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IMAGING CONTRIBUTION IN THE DIAGNOSIS OF MAXILLOMANDIBULAR LESIONS. A NEFFATI, K BOUZAÏDI, I KECHAOU, K AYACHI*, F JABNOUN, M MAAMOURI * Radiology service, MT Maamouri Hospital, Nabeul , Tunisia *ORL service, MT Maamouri Hospital, Nabeul , Tunisia . HEAD AND NECK : HN 6. INTRODUCTION.
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IMAGING CONTRIBUTION IN THE DIAGNOSIS OF MAXILLOMANDIBULAR LESIONS A NEFFATI, K BOUZAÏDI, I KECHAOU, K AYACHI*, F JABNOUN, M MAAMOURI * Radiology service, MT Maamouri Hospital, Nabeul, Tunisia *ORL service, MT Maamouri Hospital, Nabeul, Tunisia HEAD AND NECK : HN 6
INTRODUCTION • There are a variety of cysts and tumors that affect the osseous marrow and cortex of the jaw bones, which may be uniquely derived from the tissues of developing teeth. • It is important as a radiologist to know the different types of maxillo-mandibular lesions, their semiological presentation, and to guide the otolaryngologist before any treatment.
SUBJECTS AND METHODS • Study of radio-clinical cases of 6 patients • 4 men and 2 women with an average age of 37.6 years ranging from 18 to 58 years. • The clinical call signs were bone pain, tooth mobility and maxillomandibulartumefaction. • All patients were investigated by means of: - Dental Panoramic X-Ray - Facial CT scan • Pathologically confirmed by surgery or biopsy.
RESULTS • The Dental Panoramic X-Ray shows a radiolucent lesion located in - The maxilla (1case) - The mandible (5 cases) • The CT scan shows these osteolytic lesions and specify their anatomical relationship with adjacent structures. • Histological examination identified: - Radicular cyst (4 cases) - Ameloblastoma(1 case) - Mandibularbone localization of Langerhans cell histiocytosis (LCH) (1 case).
MK, 20 years CT scan shows Multilocular radiolucent lesion with undefinedborders of the maxilla. Ameloblastoma
BM, 54 years • Panoramic radiograph shows large, unilocular, expansilelesionon left molar region of mandible. • Root of third molar Is partly absorbed.
MK, 20 years CT shows samelesionwithroot resorption and thinned cortex. Pathologically, radicularcystwasproven.
AH, 18 years periapicalradiolucency on right molar region of mandible . Radicular Cyst
Patient known to have a LCH. Panoramic radiograph shows large, unilocular, expansilelesion of the mandible. Biopsy: Bone localization of Langerhans cell histiocytosis.
Radicular (Periapical) Cyst • The most common odontogenic cyst (65%) • It is thought to arise from the epithelial cell rests of Malassez in response to inflammation. • In fact, practically all radicular cysts originate in preexisting periapicalgranulomas. • Clinic: The cyst is painless when sterile and painful when infected. • Microscopically, the cyst is described with a connective tissue wall that may vary in thickness, a stratified squamous epithelium lining, and foci of chronic inflammatory cells within the lumen.
Radicular (Periapical) Cyst • Radiographic findings consist of a pulpless, nonvital tooth that has a small well-defined periapicalradiolucency at its apex. • Large cysts may involve a complete quadrant with some of the teeth occasionally mobile and some of the pulps nonvital. • Root resorption may be seen. • Treatment is extraction of the affected tooth and its periapical soft tissue or root canal if the tooth can be preserved.
Ameloblastoma • The most common odontogenic tumor. • Young adults withoutsexpredilection. • Originatesfromepithelialremnants of dental embryogenesis, without the participation of the odontogenicectomesenchyme. • It is a benign but locally invasive neoplasm.
Ameloblastoma • Three different clinicopathologic subtypes: multicystic (86%), unicystic (13%) and peripheral (extraosseus – 1%). • It is characterized by a progressive growth rate and, when untreated, may reach enormous proportions. • Early symptoms are often absent, but late symptoms may include a painless swelling, loose teeth, malocclusion, or nasal obstruction.
Ameloblastoma • Any location in the mandible or maxilla, but the regions of the inferior molars and mandibularramus are the most prevalent anatomical locations (80%). • The most common radiographic findings are unilocular and multilocular masses, septation, association with unerupted teeth, loss of lamina duraand rootresorption. • In solid or multicysticameloblastomas, a multilocularradiolucentlesionwithundefined borders is the most characteristic radiographic aspect (soap bubble or honeycomb appearance).
Ameloblastoma • In the unicystic type, the lesions usually appear as radiolucent areas with relatively well-defined borders that surround the crown of an impacted inferior third molar, resembling a dentigerous cyst. • In addition to theseosteolytic lesions, CT scan shows the loco-regional extension and their content: • Cystic type with liquid content, often voluminous, thick walled, enhanced after contrast injection. • Furthermore, it can be associated to a tissue formation.
Langerhan’s cell histiocytosis • Langerhan’s cell histiocytosis is defined as an abnormal proliferation of Langerhans cells in various organs and tissues (bone, skin, lymphnodes…) • Maxillo-mandibular localisation is the most commun, itrepresents 20,8% of non odontogenictumors. • Among facial locations, mandibular involvement is the most frequent and occurs in young people less than 20 years.
Langerhan’s cell histiocytosis • It ischaracterized by multiple radiolucent lesions, well defined, circular or oval without bone condensation reaction giving the appearance of floating teeth. • CT confirms these informations and may shows a cortical rupture in places without invasion of the soft tissues. • However, only the pathological examinationcan confirm the diagnosis.
Others • Besidetheselesionsthereothermanylesions. • In fact, tumoral and pseudotumoral (odentogenic) pathology of the maxilla forms a large diverse group with three types of tumors: • Thosederivedfromodontogenicdevice • Tumors and pseudotumors of boneorigin • Epithelialcysts of the maxilla • Theycanbedevidedalso in:
Others • Odontogenic Cysts: • Inflammatory Cysts: Radicular (periapical) Cyst, paradental Cyst • Developmental Cysts: Dentigerous (follicular) Cyst, developmental Lateral Periodontal Cyst, odontogenicKeratocyst, glandular Odontogenic Cyst (GOC).
Others • Nonodontogenic cysts Incisive Canal Cyst, stafne Bone Cyst, traumatic Bone Cyst, surgical Ciliated Cyst (of Maxilla) • Odontogenic Tumors • Epithelial Odontogenic Tumors • Ameloblastoma • Calcifying Epithelial Odontogenic Tumor • MesenchymalOdontogenic Tumors • OdontogenicMyxoma • Central OdontogenicFibroma • Cementoblastoma • Mixed Odontogenic Tumors
Others • And thenwecanfindotherrelated Jaw Lesions: • Giant Cell Lesions: Central Giant Cell Granuloma, Brown Tumor of Hyperparathyroidism, Aneurysmal Bone Cyst • Fibroosseous Lesions: Fibrous Dysplasia, Ossifying Fibroma, Condensing Osteitis
In general, well-demarcated lesions outlined by sclerotic borders suggest benign growth, while aggressive lesions tend to be ill-defined lytic lesions with possible root resorption. • With larger more aggressive lesions, CT may more clearly identify bony erosion and/or invasion into adjacent soft tissues.
CONCLUSION • The Dental Panoramic X-Rayand facial CT scan can often guide the diagnosis of maxillomandibular lesions, specify the relationship with adjacent structures and monitor its progress. • The ultimate diagnosis is still histological.