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牙科放射線學 (2)

牙科放射線學 (2). Radiological Interpretation of Maxillofacial Lesions. 顎顏面放射線影像判讀. 陳玉昆教授 : 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw. 學 習 目 標. 本課程會讓你們瞭解 :. 1. 如何判讀顎顏面放射線影像. 2. 如何書寫顎顏面放射線影像報告. References.

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牙科放射線學 (2)

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  1. 牙科放射線學(2) Radiological Interpretation of MaxillofacialLesions 顎顏面放射線影像判讀 陳玉昆教授: 高雄醫學大學 口腔病理科 07-3121101~2755 yukkwa@kmu.edu.tw

  2. 學 習 目 標 本課程會讓你們瞭解 : 1.如何判讀顎顏面放射線影像 2.如何書寫顎顏面放射線影像報告 References 1. Eric Whaites: Essentials of dental radiography & radiology 3rd edition, Chapter 1, 18, 24 p. 3-12; p. 211-215, p. 285-289 2. http//ddmfr.net 3. www.dent.ucla.edu/sod/depts/oral_rad/courses/DS422b/ 4. Farman AG et al. A sequential approach to radiological interpretation. Dent Maxillofac Radiol 2002;31:291-298 5.Galal Omami. Twenty classic signs in oral and maxillofacial radiology. Oral Radiol 2019;35:3-10 6. Eda Didem Yalcin et al. Evaluation of radiomorphometric indices and bone findings on panoramic images in patients with scleroderma. Oral Surg Oral Med Oral Pathol Oral Radiol 2019;127:e23-e30 7. www.vbgov.com/ 8. https://www.facebook.com/CookieBiteHearingLoss/ 9. Dinkar AD, et al. Primary tubuerculous osteomyelitis of the mandible: a case report. Dentomaxillofac Radiol 2008;37:415-20 10. www.santafixie.com/en/navigate-tri-spoke-front-wheel-white.html# 11. www.metaloffcuts.co.uk/product/beaten-copper-sheet/ 12. www.semanticscholar.org/paper/Odontogenic-myxoma 13. purepng.com/photo/23570/clipart-tennis-racket 14. www.cloudykitchen.com/blog/mini-cinnamon-sugar-brioche-doughnuts 15. www.featurepics.com/online/Honeycomb-Texture-2732858.aspx 16. https://www.shutterstock.com/zh-Hant/image-photo/hangung-sausages-on-white-background-580161490

  3. 牙 四 Dental Radiology--- Interpretation 牙 三 Dental Radiography--- Techniques Radiography is the photographically recording of images of the teeth and surrounding structures with use of x-ray: Can be done by hygienists and assistants Radiology is the use of radiant energy (x-ray) in the diagnosis and treatment of disease: Only dentist can practice radiology as it involves diagnosis and treatment

  4. 接 受 7 項 評 核 • 期中考 • 期末考 • Seminar • 隨堂小考 • 出席率 • 文獻收集 • 小報告 (optional) 6-1.於網路下載玉昆老師上課時指定、印出及指出資料之位置，交予學藝。 6-2. 學藝按照點名單順序列冊登記， 分別於期中與期末考週前一週給老師。 7-1.課本為主或網路資料與玉昆老師上課主題有關、以上課沒有提到之內容為限。 7-2.口病網頁首頁下載reportform，email給老師，認定者每次於期末考加1分，上 限5分。

  5. PA (Postero-Anterior) view PA view Different images Lateral view Similar images Mass of head in a different position & different shape What kind of x-rayradiography may be taken without taken two different images? Ans.: Computed tomography (CT) (CT) or cone beam CT Ref. 1

  6. Site Size • Measuring the dimensions in cm • Describing boundaries (the lesion extends from…..to…..in one dimension and extends from…..to……in the other dimension) SSSORE Site (Location) Size Shape Outline (Border) Relative density Effects on adjacent surrounding structures Ref. 1

  7. Shape • Monolocular/unilocular • Multilocular • Pseudoloculated • Round • Oval • Scalloped/undulating • Irregular Monolocuar Pseudolocuar (貝殼狀、扇型) Multilocuar Ref. 1

  8. Outline *Well-defined • Smooth • Punched-out • Corticated: a thick or thin surrounding RO line • Sclerotic: a non-uniform RO boundary • Oval • Encapsulated • Irregular Well-defined with a corticated margin Well-defined withoutcorticatedmargin Poorly (ill)-defined * Poorly (ill)-defined Ref. 1

  9. Effects on adjacent surrounding structures Relative density • Uniformly RL • RL with RO (mixed) • RO • Bony expansion 2. Downward displacement ofinferior alveolar canal 3. Thinning of cortex • Tooth displacement Ref. 1

  10. Principles of description of bony lesions affecting the jaws- more information (1) Ref. 2

  11. Principles of description of bony lesions affecting the jaws - more information (2) 1. Site (location) and size of the lesion 2. Shape of the lesion

  12. Principles of description of bony lesions affecting the jaws - more information (3) 3. Border (outline) of the lesion 4. Relative radiodensity & internal structure of the lesion 3. Borders of the lesion

  13. Principles of description of bony lesions affecting the jaws - more information (4) 5. Effects on surrounding bone 6. Effects on the bony cortex

  14. Principles of description of bony lesions affecting the jaws - more information (5) 7. Effects on adjacent teeth 8. Periosteal reaction(骨膜反應) The relation of the lesion to possible periosteal reaction (lamellar*, sunburst*, onion skin*, hair-on-end*). *文獻收集 (Ref:6-1;6-2)

  15. *文獻收集 (Ref:6-1;6-2) Twentyclassic signs in oral & maxillofacial radiology (1) Ameloblastoma of the left mandibular body. Panoramic viewof the lesion shows multilocular radiolucency of numerous small compartments (“honeycomb” pattern) Ref. 5,15

  16. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (2) Cherubism. Panoramic image shows bilateral, multilocular “soap bubble” lesions and significant jaw expansion. The internal structure is indistinguishable from a central giant cell granuloma Ref. 5

  17. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (3) Osteosarcoma of the mandible. Cross-sectional cone-beam computed tomography (CBCT) image shows an exuberant periosteal reaction with a “sunburst” pattern Ref. 5

  18. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (4) Osteosarcoma of the mandible. Note the increased bone density and irregular widening of the periodontal ligament spaces of the teeth of the left mandibular body (Garrington’s sign). Also, note the “spiking resorption” of the mesial root of the first molar Ref. 5

  19. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (5) Rheumatoid arthritis presented with temporomandibular joint (TMJ) pain and stiffness. Coronal CBCT image of the TMJ shows small remnants of the condylar heads after severe erosion, resulting in a “sharpened pencil” appearance of the condyle Ref. 5

  20. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (6) Sagittal CBCT image shows “tram-track” calcification of the facial artery (arrow) Ref. 5

  21. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (7) CBCT sialogram of the submandibular gland shows a negative filling defect in the proximal portion of Wharton’s duct (arrow). The defect suggests a minimally calcified sialolith (mucus plug). The “sausage-string” appearance of the main duct is typical of sialodochitis (管道炎) Ref. 5,16

  22. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (8) Waters view shows the “hanging drop” sign of the orbital floor blowout fracture with herniation of soft tissue into the maxillary sinus (arrow). An air-fluid level is visible in the maxillary sinus (arrowhead) (黑-白) Ref. 5

  23. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (9) Axial CBCT image of fibrous dysplasia shows an expansile lesion of the right mandible with the typical “ground-glass” appearance Ref. 5

  24. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (10) Langerhans cell histiocytosis. Lateral skull projection shows a well-defined, “punched-out” lesion in the parietal bone (arrow). In advanced cases, multiple lesions may enlarge and coalesce to form “maplike” areas referred to as “geographic skull” Ref. 5

  25. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (11) Florid cemento-osseous dysplasia. CBCT-generated panoramic image shows multiple, bilateral, mixed radiopaque-radiolucent lesions in the mandible. The epicenter of all lesions is above the inferior alveolar canal. The internal radiopacity displays “cotton-wool” sclerosis Ref. 5

  26. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (12) Panoramic image shows the typical “moth-eaten” pattern of bone destruction, areas of rarefaction, sequestrum formation, and a periosteal reaction at the inferior border of the mandible (arrow) Ref. 5

  27. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (13) Panoramic radiograph of the right second molar teeth “floating in air” because of periodontitis. Note the reactive sclerosis surrounding the periodontal defect and the generalized marginal bone loss and calculus Ref. 5

  28. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (14) Periapical radiograph of the maxillary premolars. The root tip of the first premolar root is dilacerated in the buccolingual direction so tits long axis lies along the path of the X-ray beam. Note the “bull’s eye” appearance produced by the root canal, root tip, and periodontal ligament space (arrow) Ref. 5

  29. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (15) Mandibular occlusal image shows TB osteomyelitis or Garries osteomyelitis (periosteal reaction) Mandibular occlusal image shows a calcified sialolith in Wharton’s duct. Note the position and the hint at a laminated “onionskin” internal pattern Ref. 5,9

  30. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (16) Panoramic image shows a “cookie-bite” pattern of bone destruction in the right mandible, a wide zone of transition with permeative changes within it, and lack of sclerosis at the margin Ref. 5, 8

  31. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (17) Hemangioma of the right mandible. Panoramic radiograph shows the lesion with coarse trabeculae radiating from a common center in a manner roughly resembling the spokes of a wheel. Dark spaces between trabeculae are blood cavities Ref. 5, 10

  32. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (18) Osteoma cutis. Bitewing image shows faint doughnut-shaped radiopacities in the cheek (甜甜圈) Ref. 5,14

  33. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (19) Lateral cephalometric view shows convolutional markings (“beaten-copper” appearance) in a patient without a known history of craniosynostosis Ref. 5,11

  34. *文獻收集 (Ref:6-1;6-2) Twenty classic signs in oral & maxillofacial radiology (20) Panoramic radiograph shows bilateral flattening osteophyte formation at the anterior aspect of the condyles giving a “bird’s beak” appearance Ref. 5

  35. *文獻收集 (Ref:6-1;6-2) Further classic signs in oral & maxillofacial radiology (21) Panoramic view of scleroderma shows that resorption of the bilateral angulus mandible produces an image similar to a typical “whale’s tail” Ref. 6, 7

  36. *文獻收集 (Ref:6-1;6-2) Further classic signs in oral & maxillofacial radiology (22) Periapical radiographs view of odontogenic myxoma with multilocular radiolucency of “tennis racket” appearance Ref. 12,13

  37. Question: Please describe the lesion as indicated by yellowish arrow Site Size Shape Outline Relative density Effect on adjacent structure 背! 背!背! Downward displacement There is a well-defined unilocular round shaped circumcoronal radiolucency with a corticated margin over the submerged tooth 38 extending from left retromolar area down to the mandibular angle and from distal aspect of tooth 37 up to two-third of left ramus area, measuring approximately 3  5 cm in diameter. Ref. 3

  38. More descriptions on: 1. Effect on adjacent structure 2. Development of submerged tooth There is a well-defined unilocular round shaped circumcoronal radiolucency with a corticated margin over the well-developed submerged tooth 38 (pushed downward to the inferior cortex) extending from left retromolar area down to the mandibular angle and from distal aspect of tooth 37 up to two-third of the left ramus area, measuring approximately 3  5 cm in diameter. Downward displacement of left inferior alveolar canal and thinning of the left external oblique ridge are also noted Ref. 3

  39. More examples: Ref.: oralpathol.dlearn.kmu.edu.tw

  40. Summaries 完成本課程會瞭解以下的重點 : 1. 顎顏面放射線影像之判讀 2. 書寫顎顏面放射線影像報告

  41. THANKS FOR ATTENTION 高醫學校網站

  42. A sequential approach to radiological interpretation Panoramic radiography revealed the patient to be fully edentulous. All bony outlines were within the normal range except for a 4.5 x 3.0 cm well-demarcated, unilocular homogeneous radiolucency with smooth well-corticated outline in the left body of the mandible. The lesion extended from the premolar region back to 1.5 cm anterior to the posterior margin of the mandibular ramus. There was slight expansion of the cortical outline of the lower border in the left antigonial notch region. Ref. 4

  43. A sequential approach to radiological interpretation The adjacent mandibular canal was inferiorly displaced. Canal cortical outlines were intact with no evidence of resorption and the paranasal sinuses were clear. A root fragment was noted in the region of the radiolucency in the left mandible, and there were several areas of the well- delineated radiolucency in the left mandible was that of a benign cyst or tumor. Ref. 4

  44. A sequential approach to radiological interpretation Panoramic radiography also revealed a well-delineated radiolucency rimmed by an ovoid 3.5 x 2.5 cm calcified margin, superimposed over the left mandibular ramus. The radiographic shadow of the calcified soft tissue lesion extended superiorly to the level of the mandibular sigmoid notch and 1.5 cm below the head of the left mandibular condyle, and inferiorly to 1 cm below the left mandibular foramen and lingula Ref. 4

  45. A sequential approach to radiological interpretation The principal differential interpretations were carotid aneurysm and calcified lymph node. Although carotid bruit was not clinically detected, the risk of a carotid aneurysm mandated prompt investigation of this radiographic finding. To elucidate further the position of this calcified soft-tissue lesion and the boundaries of the mandibular radiolucency, an axial CT examination was performed. Ref. 4

  46. Axial CT Axial CT Maxilla 1st cervical vertebra A sequential approach to radiological interpretation The CT confirmed the presence of the calcified-rimmed soft tissue ventral and lateral of the first cervical vertebral body and skull base. This was interpreted as compatible with aneurysm or psedoaneurysmal dilation of the internal carotid artery, measuring as large as 2.4 cm. Degenerative changes in the cervical spine were noted. Ref. 4

  47. AxialCT Axial CT Mandible, upper portion Mandible, lower portion A sequential approach to radiological interpretation Lower CT slices through the body of the mandible confirmed the homogeneously radiolucent cystic lesion with a benign appearance. There was evidence of buccal and lingual cortical expansion with attenuation. In view of the report of a probable carotid aneurysm, CT angiography was prescribed to relate this lesion to its surrounding structures. Ref. 4

  48. A sequential approach to radiological interpretation CT angiography revealed the calcified mass was intimately related to tortuous internal and external carotid arteries. Careful reformatting at various angulations failed to demonstrate a direct continuity between the internal carotid and the presumed aneurysm; however due to structural superimposition CT failed to provide a definite answer. MRIwas selected to elucidate further structures obscured in the CT angiograms. Ref. 4

  49. A sequential approach to radiological interpretation MRI revealed bright signals for the carotid artery and jugular veins bilaterally, but failed to demonstrate an aneurysm. The contents of the lesion in the left mandibular body had intermediate signal intensity Ref. 4

  50. A sequential approach to radiological interpretation Angio MaxIP MRI revealed the carotids were found to be tortuous. There was no evidence of an aneurysm of the left internal carotid artiery. The surgeon wanted additional verification of the absence of a carotid aneurysm and ordered ultrasonography. Ref. 4

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