Introduction to oral & maxillofacial Differential Diagnosis

1. Introduction to RadiologicIntroduction to Radiologic
Differential DiagnosisDifferential Diagnosis

2. DiagnosisDiagnosis
It is the ability and skillIt is the ability and skill
of the clinician toof the clinician to detectdetect
andand identifyidentify the naturethe nature
of the disease processof the disease process..

3. Components of theComponents of the
diagnostic processdiagnostic process
Case history
Physical
Examination
Special
Investigations

4. History
Physical
Examination
Special
Investigations
(if indicated)
Diagnosis
Information
Analysis
To diagnose a Temporomandibular
Disordes we have to do the following:
The Diagnostic Process

5. N
on-differential
D
iagnosis
Clinicaldiagnosis
Radigraphic
diagnosis
D
ifferential
D
iagnosis
TYPES OF DIAGNOSIS

6. Non-differential diagnosisNon-differential diagnosis
This approach is bestThis approach is best
suited to those lesionssuited to those lesions
whose features arewhose features are
specificspecific (pathognomonic)(pathognomonic)
toto themselves and bearthemselves and bear
little or nolittle or no similaritysimilarity to otherto other
lesions.lesions. It depends only onIt depends only on
thethe clinical signs andclinical signs and
symptomssymptoms

7. Differential diagnosisDifferential diagnosis
This approach is bestThis approach is best
suited to those lesionssuited to those lesions
whichwhich bear similaritybear similarity toto
other lesions and whereother lesions and where
differentiationdifferentiation betweenbetween
them is necessary . Itthem is necessary . It
necessitates thenecessitates the
application of certainapplication of certain
diagnostic ways.diagnostic ways.

8. Multilocular cyst Central Myxoma CEOT
Mural ameloblastoma Dentigerous cyst
lesions which bear similarity to otherlesionslesions which bear similarity to otherlesions

9. Tentative diagnosisTentative diagnosis
It is the top choice ofIt is the top choice of
of the probable lesionsof the probable lesions
listed on a priority basislisted on a priority basis
Ameloblastic fibro-odontoma.
Calcified Epithelial Odontogenic Tumor.
Calcifying Odontogenic Cyst.
Adenomatoid Odontogenic Tumor. = TD

10. Adenomatoid Odontogenic Tumor = FD
Final diagnosis
Is the diagnosis of a particular case proved by
Observation of the clinical behavior of the lesion.
Testing it’s response to treatment.
Special investigations.

11. 2. Pattern matching method2. Pattern matching method
Periapical radiolucent lesions.Periapical radiolucent lesions.
Pericoronal radiolucent lesions.Pericoronal radiolucent lesions.
Multilocular radiolucent lesions.Multilocular radiolucent lesions.
How can we study radigraphic lesions ?How can we study radigraphic lesions ?
11. Radiologic pathology. Radiologic pathology
Cysts of the jaws.Cysts of the jaws.
Benign tumors.Benign tumors.
Malignant tumors.Malignant tumors.

12. 1.1. Radiologic pathologyRadiologic pathology
Lesion by lesion accordingLesion by lesion according
toto Pathologic category.Pathologic category.
AmeloblastomaAmeloblastoma
Central myxomaCentral myxoma
Central odontogenic fibromaCentral odontogenic fibroma
Central Odontogenic myxomaCentral Odontogenic myxoma
Central hemangiomaCentral hemangioma
2. Pattern matching method2. Pattern matching method
Lesions are gathered according toLesions are gathered according to
Pattern Matching categoryPattern Matching category
Multilocular lesionsMultilocular lesions
AmeloblastomaAmeloblastoma
Odontogenic keratocystOdontogenic keratocyst
mucoepidermoid carcinomamucoepidermoid carcinoma
Fibrous dysplasiaFibrous dysplasia
CherubismCherubism
HyperparathyroidismHyperparathyroidism
What is the difference ?What is the difference ?

13. Radiologic Lesions
They most commonly
follow the differential
way of diagnosis.

14. Pattern matching method
This method attempts to
group various distinct
pathologic lesions by their
most usual radiologic
appearance into a list of
differential diagnosis.
Periapical RL Periapical RP
Pericoronal RL multilocular RL

15. Pattern matching
It is the simplest
method which helps
the examiner to
remember a precise list
of lesions that might give
rise to the particular
radiologic picture
discovered on
examination of the patient
Pericoronal radiolucenceis
Follicular space
Dentigerous cyst.
Ameloblastoma (mural).
Ameloblastic fibroma.
Ameloblastic Fibroodontoma.
Adenomatoid odontogenic tumor.
Odontogenic Keratocyst

16. RULE
Classifications are based on
similarities and grouping
is based on differences

17. Radiologic Lesions
Radiolucent
lesions
Radiopaque
lesions
Mixed
RL / RO
lesions

18. Radiolucent LesionsRadiolucent Lesions
MultilocularUnilocular
Multilocular
But
Separate
Multifocal
Multilocular
But
confluent
Multilocular
Tooth
Associated
Not Tooth
Associated

19. Radiopaque LesionsRadiopaque Lesions
MultipleSolitary
Multifocal Generalized
Tooth
Associated
Not Tooth
Associated

20. Mixed RL / RQ LesionsMixed RL / RQ Lesions
Not Necessarily
Tooth Associated
Tooth Associated
Tooth
Associated
Periapical
Not Tooth
Associated
Pericoronal

21. Radiologic Lesions
1. Radiolucent 90%
2. Radiopaque 8%
3. Mixed 2%

22. ?
To differentiate between
radiologic lesions , we have
to ask ourselves some
questions

23. Is the lesion ,Is the lesion , radiolucent ,radiolucent ,
radiopaque or a mixed lesionradiopaque or a mixed lesion ??
Radiolucent
Radiopaque
Mixed RL / RQ

24. Radiolucent LesionsRadiolucent Lesions
If the lesion is radiolucent , is it
unilocular or multilocular ?
UnilocularMultilocular

25. If the lesion isIf the lesion is
unilocularunilocular
what about its locationwhat about its location ??

26. Is itIs it
Tooth - associatedTooth - associated
oror
Not tooth - associatedNot tooth - associated

27. If it isIf it is
Tooth - associatedTooth - associated
What about it’s location ?What about it’s location ?

28. Tooth associatedTooth associated
radiolucent lesionsradiolucent lesions
Periapical Pericoronal Inter-radicular

29. Related to the apex of a tooth ?Related to the apex of a tooth ?
Periapical radiolucencyPeriapical radiolucency
Dental papilla (incomplete apex).
Incisive foramen.
Wide bone marrow space.
Submandibular fosse.
Submental fossa.
Mental foramen.
Anatomic patterns

30. periapical cemental dysplasia.
Vital tooth
Pathological conditions
Malignant tumors
(uncommon).

31. Pathological conditions
Non-vital tooth
Periapical granuloma
Periapical abscess
Periapical scar.
(In endodonticaly treated tooth).
Periapical (radicular) cyst
Surgical defect.

32. Is it related to the side of a root ?Is it related to the side of a root ?
(Inter-radicular)(Inter-radicular)
Lateral radicular cyst.
Periodontal abscess.
Globulomaxillary radiolucencies.
Anatomical pattern
Lateral fossa
Permanent tooth crypt (age).
Pathological conditions
Lateral periodontal cyst

33. Is it located around the crown of impacted ,Is it located around the crown of impacted ,
unerupted tooth or an odontomeunerupted tooth or an odontome (pericoronal)(pericoronal) ??
Aanatomic pattern
Follicular space ( & hyperplastic
dental follicle).

34. Dentigerous cyst.
Pathological conditions
Ameloblastic Fibroodontoma.
Adenomatoid odontogenic tumor.
Odontogenic keratocyst
Ameloblastic fibroma.
Ameloblastoma (mural).
Is it located around the crown of impacted , uneruptedIs it located around the crown of impacted , unerupted
tooth or an odontometooth or an odontome (pericoronal)(pericoronal) ??

35. Gardner’s syndrome (Intestinal polyposis type II)
Multiple pericoronal radiolucencies
Hurler’s syndrome (Mucopolysaccharidosis or Gorgolism)

36. Is itIs it
a rdiolucencya rdiolucency
NotNot
Tooth – associated ?Tooth – associated ?

37. Unilocular radiolucencies related to theUnilocular radiolucencies related to the
midline of the maxillamidline of the maxilla
Nasopalatine duct cyst
Median palatine cyst
Nasolabial cyst

38. Unilocular radiolucencies notUnilocular radiolucencies not
necessarily tooth associated.necessarily tooth associated.
Surgical defect
Anatomic patterns
Developing tooth bud
Maxillary sinus
Extraction site
Bone defects
Wide marrow space

39. Pathological conditions
Unilocular radiolucencies notUnilocular radiolucencies not
necessarily tooth associated.necessarily tooth associated.
Simple bone cyst
(traumatic cyst).
Residual area of infection
Residual cyst

40. If the lesion isIf the lesion is
multilocularmultilocular
what about it’s internal structure?what about it’s internal structure?

41. Is it multilocular butIs it multilocular but
separate (multifocal) ?separate (multifocal) ?
MULTIFOCAL

42. multilocular but separatemultilocular but separate
radiolucencies (multifocal) ?radiolucencies (multifocal) ?
Metastatic carcinoma.
Langerhans cell disease.
Leukemia.
Non-Hodgkin’s lymphoma.
Burkitt’s lymphoma.
Multiple myeloma.
Hyperparathyroidism.

43. Is it multilocular but confluentIs it multilocular but confluent
in appearance ?in appearance ? (e.g soap-bubble or honeycomb)(e.g soap-bubble or honeycomb)
If so
Does it possess well defined borders ?

44. Multilocular lesions withMultilocular lesions with
well defined borderswell defined borders
Anatomic patterns
Maxillary sinus.
Bone marrow spaces.

45. Multilocular lesions withMultilocular lesions with
well defined borderswell defined borders
Patholocical conditions
Ameloblastoma.
Odontogenic myxoma.
Central giant cell granuloma.
Central odontogenic fibroma.
Central hemangioma /
Arteriovenous shunt.
Rarities : Neurolemmoma , Neurofibroma

46. Summary
Ameloblastoma
Central giant cell granuloma
Central odontogenic fibroma
Central Odontogenic myxoma
Central hemangioma /arteriovenous malformation.
Neurolemmoma , Neurofibroma
Central
Tumors
Odontogenic keratocyst
Multilocular cyst
Aneurysmal bone cyst
Traumatic bone cyst
Lateral periodontal cyst (botryoid type)
Cysts
Well defined multilocularradiolucent lesions

47. Well defined multilocularradiolucent lesions
Calcifying odontogenic cyst
Calcifying epithelial odontogenic tumor
Calcifying
Odontogenic
lesions
Fibrous dysplasia
Cherubism
Hyperparathyroidism (brown tumor)
Bone
diseases
Intraosseous mucoepidermoid carcinoma Malignancy

48. is it ais it a
radiopaqueradiopaque
lesionlesion ??

49. Radiopaque LesionsRadiopaque Lesions
If it is a radiopaque lesion , what about
it’s distribution ?

50. Is it a solitary radiopacityIs it a solitary radiopacity
related to the apex of a tooth ?related to the apex of a tooth ?
Hypercementosis.
Foreign body
(endodontic treatment).
Periapical idiopathic
osteosclerosis.
Periapical cemental dysplasia.
Condensing osteitis.

51. Solitary radiopaque lesions with well -
demarcated borders not tooth associated ?

52. Enostosis.
Osteoblastoma.
Osteoid osteoma.
Compound odontoma.
Idiopathic osteosclerosis.
Salivary stone.
Torus or exostosis.
Osteoma.
Complex odontoma.
Solitary radiopaque lesions with well - demarcated
borders not tooth associated?

53. Solitary radiopaque lesions with well - demarcated
borders not tooth associated?
Impacted.& unerupted teeth
supernumerary teeth

54. Intraosseous foreign body.
Soft tissue radiopacity
superimposed on bone.
Focal sclerosing osteomyelitis.
Proliferative periostitis
( Garre’s osteomyelitis).
Solitary radiopaque lesions with well - demarcated
borders not tooth associated?
Retained root tip.

55. Is it a multifocal or generalizedIs it a multifocal or generalized
radiopacity ?radiopacity ?

56. multifocal or generalizedmultifocal or generalized
radiopacitiesradiopacities
Paget’s disease of bone.
Osteopetrosis.
Polyostotic fibrous dysplasia.
Diffuse sclerosing osteomyelitis.
Idiopathic osteosclerosis.
Salivary stones.
Foreign bodies.
Florid cementoosseous dysplasia.
Gardner’s syndrome.

57. Is itIs it mixed radiolucentmixed radiolucent
radiopaque lesionradiopaque lesion ??
If so
What about its location ?

58. Is itIs it
Tooth - associatedTooth - associated
oror
Not tooth - associatedNot tooth - associated

59. If it isIf it is
Tooth - associatedTooth - associated
What about it’s location ?What about it’s location ?

60. Pericoronal Periapical
Tooth – associatedTooth – associated
mixed lesionsmixed lesions

61. Calcifying odontogenic cyst.
Calcifying crown of developing tooth.
Adenomatoid odontogenic tumor.
Ameloblastic fibro-odontoma.
Located around the crown of anLocated around the crown of an
impacted , unerupted tooth or animpacted , unerupted tooth or an
dontome ?dontome ?
Calcifying epithelial odontogenic tumor
(Pindborg tumor).
Odontomas (intermediate stage).
(Pericoronal mixed lesions)

62. Located around the apexLocated around the apex
of a tooth?of a tooth?
(Periapical mixed lesions)
Sclerosing osteitis.
Cementoossifying fibroma.
Cementoblastoma.
Periapical cemental dysplasia
(intermediate stage).
Odontomas
(intermediate stage)

63. Is it a mixed lesion notIs it a mixed lesion not
necessarily tooth associated ?necessarily tooth associated ?
Not tooth associated

64. Mixed lesions notMixed lesions not
necessarily tooth associatednecessarily tooth associated
Healing surgical site.
Focal cementoosseous dysplasia.
Florid cementoosseous dysplasia.
Fibrous dysplasia.
Paget’s disease.
Chronic osteomyelitis.
Florid cementoosseous dysplasia
(intermediate stage).

65. ThankyouThankyouQuestions !Questions !