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Periapical radiolucencies./ oral surgery courses


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Periapical radiolucencies./ oral surgery courses

  1. 1. PERIAPICAL RADIOLUCENCIES INDIAN DENTAL ACADEMY Leader in continuing Dental Education www.indiandentalacademy.com
  2. 2. INTRODUCTION • Radiolucent shadows cast over partially over the periapical regions of the tooth in practically all oral radiographic survey of dentulous patients. • The radiolucent shadows are: • Anatomic • pathologic www.indiandentalacademy.com
  3. 3. • ANATOMIC RADIOLUCENCIES Unilocular: mental foramen Multilocular: maxillary sinus bone marrow spaces PATHOLOGIC RADIOLUCENCIES: inflammatory; periapical granuloma periapical abscess. periapical cyst actinomycosis . www.indiandentalacademy.com
  4. 4. • BENIGN; traumatic bone cyst nasopalatine duct cyst adenomatoid odontogenic tumor periapical cemento osseous dysplasia vascular malformations like central haemangioma ossyfying fibroma www.indiandentalacademy.com
  5. 5. • BENIGN AGGRESSIVE: odontogenic keratocyst central gaint cell granuloma odontogenic myxoma calcifying epithelial odontogenic tumor ameloblastoma MALIGNANT: metastatic www.indiandentalacademy.com
  6. 6. • TRUE ANATOMIC RADIOLUCENCIES; represent lesions that truly contacting apex of the tooth, their shadow cannot be changed by taking additional radiographs at different angles FALSE ANOTOMIC RADIOLUCENCIES; produced by anatomic cavities or lytic lesions that do not contacting apex of tooth shadows may shifted by taking additional radiographs at different angles www.indiandentalacademy.com
  7. 7. Mental foramen www.indiandentalacademy.com
  8. 8. Maxillary sinus www.indiandentalacademy.com
  9. 9. PERIAPICAL GRANULOMA : Granuloma is defined as focal area of granulomatous inflammation. It refers to a mass of chronically inflamed granulation tissue at the apex of nonvital tooth May arise after an acute condition like periapical abscess Lesions' are not static and may transforms into periapical cyst or undergo acute exacerbation www.indiandentalacademy.com
  10. 10. PATHOGENESIS As a result of successful attempt by periapical tissues to neutralise and confine the irritating toxic products that are escaping from rootcanal.The continual discharge of chronic irritating products from canal into periapical tissues this inflammatory reaction continue to induce vascular inflammatory response which makes up this entity. www.indiandentalacademy.com
  11. 11. • C/F: asymptomatic involved tooth does not demonstrate mobility or significant sensitivity to percussion Tooth does not respond to thermal or electric pulp test,tooth is nonvital R/G: loss of lamina dura • Well circumscribed radiolucency some what rounded surrounding the apex less than 1.5cm ,may have thin radiopaque border • Teeth may show extensive caries,deep restorations www.indiandentalacademy.com
  12. 12. • FEATURES SUGGESTIVE OF NONVITAL PULPS: • History of trauma • History of painful pulpitis • Dark hue of crown • Large cavity • Large restoration • Draining sinus tract • Dens in dente • Fracture of the root • Fracture of crown www.indiandentalacademy.com
  13. 13. Periapical granuloma radiographs www.indiandentalacademy.com
  14. 14. • INVESTIGATIONS: • radiography • TREATMENT: • root canal treatment www.indiandentalacademy.com
  15. 15. PERIAPICAL ABSCESS • Abscess is defined as a focal localised collection of purulent inflammatory material in tissues caused by suppuration buried in tissues or in organ or in confined space www.indiandentalacademy.com
  16. 16. Also called dentoalveolar abscess Subdivided into 2 types depend upon their radiolucency: primary or neoteric secondary or recrudescent • Primary: associated with tooth does not developed apparent periapical radiolucency • Secondary: developed in pre existing peri apical lesion,eg;granuloma,cyst www.indiandentalacademy.com
  17. 17. • Acute abscess: infection is usually acute and exudative involving periodontal tissues at the apex of the tooth with necrotic pulp. • Initial stages produces tenderness of the tooth which is often relieved by application of pressure. • In time tooth is slightly extruded from socket. • Patient may complains of high to bite on. • Tooth has increased mobility • Pulp is usually non vital www.indiandentalacademy.com
  18. 18. • Chronic type: generally presents no clinical features. • Acute exacerbation of chronic periapical abscess is known as PHOENIX ABSCESS. • If untreated frequently forms a sinus tract permitting the pus drains into surface • Proliferation of granulation tissue often forms the surface and is reffered as parulis www.indiandentalacademy.com
  19. 19. Radiographic findings: In acute type inflammation of periapical area forces the tooth slightly from socket creating increased PDL space. In chronic type peripheral ill defined radiolucency with possibility of hyperostotic border. www.indiandentalacademy.com
  20. 20. D/D: periodontal abscess  secondarily infected primary tumor  periapical granuloma  periapical cyst  non odontogenic cysts www.indiandentalacademy.com
  21. 21. • Management: Immediate drainage of pus Oral penicillin Metranidazole www.indiandentalacademy.com
  22. 22. Radiographs of periapical abscess www.indiandentalacademy.com
  23. 23. PERIAPICAL CYST • Also called radicular cyst or root end cyst or apical periodontal cyst. • cyst is defined as pathologic cavity lined by epithelium containing liquid or semi liquid or gaseous substance. • It is inflammatory, odontogenic cyst. • Origin from cell rests of malaseez of PDL cells and remnants of hertwig epithelial root sheath. • Originates from pre existing periapical granuloma. www.indiandentalacademy.com
  24. 24. • Pathogenesis: Proliferating epithelial nests increase in size, central cells starts to degenerate and liquefy b/c of ischemia to central cells. The sequence of events leads to formation of liquefied cavity lined by epithelium. • It is true cyst because it contains epithelial lining. www.indiandentalacademy.com
  25. 25. • C/F: mostly involves lateral incisors • Asymptomatic, if it becomes infected swelling and painful symptoms develop • Pulps are nonvital • If untreated slowly enlarge and causes expansion of cortical pates • Dome like swelling is seen on alveolus over periapical region of involved tooth • Aspiration of non infected cyst produces a light straw colour fluid contains abundence of cholesterol www.indiandentalacademy.com
  26. 26. R/G: Well circumscribed radiolucency surrounding the apex of the tooth grater than 1.6cm surrounded by radiopaque border. D/D: periapical granuloma periapical scar surgical defect periapical cemento osseous dysplasia traumatic bone cyst periodontal disease mandibular infected buccal cyst www.indiandentalacademy.com
  27. 27. Radiographs of periapical cyst www.indiandentalacademy.com
  28. 28. • PERIAPICAL SCAR : in teeth that have been endodontically treated for granulomas and cysts and are assumed to be well sealed, a persistent, asymptomatic non enlarging radiolucency is mostly a periapical scar • Mostly occurring in the region of anterior maxilla • It is composed of dense fibrous tissue and situated at the apex of pulpless tooth. • Tooth is asymptomatic and associated radiolucency is constant in size. www.indiandentalacademy.com
  29. 29. Periapical scar radiograph www.indiandentalacademy.com
  30. 30. • SURGICALDEFECT: Asymptomatic radiolucency that persists after root resection. • That portion of bone fails to form osseous tissue • Extraction socket also form surgical defect www.indiandentalacademy.com
  31. 31. Surgical defect www.indiandentalacademy.com
  32. 32. • MANAGEMENT OF RADICULAR CYST: • Non surgical endodontic treatment • RCT with apicoectomy • When large cysts destroyed considerable amount of bone surgical approach should be performed 1.surgical enucleation 2.surgical enucleation and restoration of defect with graft mostly autogenous bone graft. www.indiandentalacademy.com
  33. 33. • 3.marsupilisation • 4.decompression • 5.decompression with delayed enucleation • 6.creation of common chamber with the maxillary sinus or nasal mucosa www.indiandentalacademy.com
  34. 34. • TRAUMATIC BONE CYST: Also called haemorrhagic bone cyst, solitary bone cyst, simple bone cyst • It is false cyst b/c it does not have epithelial lining • C/F: h/o trauma • asymptomatic • Mandibular premolar and molar regions are most commonly involved • Usually affects age under 25 yrs. • Associated teeth are vital www.indiandentalacademy.com
  35. 35. • R/G: A well defined radiolucency above mandibular canal round to oval and may be positioned symmetrically about periapex of the root • Aspiration usually a fruitless but sometimes sero sanguinous fluid or sometimes blood • TREATMENT: surgical excision www.indiandentalacademy.com
  36. 36. Traumatic bone cyst www.indiandentalacademy.com
  37. 37. • PERIAPICAL CEMENTO OSSEOUS DYSPLASIA: • Also known as periapical cementoma • Reactive fibroosseous lesion and thought to arise from the elements in periodontal ligament • C/F: usually affects middle age group • Asymptomatic • Affects most commonly man ant teeth • Associated teeth are vital www.indiandentalacademy.com
  38. 38. R/G: 3 stages of development 1.early osteolytic or fibroblastic stage: unilocular radiolucency at apices of teeth 2.mixed radiolucent and radiopaque 3.calcified stage: radiopacity surrounded by padiolucent borders www.indiandentalacademy.com
  39. 39. PCOD www.indiandentalacademy.com
  40. 40. D/D : Anatomic radiolucencies Pulpoperiapical radiolucencies Traumatic bone cyst Malignancys Cementoblastoma Cemento ossefying fibroma Focal cemento osseous dysplasia www.indiandentalacademy.com
  41. 41. • CEMENTOBLASTOMA:benign mesenchymal odontogenic neoplasm • Attached to apex of man premolars and molars • Usually detected in calcified stage • CEMENTO OSSIFYING FIBROMA: • Occurs in younger people • Mostly premolar region • Potential to be a large lesionwww.indiandentalacademy.com
  42. 42. • TREATMENT : no treatment necessary www.indiandentalacademy.com
  43. 43. • OSTEOMYELITIS: occasionally periapical abscess develops into acute or chronic osteomyelitis. • Defined as infection of bone involves periosteum, cortex, marrow. • 2types: acute and chronic • Acute stage does not produce any radiographic changes. • Associated tooth is non vital. www.indiandentalacademy.com
  44. 44. • Chronic stage produces 4 distinct r/g images: • Completely radiolucent • Mixed radiolucent and radiopaque • Completely radiopaque • Proliferative osteitis www.indiandentalacademy.com
  45. 45. osteomyelitis www.indiandentalacademy.com
  46. 46. • D/D: chronic dento alveolar abscess infected malignant tumor pagets disease complicated with osteomyelitis eosinophilic granuloma www.indiandentalacademy.com
  47. 47. Management: • Pharmocological treatment: penicillin, metronidazole clindamycin,cephalosporins • surgical management www.indiandentalacademy.com
  48. 48. • NON RADICULAR CYSTS: on occasion non radicular cysts maybe project over the apices of teeth, they are • Incisive canal cyst • Mid palatine cyst • Median mandibular cyst • Primordial cyst www.indiandentalacademy.com
  49. 49. Nasopalatine duct cyst • Cyst like radiolucency larger than 2cm is present over the apex of vital max central incisor and can be projected away from the apex by changing horizontal angulation at a second radiograph is taken the most likely diagnosis is incisive canal cyst • Heart shaped radiolucency between roots of two central incisors www.indiandentalacademy.com
  50. 50. Nasopalatine cyst www.indiandentalacademy.com
  51. 51. Median palatal cyst • Located in midline of hard palate between two lateral palatal processes. • Arises from epithelium entrapped along the line of fusion of palatal processes of maxilla. • A well circumscribed radiolucency opposite to bicuspid and molar region www.indiandentalacademy.com
  52. 52. REFERENCES: • Differential diagnosis of oral and maxillofacial lesions-Norman k.wood and Paul w.Goaz Textbook of oral pathology-Shafers 6th edition • Brad w.Neville and Carl M.Allen • Oral radiology principles and interpretation 6th edition STUART C.WHITE,MICHAEL J.PHAROAH www.indiandentalacademy.com
  53. 53. www.indiandentalacademy.com
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