PERIAPICAL RADIOLUCENCIES رادیولوژی های پری آپیکال

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!۱ Radiolucent; Radiopaque. Pathological = Radiolucent — uniacular/mutioc ‏و‎ ‎- Mixed Solitary / Multiple. Classification-pathological ۱9 ‏نادم‎ ‎۶ tooth ره ‎coe‏ رز ۶ Radiopaque — Contacting tooth - Not contacting tooth 

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INTRODUCTION *Radiolucent shadows cast partially over the periapical regions of the tooth in practically all oral radiographic survey of dentulous patients. *The radiolucent shadows *Anatomic *pathologic 

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**ANATOMIC RADIOLUCENCIES Unilocular: mental foramen Multilocular: maxillary sinus ,bone marrow spaces *PATHOLOGIC RADIOLUCENCIES(Pulp and Periapical Radiolucencies): Inflammation in pulp;pulp necrosis periapical granuloma, periapical abscess,periapical cyst, actinomycosis,sinus mucosal hyperplasia, Osteomyeliti 

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*BENIGN; traumatic bone cyst nasopalatine duct cyst adenomatoid odontogenic tumo. periapical cemento osseous dysplasia vascular malformations like central haemangioma ossyfying fibroma 

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*BENIGN AGGRESSIVE: odontogenic keratocyst central gaint cell granuloma odontogenic myxoma calcifying epithelial odontogenic tumor ameloblastoma *MALIGNANT: metastatic 

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TRUE PERIAPICAL RADIOLUCENCIES; represent lesions that truly contacting apex of the tooth, their shadow cannot be changed by taking additional radiographs at different angles FALSE PERIAPICAL 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 

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Mental ۷۵ 

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Maxillary sinus 

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PERIAPICAL GRANULOMA : *Most common pathologic lesion with Radiolucent appearance *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 

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*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 

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DISEASE MECHANNISM cae pea amon ‏ترارح‎ ‎5 ‎Necrotc Pulp —> Apical periodontitis i Chrono ۱ 0 FIG. 20-1 Interrelationship of possible results of periapical inflammation. * > 2.5 cm diameter : choronic dentoalveolar abcess 

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۰ ۳۴۶۸۲۱۳۴5 5۱6665۲۱۷۲ 0۴ ۵۱ PULPS: ¢ History of trauma ¢ History of painful pulpitis ¢ Dark hue of crown ٠ Large cavity ٠ Large restoration ¢ Draining sinus tract ۰ Dens in dente ۰ Fracture of the root ۰ Fracture of crown 

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Periapical granuloma 

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INVESTIGATIONS: ¢ radiography TREATMENT: ¢ root canal treatment 

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PERIAPICAL ABSCESS « Abscess is defined as a focal localized collection of purulent inflammatory material in tissues Also called dentoalveolar abscess Subdivided into 2 types :depend upon their radiolucency primary or neoteric secondary or recrudescent 

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Primary: associated with tooth does + not developed apparent periapical radiolucency No Radiographic changes just widening of PDL space Secondary: developed in pre existing « peri apical lesion,eg;granuloma,cyst or scar. 

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:Acute abscess infection is usually acute and exudative involving periodontal tissues at the apex of the tooth -with necrotic pulp Initial stages produces ۰ 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 ۰ Pulp is usuallv non vital ٠ 

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:Chronic type + -generally presents no clinical features Acute exacerbation of chronic ٠ 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 

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: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 Periapical radiolucency is indeed a secondary abcess 

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D/D: periodontal abscess #secondarily infected primary tumor be periapical granuloma 4 periapical cyst $e non odontogenic cysts 

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:Management ٠ Immediate drainage of pus Oral penicillin Metranidazole 

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periapical abscess 

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PERIAPICAL CYST ** Second most common pulp and periapical lesion. ** Most common odontogenic 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 ۰ Origin from cell rests of malaseez of PDL ٠ cells and remnants of hertwig epithelial .root sheath Nearly ALL Originates from pre existing ٠» 

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۷۰ ۴۵۲۳۱۵6۳0۵۵: 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. 

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۰/۴: mostly involves Permanent lateral incisors Decidous:molars ۰ Asymptomatic, if it becomes infecte: swelling and painful symptoms develo; ¢ Pulps are nonvital ¢ If untreated slowly enlarge and causes expansion of cortical pates * Dome like swelling is seen on alveol over periapical region of involved tooth ¢ Aspiration of non infected cyst produces a light straw colour fluid contains abundence of cholesterol 

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*R/G: *Well circumscribed radiolucency surrounding the apex of the tooth >1.6cm surrounded by radiopaque border. *D/D: periapical granuloma, periapical scar, surgical defect, PCOD, traumatic bone cyst, periodontal disease, mandibular infected buccal cyst *Radicular Cyst and granuloma are distinguishable Radiographically BU radiolucency with diameter of more t| and cortical boundry is more related 

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periapical cyst 

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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 i mostly a periapical scar * Mostly occurring in the region of anterio maxilla ٠ It is composed of dense fibrous tissue anq situated at the apex of pulpless tooth. (2-5 © Tooth is asymptomatic and associated radiolucency is constant in size. Well defined radiolucency smaller than cyst or granoluma 

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Periapical scar 

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SURGICAL DEFECT Fig. ©. Intraoral peraprst radiograph showed well Asymptomatic radiolucency that persists after root resection. Both buccal and lingual plates are disruped. ¢ That portion of bone fails to form osseous tissue ¢ Extraction socket also form surgical defect Round,well defined borders,not larger than 1 cm in diameter 

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Surgical defect 

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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 and Intact Lamina Dura 

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¢ R/G: A well defined radiolucency above mandibular canal round to oval and may be positioned symmetrically about periapex of the root Between roots,scalloped appearance ¢ Aspiration usually a fruitless but sometimes blood 

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*DD: *Radicular cyst *PCOD:age,location,size(less than 0.7 cm) *KOT 

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PERIAPICAL CEMENTO - Also ‏دمم هلا نک ولو مرسمه‎ eR i ‘ i h hi to arise 7 1 ligament ° C/F: usually affects women at middle age group ° Asymptomatic ° Affects most commonly mandible- ant teeth ۰ Associated teeth are vital 

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R/G: 3 stages of development l.early osteolytic or fibroblastic stage: unilocular radiolucency at apices of teeth(mandibular incisors) Multiple Round Wel! defined Radiolucencies;vital pulps -no LD 2.mixed radiolucent and radiopaque 3.calcified stage: radiopacity surrounded by radiolucent borders 

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0/0 : Anatomic radiolucencies Pulpoperiapical radiolucencies Traumatic bone cyst Focal cemento osseous dysplasia Cemento ossefying fibroma Cementoblastoma Malignancy 

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:0 ۹ 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. 

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Initial source is a necrotic pulp lesion is restricted Periapical inflammatory lesion Infection spreads in the bone marrow ls not restricted to the root apex Osteomyelitis 

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Rapid onset Pain Swelling of the adjacent soft tissues Fever lymphadenopathy Leukocytosis Mobile & Sensitive teeth Paresthesia of the lower lip 

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¢ Chronic stage produces 4 distinct r/g images: ٠ Completely radiolucent ¢ Mixed radiolucent and radiopaque ¢ Completely radiopaque ¢ Proliferative osteitis 

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CT image of mukiple sequesra 

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Examples of sequestra, 

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Osteomyelitis of the mandible with a periosteal reaction located at the inferior cortex 

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Proliferative periostitis resulting from inflammatory lesions 

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OFibrous dysplasia (especially in children) Malignant neoplasia (e.g, Osteosarcoma, Squamous cell carcinoma} DLangerhans* cell histiocytosis QLeukemia Olymphoma 

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Y Chronic diffuse sclerosing osteomyelitis Chronic nonsuppurative osteomyelitis Y Chronic osteomyelitis with proliferative periostitis ¥ Garr é° s chronic nonsuppurative sclerosing osteitis 

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»A sequela of inadequately treated acute osteomyelitis » Arise de novo 

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> Location Posterior mandible most commonly > Periphery Better defined than in the acute phase Internal structure Regions of greater and lesser radiopacity... More chronic lesions are exceedingly radiopaque... > Effects on Surrounding Structures Periosteal new bone (similar to onion skin) Outer contour of mandible altered External root resorption, LD less apparent, PDL enlarged May develop draining fistula 

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A fistuious tract extending A fistulous tract extending through inferiorly from the apex of the the buccal cortical plate first molar through the inferior cortex of the mandible 

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¥ Fibrous dysplasia Paget disease of bone ¥ Osteosarcoma Y Langerhans’ cell histiocytosis ¥ Leukemia ¥ Lymphoma 

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i 322 osteomyelitis 

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NON RADICULAR CYSTS: © on occasion non radicular cysts maybe project over the apices of teeth, the common forms are: ¢ Incisive canal cyst ¢ Mid palatine cyst 

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Nasopalatine duct * Cyst like radio St 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 radiq roots of two central — 

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Nasopalatine cyst 

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Median palatal cyst ¢ Located in midline of hard palate between two lateral palatal processes. ¢ A well circumscribed rac opposite to bicuspid and molar region