Carte

DANISIA HABA
Dento-maxillo-facial
Imaging
Gr T. Popa" Publishing House, U.M.F. IAI

2013
Cuprins
Description CIP National Library

HABA, Danisia
Dento-maxillo-facial Imaging / Danisia Haba - Iasi
Gr.T.Popa Publishing House, 2007.
Bibliography.
ISBN 978-973-7682-15-4
616.314-073.7
Scientific reviewers:
Prof. Dr. FLOAREA FILDAN - U.M.F. "Iuliu Haieganu" Cluj-Napoca
Prof. Dr. CONSTANTIN ZAHARIA - U.M.F. "Carol Davila" Bucharest
Cover: ing. Sorin Popescu
Made with funding from CNCSIS grant no. 1204/2006
"Gr T. Popa" Publishing House

University of Medicine and Pharmacy
Iasi, 16, Universitatii str.
edituraumfiasi@yahoo.com
"Gr T. Popa" Publishing House is recognized by the National Council of
Scientific Research in Higher Education (CNCSIS)
All rights to the works belong to the author and publishing house "Gr.T.
Popa". No part of this book may be copied or transmitted by any means,
electronic or mechanical, including photocopying, without written
permission from the author or publisher.
Pattern printing executed at the University of Medicine and Pharmacy "Gr
T. Popa"
Iasi, 16, University Street, Postal Code 700115
phone 0232 301678
2
CONTENTS
1. INTRODUCTION .............................................................................. 5
1.1 The numbering of the teeth ............................................................. 7
1.2. Developmental anomalies of maxillofacial region .......................... 8
2. DENTAL DECAY AND ITS COMPLICATIONS ......................... 33
2.1. Interproximal caries ..................................................................... 35
2.2. Occlusal caries ............................................................................. 37
2.3. Caries on buccal and lingual surfaces ........................................... 38
2.4. Root caries................................................................................... 39
2.5. Cavities in included teeth ............................................................. 40
2.6. Rampant caries ............................................................................ 40
2.7. Dental recurrent / secondary caries .............................................. 41
2.8. Radiographic evaluation of tooth decay and the proper treatment of
simple cavities .................................................................................... 41
3. MARGINAL PERIODONTAL DISEASES .................................... 63
3.1. Definition .................................................................................... 63
3. 2. Anatomical aspects ..................................................................... 63
3.3. Radiographical examination......................................................... 64
3.4. Classification of periodontal lesions............................................. 66
3.5. Radiographic aspects encountered in gingivitis ............................ 66
3.6. Radiographic aspects seen in periodontitis ................................... 67
3.7. Evaluation of the treatment ......................................................... 74
4. DENTO MAXILLO FACIAL TRAUMA .................................... 77
4.1. Introduction ................................................................................. 77
4.2. Classification ............................................................................... 77
4.3. Mandibular fractures.................................................................... 80
5. JAW AND CERVICO FACIAL SOFT TISSUE CYSTS .......... 105
5.1. Periapical tissues cysts ............................................................... 107
5.2. Odontogenic cysts ..................................................................... 111
5.3. Non odontogenic cysts ............................................................... 116
5.4. Cysts of unknown origin ............................................................ 126
5.5. Cysts of the soft cervico-facial parts .......................................... 127
6. MAXILLO FACIAL BENIGN TUMOR ...................................... 135

6.1. Maxillofacial odontogenic benign tumors ................................. 135
6.2. Neodontogen tumors.................................................................. 151
7. MALIGNANT TUMORS OF THE JAWS ................................... 159
AND ORAL CAVITY ........................................................................ 159
7.1. Malignant odontogenic tumors................................................... 159
7.2. Malignant neodontogen tumors .................................................. 168
8. JAWS BONES DYSTROPHIES AND OTHER
BONE INJURIES ............................................................................... 193
8.1.The osifiant fibroma ................................................................... 193
8.2. Fibrous Dysplasia ...................................................................... 196
8.3. Central giant cell granuloma ...................................................... 199
8.4. Cherubism ................................................................................. 201
8.5. Osteopetrosis, "marble bones disease"
(Albers-Schonberg Disease) ............................................................. 203
8.6. Paget's disease ........................................................................... 204
8.7. Recklinghausen neurofibromatosis ............................................ 205
8. 8. Hyperparatiroidian osteoporosis (Recklinghausen disease) ....... 205
8.9. Mesenchymal tissue hyperplasia ................................................ 206
9. THE TEMPORO MANDIBULAR JOINT ................................... 209
9.1. Anatomo - physiological aspects of TMJ ................................... 209
9.2. Radio-imaging TMJ exploration ................................................ 211
9.3. Radio-imaging aspects in TMJ lesions ....................................... 218
10. SALIVARY GLANDS .................................................................. 233
10.1. Anatomo- physiological aspects of the salivary gland .............. 233
10.2. The radio-imaging exploration of the salivary glands ............... 234
10.3. Radio-imaging issues in salivary gland lesions ......................... 238
11. IMAGING IN IMPLANTOLOGY .............................................. 253
11.1. Preimplantation balance ........................................................... 253
11.2. Radio-imaging methods ........................................................... 254
11.3. Radio-imaging examination within the implant algorithm ........ 264
REFERENCES ................................................................................... 271
INTRODUCTION
Dento-maxillo-facial imaging is an important area of medical
imaging which has known continuous development for more than three
decades.
Based on conventional radiology, based on dental radiographs of
the skull, in various incidents, the tomography plane and sialographies,
they started to use the phase of whole exploration technique of intraoral
panoramic outbreak subsequently abandoned and in particular that the
extraoral outbreak has already become a classic in its turn, having
orthopantomography as a generic name (OPT).
This stage of development has increased the dental patients
addressability to radiology laboratories and determined the dentists to use
OPT as a first instance method for the overall assessment of dental
maxillo-facial complex status.
The second stage of development in the field of imaging was
related to the possibility of obtaining images of the human body by
processes other than X-rays (ultrasonic, electromagnetic waves). New
methods have allowed the use of such means as including diagnostic
method for dental-maxillo-facial lesions (ultrasound and magnetic
resonance imaging).
Introducing the use of the computer in dental practice - used for
processing and storing sectional images obtained with the new methods of
diagnosis CT, MRI, Seldinger angiography in recent years dental digital
radiography and Cone Beam CT - have reduced the radiation dose and
the necessary time to explore advanced imaging with the ability to view
images on the computer monitor, remote transmission, simulating surgical
technique and a protocol default optimum treatment, all aimed at
improving the quality of medical care.
This book addresses the main groups of dento-maxillo-facial
injuries which have been organized into eleven chapters, briefly
presenting the advantages and disadvantages of conventional and modern
radioimaging methods used, their diagnosis, and their imaging exemplify
common and particular aspects encountered in daily medical practice.
The presentation of this paper was ment combining the imaging
clinical characteristics, sometimes even the anatomo-pathological ones, to
highlight the importance of issuing a diagnosis based on an amount of
information from different medical examinations based on the cooperation
between all medical specialties.
Introduction
This paper is aimed to be studied by students of dental faculties,

resident doctors and medical specialists in related fields of dentistry, oralmaxillofacial surgeons and radiologists.
I would like to mention on this occasion the fruitful cooperation we
have had over the years with colleagues at the Emergency Hospital "Prof.
Dr. N. Oblu", University of OMF Surgery Clinic, Clinic of Orthodontics
and Pedodontics, Low Partial Edentation Clinic, Department of
Odontology - Periodontics, Faculty of Dentistry and Pharmacy"
Gr.T.Popa", all that allowed me to add a significant amount of illustrative
material.
I give my heartily thanks to my entire family for their support and
trust during the preparation of this paper.
Lectures presented over the years, students from the Faculty of
Dentistry and Pharmacy "Gr.T. Popa" have allowed the book to be
written, based on the idea of presenting information in a concise, easily to
be assimilated and understood way, and rich illustrated to better fix the
situations they will face in every day practice. I want this book to be an
incentive approach for them, introducing slowly but surely, the latest
imaging methods in the dental medicine office directly for the benefit of
the patients.
Danisia Haba
Chapter 1
DEVELOPMENTAL ANOMALIES OF THE TEETH

AND MAXILLO-FACIAL DEVELOPMENTAL
Man has two dentitions:
temporary or deciduous dentition (20 teeth) to erupt between 6
months and two and a half years,
permanent or secondary teeth (32 teeth) to erupt between 6 years and
18 years.
1.1 The numbering of the teeth
Since the two dentitions coexist for a period of time, it is possible to
identify each tooth by a two-digit number, the first designating one of the
quadrants in which the tooth exists, and the second showing the analyzed
tooth in one of these quadrants.
Adult classification adopted by the WHO International Dental Federation
has 4 quadrants in a clockwise direction:
1 - for higher half right maxilla
2 for top left half maxilla
3 - the left lower jaw teeth
4 - the right lower jaw teeth:
1
2
8. 7 .6 .5 .4 .3 .2 .1 .1 .2 .3 .4 .5 .6 .7 .8.
8. 7 .6 .5 .4 .3 .2 .1 .1 .2 .3 .4 .5 .6 .7 .8
4
In children we will use for temporary teeth:
5 - for upper right maxilla,
6 for top left maxilla,
7 - the left lower jaw teeth
8 - the right lower jaw teeth:
5
5 .4 .3 .2 .1 .1 .2 .3 .4 .5
5 .4 .3 .2 .1 .1 .2 .3.
8
Developmental anomalies of the teeth and maxillo-facial developmental
In temporary dentition the milk premolars and molars are replaced by

permanent premolars.
According to the American Dental Association we can achieve the
following numbering of teeth:
1 - 3 upper right molar,
8 - upper right central incisor,
9 - upper left central incisor,
16 3 top left molar,
17 - 3 lower left molar,
24 - lower left central incisor,
25 - lower right central incisor,
32 - 3 lower left molar.
Knowing these numbering we must know the following information:
tooth has a mesial side and one distal side to which are adjacent and
become approximal sides, front facing the outside is called vestibular and
it is opposite to the lingual mandible teeth and the palatal side for
maxillary teeth.
1.2. Developmental anomalies of maxillofacial region
We classify these anomalies in:
developmental anomalies of the teeth;
abnormalities in the massive facial skeletal development.
There are numerous developmental abnormalities that can affect both
teeth and maxillo-facial skeleton or skeletal assembly. It is important for
your dentist to examine and use clinical, radio-imaging and sometimes
recommending genetic tests to get a diagnosis of developmental dentomaxillo-facial abnormalities.
1.2.1 Anomalies of the teeth
These abnormalities include the following entities:
number abnormalities: agenesis, hypergenesis, odontoms,
position abnormalities: inclusion, ectopia, heterotopia, transposition,
size and volume anomalies: gigantism, dwarfism,
shape abnormalities: atypical tooth, gemination, merger,
concrescence, dense in dente, taurodontism, supernumerary roots,
structural abnormalities: imperfect amelogenesis, enamel hypoplasia,
imperfect dentinogenesis, odontodisplasia.
Dental decay and its complications
These abnormalities can be diagnosed by imaging periapical dental

radiographs and / or occlusal dental x-rays and orthopantomography exam
(OPT), that can highlight and inventory of permanent teeth and their
relationship with the roots of temporary teeth (fig.1.1). For analyzing
which is the best treatment, you can use modern imaging techniques:
computed tomography (CT) reconstructions performed by Dental CT
programme or cone beam CT volumetric computerized tomography
(CBCT).
1.2.1.1. Anomalies of number
Dental numerical abnormalities are occurring by:
deficit (agenesis) or
excess (polydontitis, hyperdontitis).
1.2.1.1.1. Abnormalities by numerical deficiency:
A genesis or partial anodonta (oligo-or hipodontitis) means reducing
the number of teeth due to lack of primitive dental bud formation.
Often we have agenesis: upper and lower third molars, the upper lateral
incisors (fig.1.1), the mandible central incisors (Fig.1.2), the two lower
premolars (Fig.1.3), the upper and lower premolar 2 (Fig. 1.4), the upper
canines of the lower lateral incisors, the first premolars in the maxillary
arch with persistence of temporary teeth.
Fig. 1.1. Anodonta the upper and lower lateral incisors.

O.P.T. Patient of 14 years.
.
Fig. 1.2. Anodonta located in the lower central incisors.

O.P.T. Patient of 8 years.
Fig. 1.3. Anodonta located in both two lower premolars.

Panoramic radiography in mandible intraoral outbreak. Patient of 13.
(Collection OMF Surgery Clinic, Iai)).
Fig. 1.4. Anodontitis to 1.5, 2.5, 3.5, 4.4, 4.5, accompanied by rotation of
the upper lateral incisors and a cuneiform aspect of the central upper teeth.
O.P.T. Patient of 10 years. Neuro-sensory severe hearing loss patient
experiences severe mental deficiency (IQ = 34). (Collection Dr. Petcu E).
10
Total anodonta or absence of all teeth is exceptionally met in common

practice, with the ectodermal Siemens polydisplasy syndrome with:
anhydrosis,
hipotricosis and
anodontitis (fig.1.5).
Fig. 1.5. Total anodontitis. O.P.T. 11 year old patient with total anodontitis
(milk and permanent teeth), a manifestation in dental maxillofacial area of
a severe ectodermal dysplasia. (Collection Dr. Zetu I).
1.2.1.1.2 Anomalies in excess
They are also called polydontitis and hyperdontitis and can be with and
without topographic preference:
polydontitis with topographic preference:
* supernumerary incisors or molars, commonly tiny (fig.1.6., b, c);
*meziotooth is a tiny tooth, supernumerary, located between the upper
central incisors (fig.1.7., b, c),
unregulated polydontitis:
*odontoms are dental malformations of the dental tissue (hamartomas)
Clinical: accidentally discovered in the jaw or mandible, without
preference for one sex,
Imaging: they appear on dental radiographs, or X-rays ,OPT in jaw scroll
incidence as radio opaque, well defined, showing a small clear space
around.
11
c
a
Fig. 1.6 .Lateral incisor as supernumerary a) OPT, patient 8 years old.
b) nannous supernumerary molar, root remnants included over 26,
c) supernumerary lateral incisor overlapping apex region 11,
retroalveolar dental radiography.
a
b
c
Fig. 1.7. Meziondens. a) Image of a meziodens in the jaw;
b), c) a dental meziodens radiography in children of 6 and 12 years old.
(Collection Dr. Zetu I).
We can meet in our daily practice:
The compound odontoma that appears as a dense mass, composed of
numerous dental micro dysmorphic elements surrounded by a radiolucent
fibrous capsule (fig.1.8., B);
The complex odontoma is a dense, a heterogenous formation, composed
of atypical dental tissue, without being able to individualize a tooth
already formed, relatively circumscribed (fig.1.9), which is sometimes
very difficult to differentiate from an ameloblastic odontoma or a
cementifiant fibroma; confirmation was made after the anatomo
pathological examination.
12
a
b
Fig. 1.8.Compound odontoma. a) occlusal radiography DISTO-front
eccentric superior patient of 14, small compound odontoma that prevents
a normal canine eruption 23. b) incidence of left mandible scroll,
compound odontoma near the apex 32 and 34, 33 included between 34
and 35.
a
b
Fig. 1.9. Complex odontoma between 35 and 36 tooth apex, panoramic
X-ray) confirmed pathological and operated by preserving distal crown
and root at 36, after surgery aspect, panoramic radiograph b).
We can also meet:
canine or supplementary premolar on jaw or mandible;
polydontitis of a number of syndromes. The condition of this type is
the cleido-cranial dysplasia or Pierre-Marie and Sainton disease. Imaging
aspects can be viewed on:
OPT under the form of dental overcrowding, supernumerary teeth,
including dysmorphic, with persistence of milk teeth adult arcades,
In the skull radiographs profile and frontal brachycephalism appears,
13
In the chest radiography: clavicle hypoplasia is found, that means it

allows a very easily approaching of the shoulders,
In pelvic radiography: there is coxa-vara, with a severe risk of
disability.
1.2.1.2. Anomalies of tooth position
These anomalies are:
inclusion,
ectopia,
heterotopia and
transposition.
The dental inclusion means the remaining of the fully developed teeth in
jaws foam, on the normal axis of eruption after their period of
physiological eruption had passed.
The delay causes are varied:
mechanical:
a lack of space (fig.1.10, Fig.1.11),
a presence of supernumerary teeth (fig.1.12)
trauma
the incorrect position of the tooth germ (fig.1.10-1.12) and
Fig. 1.10. Upper canines included because of the lack of space in the
mesiala) and disto version b) crown.
14
Fig. 1.11. Upper canine included in the mesio-coronal, version CT Dental axial
Exam), b), d), e), with 2D reconstruction, panoramic c)
and oblique-transverse or paraxial f).
Fig. 1.12. OPT in a patient of 17 years, 13 included in the mesio-coronal

version and a supernumerary nannous tooth included, superimposed on
the roots of teeth 21 and 22.
15
Genetic factors - complex malformation syndromes: cleido-cranial

disostosis, cherubism (fig.1.13).
b
c
Fig. 1.13. Cherubism. 19 year old patient diagnosed with cherubism
at 12. a) OPT, b) Scroll mandible, c) frontal profile
(Prof. Gh. Timosca collection).
Ectopia - represents the remaining of the fully developed teeth being at a

distance from their normal seat, but in their anatomical territory, having
passed their period of physiological eruption(fig.1.14);
Heterotopia - is the presence of these teeth in anatomical regions different
than the normal ones: ovaries, etc.
16
Fig. 1.14. Right canine ectopic in right maxillary sinus, left canine
included, skull radiography in the Blondeau incidence.
Transposition - is a special form of ectopic eruption of a tooth in the

archway, rather instead of another one meant to erupt in that certain place
(fig.1.15).
Fig. 1.15. Transposition between 23 and 22, persistence 63. O.P.T.

Patient of 9.
17
1.2.1.3. Abnormalities of size

Abnormalities of size are:
Macrodontitis or gigantism, is usually an isolated anomaly, affecting a
central incisor, a molar or a canine (fig.1.16).
Microdontitis, or dental hypoplasia dwarfism is an isolated anomaly
(Figure 1.17 a - c), usually affecting upper lateral incisors, wisdom teeth,
or diffuse, with a family character.
b
a
Fig. 1.16. Macrodontitis a)Photographic aspect in a child with 11 giant, b)
dental radiography with macrodontitis to 11, probably by fusion with
meziodens. ( Surgery Clinic OMF, Iai collection)
c
b
a
Fig. 1.17. Microdontitis. a) superior frontal periapical radiography with 21
nannous b) periapical radiograph with 18 nannous included, positioned
distal to maxillary c) periapical radiograph of 35 nanous
(Surgery Clinic OMF, Iai collection).
1.2.1.4. Abnormally shaped
This occurs quite frequently by aberrant ameloblastic group with atypical
tooth formation as a whole or only in the crown or root. Thus we find:
Dental fusion may be partial or total.
18
o In total merger, the absence of a tooth or a tooth more voluminous

equivalent of two neighbouring teeth. The merger made the tooth crowns
and roots occur with a single pulp chamber and root canal alone
(fig.1.18.a).
o partial fusion is achieved by the union of root crowns (dental
concrescence) of two neighbouring teeth (fig.1.18.b).
c
Fig. 1.18. Merger lower incisors 41, 42 a) X-ray retroalveolar, c) OPT
and lower incisors 31, 32, retroalveolar radiography b). (Dr. A.E. Petcu
collection).
Gemination or duplication is a dental anomaly that may be common in
upper incisors, as partial or complete.
In radiological partial duplication a more voluminous crown appears, with
a notch on the occlusal groove that continues with a vertical downward
along the area of the union of the crowns (fig.1.19). Tooth root may have a
bifida, a common crown, a pulp chamber and root canal under division.
19
b
a
Fig. 1.19. Gemination of the central incisor 11 a) X-ray retroalveolar
and b) photograph of central incisors
(Dr. A. E. Petcu collection).
concrescence is the union of two dental buds, the roots through root
cementum, sometimes resulting in a divergent orientation of the teeth
(fig.1.20).
a
b
Fig. 1.20. Concrescence of upper molars 2 and 3),
radiograph or photograph b) of extracted molars
( Surgery Clinic OMF Iasi collection).
Dens in dente or enamel-dentin invagination usually occurs in upper
lateral incisors, and corresponds to a unilateral invagination of enamel in
dentine which appears radiographically as a "candle flame" in a
dysmorphic tooth (fig.1.21).
20
b
a
Fig. 1.21. Dens in dente, the central incisor lateral 11 and 12,
retroalveolar radiographs ( Dr. C. Bucur collection)
Taurodontism is an abnormality common in Eskimos, who have an
exaggerated elongation of the pulp chamber with apparent shortening of
roots and root canals, making a point of "no waist tooth" (fig.1.22).
Fig. 1.22. Taurodontism 16 and 46. OPT.

Surgery Clinic OMF, Iai collection).
In addition to the changes listed we can meet:
*lacerations (no alignment axis root crown against secondary trauma)
*rizaliza is partial or total root resorption temporary teeth
corresponding to a physiological phenomenon (rizaliza of a milk tooth
preceding tooth eruption of a permanent one)
*root resorption is a partial or total root resorption of permanent teeth
with a pathological, post traumatic character) (fig.1.23)
21
d
e
Fig. 1.23. Corono-root laceration of 21, post-traumatic
with pulp necrosis, pre-treatment scan) and post-treatment b) molar root
physiological rizaliz 84 c) pathological root resorption 43, 44, 45 due to
a ameloblastoma d) root in tooth root resorption produced by a 84
follicular cyst e).
*Apical resection is a surgery that implies the resection of the apical

portion of a tooth gum infection after a surgical approach (fig.1.24 a)
*abnormal cusps with aspect of spurs visible in central incisors
(fig.1.24 b)
* exaggerated curving of the roots (fig.1.24 c, d)
*exaggerated angulation of the roots, which are very important to be
radiographically visualized and that helps a lot in endodontic treatment
and dental extractions (fig.1.24 s)
* enamel pearl, which appears as a node attached to the pack round
tooth enamel posterior (fig.1.24 f).
22
d
f
e
Fig. 1.24. Apical resection in the roots of premolar 24),
abnormal cusp (spur) to central incisor 11 b) molar root curving
leading to incomplete fillings of lower 3 and 2 c), d), two upper
premolar apex angulation, e) enamel pearl on the crown molar distal
edge of 27 f) (retroalveolar dental radiographs).
1.2.1.5. Abnormalities of tooth structure
Tooth structure can be changed due to:
genetic defects:
*imperfect amelogenesis
*imperfect dentinogenesis
* regional odontodisplasia.
*dentin dysplasia,
acquired defects :
* congenital syphilis,
* vitamin deficiency, irradiation, etc..
The imperfect amelogenesis is a genetic abnormality of tooth structure that
may occur in three forms:
hipomaturity of the enamel with defects in growth and final
maturation of enamel crystals that make it appear much smoother and less
opaque for the photographic visibility as a partial defect (fig.1.25.a),
presented radiographically as a tooth with a low radio opacity of a portion
of the crown (fig.1.25. b);
23
enamel hypoplasia or hereditary brown hypoplasia manifests as a

tooth with reduced enamel, the tooth has a brown tint but normal radio
opacity,
the hipocalcification of the enamel is defective in initial enamel
crystals formation and a misused increase, with a low radio opacity.
a
b
c
Fig. 1.25. Imperfect amelogenesis in right central incisor clinical visible)
and radiographically as a radiolucency b).Imperfect dentinogenesis
retroalveolar radiography in mandible premolars, with dysmorphic
crowns and early obliteration of root canals c).
The imperfect dentinogenesis is a genetic abnormality that interests

enamel and dentin, making opalescent appearance of affected teeth with
dysmorphic crowns and early obliteration of the pulp chamber and root
canal (fig.1.25 c). The condition is often associated with imperfect
osteogenesis.
Odontodisplasia ("ghost" tooth or translucent tooth) is also a genetic
abnormality, rare, more common in upper teeth, which looks ghostly,
delays or lack of eruption (fig.1.26).
24
Fig. 1.26. Odontodisplasia. Child of 9 years old with low radio opacity
anterior teeth in quadrant I and II, with no enamel, delineation, dentin
and pulp chamber array. (Collection of Pedodontics Clinic, Iai).
1.2.2. Abnormalities of the development of the massive facial skeleton
These abnormalities include:
abnormalities of the jaw or mandible,
Other rare anomalies of development or syndromes.
1.2.2.1. Mandible and maxilla abnormalities
The most common abnormalities seen in mandible are:
micrognathia (fig.1.27 a)
macrognathia (prognathism) (fig.1.27 b)
condyle hyperplasia (fig.1.28 a)
condyle hypoplasia (fig.1.28 b)
bifid condyle,
coronoid process hyperplasia.
The most common abnormalities of the jaw are:
unilateral or bilateral cleft lip,
cleft lip and palate (fig.1.29)
cleft of the palate,
cherubism (fig.1.30).
localized bone defects:
*exostosis: palatine torus / mandible (fig.1.31)
*idiopathic marrow cavity, Stafne's cavity,
25
a
Fig. 1.27. Micrognathia a) and macrognathia b).
(Collection of Orthodontics Clinic, Iai).
a
b
Fig. 1.28. Hyperplasia and hypoplasia of the mandible condyle. Axial
CT in bone window showing right condyle as increased in size,
hyperplasia) and hypoplastic appearance of rarefaction of the trabeculas
and left condyle lowering in diameter b).
26
c
d
Fig. 1.29 Nasopharyngeal left cleft palate highlighted defective between
central incisors, next to the interincisive suture, retro-alveolar
radiography), CT in bone window shows dehiscence of the hard palate
and nasal fossa left, visible in coronal reconstructions b ), sagittal c) and
direct axial section d).
Fig. 1.30. Cherubism in a child of 10 years OPT shows multiple

radiolucent maxilla and mandible, cortical thinning and breath, movement
of teeth and resorption of apices.
27
b
a
Fig. 1.31. Unilateral and bilateral mandible torus: Occlusal radiograph
showing radio opaque nodular, with net shape and relatively
homogeneous density, located on the lingual of mandible premolars area
above milohioidien muscles.
1.2.2.2. Other rare syndromes and developmental abnormalities
the microsomas of the hemifacies (fig.1.32)
cleido-cranial dysplasia (fig.1.33)
Gorlin syndrome (fig.1.34)
Eagle syndrome,
Crouzon syndrome (fig.1.35)
Apert syndrome (fig.1.36)
Mandibulo-facial disostosis (Treacher Collins) (fig.1.37)
We will show some radiographic aspects of these rare anomalies.
a
b
Fig. 1.32. Microsomia of left hemifacies, front bearing radiography
"rocks in orbit" and profile, highlighting the difference between basilar
edge of the mandible.
28
Fig. 1.33. Cleido-cranial dysplasia, frontal incidence x-ray to "rocks in

orbit" a) Profile b) and OPT c).
a
b
Fig. 1.34. Gorlin syndrome, radiograph of skull face and profile.
29
a
b
Fig. 1.35. Crouzon syndrome, radiograph presents incidence "rocks in
orbit" and profile, highlighting digitiform turibrahicefalia and fingerprints
from the calvaria.
a
b
Fig. 1.36. Apert syndrome, lateral skull radiograph hypoplasia of
maxilla) Hand frontal radiography with phalanges 2,3, 4 units b).
30
Fig. 1.37. Mandibulo-facial disostosis
31
32
Chapter 2
DENTAL DECAY AND ITS COMPLICATIONS

Dental decay is the most common dental condition in which there is a
progressive destruction of dental hard tissues initiated by organic acids
produced by microbial deposits adhering to the tooth surface. Decay
evolves from the enamel-dentine junction to the enamel, extending then
the pulp chamber.
The mechanism of dental caries is complex and there are several theories
that may explain this condition: acidogenic theory, and the theory of
endogenous proteolytic. Several factors occur, as in any multifactorial
disease: teeth and saliva, bacterial microflora, diet and the time interval in
which the transition from decalcification of enamel dentine to necrosis and
destruction is completed.
Cavities are localized in regions less accessible to local hygiene:
the fosets and ditches of grinded surfaces,
lateral surfaces of the crown (approximal), facial, oral,
cervical and root, especially in the molars, incisors, premolars and
canines.
After the localization of lesion process, caries can be divided into:
interproximal caries,
occlusal caries,
facial / lingual caries
root caries,
*caries in cement,
recurrent or secondary caries,
cavities in the included teeth (occlusal and interproximal surface).
Having in mind the degree of demineralization of hard dental structures
we can meet:
incipient caries, demineralization,
superficial caries, tooth enamel caries,
tooth enamel and dentin caries,
coronary destructions with different complications: pulp, periodontal
osteitis.
Radiographic examination of dental caries
33
Dental decay radiographically appears as radiolucent, excavated from the

surface to depth, irregularly shaped and with diffuse edges within a dental
region .
Caries diagnosis is clinical but the confirmation can be obtained by:
* dental radiographs obtained by bitewing technique for diagnosis of
early enamel caries, pack caries, secondary caries. Analysis of the time
evolution of decay is 6 months in patients with high risk, 12 months in
those with the average risk and 2 years in patients with low risk and for
children the same time interval, except for the low-risk when the
examination is repeated every 12-18 months.
dental radiographs obtained by the technique of parallel plans /
bisector technique to highlight the main types of cavities,
occlusal radiographs, "directed" X-rays and rarely OPT show
occlusal caries, caries in included teeth and secondary periapical
processes.
Usually we explore radiographically:
interproximal caries,
pack caries
occlusal caries,
cavities below / side fillings (recurrent and secondary caries)
cavities on included teeth (occlusal and interproximal surface)
complications of dental caries.
From a radiographical point of view, we can distinguish four evolutionary
stages of dental caries (fig.2.1.)
C-1: early enamel caries (<half of enamel thickness)
C-2: at least half the thickness of the enamel, but without invading the
enamel-dentine junction,
C-3: enamel-dentine junction impaired but <half way up the pulp,
C-4: affecting dentin, but> midway to the pulp chamber.
Fig. 2.1. Schematic representation of the radiographic aspect of

interproximal caries: 1, 2 amelare caries 3, 4 - enamel-dentine caries,
(After Langland and Langlais).
Since the radiological appearance of caries may vary according to
location and the evolutionary stage we exemplify each of these entities.
34
2.1. Interproximal caries

In the coronary territory mesial and distal interproximal caries occur at
different stages:
early enamel caries, enamel caries in advanced stage, caries in enamel and
dentin, appeared after the overcoming of the dentine area. These cavities
are projected on the tangential beam radiation radiographs and are easily
detected by incidence bitewing even in the molar region.
During the C1 stage we meet:
Larger clinical lesions greater than those found on radiographic
image,
decay appears as a tiny radiolucent triangle, based on the surface
enamel and enamel-dentin junction pointing slightly below the contact
with the adjacent tooth (fig.2.2.).
In general at this stage of decay, endodontic treatment is not
necessary.
If bitewing radiography is unclear or if there is any doubt regarding
their existence, the presence of cavities is not mentioned.
a
b
Fig. 22. Early interproximal caries in enamel (C1) at 24, 25, bitewing
radiograph a) and between 31, 41, periapical radiograph b).
During stage C2 we meet:
A more extensive lesion better noticed clinically than
radiographically;
A triangular radiolucent, based at the tooth surface below the
interproximal contact with the adjacent tooth (fig.2.3);
Generally, under current rules the cavity does not require endodontic
treatment.
35
Fig. 2.3. Interproximal tooth enamel caries (C2) at 14-15, 15-16, bitewing
radiograph a) and 85, as well as voluminous cavity C4 stage 84 with
opening the pulp chamber, radiographic bitewing b).
During stage C3 we meet:
An injury that progressed faster in dentin than in enamel;
A radiolucent side at enamel-dentine junction level;
Caries are treated if they affect more than 0.5 mm of dentin (fig.2.4).
Fig. 2.4. Interproximal tooth enamel (C3) at 23, 25 a) and 25 b) and decay
stage C2 26, 34-35,35-36, 36-37 b) bitewing radiographs.
During C4 stage we meet:
Decay appears as a deep dentin lesion with irregular aspect,
excavated;
The lesion may appear larger radiographic than clinical as a diffuse
radiolucent gradation, peripheral paler, U-shaped horizontally (fi.2.5);
Caries in stage C4 should be treated.
36
a
b
Deep cavity (C4) at 25 and decay stage (C2) at 24, 26, 34, 35, 36, bitewing
radiograph a) Image of a ocluzo-distal deep cavity in 36 obtained with a
video camera, b).
To radiologically see a cavity a significant demineralization of tooth
structure is required, often the clinical lesion being larger than the
radiological one. Thats why early caries can sometimes remain unnoticed
radiologically, especially if they are located interproximal where they are
'burned' by the phenomenon of "burn-out" or "marginal halo" that appears
because X-rays are tangent to the curve of the crown decay.
2.2. Occlusal caries
Grinded surface caries are clinically detected as linear or dotted. These
lesions progress on both sides of the crack, gaining the appearance of a
triangular base to dentin lesions, radiographically not easy to detect when
restricted to enamel, which appears large in the cusps. Cavities can be
extended in dentine without clearly exceeding the enamel dentine.
Radiographic: These cavities appear as linear or band transparency,
enamel-dentine junction located below, which has a rounded shape as an
"U" or a crescent with a heterogeneous transparency, much lower towards
the normal dentin (fig.2.6).
a
b
Occlusal caries present at the first maxillary and mandible molar) and
video camera image of two mandible molar occlusal caries b).
37
2.3. Caries on buccal and lingual surfaces

These cavities are easily accessible through clinical examination but it
can be difficult to detect because the radiographic beam has a
perpendicular projection on the surface of the caries with positive
summation phenomenon of enamel and dentin that masks the injury.
c
d
Fig. 2.7. Vestibular cavity in 11, interproximal cavities C4 stage in 11,
21, stage C3in 12) the "burn-out" phenomenon with a clear tape aspect
on the pack of front incisors b) pack cavity at 11 and 21 photographic
aspect c) and the pack cavity in 45 accompanied by significant retraction
of the marginal periodontium d).
Radiographic: a radiolucent round / oval shape may appear with a clear
demarcation between carious enamel and the remained enamel (fig.2.7. a).
Pack decay occurs in the space between the edge of the free edge of
enamel and gums, affecting both cementum and dentin, premolars or
anterior teeth being affected (fig.2.7.c). Sometimes small cervical caries
can be masked during clinical examination by plaque and can be easily
identified radiographically on interproximal surfaces and vestibulo-oral as
semilunar radiolucent ( fig.2.7.d) above the gum ( "black hole" aspect).
38
The differential diagnosis of pack caries is made with the "burn-out",

phenomenon, which is an artifact, visible as a radiolucent strip or triangle
(Fig. 2.7. B). It is due to the fact that in the cervical region layers crossed
by the X-ray beam are thinner and less dense than the crown, where the
enamel and dentin are highly radio opaque, and the root zone, where the
beam has to pass through layers of cement and the alveolar bone, well
mineralized, radio opaque, too. This artifact may occur in terms of the
increased exposure to factors such as those used for highlighting
interproximal caries. The "burn-out" phenomenon is characterized by:
cervical localization limited by the linear plan that passes through the
bottom of the enamel and the top of the alveolar bone,
Skin triangular or band, gradually becomes less obvious to the center
of the tooth,
occurs in all teeth x-rays, unlike recurrent caries or root caries that are
located in a tooth without an upper and lower limit.
2.4. Root caries
Root caries occurs in the space between the edge of enamel and the free
edge of gums, affecting both cementum and dentin which have marginal
periodontal lesions.
In these patients, the tooth root is covered by cementum and is no more
covered by support ligaments and the tooth is far from the alveolar wall.
Root caries can develop at different levels of the middle third, bottom or
apical (Fig. 2.8).
Radiographic: Root caries show a radiolucency without a clear
demarcation, framed to simulate saw teeth or an irregular shape, located
interproximal or vestibulo-oral. When radiolucency overlaps root canal we
can differentiate the decay and an internal granuloma (Palazzi), which
keeps the disto-channel relationship between image and granuloma on
periapical radiographs.
a
b
Fig. 2.8. Root caries in third apical to 11, with vertical retraction of
39
interdental septum and pathological apical rizaliz, distal caries in third

apical to 21 a), crown-root cavity with interradicular fracture and
resorption of the interradicular septum, b).
2.5. Cavities in included teeth
These cavities can be discovered incidentally on radiographs evaluating
the presence of a tooth cavity and around a tooth that was found included,
which shows or not the presence of an opening in the follicular bag and
one or more radiolucent cavities with imprecise limits at various levels of
the tooth (fig.2.9).
Radiographic: These cavities are radiolucent with irregular shapes and
contours.
Fig. 2.8. Wisdom tooth scaling with uncovering of

the bony wall of the follicular bag, showing deep
caries, corono-root caries in 17, too.
2.6. Rampant caries

These cavities occur in people who develop sudden, a rapid and almost
uncontrollable teeth destruction.
a
b
Fig. 2.10. Rampant caries of the upper front teeth) in a child and a
teenager b) with multiple cavities, corono-root clogged. (O.P.T).
Radiographic: These cavities occur between interproximal and cervical
areas of the teeth prior to coronary radiotrasparencies with irregular edges
and deep extension in the pulp chamber (Fig. 2.10).
40
This phenomenon is most common in: deciduous teeth of young children

and in the teenagers permanent teeth (11-19 years) and adults with
xerostomia.
2.7. Dental recurrent / secondary caries
These cavities appear under a filling, recurrent decay or appropriate in
the neighbouring area of fillings when it comes to secondary caries.
Recurrent caries may be covered by radio opacity of the metal fillings, and
are only v radiographically visible.
Radiographic: recurrent caries appear as a radiolucent filling in material
and the secondary caries - on the edge of a radiolucent filling (fig.2.11).
b
a
Secondary cavity, mesial in 25 and recurrent in 26 (bitewing radiography)
and recurrent caries in 15 periapical radiograph b).
Recurrent or secondary caries are difficult to assess if radiographic
radiolucent fillings are used, baseless, the only radiological sign is to
identify a limited diffuse area of the cavity wall, blocked in contrast with
the rest of a demarcated area.
2.8. Radiographic evaluation of tooth decay and the proper treatment
of simple cavities
Eric Whaites considers it is important to have a systematic analysis of
bitewing radiographs, and starting from the crown and continuing with the
cervical zone and the root.
Thus, in the crown:
we trace the edge of the enamel;
we draw a line in the enamel-dentine junction edge,
we note any changes in contour, enamel, eg. a possible cavity
we note any change in the density of interproximal enamel, for
example the presence of radiolucent triangular cavity products,
we note any change in the density of dentin:
41
* radiolucency "ring" / semilunar in interproximal caries and occlusal

*radiolucency round / oval in vestibulo-oral cavities,
* radio opacity reparative dentin induced by dental amalgam,
we note the presence and quality of the filling:
* above the contour of the dental crown
*under the contour of the crown,
* adaptation
*prominence to the edge and over the edge of the crown,
* recurrent caries,
We draw a line at the edge of the pulp chamber and note:
* pulp chamber size,
*the presence of reactive dentin,
*the presence of pulpolits,
The pack / root:
draw a line between the pack and third cervical root
note any changes of the line, for example possible root caries,
note any changes in the density of root dentin:
* semilunar radiolucency in pack cavity
triangular radiolucent "burn-out phenomenon or cervical
transparencies
Very important is how we systematically look upon periapical radiographs
based on stages that were synthesized by the same Eric Whaites:
The whole analysis of the radiography by:
1. evaluation of dental age of the patient,
2. scoring position, contour and density of radio transparent elements
overlapping normal from the anatomical point of view, including any
tooth development
X-ray examination of each tooth assessing:
3. crown:
presence of caries and
state of existing restorations,
4. roots:
length,
number,
morphology,
size and shape of the channels,
presence of pulpolits,
blockage of root canals,
internal resorption,
external resorption,
root fractures,
42
5. periapical tissues focusing on:

integrity, continuity and thickness:
radiolucent line of the periodontal ligament space,
lamina dura radio opacity ,
any radiolucent associated area
any radio opaque associated area
drawing trabecularization bone
6. periodontal tissues focusing on:
periodontal ligament width,
level and quality of bone growth,
any vertical or horizontal bone loss,
placement of cement,
any involvement of furcation.
Cavities once discovered are clinically confirmed radiographically,
radiographically examined in terms of the degree of involvement of dental
hard tissues and especially the relationship with the pulp chamber.
The therapeutical attitude is decided by the doctor attitudes depending on
the evolutionary stage of decay, the amount of dentin and pulp continuity
and the depth of the cavities.
The endodontic treatment once done, there are situations when it is better
to verify radiographically the correctness of the treatment, following the
same steps that we described above, we analyze coronal and radicular
changes.
Knowing that the restorative material was radio opaque or radiolucent to
X-rays we establish by analysis:
if the material completely obscures the prepared cavity
if it is properly adjusted, or
if the filling is anfractuoas and beyond crown, the overflowing filling
determins:
food retention,
poor hygiene while the advent of marginal periodontitis and
secondary caries.
The transparent crown filling can be recognized radiographically by
precise contours and regular loss of resulting substance after cavity
preparation.
Untreated cavity has a vague radiolucent limit, irregular contours and
malaced dentin.
Various treatments made with different fillings can be assessed
radiographically in terms of:
adapting filling material to the cavity edges, especially coronary
interproximal caries (fig.2.12.a) and subgingival caries;
43
a
b
Fig. 2.12. Overflowing crown restorations with secondary caries
occurrence in 16, 45,) 26 and 34 b) and horizontal retraction of marginal
periodontium b) bitewing radiographs.
Neighbouring of the filling with the pulp chamber, the thickness of
dentin between the pulp chamber and cavity
Root location and basic conformation is to protect the pulp (Fig.
2.12.b);
Changes induced by dental amalgam for reparative dentin radiopaque
aspect, different from normal dentin and possible problems of differential
diagnosis,
Dental caries beneath crown cover, which appear as a small
radiolucent area extending from the edge of the crown, apical, and much
different from the metal intensity of the crown.
The correct analysis adjusts radiolucent or radiopaque filling material
would be much easier if restorative materials should have a radiopacity
equal to or slightly higher than normal enamel for proper differentiation of
recurrent caries.
Filling root requires precise radiological analysis of the number, shape,
direction and length of roots, root canal character and after treatment, the
way the filling was performed. As a root filling material only paste or
gutta-percha cones and paste radiopaque are used. Filling material must
reach:
up to apex,
to 1-2 mm far from the apical foramen,
up to apex when infected channel,
up to 1 mm beyond the apex, where excess means greater pains, bone
resorption and the healing process is prevented.
Radiographic: we can see how root canal was filled (fig.2.13):
complete
incomplete
discontinuous
44
supraclogged,
with cutter or needle fragment tire-nerfs,
the false path (perforation) or interradicular root,
axial root fracture.
Tissue reaction to root canal fillings can be assessed radiographically as:
favourable apical obliteration by failure of forming the cement in the
apical region of the channel,
favourable settlement of
inflammatory focus and trabecular
reconstruction,
unfavourable when the paste comes over apex, with the advent of
aseptic process, apicolisis, lamina dura resorption and alveolar bone
partial absorption,
unfavourable by apical periodontal infection, or lack of sanitation in
the existing infection with the production of apical acute / chronic
periodontis
unfavourable with incomplete root fillings, and in time it can produce
a periapical granuloma.
Fig. 2.13. . Root fillings: Complete a), b), incomplete c) discontinuous

c), d), suprafilling d) pin in channel e), apical overcoming d), f). d), f).
45
2.9. Complications of dental caries

Dental caries complications can be local, regional or distant.
2.9.1. Pulp diseases
Secondary caries can occur several changes:
inflammatory or
degenerative pulp.
Pulp inflammation is considered to be generated by diffusion through the
dental channels of microbial toxins, produced by autolyzer texture dentin
or invasion of microbial germs when decay is penetrating into the pulp
chamber.
Pulpites are diagnosed clinically as:
Acute: serous, purulent, necrotic, without radiological changes,
Chronic: ulcerative, granulomatous, where radiologically we can see
deposits of secondary dentin and internal granuloma.
Secondary dentin is deposited in various forms in the pulp chamber
(fig.2.14):
room wall layers, which decrease and root canals are narrow or
disappear with the disappearance of plugging and chamber, very slow
decay appears and the pulpites evolve chronically.
submission form an ovoid mass called pulpolit, attached to the walls
of the dentin in the pulp chamber,
denticle, which is a spherical mass, delimited, located in the center of
the pulp chamber, surrounded by a radiolucent area being free or adherent
and creating difficulties during endodontic treatment.
b
a
c
Fig. 2.14. Secondary dentine coating a) looking for denticul b), and as
pulpolit and denticul c).
Internal granuloma is a lesion produced pulp tissue hyperplasia after injury

or inflammatory processes.
46
Radiological: transparency translates into ovoid, developed symmetrically

along the axis of the root canal (internal resorption of dentine), with thin
walls and sometimes a perforation or fracture aspect.
The differential diagnosis for this granuloma is made with root caries.
2.9.2. Periapical lesions
Periapical periodontitis are inflammatory processes that affect and
locate the periapical periodontium. The inflammatory processes located
periapical are transmitted from the diseased pulp chamber and root canal
through a false paths and are mainly interested in periapical periodontium,
but can cause over time changes in dental apex, too.
These lesions have characteristic clinical manifestations, but only after
about 30% loss of bone mineral salts the radiological changes occur.
Changes are relatively low in acute forms but become evident in the
chronic forms.
They allow radiographic diagnosis, determining treatment indications,
choice of therapeutic method and technique.
Radiographic: we can obtain information about the need for further
endodontic treatment, the need for a tooth periapical extraction process, or
information about fairness and efficiency of endodontic treatment.
Pathology: periapical periodontitis can be hyperemic, without obvious
radiological changes and exudative, which can be circumscribed or
radiographic diffuse. We must know that the radiographic image is
consistent with the type of lesion and pathological function and depends
on the osteodistructive or osteoconstructive in the chain of bone cells.
2.9.2.1. Acute apical periodontitis
This condition can be diagnosed based on pulsatile pain and the feeling of
aggression and tooth mobility (fig.2.15).
Radiographic: onset there is not any change in periapical or periodontal
space, but it may reveal deep caries, interproximal, an outdated or
inadequate filling of the root canal (fig.2.15.a).
It is considered that only after two weeks from the onset around the root a
zone of decalcification appears and highlights:
disappearance of periapical lamina dura,
periodontal space widening, or
radiolucent area, homogeneous,
shaped diffuse, intense periapical, round,
47
sometimes exceeding causal space between the tooth and adjacent teeth
(fig.2.15.b)
easy apical cementolise, sometimes.
d
c
Fig. 2.15. Mesio-occlusal cavity depth in 27 without radiographically
visible periapical process, 24, 25 with corono-radicular reconstruction
and expansion space periapical discrete in 25 ,without destruction of the
lamina dura), loss of lamina dura and diffuse periapical radiolucency in
the mesio-vestibular root of 26 b) incomplete corono- root fillings, in
36, 37 and widening the periapical area of disappearance of lamina dura
with a small round periapical radiolucency c) incomplete fillings at 37
with loss of lamina and widening of periapical space, 38 included with
open apex, intact lamina and normal expansion of periapical space d).
The evolution of this damage can be towards bone subperiosteal abscess
that opens the soft parts. Radiography shows in this case the place of
departure of abscess and the extent of bone lesions (fig.2.15.c).
2.9.2.2. Chronic apical periodontitis
We find two forms of chronic apical periodontitis: fibrous and diffuse
progressive granulomatose.
48
If the healing of the acute periodontitis is not completed, the chronic stage
of injury is settled and chronic arthritis and dental granuloma appear.
2.9.2.2.1. Chronic apical fibrous periodontitis
Radiographic: there is an increased radiolucency around the apex, the
spongy bone with a heterogenous osteoporosis aspect with uneven etching
channels that form the spongy bone. The main feature is the destruction of
lamina dura and the serrated contour of the irregular radiotrasparent area
(Fig. 2.16., B).
2.9.2.2.2. Progressive chronic diffuse apical periodontitis
Radiographic: it shows a radiolucent intense homogeneous zone
surrounding the apex, with regular shape but diffuse lamina dura
destruction and a discrete process of apicolisis (Fig. 2.16.c)
b
c
a
Fig. 2.16. Chronic periodontitis fiber in 45, with transparency around a
residual periapical dental pulp and destruction lamina dura), periapical
transparencies periapical at 43, 44, serrated shape and lamina dura
disruption, chronic apical periodontitis in 41 fistulising diffuse appearance
of radiolucency with irregular shape, uneven intensity, jagged outline and
diffuse b) and chronic apical diffuse periodontitis in 22 c).
2.9.2.2.3.Chronic
granuloma)
granulomatous
apical
periodontitis
(apical
Radiological: may show an intense, homogenuous radiolucency,

accompanied by the destruction of lamina dura and slightly apicolisis. The
contour is relatively net, with a regular aspect, bounding the spongy bone
without any obvious condensation around (fig.2.17., B).
49
a
b
Fig. 2.17. . Chronic apical periodontitis with a periapical radiolucent
area in the palatal root of the premolar 1) and lower central incisors b) net
shape without condensation around and disrupted lamina dura.
2.9.2.2.4. Cystic granuloma

Radiographic: a characteristic clear demarcation surrounding an intense
radiolucency, homogeneous, round or oval, creating the impression that it
is accompanied by a continuation of alveolar lamina dura. In reality this
separation is different in structure and not an extension of it.(Fig. 2.18.a).
b
a
Fig. 2.18. Granuloma cyst at the side of the palatal root in 15 with
transparency shaped net with dew lizereu around seems to continue with
the lamina), apical resection at apexes 24 which had cystic granuloma b).
2.9.2.2.5. Chronic dental abscess
This infection is characterized by chronic suppuration and the presence
of fistulas.
Radiographic: exhibit the following characteristics:
clear demarcation in chronic forms
diffuse radiolucency, acute forms surrounding a strong irregular,
round or oval, often asymmetrical form, with a significant broadening and
50
disappearance of the unilateral periodontal space and the disappearance of

lamina dura in the affected area (Fig. 2.18.b).
2.9.2.2.6. Rizaliza
Rizaliza is a process of osteolysis of the tooth root which can be
physiological and pathological in temporary teeth if it is caused by endoperiapical chronic inflammatory processes, with an obvious impairment of
cementum and dentin in permanent teeth or less often than in temporary
ones.
Radiographic: it can be seen:
a defect in the third apical root that can be shortened or amputated but
a relatively regular shape,
there is evidently widened the periodontal space with discontinuous
lamina dura, due to the concomitance of a chronic periapical process
(fig.2.19.a).
c
a
b
Fig. 2.19. Pathological rizaliza in the vestibulo-mesial root of molar 26,
showing a deep cavity in the open pulp chamber and chronic apical
diffuse periodontitis), physiological rizaliz 54 B) in 41 chronic dental
abscess, chronic apical diffuse periodontitis in 42 and 44.
.
Fig. 2.55 Physiological rizaliza differs from the pathological because it
occurs in deciduous teeth, affected or unaffected by decay.
2.9.2.2.7. Hipercementosis
This change is an apico-periapical osteocondensation process, with an
increased function of cementoblast in apical region.
Radiographic: find a change of the root tip in volume and shape that
appears thickened due the apozition of the periapical cementum, giving
the apex an aspect of "club", "stick drummer" or "clapper" (fig.2.20).
Periapical area is sometimes narrow but well defined, with the lamina dura
intact or discontinuous and granulomatous lesions.
51
d
f
e
Fig. 2.20. Hipercementosis in the premolar1 root and in the rest of the
root of the premolar 2, with a "stick drummer aspect, a), molar apices II
hipercementosis " club " aspect b) and " clapper "aspect in the mesial
root of molar I showing chronic apical diffuse periodontitis and deep
occlusal caries c) periapical hipercementosis to 36, d). , 26 s), and 34 f)
2.9.2.2.8. Condensation periapical osteitis
The bone lesion is produced by the osteoclasts pathological hyper
function occupying the areolas of the sponge bone.
Radiographic: it can highlight a radiopaque area, oval or round, which
looks amorphous, without bone hardness and contour with a relatively net
(2.21).
b
a
Fig. 2.21. Osteita condensant periapical, zon radioopac periapical
la rdcina mezial a molarului I, ovalar a) sau rotund b), cu aspect
amorf dar contur net, la rdcina mezial a molarului II care are o carie
ocluzal profund.
52
b
a
Fig. 2.21. Periapical condensed osteitis, a periapical radio opaque area in
the mesial root of molar I, the oval) and round b) amorphous aspect,
but net shape, the mesial root of molar occlusal caries II is profound.
2.9.3. Radiographs in endodontic and surgical treatment of

complicated caries
Radiographic examination best used in endodontic and surgical
treatment of complicated caries has:
periapical isometric and ortoradial radiographs by parallel plans
technique or the bisectrix technique,
panoramic radiographs (OPT),
CBCT latest or computed tomography, in scientific purposes and
particular situations.
These examinations are useful in information given both in tracking and
controlling endodontic treatment and dental caries complications in
determining treatment allowing:
highlighting the dental channel identification and channel size and
anomalies encountered: multi-channel branched blocked by dentine,
denticulate intracanalicular (fig.2.22 a)
*needle control channel access to apex (fig.2.22 g)
assessing the extent of periapical lesions, pathological forms of
possible useful choice of the endodontic treatment or type of surgery
(curettage, apical resection, amputation of roots), (fig.2.22 a, g)
control of root canal filling (correct, incomplete, overrun visible
foreign corpora as: scrap needles, old fillings) (Fig. 2.22 c, f, h)
identifying false paths with a Kerr thin needle in one or two incidences
to analyze the direction of vestibular or oral false path, or old overruns of
the periodontal evaluation processes generated by them (periodontitis,
granuloma pararadicular), (fig.2.22 c)
53
the control of the development of processes in periapical endodontic

treatment after single or combined surgery (apical resection , periapical
curettage, root amputation, therapeutic replanting) performed at various
intervals after treatment:
*good results: deleting gradually the radio transparency and the
progression of the restructuring periapical bone (fig.2.22 d)
*adverse outcomes: persistence or extension of periapical processes
with incomplete filling, obsolete periapical periapical filling scraps, false
paths, etc., (fig.2.22 b, g, h),
*favourable results in periapical radiographs made with the same
technique after a few months, one can find good results with
fibroconjunctiv scar process that has not been mineralized (persistent
Hammer shadows) or a lack of ossification of an unchanged image,
decreased or an evolutionary process with an extended radiolucency
(fig.2.22 i).
g
h
i
Fig. 2.22. Various aspects encountered in endodontic radiograph..
54
2.9.4.Radiographs in odontogenic maxillary sinus

Radiography most used in the analysis of complex decay has:
panoramic radiographs (OPT),
skull radiographs, the incidence of "tall face"
*latest CTBC, or computed tomography, CT dental programme in
particular situations that highlight the dental sinus report, visible in the
bone window and with an obvious analysis of soft tissue densities.
These examinations are useful in information provided both in controlling
endodontic treatment and in determining the treatment of dental caries
allowing sinus complications sometimes identifying the cause of acute or
chronic unilateral maxillary sinusitis, possibly occurring during endodonic
treatment:
oral-sinus communication (fig.2.23 a, b)
root with periapical osteitis extended intrasinusal (fig.2.24 a, b)
intrasinusal dental paste with the advent of an aspergilom (fig.2.25 a,
b, c, d)
intrasinusal evolving periapical cyst (fig.2.25 - 2.26).
a
b
Fig. 2.23. Periapical palatal osteitis in 16 with acute right maxillary
sinusitis, a) X-ray retroalveolar bisectorix technique, b) skull
radiography, Blondeau incidence, with full and intense opacification of
the right maxillary sinus.
55
b
a
Fig. 2.24. OPT. a) Oral sinusal communication left side, maxillary
sinusitis, b) Presurgical aspect.
CT and CT dental program made with fine sections, millimeter and
paraxial reconstruction (Fig. 2.25) and panoramic (Fig. 2.25 c, d, e, f)
allow a precise exhibition of the teeth and the periapical processes that
cause dental sinusitis.
56
f
e
Axial CT in bone window shows a cystic intrasinusal lesion in the
palatal root and in the root of the mesio-vestibular molar 16, a), i.e. a
complete opacification of the third lower left maxillary sinus with
filling with radio opaque material, b) , CT in dental panoramic
reconstructions show more cystic lesions with sinus development in 16
c), e), and odontogenic left maxillary sinusitis with intrasinusal radio
opaque material d), f).
Acute and chronic maxillary sinusitis can be complicated by:
extension to the other sinus infection,
osteitis or osteomyelitis of the sinus wall,
orbital cellulitis,
zygomatic fossa abscess or genian,
rear extension to the sphenoid sinus, cavernous sinus with concomitant
damage and major neurological signs.
Chronic sinusitis of dental origin without teeth and sinus communication
that can not be suppressed because the starting point of the disease
outbreaks infection (Fig. 2.26 e).
57
d
Fig. 2.26. Intrasinusal as a periapical
cyst)
aspect
CT
paraxial
reconstructions, b) radiographic
Blondeau incidence, c) acute
maxillary intrasinusal left sinusitis
with radio opaque dental pulp and
left maxillary sinus opacification, CT
appearance, d) showing radiographic
aspect, e) chronic right maxillary
sinusitis radiographic aspect of the
mucosa is thickened by a peripheral
radiopacity "in frame".
2.9.5. Maxillary osteomyelitis

Osteitis is an infectious process of the cortical bone of the alveolar
process.
Osteomyelitis is an infectious process of bone entirely, affecting both
cortical and spongy bone (medullary tissue)
Seeding mechanisms: direct and indirect in a hematogenetic way.
Pathology: illustrates the four stages of osteomyelitis:
1. the suffust stage (first 8-10 days)
Radiographic: increased bone transparency (the erasing of the trabecular
drawing and increasing the size of the areolas)
2. bone suppuration stage (between the 2nd and 4th week)
Radiographic: polymicrocavity bone transparency with osteolytic areas
and micro abscesses with granulation tissue (fig.27).
58
b
a
Fig. 2.27. . Acute osteomyelitis: a) early after extraction of 46: relatively
well-defined radiolucency associated with apical lesions and preexisting
periodontal lesions (indicated by black arrows), b) Acute osteomyelitis
of the right mandible ascending branch after the extraction of 48: a
moderate radiolucency in a moderate sclerosis area (indicated by black
arrows).
3. bone necrosis stage (between the 4th and 6th week)

Radiographic: seizures occur with bone fragment with an opaque halo
surrounded by a transparency and spontaneous fistulas with etching in the
vicinity (Fig. 2.28 - 2.29).
b
a
Fig. 2.28. Osteomyelitis with seizures with the more opaque fragment of
bone surrounded by a transparent halo) after extraction of molar 47 five
weeks ago, b) spontaneous fistulas and demineralization adjacent to
the areas of seizure bone infection 6 weeks old in the dental apex 34.
59
Fig. 2.29. Osteomyelitis with sequestration in the fracture, the bone

fragments opaque halo surrounded by radiolucency in the left mandible
body fractured five weeks ago and was fixed with osteosynthesis material,
not currently consistent alignment of bone fragments postero- higher
displaced. OPT.
4. stage of bone repair
Occurs after discharge (spontaneous or surgical) sequesters of the bone.
Radiographic: neo osteogenesis processes are involved and radiographic
image begins to come to normal (sometimes a more opaque area remains).
Clinical forms: the clinically osteomyelitis can be present in various
forms:
acute osteomyelitis, periapical abscess appear radiographically.
Radiographic: changes occurring after about 10 days and consisting of:
visible periapical transparency,
a lower opacity in the alveolar walls,
* bulging periosteum.
chronic osteomyelitis: - appears radiographically as a persistent bone
abscess with various radiographic aspects.
Radiographic: the main changes are:
bone demineralization,
*seizures (fig.2.30)
condensation (fig.2.31)
fistulas.
This form of osteomyelitis varies with numerous acute evolution.
One can encounter:
Diffuse sclerosing osteomyelitis with mixed small images osteo
condensated and radiolucent;
In proliferative osteomyelitis disease (Garr) one can meet radiographic
linear opaque zones alternating with transparent lines.
60
These forms are more rare and difficult to diagnose strictly by imaging.
Differential diagnosis means:
diffuse sclerosing osteomyelitis of the:
*osteosarcoma,
*Paget's disease,
proliferative osteomyelitis (Garre disease):
* Ewing osteosarcoma,
*fibrous dysplasia.
a
b
Fig. 2.30. a) chronic secondary osteomyelitis with necrosis and
sequestration b) Chronic osteomyelitis localized from the beginning with a
reactive sclerosis the dental canal.
. Sclerosing osteitis around the root residues of molars 36 and 37,

accompanied by periapical osteitis in 45, with minimal periodontal
lesions and peripheral condensation at 47, with phenomena of furcation.
16 appears with the aspect of rest root with periapical osteitis, 24 has a
deep cavity and periapical processes, and 25 and 26 have visible coronoortho-pantomography root cavities.
61
62
Chapter 3
MARGINAL PERIODONTAL DISEASES

3.1. Definition
Marginal periodontal diseases may be limited to a single element of the
periodontium or the entire complex. They can be local problems or can be
the expression of a generalized or diseases of other organs.
3. 2. Anatomical aspects
From an anatomical point of view, the marginal periodontium is a
complex, a true morphological and functional link between the maxilla
and the tooth and is composed of fibrous gingival mucosa, the alveolodental ligament, root cementum and the alveolar bone.
The periodontal space contains:
desmodont,
vascular-nervous tissue,
connective tissue
The alveolar bone exhibits:
internal alveolar cortex (lamina dura)
the external alveolar cortical
spongy.
1 - crown
2 - enamel
3 - dentine
4 - gum
5 - pulp
6 - cement
7 - nerves and
vessels
8 - root
9-alveolar
bone
trabeculae
blood
with
Fig. 3.1. Schematic representation of the anatomy of the marginal

periodontium.
63
Marginal periodontal diseases
Marginal periodontal lesions may occur due to very different causes :

septic,
mechanic(trauma)
toxic
irritative.
3.3. Radiographical examination
It is recommended after the clinical examination and allows:
assessing the extent of bone loss and furcation involvement,
the presence of local determinants,
establishes the treatment plan,
evaluates the treatment especially when using guided tissue
regeneration.
The radio imagistice methods that can be used are:
periapical radiographs using the technique of parallel plans,
bite-wing radiographs,
OPT,
*digital radiographs using radiographic substraction and
densitometric image analysis to highlight and measure the subtle
changes of the trabeculas in the alveolar ridge bone and interdental
septum,
Dental-CT and in the future increasingly CB CT scan to determine the
anatomical relationships and measurements for the augmentation of the
bony substrate with the use of dental implants.
On retro-dento-alveolar radiographs the following structures are visible:
the approximal periodontal space,
the interdental septum with lamina dura,
the approximal cement
the interradicular septum (the lower molars).
It is not easy to highlight on these radiographs the external cortico alveolar
(vestibular and oral) and the alveolar rebord (oral and vestibular), because
they lay upon the dental roots.
In the radiological diagnosis of the marginal periodontitis should be
followed:
the relationship between their crests line of interdental septa and
the line joining the enamel-cementum junctions.
The distance between these two lines is normally of 2-3 mm
(fig.3.2.a) and in the case of alveolar bone resorption, this distance is
increased (Fig. 3.2.b).
64
c
b
a
Fig. 3.2 a) Scheme: j - enamel-cement junction, the amelo-cement line, b
- septa ridge height line, normal distance between a and b is 2-3 mm
(after Whaites, 2003), minimum horizontal retraction of periodontal
visible on a lateral mandible periapical radiograph in the group b) and
bitewing radiography in the lateral area c).
We consider as periodontal disease an increasing of more than 3 mm
distance between interdental septa ridge line and enamel-cement junction,
which is accompanied by clinical signs of gingival loss of attachment
(Eric Whites, 2003).
Radiographic aspect of a healthy periodontium:
the dental septum in the posterior region has: thin, smooth margins,
well shaped bone trabeculae;
the dental anterior septum presents: sharp edges, thin, bony trabeculas
less obvious due to the small amount of bone between the previous teeth
interdental septum continues with lamina dura of the adjacent teeth,
and the junction between them creates an acute angle.
It is important to know that:
We do not always find radiographically all these characteristics of
healthy periodontium, but their absence from the X-rays is not necessarily
a periodontal lesion,
Their absence may be due to:
*a faulty technique,
*a supraexposing of the dental film, with a "burn-out"effect
normal anatomical variations in alveolar bone density and shape,
After a successful treatment, clinically speaking, the marginal
periodontium looks healthy, but radiographically signs of bone loss can
occur when the disease was active, therefore the visualized
radiographic bone loss is not an indicator of the presence of
inflammation and must be permanently linked with the clinical
examination.
65
3.4. Classification of periodontal lesions

3.4.1The inflammatory periodontal disease
Gingivitis:
Acute:
-specific
Chronic:
ic,
mative,
Periodontitis:
Acute:
Chronic:
* severe
*with an early onset:
3.4.2. General systemic diseases that may affect periodontium:

Pregnancy,
*Untreated diabetes
Medications (for epilepsy, coronary artery disease),
HIV,
Leukemia,
Down syndrome
Langerhans cells disease,
Papillon Lefevre syndrome,
Secondary MTS
3.5. Radiographic aspects encountered in gingivitis
Gingivitis is accompanied by the damage of periodontal coating without
loss of epithelial attachment and bone lysis.
In acute and chronic gingivitis radiographic exploration may reveal soft
tissue involvement.
66
In severe cases of necrotizing ulcerative gingivitis with massive

destruction of interdental papilla, interdental septum of inflammatory
osteolysis is visible radiographically.
3.6. Radiographic aspects seen in periodontitis
Periodontitis are accompanied by damage of the coating and supportive
periodontium, with loss of epithelial attachment and bone lysis.
3.6.1. Acute marginal periodontal disease
Represents an exacerbation of chronic periodontal disease.
From a radiographic point of view the bone changes occur overlapping the
basic periodontal disease and can not be differentiated.
3.6.2. Chronic marginal periodontal disease
is the most common and frequently met periodontal disease.
These lesions are characteristic by the action of the bacterian plaque
towards the depth of the periodontal space, causing bone and ligament
damage, alveolar (osteoclazy).
Chronic marginal periodontal disease may be superficial, moderate and
severe.
3.6.2.1. Superficial chronic marginal periodontal disease
In superficial chronic marginal periodontal disease a breach appears in the
supraalveolar ligament system with different radiographic aspects of early
lesions.
Radiographic:
Early lesions are:
*Marginal demineralization halistereza in vascular axis of the septum
with the view of nutrition vessels as radiolucent areas along the interdental
septum (fig.3.5.a.)
*The widening of the periodontal space at the marginal ridge, a
triangulation, the marginal ridge alveolar septum will be demineralized
and the pack will move laterally (fig, 3.5, 3.6)
*The pinching the septum, the alveolar septal crest was demineralized
(lamina dura disappeared at this level) and then was reabsorbed, resulting
the amputation of part of the alveolar ridge (fig.3.5. b, c),
67
b
a
c
Fig. 3.3. a) - c) marginal halistereza and trabecular rarefaction, vessel
visualization, marginal triangulation and septum pinch in the incisor
region.
a
b
Fig. 3.4. . a) and b) Marginal triangulation and the decrease of marginal
bone trabeculas density visible in molars- premolars region,
bite-wing radiographs.
b
c
a
Fig. 3.5. a) - c) pinching the septum in the region of the upper jaw
premolar-molar right, in the canine premolars and mandible premolarsmolars, periapical radiographs.
* local secondary factors such as plaque, cavities, no contact points,
overflowing restorations, dental versii (fig.3.6).
68
a
b
c
Fig. 3.6. Retractions due to periodontal plaque and food debris
remaining under the prosthetic), the decay or overflowing fillings b), c).
3.6.2.1. Moderate to severe chronic marginal periodontal disease
These types of lesions are present:
interdental periodontal space widening (fig.3.7)
a
b
c
Fig. 3.7. a) - c) retractions of periodontal with teeth with interdental space
enlargement and irregular layout for a typical horizontal loss of alveolar
bone height, the damage of the posterior teeth.
images of destruction of the alveolar bone (vertical and / or horizontal)
become more visible with the emergence of periodontal pockets (Fig. 3.8),
loss of acute angle shape between the lamina dura and interdental
septum with rounded angles and irregular aspects: the aspect of parodontal
pocket, funnel, sink" in ladder "(fig.3.9)
localized or generalized loss of alveolar bone support (fig.3.9);
69
Fig. 3.8. Parodontal pockets around the apices of some teeth included in
the corono-root reconstruction.
Fig. 3.9. OPT in a patient of 47 years old with advanced progressive

periodontitis with severe vertical defects around the roots of several teeth
affected, many of them with plaque deposits and periapical processes.
the destructive lesions become irreversible (Fig. 3.10),
c
a
b
Fig. 3.10. Various bone defects: a)bony lysis with radiolucent aspect of
crater or "funnel" b) interproximal septal defect, c) horizontal
radiolucent bony liza.
70
In advanced stages of periodontal disease, radiology may find:

destructions of interradicular septum (in furcation, fig. 3.11),
a
b
c
Fig. 3.11. Degrees of bone loss at pluriradicular teeth furcation.
deep periodontal funnels(around the apex site)
total marginal periodontitis (the root is floating''), when the desmodont
is completely destroyed, lamina dura missing, irregular contour of the
spongy zone).
*bone loss patterns: horizontal and / or vertical (fig.3.12 - 3.14),
Fig. 3.12. Marginal aggressive periodontitis in a patient of 51 years with

total periodontitis quadrant II, the desmodont destroyed around apex 27
located in a prosthetic device which floats in periodontal pockets.
71
Fig. 3.13. OPT in a patient of 39 years old with progressive marginal

periodontitis with horizontal and vertical severe defects around the tooth
root residues 16, 17, 24, 25 and 47, which have the appearance of
"floating teeth".
Fig. 3.14. . OPT in a patient of 34 years old with progressive marginal

periodontitis with horizontal and vertical severe defects around the
tooth apex 35, the aspect of periodonta.
3.6.3. Early-onset chronic marginal periodontal disease.
This severe localized periodontal lesion develops during adolescence.
Imaging features:
Radiographic:
Severe vertical bone loss affecting molars and / or incisors with the
advent of "periodontal funnels" around them (fig.3.15 - 3.16);
arch-shaped bone defects (fig.3.15 - 3.16),
72
sometimes generalized bone loss,

the migration of the incisors with forming of distemas,
rapid rate of bone loss (fig.3.17).
Fig. 3.15. . Juvenile periodontitis, severe vertical bone loss affecting the
mandible molars and premolars in particular, and the maxilla and
mandible incisors in a young man of 22 years old with important
phenomena of furcation in 26, 36.47, aspect of "funnel" in 45, and
"sink" in 34 and 12.
Fig. 3.16 Juvenile periodontitis, severe vertical bone loss affecting the
mandible molars and premolars especially in a young person of 21 years
old.
73
Fig. 3.17. Juvenile aggressive periodontitis, severe vertical bone loss,

affecting mandible premolars and molars in particular and the maxillary
central incisors in a 28-year young woman, leading to isolated vertical
bone loss and furcation phenomena.
3.7. Evaluation of the treatment
Traditional treatment requires repetition under more precise
radiographic examinations: OPT or periapical radiographs of parallel
technique. An alternative would be CT exploration and especially Cone
Beam CT examination with a much lower radiation than CT and will
become (if equipment prices fall), more and more used in practice in the
coming years.
Guided tissue regeneration is a new method of treatment which began to
be increasingly used in recent years.
3.7.1. Limits of radio-imaging examination in periodontal lesions
overlapping anatomical structures and two-dimensional image may
cause the following problems:
*difficulty differentiating between the buccal and lingual alveolar
ridge,
*only part of the complex bone defect is noticed
*a wall of the bone defect can hide the remaining defect
*tooth restorations can hide dense or vestibular or oral bone defects,
*vestibular or oral plaque deposits
*bone loss in the furcation region can be hidden by overlapping of
roots (the upper molars), or bone wall,
74
From a radiological point of view we only have accurate information on

the structure of bone, and the gum tissue damage is not normally
detectable on radiographs,
Bone loss is detectable when a sufficient amount of bone is lost which
leads to a significant reduction of X-ray beam,
Technical variations in positioning the film, the patient and X-ray beam
can alter the appearance of periodontal tissues. In this case it is necessary
that:
* The incidence where the radiographs are done or successive OTP have
to be standardized in terms of technique, placing the film against the
alveolar angulation, projection beam of radiation and its incidence to the
film plane (parallel technical plans, technical bisector).
Exposure factors can have a marked effect on interdental septal height,
Although OPT imaging can help assess the overall periodontal status
should be careful in its analysis associated with periapical radiographs
especially in anterior teeth because some lesions by overlapping
anatomical structures can not be correctly noticed (fig.3.18).
Juvenile aggressive periodontitis with severe vertical bone loss

particularly affects mandible premolars and molars, a young man of 24
years, with lower centrality region is reduced and imprecise.
75
76
Chapter 4
DENTO MAXILLO FACIAL TRAUMA

4.1. Introduction
Massive teeth and facial fractures are common injuries, which
considerably vary in terms of facial trauma severity or type of fracture.
The fracture path appears radiografically as an irregular radiolucency,
which interrupts the bone continuity in a particular region of the facial
massif or teeth. Radiographic examination is essential for both the initial
assessment and the development of post-treatment stage.
Diagnosis of fractures are clinically and radio-imaging achieved by
various methods: radiographs, digital volume tomography (Cone Beam
CT), computed tomography (CT).
Radio-imaging diagnosis of these various methods of exploration involves
analysis of the following elements:
the existence of the fracture, fracture location and path,
fracture aspect: single or comminutive,
displacement, angulation, overlapping of the fractured fragments,
fracture on a normal bone or on a pathological one (important in
forensic medicine)
presence of radiopaque/radiolucent foreign bodies,
involvement of facial sinuses, the orbit, the nasal fossa, one of the 3
floors of the skull base,
association with fractures at other levels of the body trauma of a sick
person)
post-fracture aspect of facial massif.
4.2. Classification
Dento-maxillo-facial trauma can be divided into 4 categories:
trauma of the teeth and supporting structures,
fractures of the mandible,
facial massif fractures,
other injuries involving: calvaria, base of the skull and intracranial
structures, cervical
spine.
77
Dento maxillo facial trauma
4.2.1. Teeth and supporting structures trauma

4.2.1.1. Classification
The classifications are different, but the most commonly used is that of
Andreasen 1992:
dental fractures,
dental dislocations,
alveolar bone fractures,
other injuries.
Dental fractures may be:
Coronary: involving enamel; dentin and enamel; enamel, dentin and
pulp; enamel, dentin and cementum; enamel, dentin, cementum and pulp.
Root: without a coronarian fracture, with a coronarian fracture.
Dental dislocation include:
concusion,
subluxation,
intrusive luxation (internal dislocation of the tooth)
extrusive luxation (external dislocation of the tooth)
lateral luxation,
avelsion (the luxation of the tooth out of the dental socket).
Alveolar bone fractures are:
* fractures with dental socket involvement,
fractures of the alveolar process,
fractures of the associated jaw,
Other injuries include:
removal of a tooth bud which may become dilacerated as a result of
laceration,
soft tissue injuries, such as laceration or imbedding of a foreign body,
injuries that occur during dental extractions include: damage to
adjacent teeth and alveolar bone fracture, ingestion or inhalation of the
avulsed tooth.
4.2.1.2. Radiographic examination
It is useful to assess the full damage of the teeth and supporting
structures, the post-treatment recovery and potential complications.
Usually one has to achieve two radiographs of interested tooth, with a
locator cone set in two different positions in the vertical plane (eg
periapical radiograph performed technique of parallel and / angle bisector
technique, occlusal radiography Belots technique).
The radiographs must be reproducible to assess the post-treatment aspect
of the teeth and supporting structures.
If accidentally a tooth is inhaled or swallowed one can produce:
78
cervical profile radiographs with a filter for the soft parts,

* pharyngo-laryngeal anterio-posterior incidences,
chest x-ray in the postero-anterior incidence and right side,
abdominal radiography in anterio-posterior incidence.
Radiographs for dental injuries give information about:
the type of dental injury,
the fracture site,
the degree of displacement of the dental fragments, the stage of the
root displacement,
condition of apical tissues,
the presence, location and movement of alveolar bone fragments,
the status of adjacent teeth and / or permanent teeth buds,
post-treatment aspect,
post-traumatic complications: resorption, infection, cessation of dental
development,
location of the inhaled or swallowed tooth.
Dental radiographs should be directed to:
irregular aspect of the discontinuity of dental bone radiolucency,
alteration of dental root.
aspect of adjacent support structures.
4.2.1.3. Radiographic aspects encountered in dental fractures and
sprains
In fig.4.1 we show the most common types of fractures and dislocations
encountered in dental practice.
79
d
e
f
Fig. 4.1. a) a) coronarian fracture in 21 (retro-dental-alveolar
radiography), b) root fracture 21 (occlusal radiograph), c) dislocations
with extrusion of 41.31 and dislocations with the avulsion of the tooth
32, d) and mandible alveolar fracture with left paramedian fragment
displacement and canine dislocation, e) post immobilization aspect with
radiopaque material, f)fracture of the alveolar rebord with intrusion of
11 and rotation of 12.
4.2.1.4. The limitations of radiographic examination

The radiological interpretation in dental trauma (due to the two
dimensional and not three-dimensional image of the radiographed teeth)
may be influenced by:
position and severity of the fracture,
the degree of displacement or separation of the fragments,
X-ray tube and film position relative to the fracture line, hence the need
for the 2 films in 2 incidences.
4.3. Mandibular fractures
They represent 3-5% of skeletal fractures and aproximatively 75% of
craniofacial fractures. They can be single or associated with other types of
fractures.
The mechanism is varied, stressed and disadvantaged by the anatomical
factors. We can meet:
direct or indirect fractures,
healthy or pathological fractures,
fractures with immediate or delayed complications.
The presumptive clinical diagnosis of the fracture leads to the following
questions:
80
What is the precise location of fracture / fractures jaw?

What impact /is needed to visualize fracture?
What are the radiological features indicating the presence of a
fracture?
How can one assess fractures radiologically?
4.3.1. The radiological exploration of the mandible fractures
The location of mandible fractures and radiographic incidence used for
the exploration of:
Body of the mandible OPT/ maxilla scroll, AP radiograph of
mandible, occlusal Simpson affected tooth periapical
Angle jaw-OPT, AP radiograph of mandible and maxilla scroll,
Canine region-OPT / jaw scroll, periapical radiograph of skull profile
*The symphysis-occlusal region inferior to 45 and 90 , OPT,
Mandibular rami: - OPT / scroll mandible, mandible radiograph PA
Condyle neck: - OPT / scroll mandible, mandible radiograph PA
Coronoid process: - OPT / jaw scroll, skull radiography incident to
high face.
Radiological characteristics of mandible fractures:
radiolucent line between separate bone fragments, fracture of buccal
and lingual cortices that may result from viewing the two radiolucent
lines,
radiopaque line when fragments overlap each other,
alteration of bone contour if the fragments are displaced, with
deformation in the lower alveolar step edge or occlusal plane.
It is well to remember that:
severity of any movement of bone fragments depends on the direction
and force of the impact,
the fracture line that results
muscles attached to each fragment and their direction
In case of a fracture line that makes the muscles to keep the two pieces
together, we can consider a fracture with a favourable progress.
If muscles do not take the two pieces together, we can consider the
fracture with poor outcome.
Radiographic control after-treatment requires the following:
alignment of bone fragments,
position of intraosseous osteosynthesis materials used
bone healing,
condition of teeth involved in the fracture,
infections or other complications.
81
4.3.2. Radio-imaging issues encountered in mandible fractures

4.3.2.1. Lateral fractures (mandible body - 21%)
They are located between the canine and wisdom molar and include:
*those with vertical or oblique fracture line (fig.4.1 - 4.6),
those with angular displacement (fig.4.2)
Fig. 4.2. . Shot comminutive fracture of the left mandible body with the
bullet retained in the mandible horizontal left ram and minimum
overlapping fragments of bone, OPT.
(Prof. D.Goglniceanu collection).
rotation or gap of a higher amplitude (fig.4.4)
* these fractures are sometimes accompanied by rupture of blood
vessels, nerve elongation or rupture and foreign body (bullet, plexiglass,
glass).
these fractures sometimes occur in a pathological bone(fig.4.6).
Radiographic examination requires: OPT pre-and post-surgery (Fig.4.3),
radiographic axial and occlusal film radiography, holistic impact of the
mandible in PA.
82
Fig. 4.3. . Postoperative aspect of fracture and bone graft, surgically

resolved by immobilization with plates and screws, OPT.
(Prof. D. Goglniceanu collection).
Fig. 4.4 Comminutive left mandible body fracture symphysis irradiated

with fragments and dislocation of dragging incisors, canine and first left
premolar (Prof. D. Goglniceanu collection).
83
b
a
a) Jaw scroll incidence. Right mandible body fracture without
displacement, b) occlusal radiograph, fracture with displacement of the
right mandible body, with minimal displacement (OMF Surgery Clinic
Collection Iasi).
b
a
Fig. 4.6. a) Left mandible body fracture with fracture path passing
through a small residual cyst and through the dental channel,
radiographic incidence of jaw scroll: b) Comminutive body left fracture
with fracture paths passing between premolars and bulky periapical cyst.
4.3.2.2. Gonion fractures (mandible angle) 17%
These fractures occur in an area of low bone strength and may have a
trajectory:
pre- muscle with secondary bone fragments movement (fig.4.7 -4.8),
muscle mass, without dislocation of the fragments.
The radiographic examination requires: OPT and holistic radiography of
the mandible in incidence before and after immobilization PA.
84
b
a
Fig. 4.7 Displaced fracture in the right gonion, mandible radiographic
incidence scroll: a) with an interest in the 48 molar socket which is in
eruption, with minimum drag fragments b) fracture displacement left
gonion, the immobilization of osteosynthesis material, but significant
displacement of the fragments and the focus of the wisdom tooth root
fracture (OMF Surgery Clinic Collection Iasi).
Fig. 4.8. a) Comminutive mandible angle fracture near the angle of the
right mandible, with the fragment ascension and molar root 48 in outbreak
incidence x-ray of the mandible jaw scroll b) comminutive fracture with
displacement of the left mandible angle, with moderate displacement of
the fragments, radiography skull incidence low face" PA. (Collection
OMF Surgery Clinic Iasi).
4.3.2.3. Median fractures (mediosymphysa)
These fractures are relatively rare in the mandible fractures because the
mentoniera symphysis resistance is an important point of the mandible.
85
Fracture line type of injury is between the two central incisors and get
parasymphysis the basilar edge of the mandible, making sometimes
inverted Y-shaped bifurcation, hence the name "lambda fracture" (fig.4.9 4.10) The radiographic examination requires: OPT, axial radiograph
occlusal film.
Fig. 4.9. Cominutive symfphysis fracture irradiated in the

parasymfiphysis area with displacement of fragments, with left displaced
subcondylian fracture and internal sprain of the mandible condyle. OPT
(Collection OMF Surgery Clinic Iasi).
Fig. 4.10. Fracture of the symphysa without displacement of the fracture

with inverted Y aspect of the follicular bag of canine 33, in the focus of
the fracture, intraoral outbreak panoramic radiography
(Collection OMF Surgery Clinic Iasi).
86
4.3.2.4. Paramedian fractures (juxtas ymphysa) 18%

These fractures are located between central and lateral incisors or
between the lateral incisors and canines.
They are:
with or without vertical and horizontal displacement,
associated with mandible condyle fractures opposite to the fracture or
post-traumatic with a foreign body penetrating the oral floor. The
radiographic examination is performed: Scroll mandible (Fig. 4.11 a) and
axial incidence with an occlusal film (Fig. 4.11 b), OPT (fig.4.12 - 4.13) to
assess the degree of horizontal displacement of bone fragments and dental
structures, useful in double paramedian fractures and / or sometimes CT
(fig.4.14).
a
b
Fig. 4.11. a) Parasymphysa left occlusal fracture, occlusal radiograph
with displacement and overlapping fragments, b) right parasymphysa
fracture, radiographic incidence scroll of the right mandible with
moderate displacement of the fragments and follicular bag of tooth 43 in
the focus of the fracture (OMF Surgery Clinic Collection Iasi).
Fig. 4.12 OPT right paramedian fracture in a patient with multiple

inclusions showing cleido-cranial dysplasia (delay in eruption of
permanent teeth, multiple inclusions with persistence of temporary teeth.
87
Fig. 4.13. Comminutive paramedian and median fracture by shooting a

bullet, panoramic intraoral outbreak radiograph.
(Prof. D. Goglniceanu Collection)
b
a
Fig. 4.14. Right juxta simphysis fracture with fragments overlapping the
bone fragments produced by projecting a metal piece, CT axial in bone
window, b) soft tissue window, showing fracture and subcutaneous
emphysema adjacent to the fracture.
4.3.2.5. Ascending rami fractures - 4%

Is achieved by direct or indirect trauma, may have a horizontal, oblique,
vertical trajectory, with moving and overlapping fragments.
Radiographic examination requires: OPT (fig.4.15) and holistic
radiography of the mandible in incidence PA.
88
Fig. 4.15. Left ascending rami fracture displacement,

produced by shooting, shot radiopacity in focus. OPT.
(Prof. D. Goglniceanu Collection)
4.3.2.6. Condylar process fractures - 34%
These fractures are numerous, different percentage assigned to the:
head
neck
subcondylian lower or higher level (fig.4.16) or.
Radiographic examination requires numerous incidence which are chosen
depending on the patient's general condition: OPT (fig.4.17), radiographic
incidence of jaw scroll, holistic radiography of the mandible in incidence
PA and CT.
Fig. 4.16 Low subcondylian right fracture, accompanied by a

parasymphysis fracture, without displacement, jaw scroll incidence
radiography (Prof. D. Goglniceanu Collection)
89
Fig. 4.17. Low subcondylian left fracture, accompanied by a coronoid

process fracture with displacement of the left and right parasymphysis
fracture without displacement, OPT after immobilization with
osteosynthesis material (Prof. D. Goglniceanu collection).
4.3.2.7. Coronoid Process Fractures
These fractures are the rare type of mandible fractures due to the
protection of the apophysis protect the skeletal muscle and the
neighbouring bones.
The radiographic examination requires incidences chosen according to the
patient's general condition: OPT (fig.4.18), radiographic of jaw scroll
incidence, holistic radiograph of the mandible in incidence PA and CT.
Fig. 4.18. Left malar fracture and left subcondylar, with amputation of
the left coronoid process, O.P.T.
(Prof. D. Goglniceanu collection).
90
4.3.3. The Limits of the Radiographic

The radiological interpretation in the mandible fractures may be
influenced by:
the position and severity of the fracture,
the degree of displacement or separation of fragments
X-ray tube and film position relative to the fracture line, hence the
need for at least 2 films in 2 different incidences.
However, if the movement of the fragments is minimal, the
radiography alone can not reveal the fracture path, and a spiral CT with
fine sections and 2D and 3D reconstructions is necessary.
4.4. The Fractures of the Facial Massive
Facial massive fractures are common and usually implied in many bone
structures.
This is due to the complexity of the facial skeleton, which requires a good
knowledge of plan and sectional radio anatomy (CT) of the region.
As it is already known, the jaw strength pillars are:
alveolo-palatine pillar,
zygomatic pillar,
front-nasal pole.
The presumptive clinical diagnosis of a fracture leads to the following
questions:
the precise location of facial fractures?
what is required for viewing the fracture incidence?
what are the radiological features indicating the presence of a fracture?
how to assess fractures radiologically?
4.4.1. The Classification of the Facial Massive Fractures
There are many types of fractures seen in the facial massive and radioimaging investigation methods used for identifying them. The most
common fractures are:
dento-alveolar fractures:- X-rays: periapycal, occlusal disto / mesioeccentric
Le Fort I fractures: - X-ray of skull incidence of "tall face"
(Tscheboul, Blonde, Waters) and X-ray of skull profile, CB-CT, CT
Le Fort II fractures: - X-ray of skull incidence of "tall face"
(Tscheboul, Blonde, Waters) and X-ray of skull profile, CB-CT, CT
Le Fort III fractures: - X-ray of skull incidence of "tall face"
(Tscheboul, Blonde, Waters) and skull radiography profile, axial CT
coronal reconstructions 2 D and 3D reconstruction,
91
zygomatic complex fractures: - X-ray of skull incidence of "tall face"

(Tscheboul, Blonde, Waters) and X-ray of skull profile
nasal-ethmoidal complex fractures: incidence of skull radiography
"tall face" (Tscheboul, Blonde, Waters) and radiography for nasal
pyramid, axial CT coronal reconstructions 2 D and 3D reconstruction,
orbital fractures: incidence of skull radiography "tall face"
(Tscheboul, Blonde, Waters) and X-ray of skull profile, axial CT
reconstructions 2 D coronal / sagittal and 3D reconstruction.
4.4.2. Imaging Radio Exploration of the Facial Massive
It is mandatory to confirm the existence of traumatic facial massive
bone lesions to achieve at least 2 incidences: one of the incidence is "tall
face " and a skull profile radiograph to remove a skull base fracture, the
fluid
level
being
radiopaque
in
the
sphenoid
sinus.
Post treatment, we must follow:
the alignment of bone fragments and bone healing,
intraosseous position of the osteosynthesis materials used
the condition of sinus and teeth involved in the fracture,
infections or other complications.
The systematic interpretation of the facial massive fractures requires, after
Eric Whaites an approach of the following:
Campbells line analysis proposed by Campbells Mc Gregor on the
front skull radiographs (OM incidence plane at 0 or 30 OM plan,
fig.4.19 a, b and 4.20 b)
bone structures analysis in profile skull radiographs (fig.4.20 a).
4.4.2.1. The Campbells Lines Analysis
Step 1.
Comparing both sides of radiographs by drawing Campbells lines.
Step 2.
Comparing both sides of radiographs by drawing the secondary curves
Ginestet, LeDinh and R. Bouquet:
Curve 1 - the side wall of the antrum and lower surface of the
zygomatic bone and zygomatic arch,
Curve 2 - the upper lateral aspect of the zygomatic arch and zygoma
body and orbital edge.
Curve 3 - internal aspect of the orbital ram
Curve 4 - external curvature of the nasal complex
92
c
d
Fig. 4.19. . a) the interpretation of Campbell's lines: COS-superior orbital
curve; COI-inferior orbital curve, CPN-palato-nasal curve, CAD dental
alignment curve b) curves of Ginestet, Le Dinh and R. Race. c), d),
Campbell's lines schematically represented on the skull.
The analyzed elements in both steps are:
any alteration or outline or shape asymmetry in bone,
deformation speed
widening sutures,
* presence of a transparent fracture line,
the fracture lines direction,
the degree of bone fragments separation,
any radiopaque line or shade indicating overlapped fragments,
We must pay a particular attention to radiographs made with X-ray tube
set at 0 degrees to the plane OM, facial fractures from 1/3 are usually
identified:
fronto-zygomatic suture,
93
fronto-nasal suture,
temporo-zygomatic sutures,
lower edges of the orbits,
sides of the antrum,
nasal septum and ethmoid complex,
All these structures are automatically checked if a systematic approach is
followed to view occipito-meatal radiographs(OM).
Step 3
Examination sinus antrum. Comparing both sides and the opacity and / or
fluid levels suggests a hemorrhage in atrum.
a
b
Fig. 4.20. Le Fort II type middle transverse fracture, a) incidence of profile
skull radiography, b) incidence of skull tall face radiography
4.4.2.2. Bone structures analysis of the profile skull radiographs
We will examine several areas (Fig. 4.20 a):
Zone 1 checked areas: frontal sinus, frontal cerebral fossa floor
including blade cribriform, back walls of the middle cerebral fossa,
sphenoid sinus, vertical walls of the pterigo-palatine fossa, the
pterigoidian blades, teeth, posterior and front
Zone 2: front-nasal suture, the lateral edge of the orbit, maxillary
antrum, hard palate, anterior margin of the jaw,
Zone 3: nasal bones, the front wall of the maxillary antrum, nasal
front spina
Particular attention must be paid to:
Frontal:
Any step deformation or destruction of bone contours,
fluid levels in the maxillary antrum,
Back:
94
Any separation or deformation stage in the anterior or posterior wall

of the frontal sinus,
Any damage to the continuity of previous cerebral fossa floor, or liquid
level in the sphenoid sinus,
Any movement down and to the rear of the facial skeleton - the most
easily detected by observing any discontinuities or distortions in front and
rear walls of pterigo-palatine fossa,
Any unevenness of occlusal posterior teeth region and change in the
degree of covering of the anterior teeth.
4.4.3. Radio Imaging Issues Encountered in Facial Massive Fractures
4.4.3.1. Lower horizontal fracture Le Fort I
This fracture occurs above alveolo-palatal column, affecting the hard
palate and the alveolar edge with the adjacent teeth (fig.4.21).
95
f
e
Fig.4.21 Le Fort I fracture (Guerrini), a) a tall face skull radiograph,
highlighting a bilateral fracture of the side walls and the sinuses clouding
with hemosinus, b) 3D CT reconstruction of the fracture profile
highlighting that isolates infrastructure as a trajectory above the teeth
apices, c) - d). Coronal CT reconstruction of maxillary sinus fracture path
visible to the union of 2/3 of upper third and lower apophyses of the
pterigoid sinuses, e) - f). CT, 3D reconstructions profile SSD and oblique
left.
4.4.3.2. Middle horizontal fracture Le Fort II
This type of fracture makes a low or transmaxilo cranio-facial disjunction
(Fig. 4.22).
96
f
e
Fig. 4.22. . Le Fort II fracture (incomplete bilateral), a) x-ray front in
tall face incidence with transverse fracture path and change lines and
curves Campbelles Ginestet, c), e), CT bone window showing the
fracture of all the walls of the jaw sinus of the great wing of right
sphenoid and zygomatic arch, d), f), CT soft tissue window showing all
the walls of the right maxillary sinus fracture priorbitar emphysema with
gentian hematoma.
4.4.3.3. Upper horizontal fracture Le Fort II
This fracture is a high cranio-facial fracture disjunction fracture,
separating the massive facial from the neurocranium (Fig. 4.23).
a
97
d
e
Fig. 4.23. . Bilateral cranio-facial high fracture-disjunction Le Fort III,
a) X-ray of skull showing high fracture incidence from passing through
the cross bilateral vomer, upper third of the nasal bones, inferior orbital
COI-curve, CPN-palato-nasal curve b) the incidence of profile skull
radiography, c) upper fragment CT MIP reconstruction showing the
transverse fracture with the inter-cranial disjunction, d), e) Axial CT
pneumatocel HAS post-traumatic cerebral edema, ischemia left front,
implying left subfalciforma petechiae.
4.4.3.4. Zigomato-maxillary complex fractures
This fracture can be:
center-facial -nasal bone fracture with orbit-nasal dislocation
latero-facial a fracture with a maxillo-malar disjunction (tripoidal or
fracture or tetrapoidal fracture) and with associated intracranial lesions
(Fig. 4.24).
98
g
h
k
Fig. 4.24. Left zigomato-maxillary complex fracture a) - c), with
displacement and clogging of the malar, or radiopaque foreign bodies,
pellet, k), and Right maxilla-zygomatic complex fracture d) - h) Axial
CT in soft tissue window and bone fractures highlighting comminutive,
overlapping fragments, hemisinusal jaw, post traumatic subarachnoid
hemorrhage and suntentorial cerebral edema, diffuse disappearance of
the tanks d), f).
4.4.3.5. Blow-up fracture of the orbit
They are produced by direct impact with an object too large to enter the
orbit and the impact force is transmitted into the median or lower orbital
bone so that the thin bone floor is fractured determining a herniation of the
orbital content in the ethmoid cells or atrum. (Fig. 4.25).
99
f
e
Fig. 4.25. Blow-up fracture of the right orbital floor with the herniation
of orbital fat: a) axial CT, b) 3D reconstruction, left orbital floor
fracture, c), d) coronal CT; right and left orbital floor fracture of the
papyrus-like blade) f) Axial and coronal CT.
Since in the conventional radiographs bony structures overlap, this type of
fracture is difficult to be highlighted and require sectional exploration , the
examination using computed tomography which allows the analysis in
bone window and soft tissue fracture, intraorbital fat examination, with or
without implying the left low muscle .
100
4.5. Other Fractures and Complex Cranio-facial Trauma

These fractures are varied and require the following explorations:
skull fractures, base profile skull, CT 2 and 3 D reconstruction (Fig.
4.26),
c
d
Fig. 4.26 Skull base and calvaria irradiated right latero-facial fracture, a),
b) Axial CT in bone window showing maxillary sinus wall fracture right
combinative of the large sphenoid wing, temporal bone, and a small
pneumatocel and subcutaneous emphysema, c) Axial CT soft tissue
window showing the areas of fronto-temporal hemorrhagic contusion
bilateral post-traumatic subarachnoid hemorrhage, d) 3D CT
reconstruction VRT right latero-facial fracture irradiated to calvaria, front
right.
intracranial injury - and sometimes MRI CT (Fig. 4.27),
101
Fig. 4.27. Multiple deep intracerebral lesions post traumatic, visible

intracranial through a cranial MRI brain examination in hipersignal the T2
sequence, cortical and subcortical located, subtentorial a), b) and
supratentorial c), d), the gray matter and parietal subarachnoid right space ,
but were not detected in cranio-cerebral CT scan, performed in an
emergency. Clinical patient had confusional syndrome, epistaxis and
abundant gentian hematoma, front and left periorbital.
cervical spine fracture-incidence X-ray of neck pain in, pro front, profile
and special odontoid, CT and MRI often highlighting concomitant
medullary lesions (Fig. 4.28).
102
d
c
Fig. 4.28. Fracture dislocation C4-C5 a) and C2-C3, b) changes of the
retrozid, c) Bodily settlement C7 fracture with minimal posterior
displacement of the retrozid, d) parietal hematoma dissecting right
vertebral artery observed in posttraumatic FS T1 MRI sequence .
103
Fig. 4.29. C6-C7 fracture with a herniated disk, post trauma, right
paramedian, sagittal sequence T2 a), sagittal T1 sequence b), C4-C5 with a
hipersignal at the vertebras in sagittal T2 sequence and compressive effect
on the LCR belt c), right vertebra artery parietal disecant hematoma post
trauma noticed in T1sequence FS
104
Chapter 5
JAW AND CERVICO FACIAL SOFT TISSUE CYSTS

There are many classifications of cysts of the jaws and soft tissue in
cervical and facial area. According to the latest O.M.S. classification in
2007 (WHO ICD 10, chapterXI Diseases of the oral cavity, salivary
glands and jaws),jaw cysts are classified into:
I.
Periapical tissues cysts:
radicular cyst:
* apical (periodontal)
* periapical
* residual
II.Odontogenic cysts:
dentiger cyst
eruption cyst
follicular cyst,
gingival cyst
lateral periodontal cyst
primordial cyst
odontogenic (primary) keratocyst
III. Neodontogebic cysts:
1. Fissure cyst:
median palatine / mandible cyst
globulo-maxillary cyst
naso-palatine cyst
incisive canal cyst
palatine papilla cyst
2. Other cysts:
traumatic bone cyst
hemorrhagic bone cyst (postsurgery)
aneurysm bone cyst
solitary bone cyst
IV. Cysts of an unknown origin:
latent cyst of the mandible bone,
Stafne's cyst.
V. Cervico-facial soft tissues cysts:
dermoid / epidermoid cyst
limfoepitelial (brachial) cyst
105
Jaw and cervico facial soft tissue cysts
nasoalveolar cyst
nasolabial cyst
brachial (lateral) cyst
thyroglossal (median) cyst.
In 2003, E. Whaites believed that the highlighting of a cystic radiolucency
located in the maxillary or mandible requires systematic analysis and the
several steps:
Step 1 - there is considered:
location
size
shape
edges or periphery of the cyst
the relative radiodensity and its internal structure
the effect upon the surrounding structures
how long has the cyst been present, if it is known.
Step 2 there is stated whether the radiolucency is:
of a normal anatomic aspect:
On the mandible level:
mentonier hole
tooth crypt
On the jaw level:
antrium
-palatinal fossa
an artefact: according to the type of scan performed, sometimes
appears:
a radiolucency by overexposure,
air overlapping shadows that appear as a radiolucent cyst,
pathological lesions:
congenital
in progress
gained.
Step 3 according to the injuries acquired one can decide which
category the radiolucency belongs to:
infection localized in the apical tissues:
* acute
*chronic
extensive infections in the jaw:
* osteomyelitis
106
* osteo radionecrosis
injuries
cysts
tumors or pseudo-tumoral lesions
giant cell lesions
cement fibrous-osseous lesions
*idiopatic lesions.
Step 4- there are taken into consideration the classifications of the
lesions in OMS lists
Step 5 - the radiological aspects of radiolucency found with each of the
pathologies described in the table above are compared. Then a list is
produced, with the differential radiological diagnosis of all pathologies
that might fit at the found lesion.
5.1. Periapical tissues cysts
5.1.1. The radicular cyst
It is an inflammatory cyst developed in the epithelial Malassez cells,
which may occur at any age.
Clinical features
epidemiology: high frequency in the maxilla, with a rate of about
70%, especially in adult males, aged between 20 and 50;
location: at the apex of any devitalized tooth, upper lateral incisors
and often in the roots of the lower molars;
dimensions: diameter 1-5cm (the smallest are difficult to be
distinguished from granulomas);
shape: round when monolocular, spherical, elongated when
multilocular;
edges: smooth (Fig. 5.1, 5.2), well-defined, corticalizated if chronic
(except in case of an infection) and continuing with the lamina dura of the
associated tooth.
107
c
Fig. 5.1. Periapical radicular cyst: a)OPT in a 19 year old with a
periapical radiolucency in 22 (which is devitalised), oval, smooth-edged,
well defined and sizes over 1 cm, b) Sketchy representation, shaded cyst
and decay depth of 21, 24 and 11, 47, past obstructions c) OPT in an
adult of 27 years, periapical cyst in the distal molar root of 36, radicular
remains 16, 21, 35, 47, 37 deep cavity with suppurative apical
periodontitis (periapical abscess).
108
e
d
f
Fig. 5.2. Radicular periapical cyst a) retroalveolar X-ray with a
radiolucency with smooth fine edges in 22 which is devitalised, b) Scroll
mandible periapical cyst at 46 which is devitalised and periapical
resorption, c) periapical cyst al. HEx40, d), e) dental CT axial and sagittal
2D reconstruction with periapical cysts in 46, 45, 44 which are in the
form of debris root f) paraxial CT reconstruction showing the reference
of the cysts with inferior dental nerve canal.
Imaging examination
Ways of examination: dental radiographs, OPT, radiographic incidence
in jaw scroll, CT.
Imaging features
smooth, well-defined, uniform radiolucency adjacent to the apex of
the devitalized tooth,
effects:
adjacent teeth are displaced, periapically resorbed, sometimes
cystic formation may cause shift antrum,
cyst may cause buccal expansion,
Pathognomic signs: absent; any periapical cyst needs a pathologist
confirmation.
Differential diagnosis: periapical granuloma, ameloblastoma,
neodontogen epithelial cysts, non epithelial neodontogenous cysts.
109
Note: Approximately 40% of benign tumors are misdiagnosed as

simple periapical cysts; any cyst requires the confirmation from the behalf
of a pathologist.
5.1.2. The residual radicular cyst
The radicular cyst is a remaining after the extraction of a devitalised tooth
that had caused the cyst.
Clinical features
epidemiology: occurs in adults older than 20
localization: apical regions of the contact area in dental - maxilla
* variable, usually 2-3 cm in diameter,
shape: round, oval when monolocular, rarely elongated when
multilocular,
edges: smooth, well-defined, corticalised (Fig. 5.3.).
b
Fig. 5.3. Residual cysts: a) Left scroll
mandible
with
a
radiolucent
formation with smooth edges,
corticalised, adjacent to an empty
socket post - extraction of molar 36,
b) well defined radiolucency after
extraction of right
mandible
horizontal ram, c) CT - sagittal
reconstruction, residual cyst in the
lower dental nerve canal.
Imaging examination
Methods of examination: dental radiographs, ortho-pantomography (OPT),
CT.
Imaging features
smooth, well-defined, uniform radiolucency,
110
effects: adjacent teeth are displaced, periapical resorption, cystic

formation may cause shift antrum, cysts may cause buccal expansion,
Differential diagnosis: unilocular ameloblastoma.
5.1.3. Lateral periodontal cyst
Cysts located lateral periodontal that are not inflammatory cysts or
odontogenic atypical keratochists. It is assumed that they develop from
cellular debris or residual dental lamina the epithelial enamel at the level
of the lateral side of the root surface.
Clinical features
epidemiology: rare occurrence in adults aged over 30.
location: lateral root surface of some vital teeth in canine / lower
premolar and upper lateral incisor region,
sizes: small, <1 cm,
shape: round, monolocular / multilocular, sometimes
edges: smooth, well defined and corticalisated.
Imaging examination
Methods of examination: dental radiographs, ortho pantomography (OPT),
CT.
Imaging characteristics
uniform radiolucent, finely shaped (Fig. 5.4)
effects: move adjacent teeth (if the lesion increases) slowly
absorbable, oral expansion if the lesion increases.
Differential diagnosis: gingival cyst, unilocular ameloblastoma.
Fig. 5.4. Lateral periodontal cyst:

situated between the edge cervical canine root
apex near the alveolar rebord
5.2. Odontogenic cysts

5.2.1. Dentiger cyst or follicular cyst
The cyst develops from the adamantine body around a dental crown
suffering a cystic degeneration.
Clinical features
epidemiology: usually teenagers or young adults, aged 20-40,
occasionally older, represent 20% of the total cysts,
111
location: the crown of a non erupted tooth and moved, especially on

the level of a tooth with a disturbed eruption, for example canines and
wisdom molars,
*dimensions: variable;> = 1cm, follicular cyst is suspected if the
follicular space exceeds 3 mm but can reach several centimeters in
diameter,
shape: round or oval, typically symmetrical encompassing the crown;
monolocular, are described 3 types according to the relationship cyst /
crown: central / lateral / round,
edges: smooth, well-defined, well corticalizated, frequently.
Imaging examination
Ways of examination: dental radiographs, ortho pantomography (OPT),
CT
c
d
Fig. 5.5. Dentiger mandible cyst: a) radiolucency with fine edges around
45, un erupted and postero-inferior moved, 54 remaining, 44 and 46
distalised; b) radio transparency with fine edges around un erupted 45, 85
and 86 remaining with physiological rizaliz; c) radiolucent soft-edged
border around the un erupted 48 with physiological rizaliza in 85
d)eruptive cyst superficially located around the crown of 48 which has an
eruption in progress.
112
*uniform transparency, well defined, with thin walls, extended round
the crown of a non erupted tooth (fig. 5.5a, b, c,) having the following
effects:
*the non-erupted tooth, moved,
*the adjacent teeth are displaced, 50% absorbed, covered by large
cysts
*oral or median expansion that can be extensive in case of large
cysts causing facial asymmetry and the movement of the antrum (Fig.
5.6).
Fig. 5. 6. Dentiger mandible cyst: OPT with Dentiger cyst in 45

included, found in corono disto version and in disto position in mandible
(Prof. D. Goglniceanu Collection).
Differential diagnosis: radicular cyst, unilocular ameloblastoma,
odontogenic keratocyst..
Note: The term refers to an eruptive odontogenic cyst located around
the crown of a tooth surface, often temporary / permanent in an ongoing
eruption (fig.5.5 d). As the cyst membrane surrounds the crown, some
authors consider it a variety of follicular cyst found in the soft tissues
covering the un erupted tooth.
5.1.2. The odontogenous keratocyst or the primary cyst
This cyst is developed in the place of a tooth, by the dental lamina
degeneration of a normal or supernumerary tooth before the formation of
the dental hard structures.
Clinical features
epidemiology: variable, 20% of the mandible odontogenic cysts,
commonly occurs between decades 2 to 4 of human life.
location:
o 75% in the mandible body / angle with a rear extension,
113
*front jaw, often in the region of canines,

dimensions: 1.9 cm variable, but usually higher in the mandible,
*shape: oval, extending along the mandible body, with minimal
medio-lateral unilocular or multilocular extention,
*edges: smooth, well-defined, well corticalizated frequently.
Imaging examination
Methods of examination: dental radiographs, ortho pantomography
(OPT), CT, MRI, and X-ray in: chest, spine, hand (in Gorlin-Goltz
syndrome).
d
c
Fig. 5.7. Keratocyst multilocular appearance, bearing radiographs in the
scrolled mandible and low horizontal portion located between the
mandible premolar and wisdom molar), b), the lesion has thickened
edges, festooned or vertical ram extension of the mandible around
wisdom teeth, internal and external cortical blowing, Gorlin-Goltz
syndrome, multiple keratocysts around wisdom teeth in the maxilla and
mandible visible on a radiograph mandible scroll c) and skull in "low
face" incidence d). (OMF Surgery Clinic Iasi collection).
114
uniform radiolucency, usually a single lesion, with the following
effects:
*adjacent teeth have minimal displacement (Fig. 5.7.a, b), rarely
resorbed roots
*large area expansion (Fig. 5.8),
*may include the crown, resembling a follicular cyst,
b
Fig. 5.8. Median and paramedian bilateral mandible keratocyst, a) OPT.
presurgery multichystic mandible lesion with bulky medina which has
fine septa, displacing but not lysing dental apexes and inferior dental
canal, deforming the jaw, blowing and uneven the lower edge of the
mandible and its cortex, b) panoramic radiography with an intraoral
focus, the aspect of the cavity and dental apexes post surgery(Prof. D.
Gogalniceanu Collection)
115
Prognosis: postoperative relapse in 20-60% of cases.

Differential diagnosis: radicular cyst, cyst dentiger, ameloblastoma, Gorlin
syndrome.
Note: Multiple odontogenic keratocysts part of baso-cell nevomatosis or
Gorlin-Goltz syndrome, characterized by:
autosomal dominant hereditary character, which appears in children
multiple odontogenic keratocysts(Fig. 5.7. C, d)
basal cell nevi scattered on the body,
multiple basal cell carcinomas and
bone abnormalities: bifid ribs, hypoplasia, spinal blocks, spina bifida,
macroskull, calcification of the epiphysis and the brain coasa.
5.3. Non odontogenic cysts
5.3.1. Fissure cysts
5.3.1.1. Nazopalatin duct cyst/ incisive canal cyst
The cyst develops in the remanent lining of the nazopalatin duct / incisive
canal.
Clinical Features
frequency: the most common non-odontogenic cysts, affecting 1% of
the total population, discovered accidentally more often at the age of
40-60.
site: on the midline of the anterior jaw, immediately posterior to the
upper central incisors,
size: variable, but usually between 6 mm and a few cm in diameter,
shape:
* round or oval overlapping the nasal septum or nasal spina past
creates the aspect of heart or inverted tear (Fig. 5.9),
one cyst monolocular,
outline: smooth, well-defined, well corticalised (in the absence of an
infection),
116
c
Fig. 5.9. Nazopalate cyst ovoid, well-defined, located between the
central incisors, vital and distalised apex, palatal expansion) occlusal
incidence, b) retroalveolar incidence c) OPT- cyst with a "heart" shape
Imaging examination
Methods of examination: dental radiographs, ortho pantomography (OPT),
CT, MRI.
Imaging Features
Radiographic
uniform radiolucency, but radio-opaque shadows sometimes
overlapping, with the following effects:
*distal adjacent teeth displaced, very slowly resorbed,
*palatal expansion, identified only f the lesion is bulky,
Differentiated diagnosis: median maxillary cyst.
117
Note: Sometimes it is necessary to differentiate between a nazopalatin duct

cyst and a naso-palatine foramen normally enlarged; the following aspects
are taken into consideration:
size: if diameter> 6 mm, it is more likely a cyst,
shape: oval foramen is usually an irregular
outline: foramen is usually well defined laterally, but not whole
circular path,
relative radiodensity: the cyst tends to be more radiolucent because of
the bone resorption.
5.3.1.2. Globulo-maxillary cyst
This is a cyst in progress, located in the 3rd facial slot keeping in mind
Tessier's classification, between the lateral incisor and canine (Fig. 5.10).
Clinical Features
frequency: rare
site: in the maxillary between the lateral incisor and canine, with
divergent roots
size: variable> 1cm (Fig. 5.11),
outline: regular, smooth or slightly contoured in case of an infection
Imaging examination
Methods of examination: dental radiographs, ortho pantomography (OPT)
CT examinations, MRI native and with contrast performed.
Fig. 5.10. Left globulo-maxillary cyst with left maxillary sinus

opacification.
118
Imaging Features
Radiographic:
well-defined radiolucency in the maxillary, between the lateral incisor
and canine,
effects: laterally displaces the apexis of the teeth adjacent to the cyst.
Differential diagnosis: radicular cyst, ameloblastoma, tumor with
mieloplaxes.
b
Fig. 5.11. Globulo-maxillary cyst: a) unilocular radiolucency between
lateral incisor and left canine, surrounded by a net pathognomonic
divergence of apexes of the lateral incisor, canine and premolars, but
without decay, b) radiolucency which at first glance resembles a globulomaxillary cyst, but is a radicular cyst developed lateral the right central
incisor apex and lateral incisor apex, which is distally displaced, as well
as canine and first premolar apexes.
5.3.1.3. Mandibular median cyst

This may be a cracking mandible median cyst.
Clinical Features
119
Epidemiology: appears relatively seldom,

Site: symphyses region,
Size: 1-3 cm,
Outline: relatively regular.
c
Fig. 5.12. Well defined radiolucency in a mandible median cyst,
unilocular, median mandible, that drives away the central incisors apexes
and the canines adjacent to the lesion, without resorption ,a), b)., The
mandible median cyst size and the well-defined edges make sometimes
difficult the differentiation of an odontogenic cyst from a neodontogenic
one, the differentiation is made only by histopathological examination c).
120
Imaging examination
Methods of examination:
Effects used for diagnosis: OPT, occlusal radiography, Belot technique,
mentonier radiographs, submentonier film.
Imaging Features
well-defined radiolucency,
which results in a slight shift of dental apexes (fig.5.12).
5.3.1.4. Maxillary median cyst
This cyst is located between upper central incisor roots and probably
develop from the epithelium of the dental burjoni.
Imaging examination
Methods of examination:
Effects used for diagnosis: OPT, periapical and occlusal radiographs using
Belot technique.
Imaging features
well-defined radiolucency, which results in: easy movement of the
dental apexes (fig.5.13).
Differential diagnosis: inter incisor channel, solitary bone cyst,
odontogenic inflammatory cysts.
a
b
Fig. 5.13. Median maxillary cyst, periapical radiograph OPT in a young
man with an interincisor radiolucency, well defined, that moves the
apexes.
5.3.2. Other bone cysts or pseudocysts

Despite the name, these entities are classified as due to the absence of
the epithelial lining of the cysts. Skeletal lesions are often frequent,
disorders affecting rarely the jaws and have a pathological nature
remained controversial.
121
5.3.2.1. Traumatic bone cyst

This is a cyst of unknown ethiology, but may be associated with minor
trauma.
Clinical Features
frequency: uncommon, met in children or young adults <20 years.
site: *in a jawbone, especially the premolar / molar region, and also
frontal
* rarely in the anterior portion of the jaw,
* size: variable, up to several cm in diameter,
shape: - unilocular,
outline: - regular, osteosclerotic.
Imaging examination
Method of examination: OPT, X-rays in the incidence of jaw scroll, with
low face CT
Imaging Features
Radiographic:
uniform radiolucency, unilocular aspect with osteosclerotic edges,
effects: minimal displacement of adjacent teeth (fig.5.14).
Differential diagnosis: ameloblastoma, keratochist, solitary bone cyst.
b
a
Fig. 5.14. Traumatic mandible cyst) incidence of jaw scroll: radiolucency
of the right mandible angle without periapical pathological rizaliz to 47,
b) radiolucency between canine and premolar roots 1, displaced, with
regular edges and multilocular appearance without rizaliz of dental
apexes, post extraction absence of 6 years molar, with normal socket, is
anatomo- apatological diagnosed as traumatic cyst.
122
5.3.2.2. Solitary bone cyst

Is a cyst of a unknown origin that has long been considered a traumatic
bone cyst because of the similarities of the imagistic aspect and because of
the location.
Clinical Features
frequency: uncommon, common in children or young adults <20
years.
site:
in a jawbone, especially the premolar / molar region, but also
frontal
seldom in the front area of the jaw
size: variable, up to a few cm in diameter,
outline - regular osteosclerotic
Imaging examination
Method of examination: OPT, X-rays in the incidence of jaw scroll, with
low face computer tomography (CT).
Imaging features
Radiographic:
uniform radiolucency, unilocular aspect with osteosclerotic edges,
injury causes a minimal displacement of the adjacent teeth (fig.5.15).
123
c
Fig. 5.15. Solitary bone cyst: visible near the right angle of incidence of
scrolled mandible, a) and the incidence of low face to the skull, b) in
another patient seen at OPT c) in the body of the mandible under the
molar root residues of 46 and 47.
CT: examination performed native and post-contrast highlights:
a radiolucency, expanding in the mandible, extending distal and
mezial,
the lesion does not destroy the cortical bone (fig.5.16) and
determins the lower movement to the basilar edge of the dental
channel
124
e
f
Fig. 5.16. Left hemimandibular solitary bone cyst CT: axial sections in
bone window a) and tissue b) shows an intracystic fluid density contrast
without destroying the cortical bone; panoramic reconstructions show
mesio-distal and vestibulo-lingual extention of the mandible cyst which
pushes the dental canal; c) and another three periapical cysts developed
in the jaw around the dental apexes 12, 24 and 26, all with root remnants
aspect d) transverse oblique reconstructions, along the dental axis outline
the cyst with fine, regular walls, the net delimitation of the cortical dental
canal and periapical fine rizaliz of the root apex of premolars 34 and 35
which are inside the top edge of the cyst e) and f).
5.3.2.3. Aneurysmal bone cyst
This cyst is located in the abundant spongy tissue bones and jaw. The
cystic cavity contains highly vascularized tissue (dilated arteries and veins
), sometimes a cavity containing blood.
Clinical features
Epidemiology: it is rarely found in adolescents,
Site: body angle of the jaw or occasionally jaw
Size: variable, up to a few cm,
Shape: unilocular or multilocular,
Outline: regular, smooth, moderately defined.
Radiographic:
round radiolucency, clear shapes with thin limestone lizereu with
limestone septa (as in ameloblastoma) that make the radiographic
diagnosis impossible (fig.5.17)
CT: examination performed native and / or post-contrast highlights:
the radiolucency, its contours, the fine limestone lizereu, the relations
with neighboring teeth and allows the measurement of intracystic densities
with Hounsfield scale (+55 to +75 UHU blood), confirming the diagnosis.
MRI: examination performed native and post-contrast highlights:
125
the cyst, confirms the diagnosis and demonstrates the features within
the cyst fluid levels visible in native and post-contrast T1 sequence in T2
and STIR sequence.
Differential diagnosis: ameloblastoma, mieloplaxis tumor, traumatic cyst.
Fig. 5.17. Aneurysmal mandible bone cyst: OPT shows a radiolucency

between the roots of teeth 43 and 44, with regular borders, multilocular
aspect with displacement but without rizaliza of dental apexes, moving
down the dental channel.
5.4. Cysts of unknown origin

5.4.1. Stafne's cyst
This marrow cavity is located near the jaw angle and has precise limits.
It corresponds to inclusions of fat tissue in the mandible or an aberrant
tissue of salivary gland.
Clinical features
epidemiology: it is rarely found in adults,
site: in the angle of the jaw or in the vertical ram,
size: 1-2 cm,
outline: - regular well defined.
Radiographic:
a round, unique radiolucency with clear contours, with no mass effect
upon the adjacent structures (fig.5.18).
126
Fig. 5.18. Stafnes bone cyst of the right mandible vertical ram.
5.5. Cysts of the soft cervico-facial parts
The anatomical cervico-facial structures can be the site of cystic lesions
frequently of an embryonic origin, but can also occur by cystic
transformation of sebaceous glands (sebaceous cyst) or of accessory
salivary gland (mucoid cyst).
The localized facial and cervical cysts are:
thyroglossal cyst - can be found in any part of vestigial thyroglossal
duct.
Clinic - submentonier, median or supratiroidian tumor;
The diagnosis is established by the CIV CT
brachial cyst - is formed from the remnants of brachial arches.
It is located latero-cervical or submandibular, frequently fistulises. The
diagnosis is established by the CIV CT
salivary retention cyst
It is dependent on small salivary glands, located in different places: on the
lips, sublingual, in the nasopharynx mucous, etc.. The diagnosis is done by
analyzing CT and MRI examinations with civ
The confirmation of the imagistic diagnosis is based on the anatomopathological examination.
5.5.1. Thyroglossal duct cyst
This is the most common congenital malformation of the neck resulting
from a ruptured infected cyst. The lesion is commonly found in children
under 10 years old, often from an infection near the midline of the neck,
around the hyoid.
Clinical features
127
Asymptomatic mass recurrent in antero-median portion of the neck or

in the side of it, which has variable sizes and can become infected causing
pain and dysphagia.
Imaging features
CT: it highlights a hypodense mass, round, without contrast attachment
when does not fistulise and contrast attachment in the periphery that
extends from the anterior or lateral fistula of the hyoid bone, between the
thyreo-hyoid muscles (fig.5.19).
d
e
f
Fig. 5.19. Thyroglossal duct cyst developed antero-lateral left. Axial CT
native and civ, showing cyst developed on the left side of the hyoid bone,
the attachment on the borders of contrast and at the level of the adjacent
fascia.
MRI: it shows a cystic mass, round, fine attachment of peripheral contrast
in non homogeneous hiposignal in sequence T1 and hipersignal intense
but non homogeneous in T2 sequence, showing peripheral contrast when
fistulizes between thyreo-hyoid muscles.
Differential diagnosis: malignant lymph nodes, thyroid adenoma, dermoid
cyst, abscess, hematoma.
128
5.5.2. Developmental abnormalities of the brachial arches

There are several developmental abnormalities of the brachial arches
that occur during the first and second month of pregnancy due to persistent
lateral cervical sinus of His, which determines the producing of cysts,
sinus tracts or fistulas.
This way it is possible to appear:
1.the first brachial arch cyst and the fistula that can develop between
the ear external canal and the angle of the mandible;
2. the second brachial arch cyst is the most common brachial cyst (95%
of cases), which develops antero or postero the sterno-mastoid-cleido
muscle;
3. the brachial arch 3 cyst is rare and develops from the posterior
pyriform sinus apex of carotid and sterno-mastoid-cleido muscle, superior
of nerve XII and very seldom in the retropharyngeal space;
4. brachial arch 4 cyst is also called the pyriform sinus fistula,
corresponding to the persistence of bracho pharyngolaryngeal ductus
between the pyriform sinus apex and posterior to tyroid and the superior
laryngeal nerve.
5.5.2.1.The cyst of brachial arch 1
It is a common lesion (90-95%) without symptoms in childhood,
developed anywhere between the ear canal and mandible angle.
Clinical features
Asymptomatic mass, cystic, recurrent, in the neuro-vascular septal side,
moving the parotid gland. It can often be infected, with pains and some
lympho-adenopathies.
Imaging features
CT: hypodense mass, round, without contrast attachment, that extends
above or to the side of the ear canal and the angle of the mandible,
including the parotid gland.
MRI: round cystic mass with fine attachment, peripheral contrast,
hiposignal in sequence T1 and T2 hipersignal in an intense sequence
(fig.5.20).
129
a
b
c
Fig. 5.20. Brachial arch 1 cyst developed right laterally, with a moderate
density contrast fluid and peripheral attachment in izosignal T1 and T2
hipersignal.
5.5.2.2. Brachial arch 2 cyst

This is at the lesion developed in a fold of ectoderm of the brachial second
slot which is located along the sterno-mastoid-cleido muscle.
Clinical features
The most frequent lesions develop in women above and under the sternomastoid cleido-retro and under the jaw angle.
Imaging features
The mass is asymptomatic with symptoms after the age of 20-25, when it
can infect, with local pain and tension.
Imaging features
Ultrasound - unilocular mass with variable ecogenicity, anecogenous or
hiperecogenous if it is infected
CT scan shows a hypodense mass, round-oval, with contrast attachment
on the border of the capsule that extends laterally anterior or posterior of
the sterno-mastoid-cleido muscle with links with internal and external
carotid. The cyst can insinuate under the belly of digastric posterior
muscle, the lateral wall of the pharynx, retrotonssils facing the
Rosenmuller dimple and towards the tip of the styloid; being often
infected, with a mass effect on the parotid and mistaken as a tumor of the
deep lobe of the parotid (fig.5.21).
MRI shows the characteristics of the cyst, which can be round or oval,
with fine grip, peripheral contrast, hypo-izosignal in the sequence T1 and
izosignal in sequence T2, signal that varies in relation to the protein
concentration of the cyst. The treatment consists of cystectomy or
cystotomy with a recurrence of 5%.
130
d
e
f
Fig. 5.21. Brachial arch 2 cyst developed in the posterior lateral angle of
the jaw, with density liquid and a moderate contrast peripheral grip.
Differential diagnosis: cystic limfangioms, chronic/metastatic adenopathy
b
a
Fig.5.22 . Brachial arch 2 cyst developed in the right lateral posterior
angle of the jaw, with liquid density a) that displaces external the parotid,
as it is shown in CT axial section post sialography
131
5.5.2.3. Salivary retention cyst in the naso pharingean cell membrane

It is located in the salivary glands of the nasopharynx cell membrane.
Clinical features
The most frequent lesion develops equally in women and men in the
nasopharynx cell membrane while it is small, asymptomatic.
CT scan shows a hypodense mass, round-oval at the level of the
nasopharynx cell membrane that can be confused with pleomorphic
adenoma of salivary gland accessory, when large.
MRI the characteristics of the cyst, which can be round or oval, with fine
grip, peripheral contrast, hiposignal in the sequence T1 and hipersignal in
sequence T2, protein concentration varies in relation with the cyst
(fig.5.23).
d
e
f
Fig. 5.23. Salivary retention cyst in nasopharingean cell membrane with
hiposignal in T1SE native sequence), d), hipersignal homogeneous in T2
FSE sequence b), e), which has a small grip on the border of the cyst,
visible contrast in T1 SE axial sequence f ) and sagittal c).
5.5.2.4. Salivary retention cyst in the lips cell membrane

It is situated in the salivary accessory glands at the level of the lips cell
membrane.
Clinical characteristics
132
The lesion most frequently develops in the lips cell membrane both in
women and men, being asymptomatic as long as it is small. (fig.5.24.)
Imaging features
CT exhibits a small hipodens mass, oval-round at the lips cell
membrane level; it has very seldom a large size and could easily be taken
as being a pleomorphus adhenoma of the salivary accessory gland.
MRI presents all the characteristics of the cyst, has a fine grip of
neighbouring contrast in T1 sequence.
c
d
Fig. 5.24. Salivary retention cyst in the upper lip cell membrane, The
external aspect a), vestibular b), intrasurgical c), and the surgical piece d).
(Surgery Clinic of OMF-Iasi collection)
133
134
Chapter 6
MAXILLO FACIAL BENIGN TUMOR

It is a tumour cell proliferation, noninflammatory, part of an organ or
tissue, leading to the formation of a non-neoplastic tissue.
Maxillofacial benign tumours can be classified into:
benign odontogenic and neodontogenic,
pseudotumour (hyperplasia).
6.1. Maxillofacial odontogenic benign tumors
Odontogenic tumors of the jaw are rare, with a relatively slow growth
rate, and derive from dental bud tissues at different stages of
odontogenesis.
They are most commonly located in the mandible, mostly intraosseous and
rarely extraosseous. Very different histological forms but different
manifestations have imposed various surgical treatment modalities.
According to the 2007 WHO classification of odontogenic tumors there are:
1. Epithelial with mature fibrous stroma without odontogenic
ectomezenchyme:
*multicystic solid ameloblastoma,
*extraosseous ameloblastoma, the peripheral type
*desmoplastic ameloblastoma,
*unicystic ameloblastoma,
*odontogenic squamous tumor,
* calcifiant odontogenic tumor (Pindborg)
* odontogenic adenomatoid tumor,
*odontogenic keratocystic tumor
2. Epithelial with odontogenic ectomezencyime with or without hard
tissue formation:
*ameloblastic fibroma,
*ameloblastic fibrodentinoma,
* ameloblastic fibro-odontoma,
*odontoma:
i. complex
ii. compound
* odonto ameloblastoma
*odontogenic cystic calcified tumor,
* ghost cells tumor
135
Maxillo facial benign tumor
3. Mesenchymal and/or ectomezenchymal odontogenic with or without

odontogenic epithelium:
*odontogenic fibroma,
*odontogenic mixom / mixofibrom,
*cementoblastoma
4. Other tumors:
*infants melanic neuroectodermal tumor.
6.1.1. Epitelial tumors with mature fibrous stroma without epithelial
odontogenic ectomezenchyme
6.1.1.1. Solid multicystic ameloblastoma
This is the most common odontogenic tumor that develops from
ameloblasts, epithelial debris from the adamantine body, hence the name
of adamantinoma.
Features:
Epidemiology: second odontogenic tumor that occurs in adults around
the age of 30 - 40
site:
*the mandible vertical rami body / angle,
*occasionally in the jaw, with expansions in all directions, in the
paranasal sinuses, orbits and skull base.
size: variable
shape:
*multilocular with distinct septa dividing the lesion into separate
compartments,
*rarely with a "honeycomb" or "soap bubbles" aspect, or
multicystic;
outline: smooth and wavy, well defined,
Imaging features:
Radiographic:
radiolucency with radio-opaque internal septa, associated in 80% of
cases with a mandible molars 3 included, which moves the adjacent teeth,
thinning them or causing their resorption, visible in OPT, in radiographs in
incidence of mandible scroll and incidence of " low face " skull.
the multicystic form contains numerous cystic spaces of various sizes
and limited by complete septa which made the appearance of "soap
bubbles" (fig.6.1, 6.2).
136
c
Fig. 6.1 Multichistic mandible ameloblastoma a) the low face incidence
shows a radiotrasparency at the level of the ascending rami of the right
mandible angle and in incidence jaw scroll.
b) shows multiple cystic images with very fine septa, large size, which
thinns but does not destroy the cortical basilar edge, "bubbles" aspect,
multicystic ameloblastoma developed around the included molar 3
arcade and horizontally located.
Fig. 6.131. Ameloblastoma multilocular shape in a patient of 34 years

old, located in the body, angle and extended at the level of at the left
mandible vertical rami with premolar 35 and 37 in a molar prosthetic
piece above the formation, with apexes rizaliza of teeth 35 and 37, the
deviation of dental canal, cortical thinning of the left hemimandible and
its deformation.
137
CT:
variable-sized tissue damage and bounded by complete septa, which
has or hasnt an extension outside the cortical mandible or maxilla;
MRI:
mixt injury, tissue and cystic of varying sizes with intermediate signal
in T1 native sequence, hyper, izosignal in sequence T2 and T1 hipersignal
grip contrast to the solid component.
Complications: infections, pathological fractures, malignant degeneration.
Differential diagnosis: ameloblastic fibroma, squamous odontogenic
tumor,
adenomatous odontogenic tumor, epithelial odontogenic fibroma,
odontogenic calcified cyst, adenoid cystic carcinoma of maxillary sinus
origin.
Prognosis: locally aggressive nature and may recur even in 10 years after
surgery may have a malignant evolution in approximately 2% of cases.
6.1.1.2. Peripheral extraosseous ameloblastoma
This histopathological entity is the homologous of the solid multicystic
intraosseous ameloblastoma.
Features:
epidemiology - represents between 1.3 and 10% of all
ameloblastomas, being more frequent in patients aged between 50 and 70.
site: in the gingival of the maxillary or mandible teeth or alveolar cell
membrane of the edentulous patient; can also be multicentered.
Imaging features:
Radiographic:
Radiolucent and radiopaque composite aspect of the dental ridge may
be accompanied by its depression or erosion (fig.6.3).
CT and MRI:
allow an analysis of injury and ensure the planning of therapy.
Differential diagnosis: peripheral odontogenic fibroma, odontogenic
squamous tumor, odontogenic gingival epithelial hamartom.
Prognosis: a lesion that recur after many years, is locally aggressive and
can become malignant.
138
Fig. 6.3. Extraosseous peripheral

ameloblastoma at the level of
dental crest for mandible incisors,
vestibular prominencing in a patient
of 57 years.
6.1.1.3. Desmoplastic ameloblastoma

This histopathological entity is a variant of ameloblastoma, with a
specific clinical aspect, imaging and histopathological.
Features:
epidemiology similar to the solid cystic ameloblastoma,
site: the maxilla or mandible, predominantly in the anterior mandible,
Imaging features:
Radiographic:
Mixed radiolucent and radiopaque aspect, with diffuse borders suggesting
a fibrous bone lesion visible on OPT, the incidence of front skull
radiography and scroll mandible incidence,
CT and MRI:
allow the analysis of injury and ensure the planning of therapy
(fig.6.4).
Prognosis: a recurrent lesion and must be observed along many years.
b
a
Fig. 6.4. Right maxillary ameloblastoma MRI examination; SE axial T1
sequence, a) FS SE axial post contrastT1 sequence highlights the
contrast tumoral grip and its setting its posterior extension into the right
retrozigomatic fat
139
6.1.1.4. The unicystic ameloblastoma

The unicystic ameloblastoma represents 10% -15% of the total
ameloblastomas.
Features:
epidemiology - 5-15% of all ameloblastomas,
site: in 90% of cases in the mandible, posterior location prevails.
Imaging features:
Radiographic:
unilocular radiolucency with net shape, highly opaque crown
associated with a non-erupted lower third molar, resembling a follicular
cyst or a radiolucent dental apex level, resembling a radicular cyst (fig.6.5)
b
a
Fig. 6.5. Unicystic ameloblastom in 36, with teeth apexes moving, front
x-ray visible, a) and panoramic b) net cortical thinning.
CT and MRI:
allow analysis of injury and ensures the planning of treatment.
Differential diagnosis: follicular cyst, residual cyst, post traumatic bone
cyst, essential keratocyst, giant cell granuloma, etc..
Prognosis: a lesion that is sometimes confused with periapical cyst and
recurrent, must be observed for many years.
6.1.1.5. Calcified epithelial odontogenic tumor (Pindborg tumor)
This unusual tumor looks like a ameloblastoma but has amyloid material
that can calcify and it is locally invasive.
Features:
Epidemiology: is 1% of the odontogenic tumors, being more frequent
in patients between 20 and 60 years old
Site: is more common in the mandible posterior region that contains a
tooth sometimes included, can have a extraosseous location in 6% of the
published cases
140
the tumor grows slowly and remains asymptomatic for a long time.
Imaging features:
Radiographic:
initially is presented as a small radiolucency,
in time, it will become multilocular, getting opaque zones of variable
sizes, amorphous, surrounding the crown of an included tooth; these
opacities may look as snowballs (fig.6.6).
CT and MRI:
allow the analysis of injury and ensure the planning of treatment.
Differential diagnosis: intraosseous squamous cell carcinoma, clear cell
odontogenic carcinoma, metastases from renal cell carcinoma or salivary
glands.
Fig. 6.6. Right mandible Pindborg tumor incidence scroll mandible

shows a large radiopaque area, heterogeneous, which includes
surrounding a premolar (35), which are small calcified masses that
replace the mandible trabecularisation, dislocates the canal inferior dental
and extends around molar 37.
6.1.1.6. Adenomatoid odontogenic tumor

This tumor is a follicular form (as a dentiger cyst) associated with tooth
retention and extrafolicular form (without any tooth included).
Features:
Epidemiology: represents 2-7% of odontogenic tumors in adults and
children.
Site: intraosseous, maxillary or mandible, in association with an
included tooth
Imaging features:
Radiographic:
unilocular radiolucency with included tooth(fig.6.7)
141
clear radiopaque frame or

multilocular with opacities under the shape small cysts inside.
CT and MRI:
allow analysis of injury and ensure the planning of treatment.
Differential diagnosis: Pindborg tumors, hamartomas.
Prognosis: lesion recurrent in 14% of cases and should be monitorised
over time.
Fig. 6.7. Adenomatoid odontogenic tumor, incidence of jaw scroll with

radiolucency, located at the angle of the right jaw with the wisdom molar
included and embedded in the lesion.
6.1.1.7. Odontogenic tumor keratocystic

This may be an intraosseous odontogenic benign tumor, unilateral or
multicystic, solitary or multiple. When multiple, events may be part of
bazicelular nevomatosis. For a long time this entity was placed among the
odontogenic cysts, but the neoplastic nature of the lesion determined its
classification into the benign odontogenic tumor group.
Features:
Epidemiology: can occur in people aged between 10 and 80 years but
prevalent in the age group of 20-30 years.
Site: Most often occurs in mandible, usually in the extension angle
with upper and lower jaw,
Clinical aspects: it tends more to expand locally, with thinning or
cortical destruction and invasion of adjacent structures, lately causing
pain, deformation and displacement of teeth in the jaw,
142
Imaging features:
Radiographic:
a radiotrasparency, round, oval with scalloped edges that invades the
body and ram, in the upward angle of the mandible (Fig. 6.8) and can
contain an included tooth (similar to ameloblastoma).
CT and MRI:
Assists in identifying multiple lesions, cortical perforations and
extensions from the jaw to the retro-maxilla-zygomatic region.
b
a
Fig. 6.8. Keratocystic odontogenic tumor in a patient of 28 years old )
with low incidence shows a radiolucency at the angle and ascending
rami of the right mandible coronoid process, with a wisdom tooth
leveled and embedded in the tumor, which is in incidence jaw scroll b)
occurs with multiple cystic images with fine septa, large thinning zones
but not destroying the cortical basilar edge.
Differential diagnosis: ameloblastomas, ameloblastic fibroma
Prognosis: a potentially aggressive lesion should be watched closely for
any daughter -cysts or malignant tendency.
6.1.2. Ectomezencyme odontogenic epithelial tumors with or without
hard tissue formation:
6.1.2.1. Ameloblastic fibroma
Odontogenic tumor is of an unusual benign odontogenic epithelial
origin mixed with ectomzenchyme. It does not contain any dental hard
tissue formation and dentin. From a histopathological point of view the
lesion is considered as an ameloblastic fibrodentinoma.
Features:
* Epidemiology: a rarely met tumor that can occur between 1 and 62
years of age,
143
Site: premolar / molar region, usually in the mandible and sometimes

in the maxilla, these tumors resemble well with the ameloblastomas, but
occurs in children and adolescents.
Evolution: slow, asymptomatic, with painless deformity of bones plan
with dental displacements and the appearance of facial asymmetry,
* Type: unilocular in the early stages, with smooth edges, well defined,
or multilocular lately
Imaging features:
Radiographic:
unilocular or multilocular radiolucency with radio-opaque internal
septa, in the angle and ascending rami of the mandible, which moves the
adjacent teeth, with buccal or lingual expansion,
In 50% of the cases are associated with non-erupted teeth (fig.6.9).
Fig.
6.9.
Left
mandible
ameloblastic fibroma in a child of
7 years, the incidence of jaw
scroll area shows a radiopaque,
homogeneous area surrounding
an included premolar (35) in a
vicinity with the temporal molar
root, which blows the cortex and
adjacent teeth
CT and MRI:
Assist in identifying multilocular lesions, mandible cortical
perforations and extensions from ascending mandible rami.
Differential diagnosis: ameloblastoma.
Prognosis: a lesion after curettage and enuclearing sometimes can recur
and become an ameloblastic fibrosarcoma of a malign origin.
6.1.2.2. Ameloblastic fibro-odontoma
This rarely met odontogenic tumor can be unilocular or multilocular and
resembles in radioimagistic terms with the ameloblastic fibroma.
Features:
Epidemiology: the lesion occurs in children aged 8-12 and rarely in
adults,
Site: in the premolars, malar, maxillar and mandible areas
develops slowly, easily infiltrating the bone, but can reach very large
sizes, with facial deformation, tooth movement, occlusion disorders and
dental eruption, with the emergence of pain, in time
144
tumor usually contains multiple small enamel or dentin and opaque or

solid masses,
Imaging features:
Radiographic:
unilocular or multilocular radiolucency, well-defined, well
circumscribed associated with an un errupted tooth.
CT and MRI:
help in identifying multilocular lesions and evaluate local extension.
Differential diagnosis: odonto ameloblastoma.
Prognosis: a lesion that is rarely recurrrent after enucleation.
6.1.2.3. Odontoma
Tissue derived from ectoderm (enamel) and mesenchymal tissue
(dentin, cementum, and pulp tissue sometimes follicular) that has an
excessive growth from the normal but are considered hamartomas. The
odontoma shows itself in two forms: the compound odontoma and the
complex odontoma.
Features:
Epidemiology: They represent 65% of the odontogenic tumors and
start shaping with the emergence of permanent teeth, frequently in the
incisor-canine region,
*Site: the compound odontoma predominates in the anterior maxilla
and mandible, and the complex odontoma is more common in the
posterior mandible
Imaging features:
Radiographic:
The compound odontoma looks like a small neo shape, with a content
made up of small radiopaque formations (fig.6.10 and 6.11), similar to
nannous teeth (2-3 teeth up to hundreds)
The complex odontoma appears as a less organized radiopacity
containing remains of enamel, dentin, cementum and pulp chamber (fig.
6.12).
location where we meet them:
*isolated odontomas, resembling the teeth, present in the alveolar
ridge,
*odontoma previa, which causes the remaining of a tooth or a group
of teeth in the inclusion;
* interradicular or satellite to a root odontoma;
*coronary odontoma.
145
b
a
Fig. 6.10. Compound odontoma with multiple nannous teeth, visible
radiopaque radiographic pre a) and postsurgery b)
b
a
Fig. 6.11. Compound odontoma multiple nannous teeth, visible
radiopaque radiographic in occlusal incidence, a ) and retroalveolar b).
b
a
Fig. 6.112. Complex odontoma visible as a less organized radiopacity,
located left mandible surrounded by a thin radiolucent halo, bordered by a
radiopaque lizereu in incidence), and occlusal jaw scroll b).
146
Differential diagnosis: cementifiant or osifiant fibroma, adenomatoid

odontogenic tumor, Pindborg tumor.
6.1.2.4. Odontoameloblastoma
This unusual lesion combines the characteristics of odontomas with
those of ameloblastomas.
Features:
Epidemiology: most lesions were diagnosed in the third decade of life,
Location: can locate in the maxilla or mandible, posterior to the
canines.
Imaging features:
Radiographic:
a multilocular or unilocular radiolucency with small radio opacities
inside and sometimes with an included tooth, which causes the movement
of the adjacent teeth.
Prognosis: it is a lesion that is locally aggressive and has the same
prognosis with ameloblastoma
6.1.2.5. Calcifiant odontogenic cystic tumor
Despite of the name, this rarely met lesion is classified by WHO as an
odontogenic tumor with odontogenic ectomezenchyme.
Features:
Epidemiology: intra- and extraosseous lesion occurring in patients
aged between 5 and 92,
* Site: typically present in the jaw and mandible incisor area-cusp,
Imaging features:
Radiographic:
monolocular radiolucency, well-defined, well-demarcated, resembling
any odontogenic cyst (fig.6.13).
Fig. 6.13. Calcified odontogenic
cystic tumor, right mandible
scroll
radiograph,
showing
monolocular radiolucency welldefined
and
circumscribed
around the apexes of the molars
47 and 48, which are vital.
147
occasionally may be associated with odontoma or with an non-erupted

teeth,
as the lesion matures one can see the amount of calcified material
with an intensity resembling that of the tooth, with opacities of varying
sizes, moving and / or causing resorption of the adjacent teeth.
6.1.3. Odontogenic mesenchymal and/or ectomesenchymal tumors
with or without and / or odontogenic epithelium
6.1.3.1. Odontogenic fibroma
This non-invasive tumor is very similar to odontogenic mixoma,
originates in the connective tissue fibroblasts of the odontogenic tooth
germ of dental development, producing an excess of collagen fiber
(fibroma).
Features:
Epidemiology: occurs at any age, in both sexes,
Location: in the mandible, with a slow growing, painless, with
deformation of the face and dental displacement.
Imaging features:
Radiographic:
the radiographic appearance is not specific to odontogenic fibroma,
appears as a multilocular radiotrasparency extended far into the jawbone,
with or without un errupted tooth in the tumor.
CT and MRI:
help in identifying the characteristics of the multilocular lesions and
evaluate local extension.
Differential diagnosis: odontogenic mixoma.
6.1.3.2. The odontogenic mixoma
This tumor originates in the connective tissue fibroblasts of
odontogenic tooth germ development, producing in excess the basal
substance (mixom). Radiologically is often difficult to distinguish it from
the odontogenic fibroma.
Features:
Epidemiology: most common in the second or third decade of life,
equally occuring in both sexes,
Location: occurs in jaws, more frequently in the mandible, in the
premolar-molar region; it grows slowly, is painless and can move teeth
Imaging features:
Radiographic:
the multilocular radiolucent radiographic appearance is stretched out,
with orthogonally crossed plans, looking like a rocket mesh or
148
honeycomb, common among the dental roots, with intense radiopaque

lizereu around,
cortical of the bone is thinned and blown sometimes resorbed
(fig.6.14).
c
d
Fig. 6.14. Odontogenic mixoma a) low face incidence with multiple
radiolucent fine bony septa, blowing the right jaw cortex; the incidence
of jaw scroll b, d) and in panoramic incidence c) tumor appears as a
multilocular area with crossed, fine plans, that blow the cortex and
deforms the basilar edge of the jaw, causing moderate rizaliza of the
apexes and neighboring teeth.
CT:
helps in identifying the multilocular lesions and evaluates local
extension.
MRI:
the injury appears as an izosignal or hiposignal in the sequence T1, T2
sequence, homogenous hiposignal and STIR, homogeneous hipersignal
post contrast T1 sequence.
Differential diagnosis: odontogenic fibroma.
Prognosis: that is a locally aggressive lesion, without giving metastases.
149
6.1.3.3.The benign cementoblastoma

The injury derives from the connective tissue of the periodontal
ligament or from the apical portion of the dental follicle. The local factors
are incriminated for producing cementoblastoma or the irritation of the
teeth or bone.
Features:
Epidemiology: The tumor grows slowly, asymptomatic, being
discovered incidentally endo osseous,
Site: In the mandible in relation with the first molar,
Staging:
*cementomic stage: radiopaque area with less intensity than the
surrounding bone, with net shape, sometimes discreetly irregular
*cementoblastic stage: deposition of mineral salts from the center to
the margins, the picture looks mixed
*osteolytic stage - round transparent area around the apex, limited
by an opaque lizereu continuous with lamina dura and sometimes with
rizaliz,
Imaging features:
Radiographic:
appears as a thin line of radiopacity surrounded by a transparent
continuous periodontal space (fig.6.15)
Differential diagnosis periapical granuloma, radicular cyst, cementomas,
osteomas.
Fig. 6.15. Cementoblastoma surrounding the root premolars 34, 35,

incidence of jaw scroll). Central odontoma at the level of the left
mandible premolar-molar region, not to be confused with
cementoblastoma (b).
150
6.1.4. Other tumors

6.1.4.1. The melanic neuro ectodermal tumor of the infant
This rarely met tumor occurs in children younger than one year old in
the anterior region of the maxilla or mandible.
Radiographically, it appears as a radiolucency with bony cloazoane and
tooth movements.
6.2. Neodontogen tumors
The neodontogen tumors are mixed (epithelial and mesenchymal) and
can be located maxillo-facial but may have other locations in the body:
osteoma,
osteoblastoma,
osteoid osteoma,
nerve tumors (scwannoma, neurofibroma)
hemangioma,
condroma.
6.2.1. The osteoma
Consists of adult bone tissue and the favourite location is the
neurocranium and facial skeleton in 3 forms: foam, compact, eburnated
(amorphous aspect).
Features:
Epidemiology: Various adults aged up to 70 years
occurs in two forms: central - enostoma (Fig. 6.16) or peripheral exostoma (fig.6.17)
151
d
c
Fig. 6.16. Central osteoma fronto-etmoido-orbital, polycyclic explored
radiographically a) and CT b, c), mandible compact osteoma visible on a
panoramic radiograph with an intraoral focus d).
b
a
Fig. 6.17. Periosteal osteoma mandible in the angle and the right upward
ram.
location:
* at the jaw (nasal apophyses, orbital floor, dental arch)
*at the mandible (the lingual face of the body, basilar edge, gonion)
*at the mandible condyle modifying the bite.
Imaging features:
Radiographic:
A round / oval, opacity may exist, attached to the cortical bone, or
may be sessile or a pedunculated lesion (often intrasinusal).
Differential diagnosis: jaw exostoses, osteoblastomas, osteoid odontoma,
odontoma, condensed osteomyelitis, cementoma.
The establishing of the diagnosis is possible only by histopathological
examination.
152
a
b
Fig. 6.18. Central osteoma at the level of the left mandible angle a) not
to be confused with a bulky cyst on the mandible salivary bunk b).
Gardner syndrome is a condition that includes intestinal polyposis,
multiple osteomas, compound odontomas, skin sebaceous cysts,
subcutaneous fibromas, supernumerary teeth (fig.6.19). the peripheral
osteoma is always present in Gardner syndrome, which has a family
character.
b
a
Fig. 6.19. Gardner syndrome multiple osteomas on the left mandible, a)
jaw scroll, b) low face incidence - X-ray of the skull.
6.2.2. Osteoid osteoma

It is an idiopathic lesion that most often develops in the cortical bone,
at the level of the basilar edge of the mandible.
Features:
Epidemiology: in young people up to 30 years old, rarely older than
that, being more common in men
Night pain is a characteristic symptom
Location: in the jaw maxillary sinus, in the mandible condyle and
body,
153
Imaging features:
Radiographic: a small transparent area (less than 2 cm) called the nidus,
round, which has inside some radiopaque foci (less than 1 cm).
6.2.3. Osteoblastoma
It is an aggressive tumor, rarely met and which interests, more
commonly, the alveolar region of the mandible. It is also called giant
osteoid osteoma, being larger than 2 cm.
Features:
Epidemiology: in young people of 20 to 30 years old, rarely in older
age, being more common in men
Site: the spine, long bones and jaw.
Is considered an advanced osteoid osteoma.
Imaging features:
Radiographic: a transparent area with only calcifications or a radio
opaque mass surrounded by a transparent halo and an opaque, marginal
lizereu. Sometimes, there is a periosteal reaction with an aspect of sunrays.
Differential diagnosis jaw exostoses, osteosarcoma, bone cyst aneurysma.
6.2.4. Neurogenic tumors
6.2.4.1. Schwannoma
These tumors originate in the Schwann cells, are localized in 10% of cases
in the mandible.
Features:
Radiographic- a transparent round / oval area, on the path of a nerve,
clearly contoured, sometimes condensed;
prognosis: has a slow growing and depending on location, can
deform the maxillary sinus or the orbit.
6.2.4.2. Neurofibroma
Can be found alone or in Recklinghausen disease.
Features:
Produces a well-defined lesion that enlarges a section of the dental
channel.
Radiographic - osteolytic area (benign) with condensed strokes, located
on a nerve path.
154
Fig. 6.20. Neurofibromatosis. OPT with an expanded dental canal and a

deflection angle of the mandible (Prof. Dr. D. Goglniceanu Collection).
6.2.5. Bone hemangioma

This lesion is an arterio-venous malformation, very rare in the jaws.
Features:
Epidemiology: it is present at any age but it is most common during
adolescence,
Location: occasionally can involve jaws, particularly the mandible.
more frequently is considered a developmental malformation of blood
vessels in the bone marrow spaces (hamartom) than a real tumor.
Imaging Features
Radiographic:
frequently multilocular lesion, accompanied by extensive displation
and associated with tooth resorption. The number and size of
compartments can vary considerably, and if they are numerous they create
the appearance of honeycomb (fig.6.21)
large lesions cause cortical expansion, with an aspect of "sunrays"
well-defined radiolucent area with enlarged trabecular spaces with
thickened trabeculae in "wheel spoke" and subcutaneous flebolits
(fig.6.22)
rarely radiolucent relatively well defined, round, not typical.
155
Fig. 6.21. Central bone hemangioma, OPT showing numerous

microlesions, radiolucent in left mandible, which permanent determine
the movement of the teeth.
Fig. 6.22.Bony hemangioma explored orto-pantomographic showing

numerous radiolucent bone lesions with calcifications (flebolits), left
subcutaneously and the widening of the trabecular space, OPT.
CT
allow the analysis of bone changes and appears as a hypodense
intraosseous area, appears as a mixed image associated with the presence
of "sunrays" or reticular appearance formed by the irradiation of bony
spiculi in the center of the tumor, accurately visualizing changes in the
trabecular jaw bone and increasing the size or affected mandible
(fig.6.23.a).
MRI
provides exploration and analysis of bone changes and muscular and
vascular structures - adjacent nerve (Fig. 6.23.b).
156
a
b
Fig. 6.23. Bone hemangioma of the left mandible explored CT with a
bone window with an axial section to highlight the expansion and
rarefaction of the trabeculas) caused by malformation of blood vessels in
the development of medullary spaces that extend into adjacent soft parts
with an aspect of "flow void" or salt and pepper in axial T2 sequence.
Prognosis: depends on the location and the risk of bleeding.
157
158
Chapter 7
MALIGNANT TUMORS OF THE JAWS

AND ORAL CAVITY
The malignant tumors of the jaw can be odontogenic and nonodontogenic.
7.1. Malignant odontogenic tumors
These tumors derive from epithelial, ectomezenchymale and / or
mesenchymale elements being part of the formal apparatus of the teeth.
They are found exclusively in maxillo-facial skeleton (intraosseous or
central) or soft tissue (gingiva) almost always supportive tissue of the
teeth or alveolar mucosa of edentulous regions.
According to the 2007 WHO classification of malignant odontogenic
tumors one can meet the following:
Odontogenic carcinoma:
metastatic ameloblastoma (malignant)
ameloblastic carcinoma primary type,
ameloblastic carcinoma secondary intraosseous type,
ameloblastic carcinoma secondary peripheral type,
primary intraosseous squamous cell carcinoma
the solid alternative
the variant tumor derived from keratocystic odontogen tumor,
the variant derived from the odontogenic cyst,
odontogenic carcinoma with clear cells,
odontogenic carcinoma with ghost cells.
Odontogenic sarcomas:
ameloblastic fibrosarcoma,
ameloblastic fibrodentinom and fibro - odontosarcoma.
7.1.1. Odontogenic carcinomas
7.1.1.1. Ameloblastom metastases (malignant ameloblastom)
This type of tumor has an evolutionary aspect of a benign
ameloblastoma (1% of cases). Typically, the primary ameloblastoma
occurs in a young adult mandible.
159
Malignant tumors of the jaws and oral cavity
Features:
Epidemiology: the average age at presentation is 30, but a third of the
patients are younger than 20.
Imaging features:
Imaging appearance is identical to that of the benign ameloblastoma.
Prognosis: after a period of about 10 years, it develops metastatic nodules
in lungs, cervical lymph nodes or extragnatic bones.
7.1.1.2. Ameloblastic carcinoma primary type
It is a rare tumor which demonstrates vague ameloblastomatic issues
identified in extensive areas of squamocellular epidermoid carcinoma.
Features:
Epidemiology: occurs in both sexes in relatively equal percentage;
grows into adulthood, being met at young persons of 30-33 years old;
Site: 2/3 of ameloblastic carcinoma develop mandible and only a third
of cases occur in the jaw.
Imaging features:
Radiographic:
radiopacity with irregular borders with cortical thinning or perforation
and infiltration of adjacent structures.
CT:
multilocular location in mandible, maxilla unique lesion, mixt aspect
combined with cortical destruction, analyzed examination in bone and
parencym window illustrates the contrast grip, extension and distant
metastasis (infratemporal fossa, masticatory space, lymph nodes,
extragnatic lungs and bones).
Differential diagnosis: Primary intraosseous squamous cell carcinoma,
clear cell odontogenic carcinoma, metastatic carcinoma.
Prognosis: has a cautious prognosis due to the aggressive nature of lung
metastases arising in short time.
7.1.1.3. Ameloblastic carcinoma secondary intraosseous type
The malignant lesion arises from preexisting benign ameloblastoamas in
old persons, usually during the seventh age decade.
Features:
Is a benign ameloblastoma evolving along years, with multiple local
recurrences after radiotherapy and rapid bone expansion, with the
160
destruction of buccal cortical or lingual mandible or maxillary sinus walls

and infiltration of adjacent soft parts.
Imaging features:
Radiographic:
radiopacity with irregular borders with cortical thinning or perforation
and infiltration of adjacent structures.
CT:
multilocular lesions in mandible, maxilla, unique in the jaw, with a
mixt tissue and osteolysis appearance that destroys the cortical and
infiltrates adjacent soft parts.
Differential diagnosis: Primary intraosseous squamous cell carcinoma,
clear cell odontogenic carcinoma, metastatic carcinoma.
a
B
c
Fig. 7.1. Secondary intrasinusal ameloblastic carcinoma expanded FIT,
FN and jugal region: a) Axial CT soft tissue in bone window in post
contrast, b) Axial CT in bone window, c) CT civ, sagittal reconstruction
in soft tissues window.
161
Prognosis: tumor development near vital structures (orbit, skull base and
the pterigopalatin fossa) are important for determining prognosis, which
can be several years.
7.1.1.4. Primary intraosseous squamous cell carcinoma
This lesion is a squamous cell carcinoma of the mandible, evolving from
odontogenic epithelial residue. It's called "intraosseous" as it develops in
the central area of the bone. Any ameloblastic differentiation was
identified. The tumor has several subcategories:
a) solid tumor invading the medullary spaces with bone resorption,
b) tumor arising from odontogenic cyst lining,
c) squamous cell carcinoma in combination with other benign epithelial
odontogenic tumors.
When the lesion destroys the cortex and goes into the mucosa, the
diagnosis becomes difficult to differentiate between solid primary
intraosseous squamous cell carcinoma and squamous cell carcinoma that
originates in the oral mucosa.
7.1.1.4.1. Primary intraosseous squamous cell carcinoma - solid
variant
Features:
Epidemiology: the average age of presentation is 52 years old, but a
fifth of cases are patients younger than 34, and one third are older than 65.
It usually occurs in men,
Site: usually in the body and the back of the jaw, rarely in the anterior
portion of the jaw,
Symptoms: Most cases are asymptomatic and discovered incidentally
at achieving dental radiographs or OPT.
Imaging features:
Radiographic:
radiopacity with irregular borders without proper contour with cortical
thinning. Large lesions cause cortical bone expansion and / or destruction.
162
b
a
Fig. 7.2. Solid primary intraosseous squamous cell carcinoma:
radiopacity with irregular borders without proper contour with thinning,
expansion of cortical bone and inferior dental canal movement) and
osteolytic lesion with irregular borders that destroys cortex and goes into
the oral mucosa causing multiple tooth extractions b ).
CT:
The tumor produces osteolysis which leads to jaw bone expansion
with irregular borders, with the aspect of "mouse-eaten"
the inferior dental canal is infiltrated by the lesion and the buccal and
lingual cortical is damaged,
the tumor can be with or without pathological fracture with obvious
contrast grip and extension of the adjacent soft parts.
Differential diagnosis:
benign ameloblastoma
clear cell odontogenic carcinoma,
metastatic carcinoma.
Prognosis: the tumor infiltrates regional and at the distance.
163
Fig. 7.3. Squamous call mandible carcinoma. Patient 57 years old in oral
leukoplakia, pain and recent fracture. a) Axial CT of tumors in tissue
window with a moderate iodofil tumor that destroys bone and extends
intraoral and vestibular b) Bone window axial section, destruction of
cortical mandible anfractuas, c), d) 2D reconstruction of the fracture
that crosses the vestibular part of the section, e), f) paraxial
reconstruction with measurements of tumor formation, with a tumor
extension into the dental channel.
164
7.1.1.4.2. Primary intraosseous squamous cell carcinoma derived from

the odontogenic keratocystic tumor
This tumor occurs in the mandible without connection to the oral mucosa
in the presence of keratocystic odontogenic tumors.
The lesion is very rare, only 13 cases published in the literature in 2007,
people over 40 years.
Features:
Epidemiology: lesion occurs equally in both sexes over 40 years,
Site: usually the posterior mandible and maxilla rarely,
Symptoms: Most cases are asymptomatic and are discovered
incidentally at while dental radiographs or OPT are performed.
Imaging features:
Radiographic:
initially, radiopacity looking as an odontogenic cyst, then radiopacity
with irregular borders without proper contour with cortical thinning;
large lesions cause cortical bone expansion and / or destruction of
lesion that penetrates the soft parts.
7.1.1.4.3. Primary intraosseous squamous cell carcinoma derived from
an odontogenic cyst
The tumor occurs in the mandible without connection with the oral
mucosa in the presence of an odontogenic cyst, other than the keratocystic
odontogenic tumor.
people over 56 years.
Features:
Epidemiology: Injuries occur more in women over 56 years
Location: usually in the back of the jaw,
Symptoms are mostly pain, paresthesia or anesthesia of the lower lip.
Imaging features:
Radiographic:
initially radiopacity looking like an odontogenic cyst, radiopacity with
regular edges and its own shape, with cortical thinning,
165
Late stage lesions may cause extensive expansion of cortical bone and
/ or destruction with the lesion that penetrates soft parts.
Prognosis: 3 molar lesion is associated with favorable prognosis.
7.1.1.5. Clear cell odontogenic carcinoma
Is a carcinoma with a low degree of malignancy, composed of islands of
cells with uniform nuclei and clear cytoplasm. The lesion is very rare, only
36 cases published in the literature in 2007, people over 60 years.
Features:
Epidemiology: about 70% develop in women aged between 17 and 89.
Site: approximately 90% of cases develop in the lower jaw, half in the
anterior and half in the posterior segment.
Symptoms are initially teeth loss and then with paraesthesia.
Imaging features:
Radiographic: various aspects, often with an unilocular expansive
radiolucent lesion, with a poorly defined border, sometimes with irregular
radiopacities, and teeth with pathological rizaliz.
Differential diagnosis: metastatic melanoma, metastatic clear cell renal
carcinoma, calcified epithelial odontogenic tumor.
Prognosis: high rate of recurrence and metastases in regional lymph
nodes, lung, bone and requires monitorising.
7.1.1.6. Odontogenic ghost cell carcinoma
Epithelial odontogenic tumor is a malignant odontogenic tumor with
characteristics of calcified and / or dentinogenic ghost cell tumor.
persons aged 23-72.
Features:
Epidemiology: lesion occurs more in males in the 4th decade of life,
Site: usually in the maxilla than in the mandible, posterior,
Symptoms are mostly paraesthesia.
Imaging Features
Radiographic:
radiolucent radiopacity with tooth movement with cortical bone
expansion and / or destruction, which infiltrate adjacent soft parts
Prognosis: is unpredictable, with local invasion and survival of
approximately 5 years.
166
7.1.2. Odontogenic sarcomas

7.1.2.1. Ameloblastic fibrosarcoma
Is an odontogenic tumor with benign epithelial component and a
malignant ectomezenchymal component, sometimes in patients with
preexisting ameloblastic fibroma.
Features:
Epidemiology: the lesion occurs between 3 and 89 years, with an
average age of onset at 27.5 years, male sex is more frequently affected.
Site: usually in the mandible (80% of cases), especially in the
posterior;
Symptoms are mostly paraesthesia and rapid expansion.
Imaging features:
Radiographic:
radiopacity with indistinct edges with tooth movement with cortical
bone expansion and / or destruction.
CT:
multilocular lesions in mandible, unique if in maxilla, mixed aspect,
destroying the cortex.
Prognosis: is unpredictable, with local aggressiveness and rarely
mediastinal lymph node or intrahepatic metastasis.
Fig. 7.4. Right mandible ameloblastic fibrosarcoma in a 12-year child

with wide radiopacity with a rapid loss of molars, cortical bone
expansion and irregular destruction of the basilar edge.
167
7.1.2.2. Fibrodentino- and ameloblastic fibro-odontosarcoma

These tumors have histologically the aspect of ameloblastic fibroma with
dysplastic dentin and enamel and / or dentin.
Features:
Epidemiology: the lesion occurs between 12 and 83 years of age, with
a peak occurrence in the 3rd decade of life,
Site: usually in the mandible, the posterior portion, rarely in the jaw,
Symptoms are mostly paraesthesia and rapid expansion.
Imaging features:
Radiographic:
radiopacity uni-or multilocular, with imprecise borders, with some
opacities representing the hard tissue present inside.
Prognosis: favourable prognosis with recurrent lesion and it is very rare
with regional metastases.
7.2. Malignant neodontogen tumors
7.2.1.Primitive malignant bone tumors intrinsic non-odontogenic
7.2.1.1.Mesenchymal non-odontogenic malignant bone tumors
Is a large group of malignancies arising from mesenchyme. Less often
than the carcinomas, they appear at younger ages and evolves with a
pseudoinfectious, disturbed state.
In terms of imaging, these cancers are classified as follows:
fosteolytic form (bone gap) - transparency,
osteocondensed-shaped intense opacity
mixed forms (gaps and opacities).
In terms of anatomo-pathology, there are numerous morphological
aspects:
osteosarcoma,
chondrosarcoma,
fibrosarcoma
rhabdomyosarcoma,
angiosarcoma,
Ewing sarcoma.
168
7.2.1.1.1. Maxillary osteosarcoma

Are primary malignant bone neoplasms in which the mesenchymal cells
produce osteoid.
Features:
Epidemiology: post irradiation increased incidence is found in Paget's
disease, fibrous dysplasia, chronic osteomyelitis etc in. Maxillary
osteosarcoma has a peak occurrence in the fourth decade of life. Some
authors have found a predominance in men, but others report that females
are slightly affected
b
a
Fig. 7.5. Osteosarcoma mixed form: osteolysis, osteogenesis and spiculi
forming at the mentoniera symphysis a), or maxilla and mandible b).
Site: Although osteosarcoma is the most common malignant bone
tumor, the location in the jaw is only 4% of all osteosarcoma and affects
the mandible body, the symphysis, the condyle, the gonion
symptoms: swelling, pain and ulceration.
Imaging features:
Radiographic:
the widening of periodontal space, bone destruction with suspended
teeth, non-homogeneous transparent areas and areas with radiopaque
inaccurate, irregular contour. Other radiological aspects encountered are:
large osteolytic areas, periosteum spiculi (sunrays), radiopaque areas
(hedgehog, combed bone), periosteal linear opacities (fig.7.5).
Differential diagnosis: Chondrosarcoma, Ewing sarcoma, plasmacytoma,
osteomyelitis, tuberculosis, metastasis and so on).
Prognosis: tumor rapidly evolving and gives metastases.
169
7.2.1.1.2. Chondrosarcoma
It is a very rare malignant tumor that originates from cartilage tissue or
derives from a malignant condrom. Usually these neoplasms occur in the
long bones, pelvis, ribs and are rare in the head and neck region which is
only 1-2%.
Features:
Epidemiology: they are extremely rare tumors of which 10% are in the
maxillofacial region. Occurs mainly in men in the third decade of life, but
with wide variations (5 months-75 years), and men and women are equally
affected;
Site: the most maxillo facial condrosarcoamas occur in the maxilla,
less frequently appear in the body of the mandible, ram, nasal septum,
paranasal sinuses;
Symptoms: swelling not painful jaw.
Imaging features:
Radiographic:
They describe two forms: central (intraosseous) or peripheral
(periosteal localized), which appear as transparent (unilateral
multilocular), respectively, transparency and calcification - ossification,
radiopacity. Dental displacements may occur, and uncharacteristic rizaliza.
C.T. and I.R.M.
can highlight: destruction cortices, the presence of intratumoral
calcifications, the invasion of the soft tissues.
Differential diagnosis: osteomyelitis, tuberculosis, metastases, etc.
Prognosis: has a locally aggressive behaviour and a high metastatic
potential.
7.2.1.1.3. Maxillary fibrosarcoma
Fibrosarcoma is a tumor of mesenchymal fibroblasts that rarely affects the
oral cavity. It is originated in the periosteum and the bone tissue.
Features:
Epidemiology: its incidence is low, 10% of cases are craniofacial, in
adults;
Site: is rare in the mandible or maxilla.
Imaging Features
Radiographic:
radio opaque mixed formation that invades the adjacent bone
structures.
170
CT
tissue mass with moderate outlet contrast, the destruction of the
cortices, showing intratumoral calcification and the invasion of the soft
tissues
Differential diagnosis: metastatic malignant schwannoma.
Prognosis: evolves rapidly and provide local or distant metastasis.
d
c
Fig. 7.6. Left maxillary fibrosarcoma: Axial CT soft tissue window in a)
and b bone) showing iodofila tumor invasion in the nasal fossa and
posterior wall of the maxillary sinus with extension in the zigomato
retro-maxillary space or a giant heterogeneous iodine catching lesion,
with the lysis of the neighboring bone structures and orbital extra-and
intracranial invasion and skull base osteolytic destruction c), d)
Fibrosarcoma (X 90HE).
7.2.1.1.4. Angiosarcoma
It is a rare malignant tumor of vascular endothelial frequently occurring in
skin or in a visceral location, but very rarely affects the oral cavity,
maxillary sinus or throat. In the area of maxillofacial tumors, either
primary or metastatic tumors could be.
171
Features:
Epidemiology: in the maxillofacial region has a very low incidence,
only 27 cases have been reported affecting the head and neck, 19 of which
been primary tumors. The age of presentation ranged from one day old to
68 years old;
Site: rarely in the jaw, which began as a lesion with a nonspecific
appearance with signs of nasal obstruction with epistaxis guiding to the
diagnosis;
Symptoms: intraoral angiosarcoamas appear as red-purple nodules
protruding into the oral cavity, which then ulcerate, with pain and
spontaneous bleeding
c
d
Fig. 7.7. Angiosarcoma: Axial CT in soft tissue window), b), c) showing
iodofil tumor, heterogeneously located in the nasal fossa extended in the
maxillary sinus, ethmoid, infratemporal fossa and left orbit, d) Axial CT
in bone window showing destruction of the walls of the maxillary sinus.
172
Imaging features:
Radiographic:
bulky lesion, osteolytic with moderate expansion in the neighbouring
structures in orbit or intracranial.
CT
Postcontrast lesion, has a strong contrast grip. (Fig. 7.7.).
Prognosis: There are aggressive tumors with a tendency to local
recurrence, lymph node and systemic metastases.
7.2.1.1.5. Rhabdomyosarcoma
It is an aggressive malignant soft tissue tumor consisting of cells derived
from primitive mesenchyme and showing a clear trend towards
miogenesis. Since the tumor is infiltrating the surrounding tissue
structures, the place of origin is difficult to identify. Although rare, they
are still the most common soft tissue tumors of the head and neck in
children.
Features:
Epidemiology: is one of the most common soft tissue sarcomas
occurring in children under 15, and are presented in three types:
embryo, which occurs in children between 8-9 years old,
pleomorphic, usually located in the maxillary sinus and occurs in
young adults,
cellular occurs more frequently in children aged between 30 months
and 5years, at the level of the naso-gentian ditch;
*Site: in children, in a cervico-facial location is the main location of
the tumor, accounting for 45% of all cases is the source jaw in 3 - 17.5%
of all cases of head and neck rabdomiosarcomas. The adult head and neck
rhabdomyosarcoma is rare and is localized mainly in the maxillary sinus
or ethmoid;
Symptoms: Skin lesion begins as a nonspecific one, with signs of nasal
obstruction, with an extensive and rapid development in all adjacent
structures.
Imaging features:
Radiographic:
bulky lesion, intense extensive osteolytic maxillo-facial extention at
the nasal passages, sinus, infratemporal fossa in orbit and intracranial
neighbouring structures, meningitis, epidural and subdural space, that put
pressure on survival in these cases, fatal in about 8 months.
173
CT
bulky tissue mass, moderate and non-homogeneous iodofila extension
with facial masiff components, and intracranial, too. Shortly it produces a
large osteolytic latero-facial area with atypical destructions small bone
remains inside the tumor (Fig. 7.8).
b
174
c
d
Fig. 7.8 Extensive embryonic type rhabdomyosarcoma: a) Axial
postcontrast CT in soft tissue window. Wide expansive process with
moderate contrast outlet, heterogeneous necrotic areas centered at FIT
right top intraorbital and intracranial extension, b) Axial CT in bone
window. Complete lysis of the zygomatic arch, maxillary sinus walls
and vertical ram mandible, c) Axial CT in soft tissue window. Tumor
occupying the right orbit and temporal region with intracranial extension
into the middle cerebral fossa d) optical microscopy: embryonal
rhabdomyosarcoma (x100, HE).
Prognosis: reserved by the appearance of distant metastases (lung, bone)

7.2.2. Primitive malignancies involving bone extrinsic:
7.2.2.1. Malignant epithelial tumors of the oral cavity
Oral cavity cancer is 2-3% of all malignant tumors, being about 96%
carcinomas and only 4% sarcomas.
7.2.2.1.1. Squamous cells carcinoma
These carcinomas may arise from premalignant lesions (leukoplakia,
eritroplazy etc.), located in the mouth mucosa of jaw or mandible.
Features
Epidemiology: occurs most often after the age of 50, affecting both
sexes equally;
Site: initial gums and tongue (40%), mouth floor, buccal mucosa,
corner intermaxillary, lips (38%), hard palate (11%) and soft palate (Fig.
7.9), maxillary sinus;
175
Symptoms: the first forms of ulcerative or nodular lesions occur

without radiographic manifestations, which become
radiographically
visible only when infiltrates bone structures.
a
b
Fig. 7.9. Recurrent squamous cell carcinoma of the left tonsillar
infratemporal fossa (FIT): a) Axial post contrast T1 FS b) coronal postcontrast T1 FS.
Imaging features:
Radiographic:
In advanced forms intraosseous extension areas infiltrative osteolytic
appear with imprecise limits, located in the mandible, the hard palate or
maxillary bone with periosteal spur limit (Codman's, known as the
"triangle of death", fig. 7.10), there may be mixed lesions, radiopaque and
radiolucent.
176
Fig. 7.10. Squamous cell floor carcinoma. Incidence of scroll mandible,

highlighting the extensive osteolytic area with vague boundaries and
periostal spur due to the osteolysis produced by the intraosseous tumor
extension.
CT
Squamous cell carcinomas are usually explored CT when bulky
because of the late discovery, when there are loco regional or perineural
extensions (Fig. 7.11.).
Carcinomas can be CT analyzed in terms of:
shape,
size,
density
extension into neighbouring regions,
relationship with vascular-nervous package surrounding the lesion,
presence of local lymph node extension, unilateral or bilateral or
presence of metastatic lesions in the distance.
177
a
b
c
Fig.7.11. Squamous cell carcinoma of the tongue base c.i.v. CT which
show a large tumor mass, iodofil, heterogeneous, extended in the
muscles of the oral cavity, the lining of the nasopharynx, the
parapharyngeal space, chewable, with a horizontal mandible rami lysis,
and with block adenopathies having the aspect of adenopathic block,
with small areas of necrosis and subcutaneous emphysema located
latero-facial left side.
Particular radio-imaging aspects of squamous carcinomas

Squamous cell carcinoma with an extention in the mandible
Frequently originates on the posterior side of tongue contours, invading
afterwards the region of mandible molar number 3.
Features:
starts with superficial shape and a late one, which is central,
intraosseous located.
Imaging features:
Radiographic:
when the lesion is located on the basilar edge of the mandible , the
aspect of the osteolysis suggests "mouse eaten bone" (fig.7.12 a, b)
destructive lesion (osteolytic), which, in superficial shape has a
diffuse irregular contour, extending into the interdental septum and the
teeth appear suspended in a transparent zone. At this level you can find
and islands of remaining bone,
If there is central debut, a diffuse demineralization, non homogeneous
with opaque islands and gaps is noticed
178
evolving, a large gap with irregular outline (sometimes condensed)

and normal bone islands, looking like 'crater', excavated with irregular
edges and teeth floating inside is formed(fig.7.12.c, d).
CT
mandible carcinomas can be analyzed in terms of size, density,
extension into neighbouring regions, comparing the vascular-nervous
package surrounding the lesion, presence of unilateral or bilateral
adenopathies or the presence of metastatic lesions, in the distance;
There are a large radiolucency with irregular frame (sometimes
condensed) looking like 'crater' excavated with irregular edges, teeth
floating inside and extensions into the extra oral soft parts.
c
d
Fig. 7.12. Infiltrating mandible squamous cell carcinoma ) Left Scroll
mandible showing advanced lesions, propagated from the edge of the
alveolar buccal mucosa floor of lysis with imprecise edges, b) large
incidence of scroll mandible tumor destruction, osteolytic, basilar edge
and horizontal right mandible rami fracture, c), d) early epithelial lesions,
osteolytic of interdental crest with movement of the apexes and rizaliz.
epidermoid carcinoma is signaled by the appearance of a fracture with
extension into inferior dental canal and oral cavity mucosa.
179
Extension in dental canal can be seen throughout the extent of using

direct CT acquisitions especially sagittal 2D reconstruction and
reconstruction of CT dental software in 2D mode, panoramic and obliquetransverse or paraxial (Fig. 7.3.c, is , f).
a
b
c
Fig. 7.13. Infiltrating mandible squamous cell carcinoma, axial native CT
and post contrast showing a left mandible tumor with a wide osteolysis
with irregular contour extended intra-and extraoral soft parts.
Differential
diagnosis:
osteomyelitis,
osteonecrosis,
osteolytic
osteosarcoma.
Prognosis: metastasis in the lung, liver, deep regions of the face, etc..
Squamous cell carcinoma with extension into the maxillary sinus
Features:
These lesions, depending on the debut, can be classified as:
carcinoma in the infrastructure, starting in the alveolar ridge or palate
(fig.7.14)
a
b
c
Fig.7.14. Infrastructure carcinoma originated in the right palate and
extension in the nasopharyngeal cavity
180
mezostructure carcinoma, started from the maxillary sinus mucosa

with loco regional extension (Fig. 7.15),
superstructure carcinoma originating in the ethmoid cells or in the
super-internal maxillary sinus with extension into the pterigopalate fossa,
infratemporal fossa, the base of skull and multiple lymph nodes laterocervical adhenopaties (Fig. 7.16).
a
b
c
Fig. 7.15. Mezostructure carcinoma, started from maxillary sinus
mucosa, axial CT of iodofil tumor a) with osteolysis, b) maseterin
extension c).
a
b
c
Fig. 7.16. Carcinoma of the superstructure started from the lining of the
maxillary sinus, sinus radiography of anterior face, axial CT iodofila
tumor, a), osteolysis, intracranial extension b) and latero-cervical lymph
nodes adhenopaties c).
Imaging features:
Radiographic:
In the early stages there is bone demineralization area, heterogeneous,
with irregular contour,
in advanced stages a radiolucent area with irregular boundaries
appears, rarely with marginal condensation, with floating -like teeth,
CT:
Carcinomas can be analyzed in terms of shape, size, density, extension
into neighbouring regions, the vascular-nervous package report
181
surrounding the lesion, the presence of the local lymph node extension,
unilateral or bilateral, or the presence of metastatic lesions in a distance.
Carcinomas are usually bulky and explored CT when discovered late,
with orbital extension in facial massif at the base of the skull and
intracranial (fig.7.17.).
e
f
Fig. 7.17. Undifferentiated squamous cell carcinoma, superstructural of
the left maxillary sinus: CT axial in a soft tissue window a), c) - iodofil
tumor is extended FIT, nasal fossa, ethmoid, orbit and intracranial b)
Axial CT in bone window - tumor lyses the walls of the maxillary sinus,
nasal fossa, pterigoid process and the great wing of the sphenoid d) HE
staining (HE x100).
182
squamous carcinomas exhibit an intracranial perineural extension,

which can be highlighted computed tomografically after administration of
contrast, in axial sections and coronal and sagittal 2D reconstructions
analyzed in the bone window and soft tissues window. This investigation
allows us to identify the presence of bone lysis in the holes in the base of
the skull, suggestive of perineural extension.
MRI:
using multiplanar acquisition, axial, coronal and sagittal and
appropriate sequences with fat suppression and contrast product injection
highlights the lesion, characterizes its structure, highlighting local and
neighbouring extensions and affected lymph nodes;
it is best to highlight the intracranial nerve. It may be interested in the
possible extension of squamous cell carcinoma with perineural origin in
the mouth.
7.2.2.2. Malignant epithelial tumors of the facial sinuses
7.2.2.2.1. Adenocarcinoma of the ethmoid
It is a rare tumor of ethmoid sinus mucosal growth caused by exposure to
dust, sawdust and leather tanning industry and is recognized as an
occupational disease.
Features:
Epidemiology: occurs mainly in men (90% of cases) and rarely in
women, sometimes after a long interval of time of exposure (30 years);
Site: usually affects ethmoid cells and evidence in the jaw, orbital and
intracranial;
Symptoms are nasal obstruction mostly small sero-sanghinolente
discharge and rapid expansion.
Imaging features:
Radiographic
radiolucent osteolytic with imprecise edges maxillary sinus, the tumor
is discovered late.
Especially CT and MRI:
shows osteolytic lesion with areas of necrosis and tumor extension to
the skull base, with damage to the ethmoid riddled blade, and even
intracranial meningeal extension (fig.7.18).
183
d
c
Fig. 7.18. Adenocarcinoma of the ethmoid with intracranial metastasis:
Axial CT showing iodofil tumor, osteolytic in the window bone and
soft parts a), b) MRI axial and coronal T1 post contrast with intracranial
extension c), d).
Prognosis: This lesion has poor prognosis due to intracranial and regional
extention.
7.2.3. Hematologic malignancies

7.2.3.1. Myeloproliferative diseases (Leukemia)
Represent a diverse group of hematopoietic tissue malignancies that are
characterized by abnormal proliferation of white blood cells. They are
usually grouped into acute and chronic forms, which are then subclassified
according to the type of cell involved. In leukemia the maxillofacial
184
changes occur due to deposits of leukemia, complicating or announcing

the disease.
Features:
Epidemiology: rare in people younger than 15;
Site: orbit, maxilla: sinus and mandible.
Imaging features:
Radiographic:
osteolytic type changes occur with ridge destruction, disappearance of
lamina dura, tooth decay, demineralization of the teeth.
Prognosis: dependent on rapid diagnosis and early treatment.
7.2.3.2. Malignant Lymphoma

Comprises a heterogeneous group of cancers developed by neoplastic
proliferation of the lymphatic system. They are generally classified into
two groups: Hodgkin's disease and non-Hodgkins lymphoma. About 85%
of all malignant lymphomas are non-Hodgkin's lymphoma. They are
classified according to the cell origin (B or T) after morphology
considering the clinical behavior (low and high malignancy).
At the jaw level, lymphomas develop out of the lymphoid tissue, and
sometimes in nonlimfoid tissue (gingiva, palate and so on).
7.2.3.2.1. Primary non-Hodgkin's lymphoma of the head and neck
Head and neck primary NHML are met, having an origin in Waldeyer
ring, oral mucosa, salivary glands, paranasal sinuses, larynx tissue, bone
structures. NHML of the jaw occurs in the marrow cavity and manifests as
an isolated lesion, solitary. To be classified as a primary lesion one must
show that there is visceral or nodal or distant metastases of a systemic
NHML. It is a rare cancer and is usually type B-cell lymphoma with high
malignancy.
Features:
Epidemiology: occurs in patients older than 40 years, especially in
women,
Site: in the maxillofacial region usually occurs in the sinuses of the
face, without causing significant osteolysis as squamous cell carcinoma,
but with perineural extension. Initial location of the mandible is only 0.6%
of NHML isolated NHML 5% of all bone tumors and 8% of all jaw
tumors;
185
symptoms: tumoral syndrome, intramaxillary or intrabucal masses,

tooth loss, bleeding, local anesthesia. If a NHML of lymphoid structure in
the head and neck, tumors affecting the maxillary bone, it is an advanced
stage of the disease and occurs by contiguity (posterior areas of the
mandible, condyle, jaw).
Imaging features:
Radiographic:
radiolucent areas (gaps) of different sizes, with clear shape with
evolving in masticatory muscles and sinus area.
CT:
iodofil moderate tumor mass, a small radiolucency and / or extension
at the bottom of nasopharynx (Fig. 7.19.).
MRI
allows accurate visualization of tumor extension both at sinus jaw
prestilian space, the infratemporal fossa and through the Eustachian tube
into the middle ear.
a
b
c
Fig. 7.19. Axial CT showing non Hodgkin lymphoma lesion in the right
Waldeyer's ring, the parapharyngeal space, the jaw muscles) causing
osteolysis of the jaw b) HE staining (HE x100) c).
7.2.3.2.2. Burkitt lymphoma

It is a rare, poorly differentiated and aggressive non-Hodgkin
lymphoma characterized by monoclonal proliferation of B lymphocytes
has the highest rate of cell proliferation of all human cancers. Various
studies suggest a strong association between Epstein-Barr Virus and
Burkitt lymphoma pathogenesis.
186
Features:
Epidemiology: is met more frequently in male children, developing
predominantly in the first decade of life;
Site: gnatic affinity for bones, particularly the jaw. The tumor can
progress very rapidly into the mouth presenting itself as a facial tumor or
mass that interests the exofitic mass in the jawbone with predisposition to
malar region;
Symptoms: mobility appears, the displacement and tooth loss and
gingival fibromucous is swollen, necrotic and ulcerated.
Imaging features:
Radiographic:
small osteolytic areas in cancellous bone and lamina dura that
ultimately achieve a confluence of large osteolytic, multilocular areas periosteal reaction with new bone formation, with aspect of "sunrays".
7.2.3.3. Multiple myeloma (Rustitzki - Kahler's disease)
It is a systemic lymphoproliferative disease with various manifestations
of B cells. The jaw lesions, although rare, are not often the first sign in
multiple myeloma. There is usually a chest/sternum damage, in ribs, in the
vertebrae. It is considered the most common hematologic cancer after
lymphomas. The tumour proliferation of plasma cells derives from the
bone marrow.
Features:
Epidemiology: meets relatively common in men around the age of 60
years, starting as a single lesion or as multiple lesions;
Site: predilection for pelvis, skull, ribs, sternum. The mandible is
interested more frequently than the maxilla. It can cause pathological bone
fractures.
symptoms: tumor syndrome, weight loss intrabucal, dental bleeding,
local anesthesia and bone pain, fatigue and paleness in multiple injuries.
Imaging features:
Radiographic:
Multiple radiolucent areas (gaps) of different sizes, with net shape
without lizereu radio-opaque peripheral osteocondensant. Sometimes
lesions may be condensed.
Differential diagnosis: osteosarcoma, osteomyelitis, lymphoma
limfoplasmocitic.
187
c
d
Fig. 7.20. Mielom multiplu cu multiple lacune radiotransparente, bine
circumscrise tanate rspndite neuniform la nivelul calotei a),
bazinului b), CT axial n fereastr de os evideniind leziunile osteolitice
de la nivelul arcadelor zigomatice i a maxilarului drept cu invazia
esuturilor moi c), d).
7.2.3.4. Ewing sarcoma of the maxillofacial region
First described by James Ewing in 1921, Ewing sarcoma or Ewing's
sarcoma is one of the most aggressive bone tumors. It is an intra-bone
malignancy with unclear pathogenesis. Neuroectodermal tumor cell is a
small, round, blue, poorly differentiated. Derived from bone marrow
mesenchymal tissue.
Features:
Epidemiology: occurs mainly in the first three decades of life,
predominantly in males;
188
Location: represents 2-7% of all Ewing sarcomas and particularly

affects mandible rami, although a few cases have been reported with jaw
tracking;
Symptoms: Skin lesion begins as a local infection and swelling that
causes distant metastases.
Imaging features:
Radiographic:
looks like osteomyelitis, there are radiolucent zones with vague shape
with marginal condensation with periosteal reaction (the onion skinning
aspect, opaque lines alternating with transparent lines) and sometimes
cause periosteal reaction in the form of perpendicular spiculi on the bone
surface ;
final form is found in wide bone destructions.
CT:
reveal tissue mass and osteolytic area with typical osteolytic
destructions of "prairie fire" type.
Differential diagnosis: osteomyelitis, tuberculosis, metastases, etc.
Prognosis: rapidly evolves and gives metastases.
7. 2.4. Tumor metastases
They are rarely met as maxillofacial metastases from malignant tumors
of the stomach, breast, lung, prostate, colon, testis, etc..
Features:
Epidemiology: more prevalent in women;
Site: mandible molars region, mandible condyle, mandible jaw or
skull base.
Imaging features:
Radiographic:
Unique radiolucency (radiolucent area) with diffuse contours,
infiltrates with strong iodofila extension in the soft parts (fig.7.21.).
189
c
d
Fig. 7.21. Metastasis of lung adenocarcinoma developed in the
zygomatic bone and FIT: a) Axial CT in bone window b) native T1 c)
Coronal T1 FS contrast product, d) T1 FS and contrast product.
Sometimes there are multiple radiolucencies (osteolytic areas) with
diffuse contours infiltrating in the sinuses, base of the skull or mandible
(Fig. 7.22.).
there are sometimes osteocondensanted areas (opaque) in the
vertical rami of the mandible and mandible condyle, usually metastases
from breast or prostate cancer (Fig. 7.23).
190
e
f
Fig. 7.22.: A) Axial CT in metastatic soft tissue window iodofil moderate
infiltration and accompanied by the hypertrophy of jaw muscles, b) Axial
CT in soft tissue window, iodofil moderate metastasis in the
infratemporal fossa floor level, infiltrating the left pterygoid muscle, CT
axial c ) and coronal plane d) bone window with tumor has led to the
osteolytis of the ceiling FIT e) metastatic mucinous carcinoma (VG X90)
f) Alcina blue coloration.
191
c
d
Fig. 7.23. Osteocondensing metastasis from breast cancer located in the
vertical ram left mandible: a), b) Axial CT soft tissue window showing
the mandible metastasis with infiltration and hypertrophy of masticatory
muscles, c), d) Axial CT in bone window showing osteocondensing and
increasing in size of the left mandible vertical ram.
192
Chapter 8
JAWS BONES DYSTROPHIES AND OTHER BONE

INJURIES
Bone dystrophies are non tumoral and non inflammatory lesions that
appear as abnormal growths of bone architecture and mineralization
determining the modifying of the shape, structure and bone radio opacity.
These lesions may be osteocondensed or osteorarefied with poles or mono
ostic events, affecting jaw in a general context or as a local event.
According to the 2007 WHO classification of fibro-osseous lesions one
can meet the following:
Osifiant fibroma,
Fibrous dysplasia,
Central granuloma with giant cells,
Cherubism,
Aneurysmal bone cyst,
Simple bone cyst.
8.1.The osifiant fibroma
This well defined lesion tissue is composed of mineralized material
fibrocelular and very varied in appearance.
Osifiant fibroids appear in two other versions: osifiant trabecular juvenile
fibroma (OTJF) and juvenile psamomatoid osifiant fibroids (JPOF).
They are also called cementifiant fibroids, cemento-osifiant fibroids,
juvenile osifiant fibroids.
This injury has long been considered an odontogenic tumor originating in
the periodontal ligament and not a benign fibrous lesion.
Features:
Epidemiology: occurs at any age, but most commonly in the 2nd and
4th decade of life, especially in women
Site: osifiant fibroids occur especially in the mandible premolars and
molar region increasing slowly with a painless deformity of lower jaw, the
jaw OTJF predilection appears and JPOF may occur in all bones of the
paranasal sinuses, slowly progressive, asymptomatic.
193
Jaws bones dystrophies and other bone injuries
Imaging features:
Radiographic:
can highlight a heterogeneous lesion with a mixed bone component
and cement focus, located in the horizontal portion of the mandible and
having a "frosted glass" aspect. This lesion determines jaw expansion that
doubles its thickness, but without infiltration of the canal or pathological
rizaliz of the dental apexes. The peripheral lesion demarcation is clear,
without capsule, visible especially in the mandible.
CT:
shows a heterogeneous lesion that may have inside areas with
different densities of cement and reshuffled bone, some confluate,
amorphous, but with clear limits, blew cortex (fig.8.1)
the lesion deformes the jaw (fig.8.2) or mandible and moves or erodes
dental apexes and extends in the adjacent regions.
Differential diagnosi:s: fibrous dysplasia.
Prognosis: the lesion grows slowly as if there does not suffer complete
surgery.
194
Fig. 8.1. Juvenile trabecular osifiant fibroma, young man of 22 years old
with a painless ram horizontal deformation of the mandible. a), b) Axial
post contrast CT, bone window and heterogeneous parenchyma lesion, right
premolar region, with limits flou, neiodofil, dense areas, irregular inside
and thin cortical. c), d) sagittal 2D reconstructions allow to study the link
with the dental canal and molars apexes e), f) panoramic and paraxial
reconstructions, g) - h) 3D VRT images with bone deformation and integral
fat.
195
f
e
Fig. 8.2. Juvenile psamomatos osifiant fibroma. a) - c) Axial CT in
soft tissue window showing a large lesion developed in the left
maxillary sinus that has inwardly areas with different densities of bone
cement and reshuffled bone, some confluate areas, amorphous, but with
clear limits that blow the cortex, reshape and deform the jawbone,
cheekbones and palate.
8.2. Fibrous Dysplasia

This lesion with a genetic transmission has as a main characteristic the
spongy bone replacement and bone marrow by connective tissue, but the
dysplasia also contains part of bone and osteoid tissue, metaplasiated.
Clinic: the lesion is asymptomatic, with increased bone volume and
deformation of the affected region;
Clinical forms:
monostic fibrous dysplasia often in the maxillary, affecting, in
order of frequency, ribs, femur, tibia, jaw, mandible;
poliostic fibrous dysplasia:
Jaffe-Lichtenstein - less severe with skin pigmentation
Mc.Cune-Albright syndrome associating more severe endocrine
disorders
196
Features:
Epidemiology: most common in children and teenagers
Site: maxilla and mandible, zygomatic bone, invading the adjacent
bones, mandible body, dental arches, sphenoid, the base of the skull, ribs,
femur.
Imaging features:
Radiographic:
opaque mass, homogeneous, and radiolucent lesions, uni-or
multilocular; initial with net shapes, then diffuse, sometimes with pagetoid
aspect associated with dental displacement, rizaliz (fig.8.3), the
disappearance of lamina dura.
Fig. 8.3. Mandibular fibrous dysplasia with mixes lesions with

radiopaque radiotrasparencies with a frosted glass appearance which
causes teeth apexes rizaliz in 44.45, 46, 34, 35, 36, distorting the
mandible bilaterally.
CT:
Frosted glass opacity at the deformed bones level (fig.8.4)
197
f
e
Fig. 8.4. Fibrous dysplasia. Axial CT in soft tissue window a) and
bone b) and sagittal 2D recostructions c) and coronal d) shows
thickening of the posterior wall of the right orbit by reshuffling the
sphenoid wing bone and part of the right temporal bone, with
exophthalmos, narrowing inferior orbital fissure, right sphenoid
bone changes and right optic nerve canal diameter, e), f). 3D
reconstructions, the SSD, sagittal and frontal bone showing
changes of big and small right sphenoid wing, the right orbit and
optic right nerve canal, right maxillary sinus size reduction and 1/2
postero-lateral of the right orbit .
osteolytic fractures with neosifiant matrix (20%), sclerotic lesions
(25%),
3 imaging features:
198
cystic: radiotrasparency or lytic lesion (21%),

sclerotic: intermediate lesions (23%),
mixed radiolucent / radiopaque, pagetoid appearance, belated
(56%)
Differential diagnosis: osifiant fibroma.
Prognosis: the lesion grows slowly in time.
8.3. Central giant cell granuloma
This lesion is a non-neoplastic mass in the jaw, relatively unusual,
causing expansive radiolucent lesions.
Features:
Epidemiology: variable, but usually in adolescents and young adults
under 30 years old.
Site: anterior mandible in the transition dentition region, frequently
crossing the midline,
Size: highly variable, up to 6 cm in diameter,
Shape: multilocular, can be monolocular in its early stages,
Outline: Smooth and corrugated relatively well defined, without clear
cortical borders.
Imaging features:
Radiographic:
Variable-sized radiolucent lesions, the larger ones have fine internal
septa (fig.8.5) or trabeculae resulting an appearance of "honeycomb" or
multilocular,
adjacent teeth to the lesion are often displaced, sometimes resorbed,
irregular bone extension at the mouth and tongue level achieves the
curled edge of the mandible.
Based on clinical and radiological effects on adjacent structures, the
central giant cell granulomas can be divided into 2 categories:
Aggressive: Typical issues with destructive lesions with increased
rate of growth, aggressive (fig.8.5)
Non-aggressive: with benign behaviour and low rate of growth
(fig.8.6)
199
a
b
Fig. 8.5. Central giant cell granuloma, aggressive. Patient of 14 years
old, incidence of jaw scroll a) shows a radiotrasparent, right
parasymphysis area, with a shift in the displacement of the premolars in
film-chin incidence b) shows multiple cystic-looking images, large
"soap bubbles", with fine internal septa that move the teeth and deform
the jaw, right parasymphysis and symphysis.
c
d
Fig. 8.6. Central giant cell granuloma, nonagressive. Patient of 12 years
with small radiolucency between 45 and 47, visible in the incidence of
jaw scroll) low face b) and Simpson occlusal c) and periapical d) where
there is external cortical blow, vestibular lesion extension with jaw
deformity.
200
Differential diagnosis: giant cell tumor of hyperparathyroidism (patients

with hypercalcemia, increased alkaline phosphatase and decreased
phosphorus).
8.4. Cherubism
Is a rare hereditary disorder with autosomal dominant, which in many
cases can occur spontaneously having as a probable cause the impaired
development of the maxillary mesenchymal tissue. The term Cherubini
which means face of an angel comes from the development of both
mandible branches, making an issue of angel paintings similar to that of
the paintings in the Renaissance.
Features:
Epidemiology: present in children before puberty (2-6 years)
Site: mandible, especially angle of the jaw and upward ram; may
interest the orbit, palate, frontal sinus;
Imaging features:
Radiographic:
Multiple radiolucencies making an issue of "soap bubbles"
with net margins, well defined,
*An increase volume of the gonions including coronoid process,
*Cortical bone blown, thin, perforated (fig.8.7)
*Significant displacement of the transition or permanent teeth,
*Dental resorptions sometimes, the transitional dentition is early
exfoliated
* Ectopic eruptions, canal shift, malformed molars.
CT:
allows an overview of direct axial lesions by image analysis, 2D and 3
D reconstructions
201
b
Fig. 8.7. Cherubism
Radiolucent lesions developed in the jaw and facial bones massif are
characterized by a sharp increase in time to complete the period of bone
growth, causing elongation of mentonier symphysis, the growth of the
gonions volume, increased cheekbones, orbital shape changes with
bilateral exophthalmos (fig.8.8).
202
a
b
Fig. 8.8. Cherubism, skull radiographs profile) and with b) a 14-year
old with dental ectopies, dental pathological rizaliza in the incisors
apexes and multiple radiotrasparencies that made an aspect of "soap
bubbles" with mandible and maxillary deformity.
8.5. Osteopetrosis, "marble bones disease" (Albers-Schonberg

Disease)
It is characterized by generalized increased density (opacity) of the
skeleton by bone deposition due to delayed bone resorption by osteoclasts
and reduced hematopoiesis in the absence of spongy tissue.
Features:
fragility of the bone with pathological fractures,
vascular compression, nerve disorders,
infantile form (the first month of life) is severe, causing death by
anemia and secondary intercurrent infections.
Imaging features:
Radiographic:
enlarged skull, hyperopaque with early closure sutures and filling of
the holes in the skull,
tendency to osteomyelitis of the jaws due to various dental diseases:
dental-alveolar ankylosis, delayed eruption / vicious corono-root
malformations.
203
8.6. Paget's disease

It is a form of deforming osteitis with chronic evolution which begins
on the long bones, on the debut, osteolytic, with bone resorption and
osteoblastic phase to follow, condensation affecting the jaw in 15-20% of
cases.
Features:
Epidemiology: present with old persons, initially debuting in the long
bones,
Site: base of the skull, long bones, visceroskull, the backbone
(fig.8.9).
c
d
Fig. 8.9. Paget's disease with an early appearance of osteoporosis in the
front and rear calvaria ), or chronic appearance of "cotton fluff" on the
calvaria b) widening and third finger osteosclerosis of the phalange c), or
opacification and enlargement of the jaw and dental hipercementosis d).
204
Imaging features:
Radiographic:
radiolucent areas alternating with radio opaque areas, with an aspect
of "cotton fluff", hence the term of pagetoid bone;
the thickening skull calvaria up to 2-3 cm, with lacunar focuses and
bone spiculi perpendicular on the external headboard, so that the "hat
becomes too small"
causing greater damage to the jaw with thick bone trabeculae and rare,
the appearance of "cotton fluff" and dental hypercementosis, and lamina
dura is whether resorbed or missing,
the backbone becomes cifoscoliotic,
affecting the long bones, the tibia and femur are hypertrophied,
elongated and curved, so the trousers "become too long".
8.7. Recklinghausen neurofibromatosis
This affection is a neuro-ectodermal dystrophy, a facomatosis.
Features:
cutaneous nevi,
neurofibromas along the nervous tracts,
changes in visceral skull bone on the trigeminal and facial tract.
The lesion is isolated or associated with other endocrine syndromes:
associated the increase of blood parathyroid hormone and
hypercalcaemia, due to an adenoma, a parathyroid adenocarcinoma or
glandular hyperplasia,
clinically asymptomatic with severe manifestations,
+ / - kidney stones and severe demineralization, pseudocystic,
frequent involvement of the mandible ( in comparison with the jaw
damage) without deformation thereof, but with the possibility of
pathological fracture;
When the lesion is unique the diagnosis is very difficult.
8. 8. Hyperparatiroidian osteoporosis (Recklinghausen disease)
This condition causes dental dystrophies, thin lesions by
hyperdisfunction, along with radiographic changes with pseudocystic
disseminated transparencies due to brown tumors in the calvaria and long
bones.
205
Features:
Epidemiology: occurs in older people who have biological criteria of
hyperparathyroidism
Site: calvaria, jaws, long bones.
Imaging features:
Radiographic:
pseudocyst showing a radiolucent appearance of "honeycomb" or
"soap bubbles" that blows the cortex, rizalizeaz teeth, causing the teeth
expulsion or blown arcade cortex (fig.8.10)
the lamina dura subtle forms are resorbed with the decalcification of
dental arches.
a
b
Fig. 8.10. Hyperparatiroid osteosis with pseudocystic transparencies,
looking like a "honeycomb" cortical blown and rizaliza of dental apexes)
panoramic radiograph, radiolucent frontal bone and skull prolile radiograph
b).
8.9. Mesenchymal tissue hyperplasia

These lesions called histicitosis X, determine the pseudo-tumoral
aspects of the soft tissues and skeleton.
The disease includes three entities with different clinical manifestations:
eosinophilic granuloma,
lipoid granuloma, Hand Schuller Christian disease
a leukemic reticulosis, Letterer-Siwe disease
All three cause bone lesions "tumor-like" caused by the proliferation of
Langerhans cells and eosinophils lymphocytes.
206
8.9. 1. Eosinophilic granuloma

The lesion is more common in young adult males.
Features:
Epidemiology: 83% of all entities, most commonly diagnosed in
adolescents in the second decade of life,
Prognosis: good, responding well to treatment.
Imaging features:
Radiographic
*when unique, gives a picture of osteolysis, with round or oval gaps
with polycyclic contours sometimes, but not peripheral bone reaction
(fig.8.11 a)
may present mixed picture, when multiple lesions with osteo-sclerotic
changes in the mandible (fig.8.11 b).
a
b
Fig. 8.11. Eosinophilic granuloma with mixed images in the horizontal
rami of the left mandible) or left mandible angle, with osteosclerotic
changes in the basilar edge of the mandible.
8.9.2. Hand-Schuller-Christian disease

This lesion invades the bones.
Features:
Epidemiology: 12% of cases, especially in children under 5 years,
with a slow growth in time(fig.8.12)
Prognosis: severe evolution, affecting the skull, ribs, jaw and
invading the skin and mucous membranes, causes diabetes insipidus,
Imaging features:
Radiographic:
207
Multiple often radiolucencies, with the destruction of the dental crests

associated in advanced cases with marginal periodontitis lesions,
a
b
Fig. 8.12. Hand-Schuller-Christian disease with mixed images at a) left
mandible condyle or mandible rami of left vertical ram, with
osteosclerotic changes of parietal bones b) geographical map layout.
mixed picture in the jaw with oseosclerotic changes (fig.8.12 a)
mixed picture in the skull causing osteosclerotic changes in the
parietal bone, looking like a geographical map (fig.8.12 b).
8.9.3.Letterer-Siwe disease
It is the most serious form, can be acute or subacute, with extensive
dissemination. common in infants and young children.
Features:
Epidemiology: affects children under 3
Site: spontaneous expulsion of dental germs and early rashes
accompanying the jaw and mandible lysis, hepato-spleno-megaliths,
lymphadenopathy, hypochromic anemia,
Prognosis: fatal outcomes.
Imaging features:
Radiographic:
can present images mixed with osteo-sclerotic changes in the
mandible,
effects: adjacent teeth are unresorbed, but sometimes the periodontal
bone support is compromised, so they appear as floating in this space.
208
Chapter 9
THE TEMPORO MANDIBULAR JOINT

Temporo-mandible joint is a diartrosis with interposed meniscus
formed by:
mandible condyle,
glenoid cavity and
anterior temporal tubercle
From an imagistic point of view, the temporo-mandible joint is very
difficult to explore, which is why there is a great variety of radio-imaging
explorations proposed over time, each highlighting certain parts of this
complex anatomy.
TMJs are very different diseases with similar clinical symptoms in most
cases, which require detailed investigations to explain the painful
dysfunction of the TMJ.
Variety of symptoms and ways to explore clinically require a good
knowledge of:
normal anatomy of TMJ
investigations available and the type of information provided,
radiological characteristics of each TMJ disease.
9.1. Anatomo - physiological aspects of TMJ
The basic components of TMJ have various characteristics.
Mandibular condyle has an ellipsoidal shape with the longest axis
transverse, with the joint surface much smaller than that of the temporal
bone.
The joint disc is composed of dense connective tissue devoid of vessels
and nerve fibers with a thin central area and a rear area, thicker than the
anterior one. The disc is attached by lateral ligaments, anterior and
posterior. The joint capsule adheres to the meniscus, is lined by synovium
and strengthened by an external ligament (resistant) and an internal
ligament (thin).
The glenoid cavity includes an anterior articular portion belonging to
the squamous part of the temporal bone and a posterior unarticulated part,
belonging to the tympanic part of the temporal bone.
209
The temporo mandibular joint
The articular tuberculae, the temporal condyle consists of the root

cross-temporal zygomatico process, has a convex posterior articular
surface with an edge.
Knowing these static elements that make up the TMJ, we must pay
attention to the types and variations of mandible movements and how they
can change the appearance of the joint. Normal movements include:
rotating condyle into the pit,
translating condyle down inside the glenoid fossa,
The disc must be attached to condyle, or moves to the front.
These two movements combine mandible condyle movement down and
forward when the patient opens his mouth.
The disc, the ligamento-muscular insertions, the capsule - are 'soft parts' of
the joint. Along the anterior contour of the meniscus are inserted the
segment (head) of the external pterygoid muscle (lateral) (fig.9.1 a).
As the mouth opens the condyle moves down and forward ( in the
glenoid cavity) is a translation movement - meniscus, with its central
portion is still moving forward, so that its middle reaches the anterior
rebord of the glenoid cavity, below it being the condyle head (fig.9.1 b).
Simultaneously, the condyle does a rotating movement on the inferior
surface of the disk.
As the mouth closes - the disk moves back.
Fig. 9.1. Schematic presentation- TMJ sagittal section in the "closed mouth"
position a), sagittal section TMJ "open mouth" position b) gc-glenoid cavity,
mc- mandible condyle, eacexternal audio channel , m-meniscus with 3 areas:
1 anterior, 2 - central, 3 rear, ar- anterior recessive, pr posterior
recessive, pf - posterior frenulum, ti temporal insertion, mi - mandible
insertion, mpl -lateral pterygoid muscle (after Cavezian R. et al. 1995)
210
9.2. Radio-imaging TMJ exploration

In E. Whaitess opinion, the exploration TMJ involves:
9.2.1 Conventional radiographs
in various incidents:
Transcranian the lateral aspect of the glenoid fossa, of the
articular eminence, the condylar head and articular space are noticed
Transpharynx - the lateral aspect of the condylian head and neck,
articular surface
OPT the lateral aspect of both condyles,
Low face the posterior aspect of both condyles (head and neck)
CT scan, both linear and spiral - all aspects of the glenoid fossa,
articular eminence, condylian head and the joint space.;
9.2.2. Other imaging investigations.
9.2.2.1 Transcranian incidences
Are done with various techniques and types of equipment. Currently we
generally use Schller incidence.
The indications for this technique are:
TMJ painful dysfunctional syndrome and internal disturbances
causing pain, crackles and mouth opening limitation, (fig.9.2)
to investigate the size and position of the articular disk - they can only
provide indirect data, knowing the relative position of the articular bone
elements,
to investigate the joint range of movement when opening and closing the
mouth.
Diagnostic information
Closed-mouth radiographs show us:
size of the joint space and indirect information on the position and
shape of the articular disk,
condyle head position in the pit,
glenoid fossa shape and condition, and articular eminence,
condylian head shape and appearance of the articular surface profile,
It allows comparison of the two TMJ.
Open-mouth radiograph shows:
changing the type of condylar movement,
comparing the movement in the two TMJs.
211
Fig. 9.2. Hypertrophy of the coronoid process (fine arrows) in

transcranial incidence of right TMJ, zygomatic arch (open arrow) much
lower, with limited mouth opening.
9.2.2.2. Transfaringian incidences

They can be achieved using a simple dental x-ray machine and
extraoral cassettes of 13/18 cm. in the dental office.
Information:
TMJ painful dysfunctional syndrome
to investigate the presence of joint damage, particularly osteoarthritis
and rheumatoid arthritis,
to investigate pathological conditions affecting the condylian head,
including cysts and tumors,
fractures of the condylian head and neck.
the condylian head shape and the lateral side surface condition in a
profile
comparison of both condyles (fig.9.3).
9.2.2.3. OPT
It is simple and useful, offering rapid diagnosis.
Advice
TMJ painful dysfunctional syndrome,
investigation of joint disease,
investigation of pathological conditions affecting the condylian head
fractures of the condylian head and neck
hypo / condylar hyperplasia.
212
condylian head shape and condition of the articular surface profile,
direct comparison of both condyles.
It replaced more and more the incidence of jaw scroll in recent years.
Fig. 9.3. Right temporo-mandible ankylosis surgery, checked at 12 years

after surgery. OPT.
9.2.2.4. The incidence of jaw scroll

Provides information about each joint space that can be analyzed
comparing right - left (fig. 9.4.a) The indications are the same as for OPT
and its place in recent years is increasingly taken over by OPT.
9.2.2.5. The low face incidence of facial massif
This radiographic technique is performed semi-axial with the mouth
closed.
Advice
investigate condylar articular surface and joint damage,
fractures of the condylian head and neck
hipo-/hyperplasia of the condyle
Technique
The patient is positioned facing the film, head tilted forward (forehead
and nose put against the box), mouth open, X-ray tube is tilted upwards at
an angle of 30 .
condylian head shape and condition of the articular surface (fig.9.4.
B)
a direct comparison of both condyles.
213
a
b
Fig. 9.4. a)Subcondylian right low fracture, accompanied by
parasymphysar fracture with minimal displacement, in incidence of jaw
scroll radiograph, b) left mandible combinative mandible angle, with
moderate displacement of the fragments without mandible condylar
fracture, incidence " low face".
9.2.2.6. Conventional tomography
It is a method of analysis of the TMJ static stage.
Advice
complete evaluation of all joints to determine the presence and
location of any damage or bone abnormalities
investigate condyles and articular fossa when the patient is unable to
open his mouth,
assessment of articular fossa fractures and especially intracapsular
fractures,
Technique
Conventional tomography methods available for obtaining TMJ include:
Linear tomography (fig.9.5)
Multidirectional "hypocycloidal" tomography
Multi-type spiral CT SCANORA type.
size of the joint space,
condyle head position in the pit,
head shape and appearance of the medial and lateral condyle of the
articular surface,
shape and appearance of the fossa and articular eminence,
information on all aspects of the joint,
the position and orientation of the fracture fragments.
214
Fig. 9.5. Right temporo-mandible ankylosis, operated controlled in 12

years after surgery, tomography with mouth opened and closed, right and
left.
9.2.2.7. Temporo-mandible orthography

It is less often used together with the use of diagnostic CT.
Advice
painful dysfunction of the TMJ long term, non responsive to usual
treatments,
articular blocking persistent history
limited opening of unknown etiology.
can give relations regarding the disk integrity and movement.
Contraindications
acute joint infection,
allergy to iodine or contrast product.
diagnostic information on the position of joint and disk components as
moving in relation to each other,
Still images of the articular components with mouth closed and mouth
open. Any movement could be noticed, be it anterior or antero-median.
integrity of the disk, the presence of any perforations.
9.2.3. Modern methods of imaging investigation
Different ways of modern imaging are now used more frequently for
investigating TMJ, because the conventional imaging can not provide all
215
the information. These methods of investigation include: CT, MRI and

arthroscopy.
9.2.3.1. Computer tomographic examination (CT)
This diagnostic method provides sectional images of the TMJ. CT's
advantage is that it can obtain images of soft and hard tissues of the joint,
including disk, at different levels, with 2D and 3D reconstructions (fig.
9.6).
c
d
Fig. 9.6. Latero-facial fracture and right juxtasymphysis shift fragments
and a small external displacement of the condyl a), c), d), CT in bone
window, b) Axial CT in soft tissue window.
shape and appearance of the condyle articular surface,
*the aspect of the fossa and articular eminence
articular disk position and shape,
disk integrity and soft tissue
the nature of any disease of the condylian head.
216
9.2.3.2. Magnetic resonance imaging (MRI)

It is one of the most useful investigations of the meniscal, bone and
tissue elements of the ATM.
useful for determining the position and shape of the disk when the
mouth is closed and when open.
sequences with mouth open / closed TMJ imaging are useful when:
There are doubts about the diagnosis of internal disturbancies,
The analysis of meniscal lesions or tumors
The assessment of the normal joint showing crackles (fig.9.7)
The exploration of the causes of joint pains,
As a presurgical evaluation before surgery.
Technique
The patient supines with the head positioned in a symmetrical antennafor
the head. Using sequences:
sagittal T1 SE sequence performed with the patient with mouth closed
and sagittal and coronal T1 SE sequence with the patient with mouth
closed;
T2 sagittal sequence with patients with closed and open mouth.
Fig. 9.7a) sequence in the coronal plane T1SE patient with mouth
closed, comparison illustrates the articulation of the left and right.
217
Fig. 9.7. b) sagittal sequence T2SE the patient with mouth closed,
illustrates the comparison of the left and right hinge.
9.2.3.3. Arthroscopy
Is a direct visualizing method that enables TMJ to certain interventional
procedures including:
washing with saline,
introduction of steroids directly into the joint,
removal of foreign bodies in the joint.
Arthroscopy is usually regarded as the last stage of the investigation and it
is done before surgical exploration of the joint.
9.3. Radio-imaging aspects in TMJ lesions
The main diseases of TMJ are:
TMJ dysfunctional pain syndrome,
internal disturbances,
osteoarthritis,
rheumatoid arthritis,
juvenile rheumatoid arthritis (Still's disease),
achilozis,
fractures and trauma,
developmental abnormalities,
benign or malignant tumors.
9.3.1 TMJ painful dysfunctional syndrome
This is the most common disorder of TMJ manifested by pains in the
masticatory muscle.
218
Features:
masticatory muscle pain is often worse in the morning and evening,
crackles and occasional stiffness.
Imaging features
CT:
condylian head and articular surface with normal form,
glenoid fossa normal form,
possible increase or decrease of the overall size of joint space - an
increase in joint space size is the only indicator of inflammation (fig.9.8)
possible shift front or rear condylian head in glenoid fossa when the
mouth is closed and the teeth are in occlusion,
reduced range of condylian motion, followed by direct sections
sagittal 2D reconstructions performed with the mouth closed and mouth
open.
a
b
Fig. 9.8. Functional painful syndrome, bilateral sagittal CT reconstruction
with minimum joint right space widening.
9.3.2. Internal TMJ disorders

The symptoms are varied and troublesome.
Features:
crackles can be painful
joint and / or muscle pain
lockjaw and hesitation when opening and closing the mouth, usually
with an open failure.
219
Imaging features
Radiographic:
an alteration of the condyle head position involving an abnormality of
disk position.
MRI:
disk position - can be sprained to the anterior or anteromedian
a movement of the disk relative to the condyle during closing and
opening the mouth (fig.9.9).
Fig. 9.9. a) T1SE sequence in the sagittal plan, the patient with open
mouth, shows the left and right joint, comparative analysis, there is an
external discrete bilateral anterolateral dislocation.
Fig. 9.9. b) sequence in the coronal plan T1SE patient with mouth closed,
shows the left and right joint, comparative analysis.
220
9.3.3. Osteoarthritis
This degenerative osteoarthritis increases as incidence with age and
often causes joint pain. Currently it is considered a systemic disease or a
complication of internal joint disorders, and stress causes the pain of the
affected joint.
Features:
Crepitation pain and trismus which is usually persistent.
Imaging features:
CT:
formation of osteophytes in the anterior portion of the articular
surface of the condylian head - which can be small or extensive (fig.9.10)
condylian head flattening in the anterior-superior edge,
subchondral sclerosis, condylian head becomes dense and radiopaque,
glenoid fossa with normal contour may become sclerotic,
rarely, posterior osteophytes may be formed, cysts and subchondral
erosions in the articular surface of the condyle head
c
d
Fig. 9.10. Degenerative artrosis CT coronal a)-b) and axial c)-d) bone
window showing osteophytes at the anterior and posterior part of the
articular surface of the condylian head, subchondral cysts, osteophytes
and erosions in the articular surface of the condyle head, and
condensation of the glenoid cavity.
221
9.3.4. Rheumatoid Arthritis

It is a generalized disease, chronic inflammatory of the connective
tissue that affects many types of joints. The involvement of TMJ can be
found especially in severe rheumatoid arthritis, but even when TMJ
symptoms are minor or moderate. Infectious arthritis outbreak originates
in a neighborhood - mastoid, middle ear or external ear
Features:
painful crepitation and trismus, which are usually persistent.
Imaging features:
CT:
flattening of condylar head, with spurs of various sizes
erosion and destruction of the articular surface of the condyle head
which can be expanded leading to an irregular outline (fig.9.11)
222
e
Fig. 9.11. Rheumatoid arthritis, axial CT a), c) and
reconstruction of the head condyle parallel to its long axis b), d)
showing condensation and intra-articular condyle, marginal
osteophytes and reduced interarticular space.
Characteristics are usually bilateral and symmetrical.

9.3.5. Juvenile rheumatoid arthritis
Rheumatic arthritis (STILL) is more common in children and is
accompanied by damage to other joints, including the cervical spine
Features:
morning discomfort in the opening movements of the mouth,
permanent painful limitation of joint movement,
painful crepitation and trismus.
in severe cases, the disease can interfere with micrognathia causing
condylar growth and asymmetry (the location is unilateral) or cause
ankylosis of TMJ.
9.3.6. Ankylosis
Real ankylosis is rare and is the result of:
trauma, particularly fractures and condylian head trauma at birth, with
bleeding in the joint,
infection
*severe juvenile rheumatoid arthritis (fig.9.12).
223
c
d
Fig. 9.12. Axial CT of bilateral ankylosis) and coronal
reconstructions b) sagittal c), d)-homogeneous block bone with
bone structure d) or heterogeneous c) - with areas of fibrosis, with
joint spacing that can be seen with difficulty.
224
e
f
Fig. 9.13. Post-traumatic right ankylosis: axial CT b), d), f) and coronal
reconstructions a), sagittal c) and parallel with the long axis of the mandible
condyle highlighting the bone block with a heterogeneous structure with
areas of fibrosis, with narrowed joint spacing , block bone joint extending
beyond the mastoid and tympanic bone.
225
Imaging features:
CT:
reduced or completely disappeared joint space (fig.913)
bone fusion between condylar head and glenoid fossa with total loss
of normal anatomic contours, contour of condyle head is discontinuous or
disappeared;
association with hypoplasia of condylian neck and jaw
underdevelopment on the affected side, causing asymmetry if stiffness
precedes the final stage of growth,
bone block joint going to exceed mastoiditis, ear canal, coronoid
process and partly the base of the skull;
bone block can have a homogenous bony structure, or uneven areas
showing fibrosis, when the joint spacing can be seen, with difficulty.
9.3.7.JTM fractures and injuries
The condylian fractures are common, they followed the mandible body
trauma frequently (fig.9.14).
Occasionally with this type of injury the condylian neck fracture does not
appear and one can see:
the condylian head fracture
the so-called intracapsular fracture or
the condyle head is pushed up into the middle cranial fossa.
Imaging features:
CT:
will demonstrate the extent of any injury which may result in
mandible unilateral or bilateral dislocation of the joint.
226
e
f
Fig. 9.14. Left condylian head fracture, CT appearance after surgery,
after the muscle-ligament reconstruction, a), b) axial sections in soft
tissue window and bone window, the mandible condyle is not seen, but
there is a turnover bony glenoid cavity and pterigoidian muscles with
hypertrofia of the left styloid apophysis.
9.3.8.TMJ dislocations
Those anterior prevail, the lateral and posterior are rare, frequently
associated with fractures of the condyle and the ear canal.
The anterior dislocations are unilateral or bilateral (fig.9.15). they are
often accidental: excessive opening of the mouth, laughing, yawning,
collisions, falling on the mandible.
For their occurrence a series of favorable conditions are required:
less depth of the glenoid cavity
227
temporal tubercule with a deleted slope

deformed mandible condyle
periarticular ligaments and capsule laxity,
decreased muscle tonus (pterigoid muscles, masseter and temporal).
Fig. 9.15. External bilateral anterolateral dislocation: T1SE sequence in

the sagittal plan, the patient with open mouth, shows the left and right
joint, comparative analysis.
Imaging features:
Radiographic:
the glenoid cavity is empty
the condyle is located below the temporal tubercule under the
zygomatic arch.
Lateral dislocations are rare and occur only in case of violent trauma, if
they are accompanied by controlateral condylar fracture, as evidenced on
axial and tangential MRI.
Posterior dislocations are possible if the external ligament is torn.
The condyle can get into the ear canal and, sometimes, when it is affected,
otoragy occurs.
Vertical dislocation is exceptional and involves the superior glenoid
cavity drilling, with penetration of the condyle in endoskull.
Recurrent dislocations involve an atypical conformation and joint
elements occur in the submeniscal floor.
If a meniscus subluxations, it remains in the glenoid cavity and the
condyle surpasses the front edge of the meniscus under the temporal
tubercle, if it exceeds produces a complete dislocation (condylomeniscus).
228
9.3.8. Developmental abnormalities

Developmental defects affecting TMJ are usually investigated using
conventional radiology. They may be divided into:
condylar hypoplasia - unilateral (fig.9.16) or bilateral
*condylar hyperplasia - unilateral or bilateral
bifid condyle or defects associated with specific syndromes.
b
Fig. 9.16. Right condylar hyperplasia visible in the low face incidence)
and orthopantomography b) with evident mandible asymmetry.
9.3.9. Tumors
Benign or malignant tumors occasionally develop in the condylian
head. The radiographic characteristics depend on the type and nature of
the tumor distorting and / or destroying the condylian head.
Benign tumors may also have this location. They are:
osteoma,
condroma,
229
osteocondroma,
fibromixoma.
9.3.9.1. Mandibular condyle osteoma
This injury is the most common benign tumor and is characterized by
an enlargement of the mandible condyle, which is accompanied by its
deformation, exceeding the glenoid cavity.
Imaging features:
Radiographic:
the enlargement of the mandible condyle with the surpassing of the
glenoid cavity.
CT:
The condylian osteoma appears as a homogeneous bone block with
bone structure that causes distortion and enlargement of the mandible
condyle with the glenoid cavity surpassing axial sections more visible in
sagittal and coronal reconstructions 2D and 3D reconstructions SSD
(fig.9.17 ) or VRT.
Differential diagnosis: - condylar hyperplasia, when appears increased but
unaltered.
a
b
Fig. 9.17. Right condylian osteoma. Sagittal reconstruction CT in bone
window) showing deformation and enlargement of the right condyle,
which exceeds net the glenoid cavity, visible in 3D reconstruction SSD b).
9.3.9.1. Malignant tumors

Malignant tumors are very rare and can develop to cause deformation
and destruction of the mandible condyle in its various forms. These
malignant tumors can be:
chondrosarcoma,
synovial sarcoma,
fibrosarcoma,
metastases from breast or lung cancer.
230
Imaging features:
CT:
Highlights osteolysis and the remodeling of the mandible condyle
with geodes, with or without bone spiculi extended adjacent in the soft
parts (depending on the type of pathology) with obvious modification of
the joint space and moderate grip or intense contrast.
Changing of the condyle is a visible tumor on axial sections analyzed
in soft tissue window (fig.9.18 a) and bone window(fig.9.18 b, d) normal
or using special filters (fig.9.18 c).
Using special filters to analyze the images in bone window (hard
filters) allows the identification of the bony changes of the
mandible condyle with geods, spiculi and the mouse eaten aspect
of the mandible condyle. (fig.9.18 c)
a
b
Fig. 9.18. Metastases from breast cancer: Axial CT in soft tissue window
shows the deformation of the right mandible condyle contour, the external
extension of the lesion in the right masticator space, more evident in the
masticator muscle and in the external pterigoid muscle a) The same
section analyzes in bone window, shows the deformed appearance,
irregular right mandible condyle with the delete of the contour and the
deforming of the cortex.
231
c
d
Fig. 9.19. Metastases from breast cancer: CT axial in bone window,
highlighting the deformed irregular aspect of the right mandible condyle,
with appearances of small geode and bony spiculi, visible around the
condyle head both in the hard filter for extremities c) and in the
standard filter, cranio-cerebral d)
232
Chapter 10
SALIVARY GLANDS
Salivary glands are twin glands, whose radio exploration offers
morphological and functional imaging if there is:
salivary colic,
intermittent glandular swelling,
persistent swelling,
hiposyalya.
All these events usually have a subsequent lesion: extra-or intraglandular:
acute or chronic inflammation, tumors (benign or malignant), diseases of
the system and dystrophies, a traumatic injury.
10.1. Anatomo- physiological aspects of the salivary gland
The salivary glands are:
main: parotid glands, submaxillary, submandibular,
accessories: multiple submucosal salivary glands accessories situated
in the mouth, pharynx or ectopic.
Parotid
* prism shaped, with big shaft located near the rear edge of the
ascending rami of the mandible, near the ear canal and is located in a
fibrous capsule,
has an acinous structure and is crossed by the external carotid artery,
external jugular vein, facial nerve and the auriculo-temporal nerve,
superficial extension, genian, the maseterin accessory lobe,
a deep extension, parapharyngeal,
an excretory canal with a length of 35-40 mm and 2-3 mm diameter
opening at the level of the second upper molar, at the pack level, through a
papilla. Saliva from the glandular acins is drained through the Stenon
channel that opens in ducts of 3-2-1 grade.
Submandibular gland (submaxillary)
of the volume is near the parotid gland which is located on the
internal face of the mandible, between gonion and hyoid,
is located in a lodge which communicates with the tonsillar region
and maxillo-pharyngeal space (fig.10.1)
contains primitive lobules - secondary and acins, covered by a
conjunctive stroma,
233
Salivary glands
mixed serous / mucous secretion, which is drained through Wharton

channel, near the lingual-sublingual frenulum, by the salivary caruncle.
a
b
Fig. 10.1. The normal appearance of a parotid gland sialography a) and
submandibular gland b).
Sublingual gland
is located on the floor of the mouth, parasagital against the tongue
frenulum,
drains the Rivinius channels, submucosal, and by the Bartholin main
channel, which opens with the Wharton channel ( of the submandibular
gland), sometimes being common and thus is the only way a sialography
can be performed.
10.2. The radio-imaging exploration of the salivary glands
The main salivary glands and sometimes the accessories can be
explored by radio imaging, using different methods, chosen having in
mind the patients symptoms:
conventional / digital radiography
sialography,
computed tomography (CT),
ultrasound,
magnetic resonance imaging (MRI),
radio isotope imaging (scintigraphy).
10.2.1. Radiography
It is the easiest, quickest and less expensive method to establish the
diagnosis of salivary stones, radiopaque stones (calculi in 90% of
submandibular gland (fig.10.2) and in 60% of parotid stones).
234
Salivary glands
a
b
Fig. 10.2. Salivary calculi a) left sublingual b) left submandibular.
Various types of radiographs of the salivary glands are performed:

for the parotid - OPT, oblique lateral, AP or AP rotated, intraoral
images of the cheeks,
for the submandibular glands - OPT, scroll mandible, occlusal and
lower at 90 and oblique (fig.10.2).
10.2.2. Sialography
The method was originated in Romania, in Cluj in 1926 by Iacobovici
and Popitza and consists of introducing a iodinated contrast medium in the
salivary duct:
liposoluble (originally lipiodol)
hidrosoluble (currently: Iopamiro, Ultravist, etc.)
They are introduced under poor pressure, until the patient feels a slight
discomfort in the gland from 1 to 1.5 ml of contrast through the drainage
hole catheterization of the Stenon channel (for parotid) ,the Warthon
channel (for submandibular glands) and the Bartholin channel (for
sublingual glands, rarely).
X-rays are done every 5-8 minutes, the first at the end of contrast
injection, the latter being in a 20'-30 ' while.
The incidences often used are:
for the sialography of the parotid gland: incidence scroll mandible and
tangential to ascending mandible ram.
for the submandibular sialography: OPT, incidence ,, jaw scroll'' and
occlusal radiographs.
The normal sialographic appearance is dominated by the presence of the
main excretory duct (of the explored gland) of the channels and possibly
235
Salivary glands
impregnated with contrast of glandular parenchyma (acins) - parenchymal

phase obtaining the " blooming tree" aspect.
The method is recommended in: chronic glandular disorders, changes in
excretory canal: congenital, traumatic, problems of space replacement
(cysts, tumors), or having a guiding aim (fig.10.3).
a
b
Fig. 10.3. Normal parotidian sialography), b) right parotid pleomorphic
adenoma, acinar filling defect, looking for "hand kept ball
Contraindications for sialography:

a history of adverse reactions to iodine,
nonspecific allergies
latent hyperthyroidism (thyrotoxicosis)
symptomatic heart failure (with the possible occurrence of acute
pulmonary edema).
10.2.3. Computed tomography (CT)
This method has been introduced in medical practice for over 35 years
being useful in the study of glandular tissue and surrounding tissue
adjacent o the salivary glands.
Normally, the parotid gland has a density higher than the fat density in the
parapharyngeal space, but lower than in the surrounding muscles.
CT examinations can be made - native monitorizing the parotid density,
using contrast (Iopamiro, Ultravist, Omnipaque)
sialo - C.T. (When sialografy is done with aqua soluble iodine, diluted
and injected before CT)
CT examination may reveal changes in certain inflammatory parotid
abscesses, cysts, tumors, mostly those glands whose volume increases and
236
Salivary glands
becomes viscous in a different way (fig.10.4), but can not make a clear
difference between various hystopathological tumor lesions.
Fig. 10.4. Tumor in the left superficial lobe of the parotid iodine,,
homogeneous, with the left jugular lymph nodes in the region, one of
them with size> 1.5 cm.
One can know that:

abscesses have a regular shape, being central iso or hiperdense
the cysts present a hypodense aspect, net limits with thin wall, giving
a content with a variable density ( fluid)
benign tumors: appear as clear outlined, homogeneous, with capsule
,with different density of the remaining parotid tissue, often hiperdense
with moderate contrast grip and small areas of necrosis or calcification,
malignant tumors:
have a vague outline, infiltrating character,
hiperdense structure (hipervascularized)
or are heterogeneous (with areas of necrosis)
10.2.4. Magnetic resonance imaging (M.R.I.)
This diagnostic method is superior to CT for its facility characteristics
in the evaluation of salivary glands and soft tissues.
Thus MRI examination shows:
hipervascularized contour tumors,
fibrous capsule,
perineural tumor extension or extensions of the tumor in the distance,
relation of parotid gland tumor lesions with adjacent spaces and
salivary canal which may be damaged;
237
Salivary glands
facial nerve lesions affecting the parotid section (fig.10.13);

a latero-cervical lymphadenopathy may accompany the tumor lesions
or tumor recurrences (fig.10.14)
balance achieved between the tumor or inflammatory pathology of
both lobes of the parotid, submandibular glands and you can perform in a
the proper sequence (sialo-MRI) the appearance of the main salivary
ducts.
10.2.5. Ultrasound
It is a quick, painless and non-invasive procedure that can achieve the
differential diagnosis between the solid or cystic glandular formations :
the solid masses are echogenic,
*are non echogene or transsonic,
detect formations with a diameter of 2-3 mm, and especially the
salivary calculi (over 2 mm) and
cysts, tumors, abscesses and autoimmune diseases.
10.2.6. Scintigraphy
Unlike other imaging techniques, studying the morphology of normal
and pathological salivary gland, scintigraphy appreciates the functional
aspects of these glands.
Using radionuclide-radiotracers, which are introduced intravenously, the
most commonly used isotope is Tc-99m and gallium pertehtenat 67citrat.
They are captured by glandular tissue and this begins after a few minutes,
maximum is 30 '-45' and then is deleted.
Currently, the detection system uses a scintillation camera, which is
connected to a computer where the images are stored, processed and then
transmitted. In different parts of a gland or in the whole, we find:
warm areas (with additional tracer retention) and
cold areas (with no radio isotope).
These are focus of hyper-or hypoactivity, generally specific to each type
of tumor lesion.
10.3. Radio-imaging issues in salivary gland lesions
10.3.1. Acute sialadenitis
Is often of viral origin and cares of 85% of the parotid gland. It occurs
more frequently in children aged 2-14 and is given by the mumps virus.
238
Salivary glands
The bacterial sialadenitis appears mostly in the parotid gland. It occurs

through retrograde infection with streptococcus and stafilococcus and can
abcede.
The ultrasound examination helps to quickly establish the diagnosis.
The sialography is contraindicated in acute inflammation of the
salivary glands.
10.3.2. Chronic sialadenitis
It is a chronic inflammation, affecting the parotid gland more. The
disease is the result of an untreated acute inflammation that occurs in case
of colic salivary ducts due to the presence of salivary gland stones can
cause obstruction and infection in time.
The parotid gland stones are highlighted by: OPT, incidences of "jaw
scroll" axial incidence, etc..
For the stones located in the Stenon channel it is recommended: AP
tangent ram incidence of jaw upward + / -; Film incidence bite (occlusion)
color Doppler sonography to highlight a hypervascularized tumor.
Radiographic:
The calculus appears as a heterogeneous radiopacity, round or oblong,
elongated.
Submandibular gland stones are highlighted by OPT, incidences "jaw
scroll", color Doppler sonography (fig.10.5).
a
b
Fig. 10.5. a) Bidimensional examination and b) Doppler submandibular
gland.
239
Salivary glands
Radiographic:
the small calculi appear as heterogeneous opacities (or one opacity),
net shaped, located between basilar edge of the mandible and the hyoid
bone.
Wharton duct stones are highlighted by Bellota or Simpson incidence
with occlusal film,
Radiographic:
one opacity, or more, located posterior to the internal mandible body
(fig.10.6 a).
when symptoms point for a salivary calculus but it is not visible
radiographically, it is recommended a sialographic exploration in which
the calculus appears as a radiolucent proximal and distal surrounded by
the contrast (fig.10.6.b).
b
a
Fig. 10.6. a) Radio opaque calculus in the right Wharton channel,
occlusal film, b) radiolucent calculi in the right Wharton channel as
visible with the help of sialography.
10.3.3. Sialodochitis
They are dilated excretory ducts caused by stones or foreign bodies
associated with ascending infection.
Sialography:
channel diameter is increased uniformly
channel lumen may be narrowed,
moniliform aspect of dilatation and narrowing.
240
Salivary glands
10.3.4.Autoimmune sialoadenits
Autoimmune sialoadenits as Sjgren's syndrome consist of:
glandular swelling, mostly of the parotid,
dry mouth, dry eye conjunctives,
rheumatoid arthritis.
Sialografic:
different evolutionary stages may be taken into account, that finally
drive to the destruction of the entire glandular tissue.
sialectatic cavities which, in time have become more numerous with
wider or less wider opacities, according to the evolutionary stage of
contrast substances in view.
Scintigraphy:
using Tc99m a correct diagnosis is established, when there is a
decreased radioisotope capture and a delay of its excretion.
C.T. M.R.I.:
they can provide additional diagnosis data regarding the morphology
and structure of the glands.
10.3.5. Cysts of the salivary gland
These lesions are rare and can be:
the mucous ones are retentions with the obstruction of the
accessory salivary gland (fig.10.7)
the best known retention cyst due to the obstruction of the
sublingual duct is ranula, which may occur in different ages.
congenital or acquired, more unilateral in the parotid gland
(fig.10.8 a, b).
a
b
c
Fig. 10.7. Ranula with various sizes visible in a clinical inspection a),
and axial CT b) and in reconstructions in the coronal plan c).
241
Salivary glands
a
b
Fig. 10.8. Cyst in the superficial lobe of the left parotid gland), standard
two-dimensional exploration and b) the Doppler.
CT:
ranula appears as a hypodense lesion, well circumscribed, with a wall
catching contrast .
the parotid cyst is well circumscribed hypodense lesion with thin wall,
moderate iodofil.
MRI:
Some patients with H.I.V. can meet multiple parotid cysts in sequence
T2 hipersignal with thin walls in a moderate contrast grip and cervical
lymphadenopathy (Figure 10.9).
242
Salivary glands
b
a
Fig. 10.9. Limfoepitelial benign recurrent parotid cysts in superficial and
deep lobe of the right parotid gland, MRI sections a) Axial T2 native b)
coronal T2 native.
10.3.6. Benign tumors of the salivary glands

These injuries are rare and are found in 80% of cases in the parotid
gland, especially in its superficial lobe.
10.3.6.1. Pleomorphic adenoma
Is the most common benign tumor, representing 70% of all benign
salivary gland tumors and approximately 80% of all parotid gland tumors.
Features:
It is encountered more in adults, more common with women. It is
unilateral, encapsulated and arises from ductal epithelium cells.
Imaging features:
b
243
Salivary glands
c
d
e
Fig. 10.10. Left parotid pleomorphic adenoma appears sialographically as a
radiolucent shape that causes a clouding defect of the posterior-lateral
portion of the gland a), b) ex. CT formation of poster-lateral portion of the
superficial lobe is round, smooth and with a moderate contrast grip c) - e).
Sialography:
the pleomorphic adenoma appears as an incomplete picture by
moving the channels in an uniform way, ball held in hand'' (Fig. 10.10.a,
b)
CT:
appears as a round mass, with net shape, homogeneous with a density
slightly higher than the rest of the glandular tissue, rarely appear
calcification with moderate contrast grip (fig.10.10 c, d, e)
MRI:
a hypersignal appears in T2, T1 hypo or izosignal with homogeneous
or heterogeneous contrast grip.
Scintigraphy:
the adenoma does not capture the isotope.
The differential diagnosis of pleomorphic adenoma is performed by:

Warthin tumor,
parotid adenoid cystic carcinoma,
parotid mucoepidermoid carcinoma.
10.3.6.2. Warthin tumor
Warthin tumor is a benign lesion, rare, multiple and bilateral.
Features:
It occurs more frequently in men in the lower lobe of the parotid gland.
244
Salivary glands
Imaging features:
CT, MRI
stands out as cystic or solid masses with nodular thickening of the
cyst wall with intermediate signal sequence in the sequence T1 and T2
hipersignal.
Scintigraphy
with Tc99m stands as a tumor, bilateral '' hot zone.
10.3.6.3. The hemangioma
This lesion is a common tumor found in children, mostly in the parotid
gland.
Imaging features:
Radiographic:
the lesion shows non homogeneous flebolits is opaque with
transparent center that determines the enlargement of the gland.
CT, MRI
shows a lesion well-defined as a neoformation, which is highly
hiperdense post contrast (fig.10.11) in izosignal T1 and T2 hypersignal
with multiple images "salt and pepper" because of its vascular structure.
Scyntiographic
with Tc99m is an hipoechogen area with hyperechogen zones due to
the flebolits.
a
b
Fig. 10.11. a) Hemolimfangiom left parotid, axial CT, native, with much
lowered tumor, izodens latero-cervical) and homogeneous contrast grip
that extends up to the lower transverse plan passing through the hyoid
bone b).
245
Salivary glands
10.3.6.4. Lipoma
This tumor of mesenchymal origin, is much more common with parotid
location.
Imaging features:
Ultrasound:
Easy highlights benign lesion and determine its character.
CT:
tumor shows low density (-80 HU), with a homogeneous structure
without contrast outlet and allow differentiation of malignant tumors.
10.4. Malignancy
Malignant tumors of the salivary glands are the most common
mucoepidermoid carcinomas, adenocarcinomas, adenoid cystic
carcinomas, acina cell carcinomas and squamous cell carcinoma.,
10.4.1. Mucoepidermoid carcinoma
Is the most common malignant salivary gland tumor arising from ductal
epithelium and representing 6% of all salivary gland tumors.
Features:
This tumor is common in women aged between 40 and 50. Usually the
lesion is a tissular mass, but may also be forms with cystic components. In
most cases it is a tumor with low or medium degree of malignancy.
Imaging features:
CT, MRI:
A rapid diagnosis of these malignancies requires:
achieving a pathology balance of both parotid lobes tumor,
highlighting reports of parotid tumor lesions with adjacent spaces and
salivary canal that may be damaged,
* highlighting the lesions affecting the facila nerve in the parotid
portion;
emphasizing latero-cervical adenopathies that may accompany tumor
lesions or tumor recurrences (fig.10.12).
246
Salivary glands
b
Fig. 10.12. Right parotid mucoepidermoid carcinoma developed with
extensive expansion in the superficial and deep zone ) with heterogeneous
contrast grip and tumor necrosis zones, HE staining (HE x100) b).
Other types of carcinomas arising in salivary glands have the following
characteristics:
1. carcinoma with acin cells, develops slowly, often in women
between 40 and 50 years old, bilateral in 3% of cases (fig.10.13)
2. adenocarcinoma, is slowly progressive, developed on a
pleomorphic adenoma (fig.10.14)
3. squamous cell carcinoma, is more rare but rapidly developing in
women older than 60,
4. adenoid cystic carcinoma with perineural spread slowly
progressive (fig.10.16).
a
b
c
Fig. 10.13. Acinar cell carcinoma. Axial CT highlighting heterogeneous
tumor surrounded by a capsule with contrast grip, located in the
superficial lobe of the left parotid gland.
247
Salivary glands
b
a
Fig. 10.14. Invasive adenocarcinoma developed on a right parotid
pleomorphic adenoma, post contrast axial CT bulky tumor with areas of
necrosis and moderate contrast grip, expanded in the space at the back of
the right retrocondilian prestilian buttonhole ) coloration HE (HE X220)
b).
Imaging features:
CT:
slow-growing tumors: well-defined masses, usually homogeneous,
with moderate contrast grip,
rapidly evolving tumors: large, imprecise edges with heterogeneous
contrast grip and areas of necrosis.
MRI:
heterogeneous mass in T1 and T2, with variable contrast grip (Fig.
10 17).
The differential diagnosis of carcinoma is made with:
salivary gland metastasis (fig.10.15)
metastasis in salivary glands (fig.10.16)
malignant pleomorphic adenoma (Fig. 10.17),
Warthin tumors
salivary gland lymphoma.
248
Salivary glands
a
b
Fig. 10.15. Right cilindrom recurrent in parotid pterigo-palatine fossa and
maxillary sinus, MRI a) Axial post contrast T1 FS
and axial T2 b).
249
Salivary glands
c
d
Fig. 10.16. Right parotid metastasis from a left palatine tonsil
carcinoma, axial CT native a)highlighting contrast grip of the primitive
tumor which has an extensive, vegetant aspect in the oropharingeal lumen
and the right parotid metastasis b) and also the presence of multiple
ganglionar metastasis c), with the same contrast grip, intense and
homogenous, located bilaterally jugulo gastric and submandible d).
250
Salivary glands
c
Fig. 10.17. Malignant left parotid adenoma with an evolution longer than
30 years, which was not operated after biopsy, and comes back after 5
years from the last biopsy, presenting a rapid growh in size and with a
compressive effect on the left latero-cervical vessels. The MRI
examination shows the tumor with areas of iso and hiposignal in a coronal
T2 SE sequence a), hiposignal in the native coronal T1 SE b) intense grip,
non homogeneous contrast in T1 coronal c), The anatomo pathology
examination establishes the magnizare of the old pleomorph adenoma.
251
Salivary glands
252
Chapter 11
IMAGING IN IMPLANTOLOGY
Edentulous or partially edentulous area reconstruction with implants,
which are base for different denture, began to be in recent years a
relatively common medical procedure.
It arises from a real subspecialization in dental medicine using
odontologic implatology as a dental surgery, as a method of rehabilitation
of edentulous areas. This method has been known for over 30 years due
Branemark's work, regarding the osseointegrating implants.
So, it is possible to create for partially or totally edentulous patients fixed
prosthesis consisting of:
an endosseous hopder (implant / implants) placed in the bone and
a superstructure (fixed denture itself).
11.1. Preimplantation balance
The achievement of the correct balance, essential for the success of the
implant in time, involves:
a correct clinical examination and
an appropriate imaging preimplantation balance, which are essential
monitorizing in time of the success or potential complications occurring
postimplant.
We have to monitorize in the balance preimplantation imaging:
the volumetric morphology of the region where the implant is carried
out;
cancellous bone structure;
periodontal component density, especially cortical bone support;
the relation to adjacent teeth and opposing teeth;
the state of the "critical structures" in the proximity: maxillary
sinuses, naso-palatine canal, nasal, inferior dental canal;
the presence of associated local diseases
TMJ condition.
qualitative analysis of alveolar bone:
bone density by evaluating cortices and spongy (trabecular
spaces);
quantitative analysis of bone likely to receive an implant:
horizontal size (vestibulo-lingual / palatal);
253
Imaging in implantology
vertical size, available bone height (distance between the

alveolar crest and "critical structure"),
the thickness of the bone cortices;
quantifying bone density (quantitative CT).
11.2. Radio-imaging methods
Radio-imaging methods commonly used in imaging the balance are:
periapical films;
orthopantomography;
computed tomography;
Cone beam CT.
11.2.1. Endobucale, periapical films
Using reference mandible images divided into 3 classes defined by
trabecular bone models is possible in evaluating trabecular bone structure
with high diagnostic accuracy (classification Lindh). You can use dental
radiographs obtained by different techniques:
periapical radiographs (retrodentoalveolar) are useful in identifying
the approximate topography surrounding anatomical structures and to
assess the relative parallelism of the edentulous area adjacent roots;
advantage: they are cheap and allow accurate qualitative assessment
of bone structure;
occlusal radiographs (bit film) can give information on the buccolingual thickness of the mandible alveolar edge;
* disadvantages: distorted image, only the width of the alveolar
process is shown.
We must remember that the measurement accuracy is reduced due to the
enhancement and inherent deformations on the endobucal films.
Fig. 11.1. Periapical radiography with 3 endosseous supports in the

mandible, without an obvious radiographic contact with the inferior
dental canal.
254
11.2.2. Orthopantomography
This method of exploration is usually used in the first instance for the
overall evaluation, the mesio-distal direction of the region of the desired
implant location.
a
Fig. 11.2. OPT preimplant a) performed with radiopaque markers in the
central area of the mandible and postimplant with endosseous implant.
Advantages:
to assess the residual bone volume;
the relationship with adjacent and antagonistic teeth;
radio-anatomical aspect of ATM;
evaluate the plan retraction of alveolar ridge;
relations with neighbouring critical structures: sinus, nasal, dental
channel.
Fig. 11.2.1. OPT realizat postimplant cu implantele endoosoase situate

mandibular median b).
255
Disadvantages:
provides a distortion and magnification of images (templates
radiopaque balls occlusion).
11.2.3. Computer tomography (CT)
This method of diagnosis is the most important imaging modality for
assessing preimplantologic evolution due to the precision, lack of
geometric deformations, high contrast images, multiplanar visualization
possibilities and use of special software imaging.
The new generation of devices can perform a full scan of the mandible and
/ or maxilla in seconds, with excellent spatial resolution and the ability to
provide very good spatial resolution both axial images and on the
reconstructed ones.
Axial sections processed with dedicated software are used for:
pre-operative evaluation of patients who are candidates for several
implants, the reconstruction of edentulous and rezorbed, ridge
2D and 3D image processing obtained with radiopaque markers;
establishing the treatment plan.
In order to reach this goal, a strict protocol should be achieved for the
region to be examined with a careful patient positioning. Images are
processed with special software, usually installed on CT, dedicated
graphics station or personal computer.
Preparation and patient positioning are essential to preserve symmetry and
perfect immobility that are vital for not having motion artifacts or artifacts
of image quality.
Advantages:
CT bone density allows the calculation of bone density based on
Hounsfield density and bone density classification: Misch, Lekholm and
Zarb.
Misch classification divides the types of bone in 5 classes:
D1> 1250 UH dense cortical bone,
D2 850-1250 UH thick or porous cortical bone at the alveolar ridge
and dense trabecular bone inside
D3 350-850 UH thin porous cortical bone at the alveolar ridge and
dense trabecular bone inside
D4 150-350 UH fine trabecular bone
D5 <150 UH immature, non-mineralized bone.
256
Lekholm and Zarb classification divides types of bone:

Type I = homogeneous compact bone,
Type II = thick compact bone with spongy dense trabecular with
good resistance
Type III = thin layer of cortical bone with a spongy trabecular
density, resistant,
Type IV = thin cortical and spongy low density.
CT images obtained can be shown as:
axial images are original images, which can be processed by
dedicated software and underlying conduct of the other types of images
(Fig. 11.3.)
panoramic images: result after computed processing of direct axial
images, which made sections in a plane full thickness panoramic dental
arches at the vestibular edge to the palatal / lingual. The physician draws
on the sections references starting from right to left, using some points
drawn midway of the cortex which merge into a curve (fig.11.3).
Dental CT Program suggests 2.7 curves (Fig. 11.4 - 11.5) from first,
considered as reference, which are parallel within 1 - 2 mm of each other
in the jaw or mandible, which were called "panoscans ".
a
b
Fig. 11.3. Axial images dotted line curve hand performed, passing
through the middle of the arcades, parallel to the cortical at jaw level a)
and the mandible b).
257
a
b
Fig. 11.4. Curves called "panoscans", passing through arches cortices,
parallel to the jaw cortical) and mandible b) allowing to get panoramic
images.
a
b
Fig. 11.5. Panoramic reconstruction (panoscans) post processing: the right
hemimaxilla a) and right lower jaw b) partial edentulous.
sectional images in different planes (coronal, sagittal, oblique, radial)
2D reconstructions bring the richest deal of information about bone
quality, implant size and angulation required when images are called
paraxial obtained by a perpendicular plan to the median line of the dental
arches (fig.11.6).
3D images that provide information on the position of radio-opaque
markers, remaining bone surfaces anatomy and teeth (fig.11.7).
These CT images can be shown to the implantologs in two ways:
printed on a solid support (radiological film);
computerized data base that can be processed with dedicated software
- specific: SimPlant (Columbia Scientific Inc., Edmonds, Washington,
USA); SurgiCaseTM (Materialise NV, Leuven, Belgium); coDiagnostiX
(IVS Solutions AG, Chemnitz, Germany ) ImPlacer (Pacific Coast
Software Inc., Los Angeles, California, USA).
258
d
c
Fig. 11.6. Dental CT paraxial reconstructions with actual measurements
of height, thickness and density of the maxillary edentulous ridge), c) and
mandible b), d).
259
c
d
Fig. 11.7. 3D reconstruction, a) "surface" with an analysis of the aspect,
or the external surface of the lower half of the face massif, shaded surface
display type SSD, b) MIP that highlights the shape of teeth, postoperative
appearance of the mandible and c) , d) volume renderings VRT that
allows in-depth analysis of a particular sector of tooth shape, the lateral
incisor lacking and the teeth fixed at the bracket level.
The dedicated programmes, although having high initial costs, offer

reconstructions panoscan type,, paraxial, 3D, with size measurement
capability on a screen, easurement of bone density, angle of interest and
ways of evaluating interactive images.
Disadvantages:
the patient is relatively low irradiated with the modern equipment
with spiral acquisition.
The calculated biological effect on patient causes a relatively low
irradiation:
CT: 20 to 100 mrem (0.200 to 1.00 mSv)
RDA: 2.5 to 6 mrem (0.025 to 0.06 mSv)
OPT: 0.6 to 1.2 mrem (0.006 to 0.012 mSv)
260
The risk of a fatal malignancy: is maximum to a young man

(1:20.000 cases) and a minimum in a woman of 65 (1:200.000 cases).
metal artifacts may occur due to metal-ceramic works, large amalgam
fillings can cause loss of detail in the occlusal plan, but usually does not
cause artifacts below the ridge. Titanium and titanium alloys usually do
not produce artifacts.
11.2.4. Cone beam CT (CBCT)
CBCT exploration represents about 40% of all investigations.
The exploration allows the investigation of edentulous ridge, analyzes the
quality and quantity of bone tissue, relations with neighboring structures,
the success of the implant, bone interface, successful integration and
charging status.
We may:
perform the resorbed mandible ridge analysis (fig.11.8)
the exploration is performed before restoring the bone crest in
anodonii (Fig. 11.9.a) and if bone reconstruction, we can plan the
reconstruction zone (Fig. 11.9.b);
the examination is used in maxillary sinus lifting plan or mandible
augmentation (fig.11.10);
Fig. 11.8. CBCT in a 2D reconstructed mandible, panoramic and allows

the analysis of resorbed mandible ridge in the edentulous zone.
261
a
b
Fig. 11.9. CBCT in the mandible a) panoramic reconstruction with
marker at the upper limit of the dental canal, b) CBCT in maxillary with
transverse oblique sections on the partial edentulous arch (document QR)
Fig. 11.10. CBCT in the mandible reconstructed in a panoramic way

which highlights the reduced partial edentation in the right mandible
region.
3D reconstructions view in a three-dimensional way the explored
volume. (fig.11.11).
262
Fig. 11.11. CBCT with 3D reconstruction of the edentulous area.

Together with these techniques frequently used in preimplantation
diagnosis, other diagnostic methods may be used, too: teleradiography,
lateral cephalometric, classical plan tomography, Scanora technique,
magnetic resonance imaging (MRI).
11.2.5. Teleradiography
It is a radiographic technique that allows us to evaluate:
the height of the available bone;
the height of the alveolar process;
advantage: does not deform and does not enlarge the images.
disadvantages: can only be used for molar-premolar region.
11.2.6. Classical flat tomography
Allows us to assess:
cortical bone;
spongy bone mineralization;
bone texture;
height and transverse diameters;
Advantage it is without overlapping bone;
Disadvantages: significant irradiation, analysis of a limited area.
11.2.7. Scanora technique
It is a technique that combines multi radiography principle through the
slot with spiral CT.
advantages:
263
great panoramic images;

radial tomographies of maxillofacial structures;
brings more diagnostic information than intraoral radiographs or
OPT;
maximum efficiency: 1-6 implantation sites;
acquisition and operating costs, irradiation (vs. CT).
disadvantages:
* maxillary and mandible CT images may be difficult to interpret,
involving a skilled radio- physician;
o cost (vs. RDA, OPT).
b
a
Fig. 11.12. Positron Scanora system) device to explore,
b) sagittal sections from previous dental ridge, Edentia.
11.2.8. Magnetic resonance imaging (MRI)
It is rarely used, average field MRI exam (1-1, 5 T) and low field (0.4
to 0.5 T) which identifies, precisely:
inferior vasculo- alveolar nerve package;
the bottom edge of the maxillary sinus;
bone structure of interest (cortical spongy);
any associated pathology.
Disadvantages: the price and availability data and artifacts of
ferromagnetic materials.
11.3. Radio-imaging examination within the implant algorithm
A radio-imaging exam stages include:
diagnostic phase,
preimplantation stage (partially overlapping diagnostic phase),
intraoperative examination,
post-implantation exam.
264
11.3.1. The diagnostic phase

The examination success depends on the patient's general and local
condition, and therefore requires a thorough clinical examination to
eliminate the conditions that may affect a short or long-term prognosis of
implant.
The radio imaging examination can cause local contraindications:
root debris in alveolar bone thickness;
*some local inflammatory processes;
deficient bone bed quality.
The investigations include: OPT, intraoral radiography, tomography
provide additional data, and computed tomography Scanora technique.
11.3.2. The preimplantation stage
Radio-imaging examination should provide answers:
where to locate each implant;
how thick and long will each implant be(fig.11.13);
what is the angle of insertion;
if bone quality is sufficient (eg. Density);
which is the best prosthetic system;
what is the topography of critical anatomical structures.
Fig. 11.13. Oblique cross section in the jaw with measurements in the
anterior area. Measurements show the possibility of achieving an implant
having a bone bed with a vertical size of 18.6 mm, diameter of 9.4 mm
cervical and apical diameter of 7.8 mm (imag.24) but with fine trabeculae,
with an average density of 350 HU (imag.23), type D3 Misch
classification.
All these questions can be answered by a
programme that can analyze:
265
CT and with CT Dental
the volumetric morphology of the region where the implant is made,

including bone edges, submandibular fossa, types of development, postextraction irregularities;
spongy bone structure and density of periodontal components,
especially the cortical bone support (fig.11.14);
b
Fig. 11.14. Paraxial reconstruction of the mandible) which shows a dense
cortical with trabecular bone density and fine 1628HU inside, with an
average density of 374 HU, or jaw b) a dense cortical trabecular bone but
a fine, very low density of 165 HU.
Relationship with the adjacent and opposing teeth;
The "critical structures" proximity (maxillary sinuses, nazopalatin
canal, nasal passages, inferior dental canal, the mentonier hole)
The presence of any associated local condition.
It can make a qualitative analysis of bone density measuring alveolar bone
cortices, the spongy (trabecular spaces) and a quantitative analysis of the
bone likely to receive an implant, measuring:
horizontal size - cortical thickness (vestibulo-lingual/palatinal)
266
vertical size, the height of the available bone (distance between the
alveolar bone crest and a "critical structure");
bone density (quantitative computed tomography).
The basic rule used in implantology is "to create a model with the desired
results and then determine how this model can be achieved". The position
is determined by placing implants in the edentulous parts of a radiopaque
guide plate, which can be:
small radiopaque markers at the level of mouth bracket, showing the
position of each meziodistal implant suggested;
external surface of the guide plate can be brushed with a radiopaque
substance (barium sulphate thin paste);
free air spaces can be used as markers of edentulous areas.
The guide plate can be performed automatically by the process called
stereolithography, which can generate a physical model of computer data
by strengthening acrylic resin liquid under the action of a laser beam
guided by computer.
CT use in dental implantology, the interactive planning software and
surgical guide plates may help reduce the duration of surgery, can improve
the aesthetic result and may contribute to a favorable prognosis of the
implant.
11.3.3. Intraoperative phase
Checking intraoperative placement of implants can be made:
retrodentoalveolar dental X-rays, CT and a computerized control system
according implantation Dental CT images;
This system called IGI - "Image Guided Implantology" allows:
loading the patients database into a computer;
analysing of these images;
planning the surgical treatment
its compliance with real-time guidance of implantation.
The surgeon is helped to achieve a correct implantation by charging the
computer system drill movements and comparing these with the preprogrammed movements.
11.3.4. Post-implantation control
Can be done immediately aiming to see:
topography of the implant;
any early complication (incorrect positioning, fractures);
267
As radiological techniques, there can be used: intraoral radiographs, OPT,

CT;
The remote control analyzes:
skeletal appearance, absence / presence of lizereu flou, smooth and
healthy appearance of peripheral bone, the implant axis, integrity;
can assess post-implantation complications;
Radiographic techniques: RDA radiographs, or CT OPT. are preffered.
11.3.5. Complications after implant
infection / inflammation (fig.11.5);
overload or rejection,
breaking / bending of the implant
incorrect positioning.
Infection / inflammation
The most common implant infections are caused by:
Bacterial invasion in the proximity;
Fig. 11. 15. Suprainfection of the maxilar comblaj material from an

infection in the proximity of the left lateral incisive apex, visible at the
level of right maxilla anterior cortex.
acceleration of peri-implant bone resorption;
suprainfection comblaj material from the maxillary sinus.
Implant rejection can occur through:
activation of immune defense mechanisms of the body;
the deficiency of the healing mechanisms;
an osseointegration deficiency;
The radiographic highlighting is done by CT examination, which exhibits
the axial and coronal sections, coronar reconstructions, sagittal or
panoramic, peri implant bone resorption and possibly implant
displacement.
268
The overuse and the non-axial tension of the implants and the too reduced
number of implants for the existing superstructure may cause microfractures.
Progressive radiographic bone resorption occurs at the implant package.
Breaking / bending of the implant
They can appear in bruxism or in case of fracture.
Radiographic bone continuity solution is (+ / - cortical) of interest in:
nasal floor;
maxillary antrum floor;
mandible canal.
Incorrect positioning
It is explored relatively fast postimplant, looking for, by CT:
implant position in relation to: nasal passages, maxillary sinus or
mandible canal.
We believe that:
the permanent development of implant dentistry requires radioimaging exploration in the preimplantation phase, phase of the
implantation and post-implantation to assess possible complications.
We must be attentive to patient irradiation, which requires a useful
collaboration between implant and radiologist.
Dental CT reconstruction programme is simple, easy to perform and
provides information that substantially increase the quality and reliability
during the implant.
Cone Beam CT - is a less irradiant examination, fast and useful capturing
quality information regarding the sites of implantation.
269
270
REFERENCES
1. JJ Abrams, Kalyanpur A. Dental implants and dental CT software
programs. Semin Ultrasound CT MR. 1995, 16:468-486.
2. kesson L, Rohlin M., J. Marginal bone in periodontal Hakkansson
disease: an evaluation of image quality in panoramic and intra-oral
radiography. Dentomaxillofac Radiola. 1989 14:1053-1055.
3. American Academy of Oral and Maxillofacial Radiology. Radiology
Practice Committee. Updated quality assurance self-assessment exercise in
intraoral and panoramic radiography. Oral Surg Oral Med Oral Pathol.
2000, 89: 369-374.
4. Barnes L., Eveson JW, Reichart P, Sidransky D. Pathology and
Genetics of Head and Neck Tumours, IARC Press, Lyon, 2005.
5. Cavzian R., Pasquet G. Techniques of radiology DENTAIRE. Editions
Techniques. Encyclia Med Chir. Paris. Squelette radiology normal. 1992,
30 850 A10 18.
6. Cavzian R., G. Pasquet, Thibierge M., EA Cabanais Justice et imaging
en odontostomatology. The medical responsibility to DENTAIRE
maxillofacial radiology. Currently Odonto-stoma. 1993, 182:291-311.
7. Cavzian R., G. Pasquet, G. Bell, G. Imagery dental Baller maxillaire.
2nd ed. Paris: Masson, 2001.
8. Dermaut LR, A. Apical root resorption Demnuck on upper incisors
caused an by intrusive tooth movement: a study Radiology. Am J Orthod
Dentofac Orthop. 1986, 90:321-326.
9. Doyon D., Pajoni D., Idir ABC, Jouan E., R. Carlier, Savana S., dental
Imagery maxillaire, Masson, Paris, 1995.
10. Farman AG, Nortj CJ, Wood RE, Oral and maxillofacial Diagnostic
Imaging, Mosby, St. Louis, 1993.
11. Goaz P.W., White SC. Oral radiology. St. Louis: Mosby, 1987.
12. Gorlin RJ, Nevoid basal cell carcinoma syndrome. Deerm Clin. 1995,
13:1.
13. D. Haba, techniques commonly used in dental radiology, Ed Junimea,
Iasi, 2005.
14. D. Haba, CT and MRI Radioanatomia deep regions of the face.
Practical guide, Ed Junimea, Iasi, 2005.
15. J.I. Haring, Howerton L.J., Dental radiography. Prinicples and
Techniques, 3rd Edition, Saunders Elsevier, St. Louis, 2006.
271
16. Isberg A., Stenstrom B., Iscacsson G., Frequency of bilateral

temporomandibular joint disc displacement in Patients with unilateral
SYMPTOMS: A 5 - year follow-up of the asymptomatic joint. A clinical
study and arthrotomographic. Dentomaxillofac Radiola. 1991, 20:73-76.
17. Lacan A., Nouvelle Imagery DENTAIRE. Scanner - Dentascan - MRI
CDP Editions, Paris, 1992.
18. RP Langlais, OE Langland, CJ Nortje, Diagnostic imaging of the jaws.
Baltimoure: Williams and Wilkins, 1995.
19. Laudenbach P., E. Bonneau, G. Korach et maxillofacial radiographic
panoramique DENTAIRE. Paris: Masson, 1977.
20. Lopez AJ, Cavzian R., MT Iba-Zizen, Imagery often seem resonance
magntique temporomandibularies articulations. Currently OdontoStomatol 1993, 182:291-311
21. Mafee MF, Valvassori GE, Becker M. Imaging of the Head and Neck,
2nd Edition, Thieme, Stuttgart, 2005, 353-725.
22. Duverneuil N. Martin, J. Chiras, maxillofacial Imagery. Paris:
Medicine-Sciences Flammarion, 1997.
23. Musgrove BT, Moody GH. Synovial chondromatosis of the
temporomandibular joint. Int J Oral Maxillofac Surg. 1991, 20:93.
24. Tal H, Moses O., A comparison of panoramic radiography with
computed tomography in the planning of implant surgery.
Dentomaxillofac Radiola. 1991, 20:40-42.
25. Third Thu Escudos B., Cavzian R., G. Pasquet, L'en coupes en
implant imaging: CT scans logiciel avec spcifique. Actualits OdontoStomatol. 1993, 181:73-89.
26. Tasaka MM, Westesson PL, temporomandibular joint Accuracy
diagnosis with MR imaging sagittal and corono. Radiology 1993,
186:701-707.
27. R.I. Webber, The future of dental imaging. Where do we go from
here? Dentomaxillofac Radiola. 1999, 46:9-29.
28. White SC, Pharaoah M.J., eds. Oral Radiology: Principles and
Interpretation. 4th edition St. Louis: Mosby. 1999:622-635.
29. Whaites E., Essentials of Dental radiography and Radiology, 3rd
Edition, Churchill Livingstone, Edinburgh, 2002.
30. Zilkha A. Computed tomography in facial trauma. Radiology. 1982,
144:545-548.
272

Carte

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Carte

Enviado por

Direitos autorais:

Formatos disponíveis

DANISIA HABA

Gr T. Popa" Publishing House, U.M.F. IAI

Description CIP National Library

"Gr T. Popa" Publishing House

6. MAXILLO FACIAL BENIGN TUMOR ...................................... 135

This paper is aimed to be studied by students of dental faculties,

DEVELOPMENTAL ANOMALIES OF THE TEETH

Developmental anomalies of the teeth and maxillo-facial developmental

In temporary dentition the milk premolars and molars are replaced by

Dental decay and its complications

These abnormalities can be diagnosed by imaging periapical dental

Fig. 1.1. Anodonta the upper and lower lateral incisors.

Developmental anomalies of the teeth and maxillo-facial developmental

Fig. 1.2. Anodonta located in the lower central incisors.

Fig. 1.3. Anodonta located in both two lower premolars.

Dental decay and its complications

Total anodonta or absence of all teeth is exceptionally met in common

Developmental anomalies of the teeth and maxillo-facial developmental

Dental decay and its complications

Developmental anomalies of the teeth and maxillo-facial developmental

In the chest radiography: clavicle hypoplasia is found, that means it

Dental decay and its complications

Fig. 1.12. OPT in a patient of 17 years, 13 included in the mesio-coronal

Developmental anomalies of the teeth and maxillo-facial developmental

Genetic factors - complex malformation syndromes: cleido-cranial

Ectopia - represents the remaining of the fully developed teeth being at a

Dental decay and its complications

Transposition - is a special form of ectopic eruption of a tooth in the

Fig. 1.15. Transposition between 23 and 22, persistence 63. O.P.T.

Developmental anomalies of the teeth and maxillo-facial developmental

1.2.1.3. Abnormalities of size

Dental decay and its complications

o In total merger, the absence of a tooth or a tooth more voluminous

Developmental anomalies of the teeth and maxillo-facial developmental

Dental decay and its complications

Fig. 1.22. Taurodontism 16 and 46. OPT.

Developmental anomalies of the teeth and maxillo-facial developmental

*Apical resection is a surgery that implies the resection of the apical

Dental decay and its complications

Developmental anomalies of the teeth and maxillo-facial developmental

enamel hypoplasia or hereditary brown hypoplasia manifests as a

The imperfect dentinogenesis is a genetic abnormality that interests

Dental decay and its complications

Developmental anomalies of the teeth and maxillo-facial developmental

Dental decay and its complications

Fig. 1.30. Cherubism in a child of 10 years OPT shows multiple

Developmental anomalies of the teeth and maxillo-facial developmental

Dental decay and its complications

Fig. 1.33. Cleido-cranial dysplasia, frontal incidence x-ray to "rocks in

Developmental anomalies of the teeth and maxillo-facial developmental

Dental decay and its complications

Fig. 1.37. Mandibulo-facial disostosis

Developmental anomalies of the teeth and maxillo-facial developmental

DENTAL DECAY AND ITS COMPLICATIONS

Dental decay and its complications

Dental decay radiographically appears as radiolucent, excavated from the

Fig. 2.1. Schematic representation of the radiographic aspect of

Dental decay and its complications

2.1. Interproximal caries

Dental decay and its complications

Dental decay and its complications

Dental decay and its complications

2.3. Caries on buccal and lingual surfaces

Dental decay and its complications