Radiographic Differential Diagnosis 2008

Radiographic differentialRadiographic differential
diagnosis of common oraldiagnosis of common oral
diseasesdiseases
Dr. Suresh.C.S. BDS; MDS; MDSc (UK)Dr. Suresh.C.S. BDS; MDS; MDSc (UK)
College of Dentistry, KFU,College of Dentistry, KFU,
Dammam, KSA.Dammam, KSA.

ClassificationClassification
- Anatomical- Radiolucent; Radiopaque.Anatomical- Radiolucent; Radiopaque.
- PathologicalPathological
- Radiolucent –- Radiolucent – unilocular/multilocularunilocular/multilocular
- Radiopaque- Radiopaque
- Mixed- Mixed
------ Solitary / Multiple.------ Solitary / Multiple.

Classification-pathologicalClassification-pathological
RadiolucentRadiolucent – Contacting tooth– Contacting tooth
- Not contacting tooth- Not contacting tooth
MixedMixed – Contacting tooth– Contacting tooth
RadiopaqueRadiopaque – Contacting tooth– Contacting tooth

Classification-pathologicalClassification-pathological
Radiolucent – Contacting toothRadiolucent – Contacting tooth
1. Periapical1. Periapical
- Usually sequelae of pulpitis.- Usually sequelae of pulpitis.
Periapical granuloma; Radicular cyst; Abcess;Periapical granuloma; Radicular cyst; Abcess;
Osteomyelitis, Periapical cementoma.Osteomyelitis, Periapical cementoma.
2.2. PericoronalPericoronal
Follicular spaces; Dentigerous cysts; Ameloblastoma;Follicular spaces; Dentigerous cysts; Ameloblastoma;
Adeno ameloblastoma.Adeno ameloblastoma.

Periapical-radiolucentPeriapical-radiolucent
Periapical granulomaPeriapical granuloma – well circumscribed, rounded– well circumscribed, rounded
-around apex. May’ve thin radiopaque border. Tooth may-around apex. May’ve thin radiopaque border. Tooth may
have deep caries/restorations. Tooth-non-vital.have deep caries/restorations. Tooth-non-vital.

Radicular cystRadicular cyst –– involve apex of permanent tooth. Untreatedinvolve apex of permanent tooth. Untreated
cyst slowly enlarge, expand and thin cortex – crackling soundcyst slowly enlarge, expand and thin cortex – crackling sound
(crepitus). If infected, all painful symptoms of an abscess develops.(crepitus). If infected, all painful symptoms of an abscess develops.

chronic & acute Dento alveolar abscesschronic & acute Dento alveolar abscess::
 Small/large radiolucencies.Small/large radiolucencies.
 May have cortical expansion.May have cortical expansion.
 Associated tooth- non is vital.Associated tooth- non is vital.
 Teeth with a/c abscess –pain to percussion (high to bite on )Teeth with a/c abscess –pain to percussion (high to bite on )
- PDL abscess originating in deep PDL pocket – PA- PDL abscess originating in deep PDL pocket – PA
radiolucency + intra bony Pocket;radiolucency + intra bony Pocket; pulp vital usuallypulp vital usually..

Periapical abscessPeriapical abscess

Osteomyelitis:Osteomyelitis:
 Seen rarely in maxilla (due to rich blood supply).Seen rarely in maxilla (due to rich blood supply).
 Non vital pulp, sensitive to percussion or associated with acuteNon vital pulp, sensitive to percussion or associated with acute
or chronic PA abscess.or chronic PA abscess.
 Borders: poorly defined and ragged.Borders: poorly defined and ragged.
Sinus tract –Sinus tract –
 if present, appears as a radiolucency from the PA radiolucencyif present, appears as a radiolucency from the PA radiolucency
through the cortical plate opening on the skin or mucosa.through the cortical plate opening on the skin or mucosa.
If sequestrum seen (segment of dead bone) & largeIf sequestrum seen (segment of dead bone) & large
enough, it appears radiopaque within a radiolucency.enough, it appears radiopaque within a radiolucency.

Osteomyelitis
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102:94-8)

- PACOD (Periapical cementoma):PACOD (Periapical cementoma):
 its early stage: round well defined borders,its early stage: round well defined borders,
associated with vital tooth.associated with vital tooth.
 Usually in mandibular incisors; asymptomatic.Usually in mandibular incisors; asymptomatic.
 If it’s a pulpo-periapical lesion: non vital pulp.If it’s a pulpo-periapical lesion: non vital pulp.

Periapical Cemental Dysplasia

Pericoronal - radiolucentPericoronal - radiolucent
Follicular spaceFollicular space::
 Surrounding crowns of unerupted teeth.Surrounding crowns of unerupted teeth.
 Homogenous radiolucent halo with a thin outer radiopaqueHomogenous radiolucent halo with a thin outer radiopaque
border, that is continuous with LD.border, that is continuous with LD.
 Normal follicular spaces usually decrease in size with age.Normal follicular spaces usually decrease in size with age.

Dentigerous cystDentigerous cyst: Mostly: Mostly
 mandibular 3mandibular 3rdrd
molarmolar
 maxillary- Cmaxillary- C
 mandibular - premolarmandibular - premolar
 maxillary- 3maxillary- 3rdrd
MolarMolar
AmeloblastomaAmeloblastoma – Infiltrate bone– Infiltrate bone

Adeno ameloblastomaAdeno ameloblastoma – (AOT)-– (AOT)-
 Benign & non-invasive.Benign & non-invasive.
 It differs from ameloblastoma.It differs from ameloblastoma.
 AOT-slow growing tumor, doesn’t infiltrate bone.AOT-slow growing tumor, doesn’t infiltrate bone.
 Displace teeth but doesn’t cause root resorption.Displace teeth but doesn’t cause root resorption.
 Common in anterior maxilla.Common in anterior maxilla.
 Expand cortical plate, produces clinical swelling,Expand cortical plate, produces clinical swelling,
no soft tissue invasion.no soft tissue invasion.

Radiolucencies- not contacting teethRadiolucencies- not contacting teeth
- Inter radicularInter radicular
- Solitary cyst – likeSolitary cyst – like
- MultilocularMultilocular
- Solitary, ragged, poorly defined bordersSolitary, ragged, poorly defined borders
- Multiple separateMultiple separate
- Generalized rarefactionGeneralized rarefaction

Inter radicular radiolucenciesInter radicular radiolucencies :: That occur b/w roots ofThat occur b/w roots of
teeth.teeth.
periodontal pocket:periodontal pocket:
 periodontal bone loss (horizontal vertivcal) appear onperiodontal bone loss (horizontal vertivcal) appear on
films.films.
 Occurs closer to involved tooth contacting its surface.Occurs closer to involved tooth contacting its surface.
 Confirmed diagnosis by placing a periodontal probe intoConfirmed diagnosis by placing a periodontal probe into
the defect.the defect.

Furcation involvementFurcation involvement::
 Seen in advanced periodontal disease.Seen in advanced periodontal disease.
 Produces furcation involvement.Produces furcation involvement.
 Usually seen in mandibular molars,Usually seen in mandibular molars,
where bifurcation is devoid of bone &where bifurcation is devoid of bone &
shows a radiolucency.shows a radiolucency.
 Usually a probe can be introd. intoUsually a probe can be introd. into
bifurcation area from the B/L aspect.bifurcation area from the B/L aspect.
 LD remains intact in furcation in normalLD remains intact in furcation in normal
furcationfurcation..

 Lateral Radicular cystLateral Radicular cyst::
 Associated with non vital pulp.(near to lateral accessoryAssociated with non vital pulp.(near to lateral accessory
canal opening).canal opening).
 If infected, pain, swelling occur on offending tooth;If infected, pain, swelling occur on offending tooth;
sensitive to percussionsensitive to percussion

Primordial cystPrimordial cyst::
 Cyst like radiolucencies,Cyst like radiolucencies,
 not contacting tooth.not contacting tooth.
 May occur in a region where a toothMay occur in a region where a tooth
may’ve failed to develop.may’ve failed to develop.
Odontogenic tumorsOdontogenic tumors::
 Usually Odontomas.Usually Odontomas.
 Freq seen as inter radicularFreq seen as inter radicular
radiolucencies.radiolucencies.
 In its radiolucent stage: cyst like withIn its radiolucent stage: cyst like with
a well defined border.a well defined border.
Odontomas

Globulomaxillary cystGlobulomaxillary cyst::
 Asymptomatic.Asymptomatic.
 If large, expands cortical plate buccally;If large, expands cortical plate buccally;
 if secondary infected, pain.if secondary infected, pain.
 Inverted tear shaped radiolucency.Inverted tear shaped radiolucency.

Incisive canal cystIncisive canal cyst::
 Cyst like radiolucency.Cyst like radiolucency.
 Maxillary central incisor.Maxillary central incisor.
 Often – antr nasal spine is seen over the supr portion of the cyst as aOften – antr nasal spine is seen over the supr portion of the cyst as a
radiopaque shadow, thus producing a Heart- shaped radiolucency.radiopaque shadow, thus producing a Heart- shaped radiolucency.

MalignancieMalignancies:s:
 May begin in inter septal bone and usually present as radiolucencies withMay begin in inter septal bone and usually present as radiolucencies with
poorly marginated borders.poorly marginated borders.
 If they involve PDL early in their development, charact. pds a band likeIf they involve PDL early in their development, charact. pds a band like
widening image of PDL.widening image of PDL.
Lateral periodontal cystLateral periodontal cyst::
 More in mandibular Canine & premolar.More in mandibular Canine & premolar.
 Adjacent teeth’ve vital pulpsAdjacent teeth’ve vital pulps..
 Round/oval, well defined, often with sclerotic border.Round/oval, well defined, often with sclerotic border.

 Median mandibular cystMedian mandibular cyst: Occurs in symphyseal: Occurs in symphyseal
region of L/jaw. If the adj teeth are non-vital, it isregion of L/jaw. If the adj teeth are non-vital, it is
usually a radicular cyst.usually a radicular cyst.

Solitary cyst like:Solitary cyst like:
Post extraction socketPost extraction socket: sometimes show cyst like radiolucency after: sometimes show cyst like radiolucency after
extraction. H/o extn exists.extraction. H/o extn exists.
Residual cystResidual cyst: Is a radicular/ another cyst that has remained after its: Is a radicular/ another cyst that has remained after its
associated tooth has been lost. Usually over 20 yrs & more inassociated tooth has been lost. Usually over 20 yrs & more in
Maxilla.Maxilla.

 Lingual MNDlr bone defect (Stafne’s cyst):Lingual MNDlr bone defect (Stafne’s cyst):
 Invagination in the median surface of mandible.Usually 3Invagination in the median surface of mandible.Usually 3rdrd
M, angle area.M, angle area.
 Located inferior to mandibular canal in 3Located inferior to mandibular canal in 3rdrd
molar area.molar area.
 Asymptomatic, Unilocular/multilocular, lined by cortexAsymptomatic, Unilocular/multilocular, lined by cortex

Odontogenic Keratocyst (OKC)Odontogenic Keratocyst (OKC)::
 Usually in 2Usually in 2ndnd
& 3& 3rdrd
decades.decades.
Findings suggestive of OKC:Findings suggestive of OKC:
1. Cyst like radiolucency in MNDlr 31. Cyst like radiolucency in MNDlr 3rdrd
M region/ ramus.M region/ ramus.
2. A diameter of > 3 cm.2. A diameter of > 3 cm.
3. Unilocular cyst like radiolucency with scalloped margins.3. Unilocular cyst like radiolucency with scalloped margins.
4. Multilocular cyst.4. Multilocular cyst.
5. Odorless, creamy or caseous contents on aspiration.5. Odorless, creamy or caseous contents on aspiration.

OKC

Primordial cyst:Primordial cyst: B/w 10 & 30 yrs. MNDlr 3B/w 10 & 30 yrs. MNDlr 3rdrd
M. rarely produces corticalM. rarely produces cortical
expansion. Usually in areas where a tooth failed to develop.expansion. Usually in areas where a tooth failed to develop.

AmeloblastomaAmeloblastoma::
 Asymptomatic initially.Asymptomatic initially.
 Expands, perforates cortical plates.Expands, perforates cortical plates.
 Feels firm if it is of solid type.Feels firm if it is of solid type.
 Cystic type is soft & fluctuant and straw colored fluid canCystic type is soft & fluctuant and straw colored fluid can
be aspirated in some cases.be aspirated in some cases.

Multilocular type:Multilocular type:
Terms – Soap bubble, honey comb and tennisTerms – Soap bubble, honey comb and tennis
racket – used to describe the variousracket – used to describe the various
radiographic images of multilocular lesions.radiographic images of multilocular lesions.

Soap bubble appearance

AmeloblastomaAmeloblastoma: Multilocular type may be of soap bubble/honey comb: Multilocular type may be of soap bubble/honey comb
variety.variety.

Solitary radiolucencies with ragged & poorlySolitary radiolucencies with ragged & poorly
defined borders:defined borders:
Chronic osteitis & osteomyelitisChronic osteitis & osteomyelitis::
 Inflammation of bone caused by pathogenicInflammation of bone caused by pathogenic
microorganism,microorganism,
 Osteitis: when just alveolar bone is affected.Osteitis: when just alveolar bone is affected.
 If basal bone of jaws is involved, this process isIf basal bone of jaws is involved, this process is
Osteomyelitis.Osteomyelitis.

Multiple separate, well definedMultiple separate, well defined
radiolucencies:radiolucencies:
- Multiple cysts/granulomasMultiple cysts/granulomas

Generalized rarefactions of jaw bones:Generalized rarefactions of jaw bones:
-Hyperparathyroidism-Hyperparathyroidism::
-Osteoporosis-Osteoporosis::

Osteoporosis

Mixed lesions – contacting toothMixed lesions – contacting tooth
Mixed lesions assoc: with teeth:Mixed lesions assoc: with teeth:
1.1. Peri apical mixed lesions.Peri apical mixed lesions.
2.2. Pericoronal mixed lesions.Pericoronal mixed lesions.
Peri apical mixed lesions:Peri apical mixed lesions:
Calcifying crown of developing toothCalcifying crown of developing tooth::

Calcifying crowns of
-developing teeth

Calcified material with in an intermediate stage odontomaCalcified material with in an intermediate stage odontoma

Pericoronal mixed lesions:Pericoronal mixed lesions:
Odontoma – intermediate stageOdontoma – intermediate stage..

Mixed lesions – not contacting toothMixed lesions – not contacting tooth
1.1. Healing surgical siteHealing surgical site: h/o Surgery.: h/o Surgery.
2.2. chronic Osteomyelitischronic Osteomyelitis::

RadiopacitiesRadiopacities
Contacting toothContacting tooth – Periapical radiopacities– Periapical radiopacities
Not contacting toothNot contacting tooth ––
- Solitary- Solitary
- Multiple separate- Multiple separate
- Generalized opacification- Generalized opacification

Radiopacities contacting toothRadiopacities contacting tooth
Periapical radiopacities:Periapical radiopacities:
1.1. Condensing or sclerosing osteitisCondensing or sclerosing osteitis::
Sclerosis of bone induced by an inflamm.Sclerosis of bone induced by an inflamm.
or infec. that most often occurs as aor infec. that most often occurs as a
pulpo periapical lesion. Non-vital teeth.pulpo periapical lesion. Non-vital teeth.
Usually in MND – 1Usually in MND – 1stst
M & PM.M & PM.

2.2. Mature periapical cemental dysplasiaMature periapical cemental dysplasia

Periapical Cemental Dysplasia

Solitary radiopacities not contacting toothSolitary radiopacities not contacting tooth
True intra bony radiopacities:True intra bony radiopacities:
a.a. Tori.Tori.
b.b. Unerupted, impacted & supernumeraryUnerupted, impacted & supernumerary
teeth.teeth.
c.c. Retained roots.Retained roots.
d.d. Focal & diffuse sclerosing osteomyelitisFocal & diffuse sclerosing osteomyelitis

Multiple separate radiopacities not contacting toothMultiple separate radiopacities not contacting tooth
1.1. Tori & exostosesTori & exostoses
2.2. Multiple retained rootsMultiple retained roots
Mandibular tori

Multiple separate radiopacities not contacting toothMultiple separate radiopacities not contacting tooth
3. Multiple hypercementosis3. Multiple hypercementosis
4. Multiple embedded/impacted teeth4. Multiple embedded/impacted teeth
Hypercementosis

Generalized radiopacitiesGeneralized radiopacities
D/d of Gen. radiopacities of jaw bones:D/d of Gen. radiopacities of jaw bones:
 OsteopetrosisOsteopetrosis
 Normal variations in form & density.Normal variations in form & density.

Generalized radiopacitiesGeneralized radiopacities
Dense radiographic images of the jaw bonesDense radiographic images of the jaw bones
may be seen in patients who have heavymay be seen in patients who have heavy
jaw bones or are over weight.jaw bones or are over weight.
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Radiographic Differential Diagnosis 2008

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