Solitary radiolucencies with ragged & poorly defined bordersSeyed mohammad reza masoumiStudent Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

Most common lesions includethe following:

• CHRONIC OSTEITIS• CHRONIC OSTEOMYELITIS• HEMATOPOIETIC BONE MARROW DEFECT• FIBROUS DYSPLASIA-EARLY LESION• OSTEOSARCOMA• CHONDROSARCOMA• METASTATIC TUMORS TO THE JAWS• SQUAMOUS CELL CARCINOMA

Chronic osteitis (chronic alveolar abscess)

Chronic osteitis (chronic alveolar abscess)• Inflammation or infection usually occurs around the roots of a

tooth• inciting tooth is pulpless and usually tender to percussion. • A sinus may be present and may pass through the alveolar

bone to open onto the mucosa generally near the level of the apex.

Differential diagnosis

• The presence of an intraalveolar draining sinus is not conclusive evidence that a radiolucent area is a chronic osteitis, an abscess, or osteomyelitis.

Management

• Extraction• RCT• Curettage and

microscopic evaluation for rejection of malignancies.

OSTEOMYELITIS

• The most common location is the posterior body of the mandibleIs an inflammation of the bone caused by pathogenic microorganisms

• The disease process is empirically considered osteitis when just the alveolar bone is affected.

• If the basal bone of the jaws is involved, the process is considered osteomyelitis

• This infectious process creates an effective barrier to viable bone and vascularization.

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Radiographic features

• The hallmark of osteomyelitis is the development of sequestra.

• periosteal reaction is a characteristic but not pathognomonic• Osteomyelitis of the mandible most frequently occurs in the

body radiographically an early acute osteomyelitis does not show bony changes because of the rapid onset.

• lesion often appears as a somewhat linear radiolucency with ragged borders possibly varying in width as it follows the fracture line through the bone

• Often the surrounding bony borders are denser than the adjacent normal bone.

The types of osteomyelitis are listed belowI. Acute osteomyelitis2. Chronic osteomyelitis3. Proliferative periostitis4. Sclerosing osteomyelitis

OSTEOMYELITIS

Chronic osteomyelitis

• Recurrent chronic supportive osteomyelitis of the mandible

Chronic osteomyelitis

• spotty areas of osteolysis and reactive sclerosis, which are rendered even more visible along the course of the mandibular canal.

Differential diagnosis

• Very sclerotic, radiopaque chronic lesions of osteomyelitis may be difficult to differentiate from fibrous dysplasia, Paget's disease, and osteosarcoma.

HEMATOPOIETIC BONE MARROW DEFECT

• It can appear as a radiolucent lesion with ragged, poorly defined border

• Usually the suspicion index is so low with these lesions that the clinician chooses to radiograph the lesion in 3 to 6 months‘ time to ensure that it is not enlarging.

FIBROUS DYSPLASIA• a hamartomatous fibroosseous lesion not of periodontal

ligament origin• in its early stage• The solitary (monostotic) form of fibrous dysplasia, which

accounts for 70% of all cases• Fibrous dysplasia involves the maxilla almost twice as often as

the mandible and occurs more frequently in the posterior aspect

• Radiolucent to radiopaque• Trabecular, wispy and finger print pattern when progression of

lesion is seen.

FIBROUS DYSPLASIA

Differential diagnosis

• Metabolic bone diseases such as hyperparathyroidism • Paget's disease• Osteomyelitis• cementoossifying fibroma• Osteosarcoma

Osteosarcoma • Malignant neoplasm of bone�• New bone is produced by the lesion (not by reactive bone �

formation of surrounding osteoclasts)• Three major types�1. Chondroblastic2. Osteoblastic3. Fibroblastic

Clinical Features• Rare. Jaws account for only 7% of all osteosarcomas• 2:1 Male: Female ratio�• Peak in 4th decade�• Initially reported due to swelling or bleeding�

Osteosarcoma

Radiographic FeaturesLocation

• Location– More common in the mandible– Usually arises in the posterior mandible. the molar areas and ramus are most commonly affected– In maxilla, usually arises in the posterior.• The ridge, sinus, and palate

are most commonly affected

Borders and shape

• – Ill-defined– Radiolucent without capsule or surrounding osteosclerosis– If the periosteum is involved, sunray spicules (aka: “hair-on-end” trabeculae, or orthoradial striations) may be present

Radiographic Features• Effects on adjacent structures– Widening of the PDL– Destruction of cortices– May destroy or widen the cortex of the inferior alveolar canal

Differential diagnosis

• Chondrosarcoma• Metastatic tumors• Fibrooseuss lesions

Chondrosarcoma• Malignancy of cartilaginous origin�• Firm to hard bony mass of long duration�• Four subtypes�1. Clear cell2. Dedifferentiated3. Myxoid4. Mesenchymal• Occurs within the bone, peripheral to the bone, or, less �

commonly, in soft tissue• Mean age: 47 yrs Affects males and females equally�

Radiographic FeaturesLocation

• Location�– Unusual in the facial bones. Accounts for only 10% of all cases– Occurs equally in maxilla and mandible nearcartilage– Maxillary lesions tend toward the anterior, while mandibular lesions occur in the coronoid process, head of the condyle and neck, and sometimes in the mandibular symphysis

Borders and shape

• Borders and Shape�– Round, ovoid, or lobulated– Borders can range from smooth and well corticated to indistinct– If the periosteum is involved, sunray spicules (aka: “hair-on-end” trabeculae, or orthoradial• striations)

Chondrosarcoma

Radiographic Features

• Internal architecture– May appear as multilocular lucencies to highlycalcified lesions. Usual appearance is mixeddensity– Radiographic appearance – may be“flocculent” (snow-like)– “Moth eaten appearance” may be seen, amidislands of unaffected bone

Differential Diagnosis

• Osteosarcoma�• Benign fibro osseous lesions�• Odontogenic myxoma�• Fibroma�• Osteoma�• Ameloblastoma�• Central bone malignancies�

Metastatic Lesions

• Metastatic tumors are foci of malignant disease that �originated in a distant primary tumor

• Usual pathway is through the bloodstream metastases �located in the jaws generally arise from primary tumors located below the clavicles

• Usually, the primary has been discovered prior to the �discovery of jaw metastases

Clinical Features

• � Most common in 5th to 7th decade of life � Complaints may include:– Pain– Numbness– Paresthesia– Bleeding– Pathologic fracture of the mandible

Radiographic Features

• � Location– Posterior regions of the jaws– More common in: mandible > maxilla >maxillary sinus > anterior�hard palate> mandibular condyle– Metastases may be bilateral– Lesions may be located in the periodontalligament space. They may be confused withperiodontal or apical inflammatory lesions

Radiographic Features

Borders and Shape

– Moderately well-demarcated– Non-corticated borders– May also have ill-defined, invasive borders– Polymorphous in shape (i.e.: irregular)

Effects on adjacent structures

• – Effacement of the lamina dura– Widening of the PDL space– Periosteal reaction. May perforate corticesand form a soft tissue mass extraorally orintraorally– Teeth may “float” in a soft tissue mass andmay be displaced

Metastatic Lesions

Squamous Cell Carcinoma

• Since SCC is the most common malignant lesion inthe oral cavity, it is also the most common malignancy toproduce radiolucent lesions in the jawbones

Clinical Appearance

• Red, white, or mixed lesion�• Ulcerated�• Indurated or rolled borders�• Can be painful or painless�• Rubbery or hard lymph nodes that are “fixed” to underlying �

structures.• Usually occurs in patients >50 years�• More common in males�

Radiographic features

• � Location– Often on lateral border of the tongueTherefore, it is seen radiographically in theposterior mandible– Lesions in lip and floor of the mouth mayinvade anterior mandible– Ginigival lesions may initially mimicperiodontal disease

Radiographic features

• � Shape and Borders– Commonly irregular and ill-defined borders– Finger-like projections demonstrating invasion– Occasionally, the lesion may have smoothborders, indicating erosion– Pathologic fractures may occur. Sharp, thinedges may be evident

Radiographic features

• � Effects on adjacent structures– Periodontal ligament space will initially appearto widen. Eventually, teeth will appear to“float” in the lesion, and may be displaced aslesion expands– Tumor may spread along the mandibularcanal, giving a widened appearance– Adjacent cortical borders may be effaced(destroyed)

Squamous Cell Carcinoma