Radiology II Forth Year

1. Diseases of bone manifested
in the jaws
By
Dr. Hassan M Abouelkheir
BDS, Msc, Phd.

2. Bone Dysplasias:
• A group of conditions in which normal
bone is replaced with fibrous tissue
containing abnormal bone or
cementum.

3. Fibrous dysplasia:
• It is one type of bone
dysplasia where cancellous
bone is replaced by fibrous
tissue with disoreintation of
bone trabeculae
• It is either monostatic
(solitary) or polystatic
(Jafee type)→Café au lait
spots, hyperfunction of one
of more of endocrine glands.

4. Clinical features
• Monostatic→70% more in old age, no
sexual predilection.
• More common in jaws, tibia,femer. It
may cause unilateral facial deformity
or swelling, or may discovered by
routine x-rays.
• Polystatic→ childern less than 10
years , McCune-Albright syndrome
(more in female).

5. R
Fibrous dysplasia:
a “ground glass”
(“frosted glass”)
appearance is
typical in
extra-oral
radiographs.
Water’s view showing large lesion of left
maxilla. Note lesion is restricted to one bone
and does not cross the midline.

6. Radiographic features:
• Location: 2:1 maxilla to
mandible
• More posteriorly and
unilateral.
• Periphery:ill defined with
gradual blending of normal
trabecular bone.
• Boundaries may be sharp &
corticated
• Internal structure: density &
trabecular pattern of fibrous
dysplasia more pronounced in
mandible and more
homogeneous in the maxilla.

7. • Internal aspects ranges
from radiolucent,
radiopaque to mixed
lesion.
• Abnormal trabecular
pattern →ground-glass
appearance, peau
d’orange, cotton wool or
amorphous dense
pattern.
• Radiolucent regions
resembling cysts may
occur in mature lesions
of fibrous dysplasia.

8. Fibrous dysplasia: note enlargement of
affected area, buccal expansion of the
left mandible with granular opacity. Lesion
melds with surrounding bone (PA view).

9. • Effects on surrounding
structures:
• Expansion with
maintenance of a
thinned outer cortex.
• Lateral wall of
maxillary sinus
involvement .
• Loss of lamina dura
with abnormal bone
pattern around teeth &
may displace them.

10. Fibrous dysplasia:
note enlargement of
affected area, buccal
expansion of the
maxilla and “orange
peel” opacity
(topographic occlusal
view).

11. Fibrous dysplasia:
Water’s view
showing lesion in
left maxilla. Note
difference in
lateral walls of
the two maxillary
sinuses.
R

12. Fibrous dysplasia:
cropped panoramic
radiograph showing
lesion of the left
maxilla. The lesion is
radiopaque with some
radiolucent mottling.
It melds with the
surrounding bone.
LL

13. Fibrous dysplasia:
note enlargement of
affected area, buccal
expansion of the
mandible and
granular opacity
(true occlusal view).

14. Fibrous dysplasia:
“orange peel”appearance of fine dense
trabeculae seen on intra-oral radiography
in late stage.

15. Fibrous dysplasia: Status X view of unusual bilateralFibrous dysplasia: Status X view of unusual bilateral
case in maxilla. Note ground glass appearance.case in maxilla. Note ground glass appearance.

16. Fibrous dysplasia: Note orange peel appearanceFibrous dysplasia: Note orange peel appearance
of trabeculations on intraoral radiography (Caseof trabeculations on intraoral radiography (Case
courtesy of Dr. Robert P. Langlais)courtesy of Dr. Robert P. Langlais)

17. Differential diagnosis
• Hyperparathyroidism→ polystatic,
bilateral & no bone expansion.
• Paget’s disease→ older age, whole
mandible is involved.
• Periapical cemental
dysplasia→epicentral in periapical
region, bilateral.

18. Periapical CementalPeriapical Cemental
dysplasia(PCD)dysplasia(PCD)
• Definition:
• localized change in the normal bone
metabolim where cancellous bone is
replaced with fibrous tissue or
cementum like material.

19. Clinical features:
• Middle age , 9:1 F:M 3:1 black :white.
• Teeth are vital most common in lower
anterior teeth.
• No pain .
• Discovered by routine x-ray.

20. Radiographic features
• Location:
• At the apex of the
tooth or over apical 3rd
of the root.
• Predilection for
mandibular anterior
teeth.
• Periphery& shape: well
defined radiolucent
border surrounded by
sclerotic bone.

21. • Internal structure:
• It depends on maturity
of the lesion.
• 11stst
stagestage → radiolucency
at the apex of the tooth
with loss of lamina dura.
• 22ndnd
stagestage→ mixed
lesion , radiopaque
tissue in radiolucent
structure.
• Last stageLast stage → a total
radiopaque areas with or
without thin rim of
radiolucent margin.

22. Periapical cemental
Dysplasia:
Stage III:
homogeneous
opacification -
but note that the
periodontal ligament
spaces are still intact.

23. Effects on surrounding
structures:
• Loss of lamina dura .
• Widening of PDL space .
• Hypercementosis of
affected teeth.
• Expansion of the bone
may occurs.
• DD:- rarefying osteitis→
vitality testing.
• Bengin
cementoblastoma →
clinical & radiographic.
• Odontoma → tooth-like
structure.

24. Florid Osseous Dysplasia
• Synonyms: gigantiform cementoma &
familial multiple cementomas.
• Definition : FOD is awide spread form
of PCD. A cancellous bone is replaced
with dense, acellular cemento-osseous
tissue in background of fibrous ct.
• If PCD is identified in 3 or 4 quadrants
→FOD.

25. Clinical features:Clinical features:
• Most common in middle aged
females.
• Intermittent, poorly
localized pain in affected
bone.
• Bony swelling in extensive
lesions.
• Radiographic:
Periphery:Periphery:
• Bilateral in both jaws.
• Most common posterior to
mandibular cuspid.

26. Internal structure:
• Mixed raiolucent-
radiopaque→ complete
radiopaque.
• Simple bone cyst may
developed.
• Cotton-wool appearance →
largen amorphous calcified
areas.
Effect on surrounding
structure:
• Apical displacement of ID
canal.
• Superior displacement of
Max.antrum.
• Buccolingual displacement
of mandibular bone.
• Hypercementosis of
involved teeth.

27. Differential diagnosis:
• Paget’s disease→ wool-type radiopaque
regions with hypercementosis.
• affect the entire jaw While FOD → above
ID canal.
• Polystatic envolvement.
• Chronic sclerosing osteomyelitis.
• Management: conservative .

28. Other lesions of the bone:
• 1- Cemento-ossifying fibroma (COF):
• it behaves like a benign bone
neoplasm.
• If calcified part→ ossifying fibroma, if it
is cementum→ cementifying fibroma.
• Clinical features:Clinical features: young adult females ,
displacement of teeth is early signs then
rapid growth leads to deformity of the
jaw.

29. Radiographic features:
• Location:
• mandibular Facial bone premolar –
molar regions.
• In maxilla canine and zygomatic
region.
• Periphery: well defined radiolucent
line (fibrous capsule).
• Internal structure:mixed radiolucent-
radiopaque density.
• Effects on surrounding
structures→expansion of outer
cortical bone.
• Management : surgical enucleation or
resection.

30. 2 –central giant cell granuloma
• It is a reactive lesion not
neoplastic.
• Clinical Features: under 20
years of age.
• Painless slowly growing
swelling.
• Radiographic features:
• Location : twice in mand<
max.
• Anterior to 1st
molar.
• Periphery → well defined
margins.

31.  Internal structure:
granular pattern of
calcification with ill
defined, wispy septa.
 Effect on surrounding
structurs:
 Displace & resorbe
teeth.
 Loss of lamina dura.
 Management :
 Enucleation &
curettage.

32. 3- Aneurysmal bone cyst.
• It is considered a reactive bone lesion
rather than a cyst or neoplasm.
• Clinical features:
• Under 30 years and more female
predilection.
• Rapid bony swelling.

33. Radiographic features:
• Mand. To max. 3:2 at
molar & ramus areas.
• Periphery : well defined
circular or hydraulic.
• Internal structure: no
structure or multilocular
appearance.
• Effects on surrounding
structure:expansion of
outer cortex.
• Management : surgical
curettage & partial
resection. High
recurrence rate (19%).

34. 4- cherubim:
• It is inherited
developmental
abnormality that causes
bilateral enlargement of
jaws.
• Clinical features:
• Age 2-years.
• Firm painless bilateral
enlargement of lower
face (chubby) .

35. Radiographic:
• Location: posterior mandible,
ramus, tuberosity.
• Periphery: well define
corticated.
• Internal structure: fine
granular and multilocular
pattern.
• Effects on surrounding
structures: expansion of the
cortical boundaries of the
maxilla & mandible.
• Management: conservative
surgical procedures if
required.

36. 5- Paget’s disease:
• It is a condition of abnormal
resorption and apposition of
osseous tissue in one or
more bones.
• Clinical features:
• Middle & old age (40ys) more
in males than females.
• Enlaged & deformed bones,
bowing of the legs,
curvature of the spine &
enlargement of the skull.

37. Radiographic features:
• Location: It occurs more
often in pelvis, femur,
skull and vertebrae and
infrequently in jaws.
• Maxilla twice than
mandible bilateral.
• Internal structure:
3 stages:
• - early radiolucent
resorptive stage.
• - ground glass appearing
second stage.
• - dense radiopaque
appositional late stage.

38. • The trabeculae may be long
and align themselves in
horizontal linear pattern.
• Effects on surrounding
structures:
• Enlargement of affected
bone (prominent pagetoid
skull bones three times.
• Loss of lamina dura and
irrigular hypercementosis.
• Management:
• Calcitonin for pain and <se
Alkaline phosphatase.
• Sodium etidronate→ covers
bone surfaces and retard
bone resorption & formation.
• Complications: delayed
extraction healing, jaw
osteomylitis, 10% of cases →
osteogenic sarcoma.

39. Paget’s disease of bone:
early
demineralization phase
with osteoporosis
circumscripta of skull both
anteriorly
and posteriorly

40. • generalized
• hypercementosis
• is a frequently
• reported
association.

41. 6- Langerhan’s cell Histocytosis:
• It is abnormal proliferation of Langerhan’s
cells of histiocytes that normally found on
the skin.
• It is newly classified into ;
• 1- unifocal or multifocal eosinophilic
granuloma.
• 2- malignant disease→ Letterer- Siwe
disease and variants of histiocytic lymphoma.

42. Clinical features:
• Eosinophilic granuloma (EG) affect
bony skeleton, in chilern & young
adult.
• Bony swelling, soft tissue mass,
gingivitis, pain and ulceration.
• It may be acompained by dibetes
insipidus and exophthalmos →Hand-
Schϋller-Christian disease.

43. • Letterer-Siwe disease is a malignant
form of LCH in infants under 3 years of
age .
• Soft tissue and bony granulomatous
reactions dissiminated throughout the
body, hepatospleenomegaly, anemia,
lymphadenopathy, hemorrhge.
• Death within several weeks.

44. Radiographic features:
• It is divided into 2 types
that occur in alveolar bone
and that occur intra-
osseous else where in jaws.
• Location: alveolar type is
multiple while intraosseous
type is solatory.
• Posterior part of mandible
and ramus are more
common sites.
• Periphery and shape:
moderate to well defined
without cortication.

45. • Internal structure:
totally radiolucent.
• Effect on surrounding
structures: alveolar
type show scooped-out
bone distruction with
loss of lamina dura.
• Intraosseous type
shows periosteal new
bone formation and
may destroy outer
cortex.
• Management: surgical
curettage or limited
radiation therapy.