: lesion occurs more in males in the 4th decade of life,
Site: usually in the maxilla than in the mandible, posterior,
Symptoms are mostly paraesthesia.
Imaging Features
Radiographic:
radiolucent radiopacity with tooth movement with cortical bone
expansion and / or destruction, which infiltrate adjacent soft parts
Prognosis: is unpredictable, with local invasion and survival of
approximately 5 years.
166
167
168
b
a
Fig. 7.5. Osteosarcoma mixed form: osteolysis, osteogenesis and spiculi
forming at the mentoniera symphysis a), or maxilla and mandible b).
Site: Although osteosarcoma is the most common malignant bone
tumor, the location in the jaw is only 4% of all osteosarcoma and affects
the mandible body, the symphysis, the condyle, the gonion
symptoms: swelling, pain and ulceration.
Imaging features:
Radiographic:
the widening of periodontal space, bone destruction with suspended
teeth, non-homogeneous transparent areas and areas with radiopaque
inaccurate, irregular contour. Other radiological aspects encountered are:
large osteolytic areas, periosteum spiculi (sunrays), radiopaque areas
(hedgehog, combed bone), periosteal linear opacities (fig.7.5).
Differential diagnosis: Chondrosarcoma, Ewing sarcoma, plasmacytoma,
osteomyelitis, tuberculosis, metastasis and so on).
Prognosis: tumor rapidly evolving and gives metastases.
169
7.2.1.1.2. Chondrosarcoma
It is a very rare malignant tumor that originates from cartilage tissue or
derives from a malignant condrom. Usually these neoplasms occur in the
long bones, pelvis, ribs and are rare in the head and neck region which is
only 1-2%.
Features:
Epidemiology: they are extremely rare tumors of which 10% are in the
maxillofacial region. Occurs mainly in men in the third decade of life, but
with wide variations (5 months-75 years), and men and women are equally
affected;
Site: the most maxillo facial condrosarcoamas occur in the maxilla,
less frequently appear in the body of the mandible, ram, nasal septum,
paranasal sinuses;
Symptoms: swelling not painful jaw.
Imaging features:
Radiographic:
They describe two forms: central (intraosseous) or peripheral
(periosteal localized), which appear as transparent (unilateral
multilocular), respectively, transparency and calcification - ossification,
radiopacity. Dental displacements may occur, and uncharacteristic rizaliza.
C.T. and I.R.M.
can highlight: destruction cortices, the presence of intratumoral
calcifications, the invasion of the soft tissues.
Differential diagnosis: osteomyelitis, tuberculosis, metastases, etc.
Prognosis: has a locally aggressive behaviour and a high metastatic
potential.
7.2.1.1.3. Maxillary fibrosarcoma
Fibrosarcoma is a tumor of mesenchymal fibroblasts that rarely affects the
oral cavity. It is originated in the periosteum and the bone tissue.
Features:
Epidemiology: its incidence is low, 10% of cases are craniofacial, in
adults;
Site: is rare in the mandible or maxilla.
Imaging Features
Radiographic:
radio opaque mixed formation that invades the adjacent bone
structures.
170
CT
tissue mass with moderate outlet contrast, the destruction of the
cortices, showing intratumoral calcification and the invasion of the soft
tissues
Differential diagnosis: metastatic malignant schwannoma.
Prognosis: evolves rapidly and provide local or distant metastasis.
d
c
Fig. 7.6. Left maxillary fibrosarcoma: Axial CT soft tissue window in a)
and b bone) showing iodofila tumor invasion in the nasal fossa and
posterior wall of the maxillary sinus with extension in the zigomato
retro-maxillary space or a giant heterogeneous iodine catching lesion,
with the lysis of the neighboring bone structures and orbital extra-and
intracranial invasion and skull base osteolytic destruction c), d)
Fibrosarcoma (X 90HE).
7.2.1.1.4. Angiosarcoma
It is a rare malignant tumor of vascular endothelial frequently occurring in
skin or in a visceral location, but very rarely affects the oral cavity,
maxillary sinus or throat. In the area of maxillofacial tumors, either
primary or metastatic tumors could be.
171
Features:
Epidemiology: in the maxillofacial region has a very low incidence,
only 27 cases have been reported affecting the head and neck, 19 of which
been primary tumors. The age of presentation ranged from one day old to
68 years old;
Site: rarely in the jaw, which began as a lesion with a nonspecific
appearance with signs of nasal obstruction with epistaxis guiding to the
diagnosis;
Symptoms: intraoral angiosarcoamas appear as red-purple nodules
protruding into the oral cavity, which then ulcerate, with pain and
spontaneous bleeding
c
d
Fig. 7.7. Angiosarcoma: Axial CT in soft tissue window), b), c) showing
iodofil tumor, heterogeneously located in the nasal fossa extended in the
maxillary sinus, ethmoid, infratemporal fossa and left orbit, d) Axial CT
in bone window showing destruction of the walls of the maxillary sinus.
172
Imaging features:
Radiographic:
bulky lesion, osteolytic with moderate expansion in the neighbouring
structures in orbit or intracranial.
CT
Postcontrast lesion, has a strong contrast grip. (Fig. 7.7.).
Prognosis: There are aggressive tumors with a tendency to local
recurrence, lymph node and systemic metastases.
7.2.1.1.5. Rhabdomyosarcoma
It is an aggressive malignant soft tissue tumor consisting of cells derived
from primitive mesenchyme and showing a clear trend towards
miogenesis. Since the tumor is infiltrating the surrounding tissue
structures, the place of origin is difficult to identify. Although rare, they
are still the most common soft tissue tumors of the head and neck in
children.
Features:
Epidemiology: is one of the most common soft tissue sarcomas
occurring in children under 15, and are presented in three types:
embryo, which occurs in children between 8-9 years old,
pleomorphic, usually located in the maxillary sinus and occurs in
young adults,
cellular occurs more frequently in children aged between 30 months
and 5years, at the level of the naso-gentian ditch;
*Site: in children, in a cervico-facial location is the main location of
the tumor, accounting for 45% of all cases is the source jaw in 3 - 17.5%
of all cases of head and neck rabdomiosarcomas. The adult head and neck
rhabdomyosarcoma is rare and is localized mainly in the maxillary sinus
or ethmoid;
Symptoms: Skin lesion begins as a nonspecific one, with signs of nasal
obstruction, with an extensive and rapid development in all adjacent
structures.
Imaging features:
Radiographic:
bulky lesion, intense extensive osteolytic maxillo-facial extention at
the nasal passages, sinus, infratemporal fossa in orbit and intracranial
neighbouring structures, meningitis, epidural and subdural space, that put
pressure on survival in these cases, fatal in about 8 months.
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CT
bulky tissue mass, moderate and non-homogeneous iodofila extension
with facial masiff components, and intracranial, too. Shortly it produces a
large osteolytic latero-facial area with atypical destructions small bone
remains inside the tumor (Fig. 7.8).
b
174
c
d
Fig. 7.8 Extensive embryonic type rhabdomyosarcoma: a) Axial
postcontrast CT in soft tissue window. Wide expansive process with
moderate contrast outlet, heterogeneous necrotic areas centered at FIT
right top intraorbital and intracranial extension, b) Axial CT in bone
window. Complete lysis of the zygomatic arch, maxillary sinus walls
and vertical ram mandible, c) Axial CT in soft tissue window. Tumor
occupying the right orbit and temporal region with intracranial extension
into the middle cerebral fossa d) optical microscopy: embryonal
rhabdomyosarcoma (x100, HE).
175
a
b
Fig. 7.9. Recurrent squamous cell carcinoma of the left tonsillar
infratemporal fossa (FIT): a) Axial post contrast T1 FS b) coronal postcontrast T1 FS.
Imaging features:
Radiographic:
In advanced forms intraosseous extension areas infiltrative osteolytic
appear with imprecise limits, located in the mandible, the hard palate or
maxillary bone with periosteal spur limit (Codman's, known as the
"triangle of death", fig. 7.10), there may be mixed lesions, radiopaque and
radiolucent.
176
177
a
b
c
Fig.7.11. Squamous cell carcinoma of the tongue base c.i.v. CT which
show a large tumor mass, iodofil, heterogeneous, extended in the
muscles of the oral cavity, the lining of the nasopharynx, the
parapharyngeal space, chewable, with a horizontal mandible rami lysis,
and with block adenopathies having the aspect of adenopathic block,
with small areas of necrosis and subcutaneous emphysema located
latero-facial left side.
178
c
d
Fig. 7.12. Infiltrating mandible squamous cell carcinoma ) Left Scroll
mandible showing advanced lesions, propagated from the edge of the
alveolar buccal mucosa floor of lysis with imprecise edges, b) large
incidence of scroll mandible tumor destruction, osteolytic, basilar edge
and horizontal right mandible rami fracture, c), d) early epithelial lesions,
osteolytic of interdental crest with movement of the apexes and rizaliz.
epidermoid carcinoma is signaled by the appearance of a fracture with
extension into inferior dental canal and oral cavity mucosa.
179
a
b
c
Fig. 7.13. Infiltrating mandible squamous cell carcinoma, axial native CT
and post contrast showing a left mandible tumor with a wide osteolysis
with irregular contour extended intra-and extraoral soft parts.
Differential
diagnosis:
osteomyelitis,
osteonecrosis,
osteolytic
osteosarcoma.
Prognosis: metastasis in the lung, liver, deep regions of the face, etc..
Squamous cell carcinoma with extension into the maxillary sinus
Features:
These lesions, depending on the debut, can be classified as:
carcinoma in the infrastructure, starting in the alveolar ridge or palate
(fig.7.14)
a
b
c
Fig.7.14. Infrastructure carcinoma originated in the right palate and
extension in the nasopharyngeal cavity
180
a
b
c
Fig. 7.15. Mezostructure carcinoma, started from maxillary sinus
mucosa, axial CT of iodofil tumor a) with osteolysis, b) maseterin
extension c).
a
b
c
Fig. 7.16. Carcinoma of the superstructure started from the lining of the
maxillary sinus, sinus radiography of anterior face, axial CT iodofila
tumor, a), osteolysis, intracranial extension b) and latero-cervical lymph
nodes adhenopaties c).
Imaging features:
Radiographic:
In the early stages there is bone demineralization area, heterogeneous,
with irregular contour,
in advanced stages a radiolucent area with irregular boundaries
appears, rarely with marginal condensation, with floating -like teeth,
CT:
Carcinomas can be analyzed in terms of shape, size, density, extension
into neighbouring regions, the vascular-nervous package report
181
surrounding the lesion, the presence of the local lymph node extension,
unilateral or bilateral, or the presence of metastatic lesions in a distance.
Carcinomas are usually bulky and explored CT when discovered late,
with orbital extension in facial massif at the base of the skull and
intracranial (fig.7.17.).
e
f
Fig. 7.17. Undifferentiated squamous cell carcinoma, superstructural of
the left maxillary sinus: CT axial in a soft tissue window a), c) - iodofil
tumor is extended FIT, nasal fossa, ethmoid, orbit and intracranial b)
Axial CT in bone window - tumor lyses the walls of the maxillary sinus,
nasal fossa, pterigoid process and the great wing of the sphenoid d) HE
staining (HE x100).
182
183
d
c
Fig. 7.18. Adenocarcinoma of the ethmoid with intracranial metastasis:
Axial CT showing iodofil tumor, osteolytic in the window bone and
soft parts a), b) MRI axial and coronal T1 post contrast with intracranial
extension c), d).
Prognosis: This lesion has poor prognosis due to intracranial and regional
extention.
a
b
c
Fig. 7.19. Axial CT showing non Hodgkin lymphoma lesion in the right
Waldeyer's ring, the parapharyngeal space, the jaw muscles) causing
osteolysis of the jaw b) HE staining (HE x100) c).
186
Features:
Epidemiology: is met more frequently in male children, developing
predominantly in the first decade of life;
Site: gnatic affinity for bones, particularly the jaw. The tumor can
progress very rapidly into the mouth presenting itself as a facial tumor or
mass that interests the exofitic mass in the jawbone with predisposition to
malar region;
Symptoms: mobility appears, the displacement and tooth loss and
gingival fibromucous is swollen, necrotic and ulcerated.
Imaging features:
Radiographic:
small osteolytic areas in cancellous bone and lamina dura that
ultimately achieve a confluence of large osteolytic, multilocular areas periosteal reaction with new bone formation, with aspect of "sunrays".
7.2.3.3. Multiple myeloma (Rustitzki - Kahler's disease)
It is a systemic lymphoproliferative disease with various manifestations
of B cells. The jaw lesions, although rare, are not often the first sign in
multiple myeloma. There is usually a chest/sternum damage, in ribs, in the
vertebrae. It is considered the most common hematologic cancer after
lymphomas. The tumour proliferation of plasma cells derives from the
bone marrow.
Features:
Epidemiology: meets relatively common in men around the age of 60
years, starting as a single lesion or as multiple lesions;
Site: predilection for pelvis, skull, ribs, sternum. The mandible is
interested more frequently than the maxilla. It can cause pathological bone
fractures.
symptoms: tumor syndrome, weight loss intrabucal, dental bleeding,
local anesthesia and bone pain, fatigue and paleness in multiple injuries.
Imaging features:
Radiographic:
Multiple radiolucent areas (gaps) of different sizes, with net shape
without lizereu radio-opaque peripheral osteocondensant. Sometimes
lesions may be condensed.
Differential diagnosis: osteosarcoma, osteomyelitis, lymphoma
limfoplasmocitic.
187
c
d
Fig. 7.20. Mielom multiplu cu multiple lacune radiotransparente, bine
circumscrise tanate rspndite neuniform la nivelul calotei a),
bazinului b), CT axial n fereastr de os evideniind leziunile osteolitice
de la nivelul arcadelor zigomatice i a maxilarului drept cu invazia
esuturilor moi c), d).
7.2.3.4. Ewing sarcoma of the maxillofacial region
First described by James Ewing in 1921, Ewing sarcoma or Ewing's
sarcoma is one of the most aggressive bone tumors. It is an intra-bone
malignancy with unclear pathogenesis. Neuroectodermal tumor cell is a
small, round, blue, poorly differentiated. Derived from bone marrow
mesenchymal tissue.
Features:
Epidemiology: occurs mainly in the first three decades of life,
predominantly in males;
188
Imaging features:
Radiographic:
looks like osteomyelitis, there are radiolucent zones with vague shape
with marginal condensation with periosteal reaction (the onion skinning
aspect, opaque lines alternating with transparent lines) and sometimes
cause periosteal reaction in the form of perpendicular spiculi on the bone
surface ;
final form is found in wide bone destructions.
CT:
reveal tissue mass and osteolytic area with typical osteolytic
destructions of "prairie fire" type.
Differential diagnosis: osteomyelitis, tuberculosis, metastases, etc.
Prognosis: rapidly evolves and gives metastases.
7. 2.4. Tumor metastases
They are rarely met as maxillofacial metastases from malignant tumors
of the stomach, breast, lung, prostate, colon, testis, etc..
Features:
Epidemiology: more prevalent in women;
Site: mandible molars region, mandible condyle, mandible jaw or
skull base.
Imaging features:
Radiographic:
Unique radiolucency (radiolucent area) with diffuse contours,
infiltrates with strong iodofila extension in the soft parts (fig.7.21.).
189
c
d
Fig. 7.21. Metastasis of lung adenocarcinoma developed in the
zygomatic bone and FIT: a) Axial CT in bone window b) native T1 c)
Coronal T1 FS contrast product, d) T1 FS and contrast product.
Sometimes there are multiple radiolucencies (osteolytic areas) with
diffuse contours infiltrating in the sinuses, base of the skull or mandible
(Fig. 7.22.).
there are sometimes osteocondensanted areas (opaque) in the
vertical rami of the mandible and mandible condyle, usually metastases
from breast or prostate cancer (Fig. 7.23).
190
e
f
Fig. 7.22.: A) Axial CT in metastatic soft tissue window iodofil moderate
infiltration and accompanied by the hypertrophy of jaw muscles, b) Axial
CT in soft tissue window, iodofil moderate metastasis in the
infratemporal fossa floor level, infiltrating the left pterygoid muscle, CT
axial c ) and coronal plane d) bone window with tumor has led to the
osteolytis of the ceiling FIT e) metastatic mucinous carcinoma (VG X90)
f) Alcina blue coloration.
191
c
d
Fig. 7.23. Osteocondensing metastasis from breast cancer located in the
vertical ram left mandible: a), b) Axial CT soft tissue window showing
the mandible metastasis with infiltration and hypertrophy of masticatory
muscles, c), d) Axial CT in bone window showing osteocondensing and
increasing in size of the left mandible vertical ram.
192
Chapter 8
Features:
Epidemiology: occurs at any age, but most commonly in the 2nd and
4th decade of life, especially in women
Site: osifiant fibroids occur especially in the mandible premolars and
molar region increasing slowly with a painless deformity of lower jaw, the
jaw OTJF predilection appears and JPOF may occur in all bones of the
paranasal sinuses, slowly progressive, asymptomatic.
193
Imaging features:
Radiographic:
can highlight a heterogeneous lesion with a mixed bone component
and cement focus, located in the horizontal portion of the mandible and
having a "frosted glass" aspect. This lesion determines jaw expansion that
doubles its thickness, but without infiltration of the canal or pathological
rizaliz of the dental apexes. The peripheral lesion demarcation is clear,
without capsule, visible especially in the mandible.
CT:
shows a heterogeneous lesion that may have inside areas with
different densities of cement and reshuffled bone, some confluate,
amorphous, but with clear limits, blew cortex (fig.8.1)
the lesion deformes the jaw (fig.8.2) or mandible and moves or erodes
dental apexes and extends in the adjacent regions.
Differential diagnosi:s: fibrous dysplasia.
Prognosis: the lesion grows slowly as if there does not suffer complete
surgery.
194
Fig. 8.1. Juvenile trabecular osifiant fibroma, young man of 22 years old
with a painless ram horizontal deformation of the mandible. a), b) Axial
post contrast CT, bone window and heterogeneous parenchyma lesion, right
premolar region, with limits flou, neiodofil, dense areas, irregular inside
and thin cortical. c), d) sagittal 2D reconstructions allow to study the link
with the dental canal and molars apexes e), f) panoramic and paraxial
reconstructions, g) - h) 3D VRT images with bone deformation and integral
fat.
195
f
e
Fig. 8.2. Juvenile psamomatos osifiant fibroma. a) - c) Axial CT in
soft tissue window showing a large lesion developed in the left
maxillary sinus that has inwardly areas with different densities of bone
cement and reshuffled bone, some confluate areas, amorphous, but with
clear limits that blow the cortex, reshape and deform the jawbone,
cheekbones and palate.
Features:
Epidemiology: most common in children and teenagers
Site: maxilla and mandible, zygomatic bone, invading the adjacent
bones, mandible body, dental arches, sphenoid, the base of the skull, ribs,
femur.
Imaging features:
Radiographic:
opaque mass, homogeneous, and radiolucent lesions, uni-or
multilocular; initial with net shapes, then diffuse, sometimes with pagetoid
aspect associated with dental displacement, rizaliz (fig.8.3), the
disappearance of lamina dura.
197
f
e
Fig. 8.4. Fibrous dysplasia. Axial CT in soft tissue window a) and
bone b) and sagittal 2D recostructions c) and coronal d) shows
thickening of the posterior wall of the right orbit by reshuffling the
sphenoid wing bone and part of the right temporal bone, with
exophthalmos, narrowing inferior orbital fissure, right sphenoid
bone changes and right optic nerve canal diameter, e), f). 3D
reconstructions, the SSD, sagittal and frontal bone showing
changes of big and small right sphenoid wing, the right orbit and
optic right nerve canal, right maxillary sinus size reduction and 1/2
postero-lateral of the right orbit .
osteolytic fractures with neosifiant matrix (20%), sclerotic lesions
(25%),
3 imaging features:
198
199
a
b
Fig. 8.5. Central giant cell granuloma, aggressive. Patient of 14 years
old, incidence of jaw scroll a) shows a radiotrasparent, right
parasymphysis area, with a shift in the displacement of the premolars in
film-chin incidence b) shows multiple cystic-looking images, large
"soap bubbles", with fine internal septa that move the teeth and deform
the jaw, right parasymphysis and symphysis.
c
d
Fig. 8.6. Central giant cell granuloma, nonagressive. Patient of 12 years
with small radiolucency between 45 and 47, visible in the incidence of
jaw scroll) low face b) and Simpson occlusal c) and periapical d) where
there is external cortical blow, vestibular lesion extension with jaw
deformity.
200
8.4. Cherubism
Is a rare hereditary disorder with autosomal dominant, which in many
cases can occur spontaneously having as a probable cause the impaired
development of the maxillary mesenchymal tissue. The term Cherubini
which means face of an angel comes from the development of both
mandible branches, making an issue of angel paintings similar to that of
the paintings in the Renaissance.
Features:
Epidemiology: present in children before puberty (2-6 years)
Site: mandible, especially angle of the jaw and upward ram; may
interest the orbit, palate, frontal sinus;
Imaging features:
Radiographic:
Multiple radiolucencies making an issue of "soap bubbles"
with net margins, well defined,
*An increase volume of the gonions including coronoid process,
*Cortical bone blown, thin, perforated (fig.8.7)
*Significant displacement of the transition or permanent teeth,
*Dental resorptions sometimes, the transitional dentition is early
exfoliated
* Ectopic eruptions, canal shift, malformed molars.
CT:
allows an overview of direct axial lesions by image analysis, 2D and 3
D reconstructions
201
b
Fig. 8.7. Cherubism
Radiolucent lesions developed in the jaw and facial bones massif are
characterized by a sharp increase in time to complete the period of bone
growth, causing elongation of mentonier symphysis, the growth of the
gonions volume, increased cheekbones, orbital shape changes with
bilateral exophthalmos (fig.8.8).
202
a
b
Fig. 8.8. Cherubism, skull radiographs profile) and with b) a 14-year
old with dental ectopies, dental pathological rizaliza in the incisors
apexes and multiple radiotrasparencies that made an aspect of "soap
bubbles" with mandible and maxillary deformity.
c
d
Fig. 8.9. Paget's disease with an early appearance of osteoporosis in the
front and rear calvaria ), or chronic appearance of "cotton fluff" on the
calvaria b) widening and third finger osteosclerosis of the phalange c), or
opacification and enlargement of the jaw and dental hipercementosis d).
204
Imaging features:
Radiographic:
radiolucent areas alternating with radio opaque areas, with an aspect
of "cotton fluff", hence the term of pagetoid bone;
the thickening skull calvaria up to 2-3 cm, with lacunar focuses and
bone spiculi perpendicular on the external headboard, so that the "hat
becomes too small"
causing greater damage to the jaw with thick bone trabeculae and rare,
the appearance of "cotton fluff" and dental hypercementosis, and lamina
dura is whether resorbed or missing,
the backbone becomes cifoscoliotic,
affecting the long bones, the tibia and femur are hypertrophied,
elongated and curved, so the trousers "become too long".
8.7. Recklinghausen neurofibromatosis
This affection is a neuro-ectodermal dystrophy, a facomatosis.
Features:
cutaneous nevi,
neurofibromas along the nervous tracts,
changes in visceral skull bone on the trigeminal and facial tract.
The lesion is isolated or associated with other endocrine syndromes:
associated the increase of blood parathyroid hormone and
hypercalcaemia, due to an adenoma, a parathyroid adenocarcinoma or
glandular hyperplasia,
clinically asymptomatic with severe manifestations,
+ / - kidney stones and severe demineralization, pseudocystic,
frequent involvement of the mandible ( in comparison with the jaw
damage) without deformation thereof, but with the possibility of
pathological fracture;
When the lesion is unique the diagnosis is very difficult.
8. 8. Hyperparatiroidian osteoporosis (Recklinghausen disease)
This condition causes dental dystrophies, thin lesions by
hyperdisfunction, along with radiographic changes with pseudocystic
disseminated transparencies due to brown tumors in the calvaria and long
bones.
205
Features:
Epidemiology: occurs in older people who have biological criteria of
hyperparathyroidism
Site: calvaria, jaws, long bones.
Imaging features:
Radiographic:
pseudocyst showing a radiolucent appearance of "honeycomb" or
"soap bubbles" that blows the cortex, rizalizeaz teeth, causing the teeth
expulsion or blown arcade cortex (fig.8.10)
the lamina dura subtle forms are resorbed with the decalcification of
dental arches.
a
b
Fig. 8.10. Hyperparatiroid osteosis with pseudocystic transparencies,
looking like a "honeycomb" cortical blown and rizaliza of dental apexes)
panoramic radiograph, radiolucent frontal bone and skull prolile radiograph
b).
206
a
b
Fig. 8.11. Eosinophilic granuloma with mixed images in the horizontal
rami of the left mandible) or left mandible angle, with osteosclerotic
changes in the basilar edge of the mandible.
207
a
b
Fig. 8.12. Hand-Schuller-Christian disease with mixed images at a) left
mandible condyle or mandible rami of left vertical ram, with
osteosclerotic changes of parietal bones b) geographical map layout.
mixed picture in the jaw with oseosclerotic changes (fig.8.12 a)
mixed picture in the skull causing osteosclerotic changes in the
parietal bone, looking like a geographical map (fig.8.12 b).
8.9.3.Letterer-Siwe disease
It is the most serious form, can be acute or subacute, with extensive
dissemination. common in infants and young children.
Features:
Epidemiology: affects children under 3
Site: spontaneous expulsion of dental germs and early rashes
accompanying the jaw and mandible lysis, hepato-spleno-megaliths,
lymphadenopathy, hypochromic anemia,
Prognosis: fatal outcomes.
Imaging features:
Radiographic:
can present images mixed with osteo-sclerotic changes in the
mandible,
effects: adjacent teeth are unresorbed, but sometimes the periodontal
bone support is compromised, so they appear as floating in this space.
208
Chapter 9
209
Fig. 9.1. Schematic presentation- TMJ sagittal section in the "closed mouth"
position a), sagittal section TMJ "open mouth" position b) gc-glenoid cavity,
mc- mandible condyle, eacexternal audio channel , m-meniscus with 3 areas:
1 anterior, 2 - central, 3 rear, ar- anterior recessive, pr posterior
recessive, pf - posterior frenulum, ti temporal insertion, mi - mandible
insertion, mpl -lateral pterygoid muscle (after Cavezian R. et al. 1995)
210
211
Diagnostic information
condylian head shape and condition of the articular surface profile,
direct comparison of both condyles.
It replaced more and more the incidence of jaw scroll in recent years.
a
b
Fig. 9.4. a)Subcondylian right low fracture, accompanied by
parasymphysar fracture with minimal displacement, in incidence of jaw
scroll radiograph, b) left mandible combinative mandible angle, with
moderate displacement of the fragments without mandible condylar
fracture, incidence " low face".
9.2.2.6. Conventional tomography
It is a method of analysis of the TMJ static stage.
Advice
complete evaluation of all joints to determine the presence and
location of any damage or bone abnormalities
investigate condyles and articular fossa when the patient is unable to
open his mouth,
assessment of articular fossa fractures and especially intracapsular
fractures,
Technique
Conventional tomography methods available for obtaining TMJ include:
Linear tomography (fig.9.5)
Multidirectional "hypocycloidal" tomography
Multi-type spiral CT SCANORA type.
Diagnostic information
size of the joint space,
condyle head position in the pit,
head shape and appearance of the medial and lateral condyle of the
articular surface,
shape and appearance of the fossa and articular eminence,
information on all aspects of the joint,
the position and orientation of the fracture fragments.
214
215
c
d
Fig. 9.6. Latero-facial fracture and right juxtasymphysis shift fragments
and a small external displacement of the condyl a), c), d), CT in bone
window, b) Axial CT in soft tissue window.
Diagnostic information
shape and appearance of the condyle articular surface,
*the aspect of the fossa and articular eminence
articular disk position and shape,
disk integrity and soft tissue
the nature of any disease of the condylian head.
216
Fig. 9.7a) sequence in the coronal plane T1SE patient with mouth
closed, comparison illustrates the articulation of the left and right.
217
Fig. 9.7. b) sagittal sequence T2SE the patient with mouth closed,
illustrates the comparison of the left and right hinge.
9.2.3.3. Arthroscopy
Is a direct visualizing method that enables TMJ to certain interventional
procedures including:
washing with saline,
introduction of steroids directly into the joint,
removal of foreign bodies in the joint.
Arthroscopy is usually regarded as the last stage of the investigation and it
is done before surgical exploration of the joint.
9.3. Radio-imaging aspects in TMJ lesions
The main diseases of TMJ are:
TMJ dysfunctional pain syndrome,
internal disturbances,
osteoarthritis,
rheumatoid arthritis,
juvenile rheumatoid arthritis (Still's disease),
achilozis,
fractures and trauma,
developmental abnormalities,
benign or malignant tumors.
9.3.1 TMJ painful dysfunctional syndrome
This is the most common disorder of TMJ manifested by pains in the
masticatory muscle.
218
Features:
masticatory muscle pain is often worse in the morning and evening,
crackles and occasional stiffness.
Imaging features
CT:
condylian head and articular surface with normal form,
glenoid fossa normal form,
possible increase or decrease of the overall size of joint space - an
increase in joint space size is the only indicator of inflammation (fig.9.8)
possible shift front or rear condylian head in glenoid fossa when the
mouth is closed and the teeth are in occlusion,
reduced range of condylian motion, followed by direct sections
sagittal 2D reconstructions performed with the mouth closed and mouth
open.
a
b
Fig. 9.8. Functional painful syndrome, bilateral sagittal CT reconstruction
with minimum joint right space widening.
219
Imaging features
Radiographic:
an alteration of the condyle head position involving an abnormality of
disk position.
MRI:
disk position - can be sprained to the anterior or anteromedian
a movement of the disk relative to the condyle during closing and
opening the mouth (fig.9.9).
Fig. 9.9. a) T1SE sequence in the sagittal plan, the patient with open
mouth, shows the left and right joint, comparative analysis, there is an
external discrete bilateral anterolateral dislocation.
Fig. 9.9. b) sequence in the coronal plan T1SE patient with mouth closed,
shows the left and right joint, comparative analysis.
220
9.3.3. Osteoarthritis
This degenerative osteoarthritis increases as incidence with age and
often causes joint pain. Currently it is considered a systemic disease or a
complication of internal joint disorders, and stress causes the pain of the
affected joint.
Features:
Crepitation pain and trismus which is usually persistent.
Imaging features:
CT:
formation of osteophytes in the anterior portion of the articular
surface of the condylian head - which can be small or extensive (fig.9.10)
condylian head flattening in the anterior-superior edge,
subchondral sclerosis, condylian head becomes dense and radiopaque,
glenoid fossa with normal contour may become sclerotic,
rarely, posterior osteophytes may be formed, cysts and subchondral
erosions in the articular surface of the condyle head
c
d
Fig. 9.10. Degenerative artrosis CT coronal a)-b) and axial c)-d) bone
window showing osteophytes at the anterior and posterior part of the
articular surface of the condylian head, subchondral cysts, osteophytes
and erosions in the articular surface of the condyle head, and
condensation of the glenoid cavity.
221
222
e
Fig. 9.11. Rheumatoid arthritis, axial CT a), c) and
reconstruction of the head condyle parallel to its long axis b), d)
showing condensation and intra-articular condyle, marginal
osteophytes and reduced interarticular space.
223
c
d
Fig. 9.12. Axial CT of bilateral ankylosis) and coronal
reconstructions b) sagittal c), d)-homogeneous block bone with
bone structure d) or heterogeneous c) - with areas of fibrosis, with
joint spacing that can be seen with difficulty.
224
e
f
Fig. 9.13. Post-traumatic right ankylosis: axial CT b), d), f) and coronal
reconstructions a), sagittal c) and parallel with the long axis of the mandible
condyle highlighting the bone block with a heterogeneous structure with
areas of fibrosis, with narrowed joint spacing , block bone joint extending
beyond the mastoid and tympanic bone.
225
Imaging features:
CT:
reduced or completely disappeared joint space (fig.913)
bone fusion between condylar head and glenoid fossa with total loss
of normal anatomic contours, contour of condyle head is discontinuous or
disappeared;
association with hypoplasia of condylian neck and jaw
underdevelopment on the affected side, causing asymmetry if stiffness
precedes the final stage of growth,
bone block joint going to exceed mastoiditis, ear canal, coronoid
process and partly the base of the skull;
bone block can have a homogenous bony structure, or uneven areas
showing fibrosis, when the joint spacing can be seen, with difficulty.
9.3.7.JTM fractures and injuries
The condylian fractures are common, they followed the mandible body
trauma frequently (fig.9.14).
Occasionally with this type of injury the condylian neck fracture does not
appear and one can see:
the condylian head fracture
the so-called intracapsular fracture or
the condyle head is pushed up into the middle cranial fossa.
Imaging features:
CT:
will demonstrate the extent of any injury which may result in
mandible unilateral or bilateral dislocation of the joint.
226
e
f
Fig. 9.14. Left condylian head fracture, CT appearance after surgery,
after the muscle-ligament reconstruction, a), b) axial sections in soft
tissue window and bone window, the mandible condyle is not seen, but
there is a turnover bony glenoid cavity and pterigoidian muscles with
hypertrofia of the left styloid apophysis.
9.3.8.TMJ dislocations
Those anterior prevail, the lateral and posterior are rare, frequently
associated with fractures of the condyle and the ear canal.
The anterior dislocations are unilateral or bilateral (fig.9.15). they are
often accidental: excessive opening of the mouth, laughing, yawning,
collisions, falling on the mandible.
For their occurrence a series of favorable conditions are required:
less depth of the glenoid cavity
227
Imaging features:
Radiographic:
the glenoid cavity is empty
the condyle is located below the temporal tubercule under the
zygomatic arch.
Lateral dislocations are rare and occur only in case of violent trauma, if
they are accompanied by controlateral condylar fracture, as evidenced on
axial and tangential MRI.
Posterior dislocations are possible if the external ligament is torn.
The condyle can get into the ear canal and, sometimes, when it is affected,
otoragy occurs.
Vertical dislocation is exceptional and involves the superior glenoid
cavity drilling, with penetration of the condyle in endoskull.
Recurrent dislocations involve an atypical conformation and joint
elements occur in the submeniscal floor.
If a meniscus subluxations, it remains in the glenoid cavity and the
condyle surpasses the front edge of the meniscus under the temporal
tubercle, if it exceeds produces a complete dislocation (condylomeniscus).
228
b
Fig. 9.16. Right condylar hyperplasia visible in the low face incidence)
and orthopantomography b) with evident mandible asymmetry.
9.3.9. Tumors
Benign or malignant tumors occasionally develop in the condylian
head. The radiographic characteristics depend on the type and nature of
the tumor distorting and / or destroying the condylian head.
Benign tumors may also have this location. They are:
osteoma,
condroma,
229
osteocondroma,
fibromixoma.
9.3.9.1. Mandibular condyle osteoma
This injury is the most common benign tumor and is characterized by
an enlargement of the mandible condyle, which is accompanied by its
deformation, exceeding the glenoid cavity.
Imaging features:
Radiographic:
the enlargement of the mandible condyle with the surpassing of the
glenoid cavity.
CT:
The condylian osteoma appears as a homogeneous bone block with
bone structure that causes distortion and enlargement of the mandible
condyle with the glenoid cavity surpassing axial sections more visible in
sagittal and coronal reconstructions 2D and 3D reconstructions SSD
(fig.9.17 ) or VRT.
Differential diagnosis: - condylar hyperplasia, when appears increased but
unaltered.
a
b
Fig. 9.17. Right condylian osteoma. Sagittal reconstruction CT in bone
window) showing deformation and enlargement of the right condyle,
which exceeds net the glenoid cavity, visible in 3D reconstruction SSD b).
Imaging features:
CT:
Highlights osteolysis and the remodeling of the mandible condyle
with geodes, with or without bone spiculi extended adjacent in the soft
parts (depending on the type of pathology) with obvious modification of
the joint space and moderate grip or intense contrast.
Changing of the condyle is a visible tumor on axial sections analyzed
in soft tissue window (fig.9.18 a) and bone window(fig.9.18 b, d) normal
or using special filters (fig.9.18 c).
Using special filters to analyze the images in bone window (hard
filters) allows the identification of the bony changes of the
mandible condyle with geods, spiculi and the mouse eaten aspect
of the mandible condyle. (fig.9.18 c)
a
b
Fig. 9.18. Metastases from breast cancer: Axial CT in soft tissue window
shows the deformation of the right mandible condyle contour, the external
extension of the lesion in the right masticator space, more evident in the
masticator muscle and in the external pterigoid muscle a) The same
section analyzes in bone window, shows the deformed appearance,
irregular right mandible condyle with the delete of the contour and the
deforming of the cortex.
231
c
d
Fig. 9.19. Metastases from breast cancer: CT axial in bone window,
highlighting the deformed irregular aspect of the right mandible condyle,
with appearances of small geode and bony spiculi, visible around the
condyle head both in the hard filter for extremities c) and in the
standard filter, cranio-cerebral d)
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Chapter 10
SALIVARY GLANDS
Salivary glands are twin glands, whose radio exploration offers
morphological and functional imaging if there is:
salivary colic,
intermittent glandular swelling,
persistent swelling,
hiposyalya.
All these events usually have a subsequent lesion: extra-or intraglandular:
acute or chronic inflammation, tumors (benign or malignant), diseases of
the system and dystrophies, a traumatic injury.
10.1. Anatomo- physiological aspects of the salivary gland
The salivary glands are:
main: parotid glands, submaxillary, submandibular,
accessories: multiple submucosal salivary glands accessories situated
in the mouth, pharynx or ectopic.
Parotid
* prism shaped, with big shaft located near the rear edge of the
ascending rami of the mandible, near the ear canal and is located in a
fibrous capsule,
has an acinous structure and is crossed by the external carotid artery,
external jugular vein, facial nerve and the auriculo-temporal nerve,
superficial extension, genian, the maseterin accessory lobe,
a deep extension, parapharyngeal,
an excretory canal with a length of 35-40 mm and 2-3 mm diameter
opening at the level of the second upper molar, at the pack level, through a
papilla. Saliva from the glandular acins is drained through the Stenon
channel that opens in ducts of 3-2-1 grade.
Submandibular gland (submaxillary)
of the volume is near the parotid gland which is located on the
internal face of the mandible, between gonion and hyoid,
is located in a lodge which communicates with the tonsillar region
and maxillo-pharyngeal space (fig.10.1)
contains primitive lobules - secondary and acins, covered by a
conjunctive stroma,
233
Salivary glands
a
b
Fig. 10.1. The normal appearance of a parotid gland sialography a) and
submandibular gland b).
Sublingual gland
is located on the floor of the mouth, parasagital against the tongue
frenulum,
drains the Rivinius channels, submucosal, and by the Bartholin main
channel, which opens with the Wharton channel ( of the submandibular
gland), sometimes being common and thus is the only way a sialography
can be performed.
10.2. The radio-imaging exploration of the salivary glands
The main salivary glands and sometimes the accessories can be
explored by radio imaging, using different methods, chosen having in
mind the patients symptoms:
conventional / digital radiography
sialography,
computed tomography (CT),
ultrasound,
magnetic resonance imaging (MRI),
radio isotope imaging (scintigraphy).
10.2.1. Radiography
It is the easiest, quickest and less expensive method to establish the
diagnosis of salivary stones, radiopaque stones (calculi in 90% of
submandibular gland (fig.10.2) and in 60% of parotid stones).
234
Salivary glands
a
b
Fig. 10.2. Salivary calculi a) left sublingual b) left submandibular.
235
Salivary glands
a
b
Fig. 10.3. Normal parotidian sialography), b) right parotid pleomorphic
adenoma, acinar filling defect, looking for "hand kept ball
Salivary glands
becomes viscous in a different way (fig.10.4), but can not make a clear
difference between various hystopathological tumor lesions.
Fig. 10.4. Tumor in the left superficial lobe of the parotid iodine,,
homogeneous, with the left jugular lymph nodes in the region, one of
them with size> 1.5 cm.
Salivary glands
238
Salivary glands
a
b
Fig. 10.5. a) Bidimensional examination and b) Doppler submandibular
gland.
239
Salivary glands
Radiographic:
the small calculi appear as heterogeneous opacities (or one opacity),
net shaped, located between basilar edge of the mandible and the hyoid
bone.
Wharton duct stones are highlighted by Bellota or Simpson incidence
with occlusal film,
Radiographic:
one opacity, or more, located posterior to the internal mandible body
(fig.10.6 a).
when symptoms point for a salivary calculus but it is not visible
radiographically, it is recommended a sialographic exploration in which
the calculus appears as a radiolucent proximal and distal surrounded by
the contrast (fig.10.6.b).
b
a
Fig. 10.6. a) Radio opaque calculus in the right Wharton channel,
occlusal film, b) radiolucent calculi in the right Wharton channel as
visible with the help of sialography.
10.3.3. Sialodochitis
They are dilated excretory ducts caused by stones or foreign bodies
associated with ascending infection.
Sialography:
channel diameter is increased uniformly
channel lumen may be narrowed,
moniliform aspect of dilatation and narrowing.
240
Salivary glands
10.3.4.Autoimmune sialoadenits
Autoimmune sialoadenits as Sjgren's syndrome consist of:
glandular swelling, mostly of the parotid,
dry mouth, dry eye conjunctives,
rheumatoid arthritis.
Sialografic:
different evolutionary stages may be taken into account, that finally
drive to the destruction of the entire glandular tissue.
sialectatic cavities which, in time have become more numerous with
wider or less wider opacities, according to the evolutionary stage of
contrast substances in view.
Scintigraphy:
using Tc99m a correct diagnosis is established, when there is a
decreased radioisotope capture and a delay of its excretion.
C.T. M.R.I.:
they can provide additional diagnosis data regarding the morphology
and structure of the glands.
10.3.5. Cysts of the salivary gland
These lesions are rare and can be:
the mucous ones are retentions with the obstruction of the
accessory salivary gland (fig.10.7)
the best known retention cyst due to the obstruction of the
sublingual duct is ranula, which may occur in different ages.
congenital or acquired, more unilateral in the parotid gland
(fig.10.8 a, b).
a
b
c
Fig. 10.7. Ranula with various sizes visible in a clinical inspection a),
and axial CT b) and in reconstructions in the coronal plan c).
241
Salivary glands
a
b
Fig. 10.8. Cyst in the superficial lobe of the left parotid gland), standard
two-dimensional exploration and b) the Doppler.
CT:
ranula appears as a hypodense lesion, well circumscribed, with a wall
catching contrast .
the parotid cyst is well circumscribed hypodense lesion with thin wall,
moderate iodofil.
MRI:
Some patients with H.I.V. can meet multiple parotid cysts in sequence
T2 hipersignal with thin walls in a moderate contrast grip and cervical
lymphadenopathy (Figure 10.9).
242
Salivary glands
b
a
Fig. 10.9. Limfoepitelial benign recurrent parotid cysts in superficial and
deep lobe of the right parotid gland, MRI sections a) Axial T2 native b)
coronal T2 native.
b
243
Salivary glands
c
d
e
Fig. 10.10. Left parotid pleomorphic adenoma appears sialographically as a
radiolucent shape that causes a clouding defect of the posterior-lateral
portion of the gland a), b) ex. CT formation of poster-lateral portion of the
superficial lobe is round, smooth and with a moderate contrast grip c) - e).
Sialography:
the pleomorphic adenoma appears as an incomplete picture by
moving the channels in an uniform way, ball held in hand'' (Fig. 10.10.a,
b)
CT:
appears as a round mass, with net shape, homogeneous with a density
slightly higher than the rest of the glandular tissue, rarely appear
calcification with moderate contrast grip (fig.10.10 c, d, e)
MRI:
a hypersignal appears in T2, T1 hypo or izosignal with homogeneous
or heterogeneous contrast grip.
Scintigraphy:
the adenoma does not capture the isotope.
Salivary glands
Imaging features:
CT, MRI
stands out as cystic or solid masses with nodular thickening of the
cyst wall with intermediate signal sequence in the sequence T1 and T2
hipersignal.
Scintigraphy
with Tc99m stands as a tumor, bilateral '' hot zone.
10.3.6.3. The hemangioma
This lesion is a common tumor found in children, mostly in the parotid
gland.
Imaging features:
Radiographic:
the lesion shows non homogeneous flebolits is opaque with
transparent center that determines the enlargement of the gland.
CT, MRI
shows a lesion well-defined as a neoformation, which is highly
hiperdense post contrast (fig.10.11) in izosignal T1 and T2 hypersignal
with multiple images "salt and pepper" because of its vascular structure.
Scyntiographic
with Tc99m is an hipoechogen area with hyperechogen zones due to
the flebolits.
a
b
Fig. 10.11. a) Hemolimfangiom left parotid, axial CT, native, with much
lowered tumor, izodens latero-cervical) and homogeneous contrast grip
that extends up to the lower transverse plan passing through the hyoid
bone b).
245
Salivary glands
10.3.6.4. Lipoma
This tumor of mesenchymal origin, is much more common with parotid
location.
Imaging features:
Ultrasound:
Easy highlights benign lesion and determine its character.
CT:
tumor shows low density (-80 HU), with a homogeneous structure
without contrast outlet and allow differentiation of malignant tumors.
10.4. Malignancy
Malignant tumors of the salivary glands are the most common
mucoepidermoid carcinomas, adenocarcinomas, adenoid cystic
carcinomas, acina cell carcinomas and squamous cell carcinoma.,
10.4.1. Mucoepidermoid carcinoma
Is the most common malignant salivary gland tumor arising from ductal
epithelium and representing 6% of all salivary gland tumors.
Features:
This tumor is common in women aged between 40 and 50. Usually the
lesion is a tissular mass, but may also be forms with cystic components. In
most cases it is a tumor with low or medium degree of malignancy.
Imaging features:
CT, MRI:
A rapid diagnosis of these malignancies requires:
achieving a pathology balance of both parotid lobes tumor,
highlighting reports of parotid tumor lesions with adjacent spaces and
salivary canal that may be damaged,
* highlighting the lesions affecting the facila nerve in the parotid
portion;
emphasizing latero-cervical adenopathies that may accompany tumor
lesions or tumor recurrences (fig.10.12).
246
Salivary glands
b
Fig. 10.12. Right parotid mucoepidermoid carcinoma developed with
extensive expansion in the superficial and deep zone ) with heterogeneous
contrast grip and tumor necrosis zones, HE staining (HE x100) b).
Other types of carcinomas arising in salivary glands have the following
characteristics:
1. carcinoma with acin cells, develops slowly, often in women
between 40 and 50 years old, bilateral in 3% of cases (fig.10.13)
2. adenocarcinoma, is slowly progressive, developed on a
pleomorphic adenoma (fig.10.14)
3. squamous cell carcinoma, is more rare but rapidly developing in
women older than 60,
4. adenoid cystic carcinoma with perineural spread slowly
progressive (fig.10.16).
a
b
c
Fig. 10.13. Acinar cell carcinoma. Axial CT highlighting heterogeneous
tumor surrounded by a capsule with contrast grip, located in the
superficial lobe of the left parotid gland.
247
Salivary glands
b
a
Fig. 10.14. Invasive adenocarcinoma developed on a right parotid
pleomorphic adenoma, post contrast axial CT bulky tumor with areas of
necrosis and moderate contrast grip, expanded in the space at the back of
the right retrocondilian prestilian buttonhole ) coloration HE (HE X220)
b).
Imaging features:
CT:
slow-growing tumors: well-defined masses, usually homogeneous,
with moderate contrast grip,
rapidly evolving tumors: large, imprecise edges with heterogeneous
contrast grip and areas of necrosis.
MRI:
heterogeneous mass in T1 and T2, with variable contrast grip (Fig.
10 17).
The differential diagnosis of carcinoma is made with:
salivary gland metastasis (fig.10.15)
metastasis in salivary glands (fig.10.16)
malignant pleomorphic adenoma (Fig. 10.17),
Warthin tumors
salivary gland lymphoma.
248
Salivary glands
a
b
Fig. 10.15. Right cilindrom recurrent in parotid pterigo-palatine fossa and
maxillary sinus, MRI a) Axial post contrast T1 FS
and axial T2 b).
249
Salivary glands
c
d
Fig. 10.16. Right parotid metastasis from a left palatine tonsil
carcinoma, axial CT native a)highlighting contrast grip of the primitive
tumor which has an extensive, vegetant aspect in the oropharingeal lumen
and the right parotid metastasis b) and also the presence of multiple
ganglionar metastasis c), with the same contrast grip, intense and
homogenous, located bilaterally jugulo gastric and submandible d).
250
Salivary glands
c
Fig. 10.17. Malignant left parotid adenoma with an evolution longer than
30 years, which was not operated after biopsy, and comes back after 5
years from the last biopsy, presenting a rapid growh in size and with a
compressive effect on the left latero-cervical vessels. The MRI
examination shows the tumor with areas of iso and hiposignal in a coronal
T2 SE sequence a), hiposignal in the native coronal T1 SE b) intense grip,
non homogeneous contrast in T1 coronal c), The anatomo pathology
examination establishes the magnizare of the old pleomorph adenoma.
251
Salivary glands
252
Chapter 11
IMAGING IN IMPLANTOLOGY
Edentulous or partially edentulous area reconstruction with implants,
which are base for different denture, began to be in recent years a
relatively common medical procedure.
It arises from a real subspecialization in dental medicine using
odontologic implatology as a dental surgery, as a method of rehabilitation
of edentulous areas. This method has been known for over 30 years due
Branemark's work, regarding the osseointegrating implants.
So, it is possible to create for partially or totally edentulous patients fixed
prosthesis consisting of:
an endosseous hopder (implant / implants) placed in the bone and
a superstructure (fixed denture itself).
11.1. Preimplantation balance
The achievement of the correct balance, essential for the success of the
implant in time, involves:
a correct clinical examination and
an appropriate imaging preimplantation balance, which are essential
monitorizing in time of the success or potential complications occurring
postimplant.
We have to monitorize in the balance preimplantation imaging:
the volumetric morphology of the region where the implant is carried
out;
cancellous bone structure;
periodontal component density, especially cortical bone support;
the relation to adjacent teeth and opposing teeth;
the state of the "critical structures" in the proximity: maxillary
sinuses, naso-palatine canal, nasal, inferior dental canal;
the presence of associated local diseases
TMJ condition.
qualitative analysis of alveolar bone:
bone density by evaluating cortices and spongy (trabecular
spaces);
quantitative analysis of bone likely to receive an implant:
horizontal size (vestibulo-lingual / palatal);
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Imaging in implantology
Imaging in implantology
11.2.2. Orthopantomography
This method of exploration is usually used in the first instance for the
overall evaluation, the mesio-distal direction of the region of the desired
implant location.
a
Fig. 11.2. OPT preimplant a) performed with radiopaque markers in the
central area of the mandible and postimplant with endosseous implant.
Advantages:
to assess the residual bone volume;
the relationship with adjacent and antagonistic teeth;
radio-anatomical aspect of ATM;
evaluate the plan retraction of alveolar ridge;
relations with neighbouring critical structures: sinus, nasal, dental
channel.
255
Imaging in implantology
Disadvantages:
provides a distortion and magnification of images (templates
radiopaque balls occlusion).
11.2.3. Computer tomography (CT)
This method of diagnosis is the most important imaging modality for
assessing preimplantologic evolution due to the precision, lack of
geometric deformations, high contrast images, multiplanar visualization
possibilities and use of special software imaging.
The new generation of devices can perform a full scan of the mandible and
/ or maxilla in seconds, with excellent spatial resolution and the ability to
provide very good spatial resolution both axial images and on the
reconstructed ones.
Axial sections processed with dedicated software are used for:
pre-operative evaluation of patients who are candidates for several
implants, the reconstruction of edentulous and rezorbed, ridge
2D and 3D image processing obtained with radiopaque markers;
establishing the treatment plan.
In order to reach this goal, a strict protocol should be achieved for the
region to be examined with a careful patient positioning. Images are
processed with special software, usually installed on CT, dedicated
graphics station or personal computer.
Preparation and patient positioning are essential to preserve symmetry and
perfect immobility that are vital for not having motion artifacts or artifacts
of image quality.
Advantages:
CT bone density allows the calculation of bone density based on
Hounsfield density and bone density classification: Misch, Lekholm and
Zarb.
Misch classification divides the types of bone in 5 classes:
D1> 1250 UH dense cortical bone,
D2 850-1250 UH thick or porous cortical bone at the alveolar ridge
and dense trabecular bone inside
D3 350-850 UH thin porous cortical bone at the alveolar ridge and
dense trabecular bone inside
D4 150-350 UH fine trabecular bone
D5 <150 UH immature, non-mineralized bone.
256
Imaging in implantology
a
b
Fig. 11.3. Axial images dotted line curve hand performed, passing
through the middle of the arcades, parallel to the cortical at jaw level a)
and the mandible b).
257
Imaging in implantology
a
b
Fig. 11.4. Curves called "panoscans", passing through arches cortices,
parallel to the jaw cortical) and mandible b) allowing to get panoramic
images.
a
b
Fig. 11.5. Panoramic reconstruction (panoscans) post processing: the right
hemimaxilla a) and right lower jaw b) partial edentulous.
sectional images in different planes (coronal, sagittal, oblique, radial)
2D reconstructions bring the richest deal of information about bone
quality, implant size and angulation required when images are called
paraxial obtained by a perpendicular plan to the median line of the dental
arches (fig.11.6).
3D images that provide information on the position of radio-opaque
markers, remaining bone surfaces anatomy and teeth (fig.11.7).
These CT images can be shown to the implantologs in two ways:
printed on a solid support (radiological film);
computerized data base that can be processed with dedicated software
- specific: SimPlant (Columbia Scientific Inc., Edmonds, Washington,
USA); SurgiCaseTM (Materialise NV, Leuven, Belgium); coDiagnostiX
(IVS Solutions AG, Chemnitz, Germany ) ImPlacer (Pacific Coast
Software Inc., Los Angeles, California, USA).
258
Imaging in implantology
d
c
Fig. 11.6. Dental CT paraxial reconstructions with actual measurements
of height, thickness and density of the maxillary edentulous ridge), c) and
mandible b), d).
259
Imaging in implantology
c
d
Fig. 11.7. 3D reconstruction, a) "surface" with an analysis of the aspect,
or the external surface of the lower half of the face massif, shaded surface
display type SSD, b) MIP that highlights the shape of teeth, postoperative
appearance of the mandible and c) , d) volume renderings VRT that
allows in-depth analysis of a particular sector of tooth shape, the lateral
incisor lacking and the teeth fixed at the bracket level.
260
Imaging in implantology
261
Imaging in implantology
a
b
Fig. 11.9. CBCT in the mandible a) panoramic reconstruction with
marker at the upper limit of the dental canal, b) CBCT in maxillary with
transverse oblique sections on the partial edentulous arch (document QR)
262
Imaging in implantology
Imaging in implantology
b
a
Fig. 11.12. Positron Scanora system) device to explore,
b) sagittal sections from previous dental ridge, Edentia.
11.2.8. Magnetic resonance imaging (MRI)
It is rarely used, average field MRI exam (1-1, 5 T) and low field (0.4
to 0.5 T) which identifies, precisely:
inferior vasculo- alveolar nerve package;
the bottom edge of the maxillary sinus;
bone structure of interest (cortical spongy);
any associated pathology.
Disadvantages: the price and availability data and artifacts of
ferromagnetic materials.
11.3. Radio-imaging examination within the implant algorithm
A radio-imaging exam stages include:
diagnostic phase,
preimplantation stage (partially overlapping diagnostic phase),
intraoperative examination,
post-implantation exam.
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Imaging in implantology
Fig. 11.13. Oblique cross section in the jaw with measurements in the
anterior area. Measurements show the possibility of achieving an implant
having a bone bed with a vertical size of 18.6 mm, diameter of 9.4 mm
cervical and apical diameter of 7.8 mm (imag.24) but with fine trabeculae,
with an average density of 350 HU (imag.23), type D3 Misch
classification.
All these questions can be answered by a
programme that can analyze:
265
Imaging in implantology
b
Fig. 11.14. Paraxial reconstruction of the mandible) which shows a dense
cortical with trabecular bone density and fine 1628HU inside, with an
average density of 374 HU, or jaw b) a dense cortical trabecular bone but
a fine, very low density of 165 HU.
Relationship with the adjacent and opposing teeth;
The "critical structures" proximity (maxillary sinuses, nazopalatin
canal, nasal passages, inferior dental canal, the mentonier hole)
The presence of any associated local condition.
It can make a qualitative analysis of bone density measuring alveolar bone
cortices, the spongy (trabecular spaces) and a quantitative analysis of the
bone likely to receive an implant, measuring:
horizontal size - cortical thickness (vestibulo-lingual/palatinal)
266
Imaging in implantology
vertical size, the height of the available bone (distance between the
alveolar bone crest and a "critical structure");
bone density (quantitative computed tomography).
The basic rule used in implantology is "to create a model with the desired
results and then determine how this model can be achieved". The position
is determined by placing implants in the edentulous parts of a radiopaque
guide plate, which can be:
small radiopaque markers at the level of mouth bracket, showing the
position of each meziodistal implant suggested;
external surface of the guide plate can be brushed with a radiopaque
substance (barium sulphate thin paste);
free air spaces can be used as markers of edentulous areas.
The guide plate can be performed automatically by the process called
stereolithography, which can generate a physical model of computer data
by strengthening acrylic resin liquid under the action of a laser beam
guided by computer.
CT use in dental implantology, the interactive planning software and
surgical guide plates may help reduce the duration of surgery, can improve
the aesthetic result and may contribute to a favorable prognosis of the
implant.
11.3.3. Intraoperative phase
Checking intraoperative placement of implants can be made:
retrodentoalveolar dental X-rays, CT and a computerized control system
according implantation Dental CT images;
This system called IGI - "Image Guided Implantology" allows:
loading the patients database into a computer;
analysing of these images;
planning the surgical treatment
its compliance with real-time guidance of implantation.
The surgeon is helped to achieve a correct implantation by charging the
computer system drill movements and comparing these with the preprogrammed movements.
11.3.4. Post-implantation control
Can be done immediately aiming to see:
topography of the implant;
any early complication (incorrect positioning, fractures);
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Imaging in implantology
268
Imaging in implantology
The overuse and the non-axial tension of the implants and the too reduced
number of implants for the existing superstructure may cause microfractures.
Progressive radiographic bone resorption occurs at the implant package.
Breaking / bending of the implant
They can appear in bruxism or in case of fracture.
Radiographic bone continuity solution is (+ / - cortical) of interest in:
nasal floor;
maxillary antrum floor;
mandible canal.
Incorrect positioning
It is explored relatively fast postimplant, looking for, by CT:
implant position in relation to: nasal passages, maxillary sinus or
mandible canal.
We believe that:
the permanent development of implant dentistry requires radioimaging exploration in the preimplantation phase, phase of the
implantation and post-implantation to assess possible complications.
We must be attentive to patient irradiation, which requires a useful
collaboration between implant and radiologist.
Dental CT reconstruction programme is simple, easy to perform and
provides information that substantially increase the quality and reliability
during the implant.
Cone Beam CT - is a less irradiant examination, fast and useful capturing
quality information regarding the sites of implantation.
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Imaging in implantology
270
REFERENCES
1. JJ Abrams, Kalyanpur A. Dental implants and dental CT software
programs. Semin Ultrasound CT MR. 1995, 16:468-486.
2. kesson L, Rohlin M., J. Marginal bone in periodontal Hakkansson
disease: an evaluation of image quality in panoramic and intra-oral
radiography. Dentomaxillofac Radiola. 1989 14:1053-1055.
3. American Academy of Oral and Maxillofacial Radiology. Radiology
Practice Committee. Updated quality assurance self-assessment exercise in
intraoral and panoramic radiography. Oral Surg Oral Med Oral Pathol.
2000, 89: 369-374.
4. Barnes L., Eveson JW, Reichart P, Sidransky D. Pathology and
Genetics of Head and Neck Tumours, IARC Press, Lyon, 2005.
5. Cavzian R., Pasquet G. Techniques of radiology DENTAIRE. Editions
Techniques. Encyclia Med Chir. Paris. Squelette radiology normal. 1992,
30 850 A10 18.
6. Cavzian R., G. Pasquet, Thibierge M., EA Cabanais Justice et imaging
en odontostomatology. The medical responsibility to DENTAIRE
maxillofacial radiology. Currently Odonto-stoma. 1993, 182:291-311.
7. Cavzian R., G. Pasquet, G. Bell, G. Imagery dental Baller maxillaire.
2nd ed. Paris: Masson, 2001.
8. Dermaut LR, A. Apical root resorption Demnuck on upper incisors
caused an by intrusive tooth movement: a study Radiology. Am J Orthod
Dentofac Orthop. 1986, 90:321-326.
9. Doyon D., Pajoni D., Idir ABC, Jouan E., R. Carlier, Savana S., dental
Imagery maxillaire, Masson, Paris, 1995.
10. Farman AG, Nortj CJ, Wood RE, Oral and maxillofacial Diagnostic
Imaging, Mosby, St. Louis, 1993.
11. Goaz P.W., White SC. Oral radiology. St. Louis: Mosby, 1987.
12. Gorlin RJ, Nevoid basal cell carcinoma syndrome. Deerm Clin. 1995,
13:1.
13. D. Haba, techniques commonly used in dental radiology, Ed Junimea,
Iasi, 2005.
14. D. Haba, CT and MRI Radioanatomia deep regions of the face.
Practical guide, Ed Junimea, Iasi, 2005.
15. J.I. Haring, Howerton L.J., Dental radiography. Prinicples and
Techniques, 3rd Edition, Saunders Elsevier, St. Louis, 2006.
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