Differential diagnosis of Multilocular
Radiolucencies – Part 1
Specific learning objective
• To know the criteria for defining
a multilocular radiolucency.
• To enumerate different diseases
with multilocular appearance
DR.S.KARTHIGA KANNAN
• To know the differentiating
radiographic features among
them.
PROFESSOR
ORAL MEDICINE & RADIOLOGY
Criteria for Multilocular
Radiolucencies
Periapical Radiolucency
Pericoronal Radiolucency
Inter-radicular Radiolucency
Introduction
Multilocular radiolucency
Pathogenesis
• Multiple, adjacent, frequently
Multilocular radiolucency
classification
•
– Odontogenic keratocyst
coalescing and overlapping
– Simple /Traumatic bone cyst
pathologic compartments in
bone
Multilocular cyst
– Aneurysmal bone cyst
•
Ameloblastoma
• True multilocular lesions
•
Odontogenic myxoma
contains two or more
•
Central giant cell granuloma
•
Cherubism
•
Giant cell lesion of
hyperparathyroidism
•
Vascular malformations – central
hemangioma
pathologic chambers partially
separated by septa of bone
• More common in mandible
Different Multilocular Radiolucent
Appearances
•
Soap Bubble Appearance –
– Consisting of circular compartments of varying
size and appear to somewhat overlap.
 Honey comb appearance –
- Lesions whose compartments are small
and tend to be uniform in size
• Tennis racket appearance –
Lesions composed of angular compartments
that result from development of more or
less straight septa.
Multilocular cyst
Keratocystic Odontogenic Tumor
Or Odontogenic keratocyst
•
The pathology appear unilocular or
multilocular cyst clinically but it
enlarge by the growth of lining
epithelium showing tumor like
character –Mural Growth
•
Commonly seen in mandible
premolar and molar region
•
Age predilection – 2nd to 3rd decade
•
Sex predilection – Male > Female
•
Grows anterio-posterior initially and
asymptomatic and may be noticed
on routine examination
•
Later may cause swelling and facial
asymmetry, but never causes
paresthesia
unless
secondarily
infected.
Radiographic appearence
•
•
•
Location
90% posterior body of mandible
behind canine
Epicentre above inferior alveolar
canal
•
Border – well defined, uniform or
scalloped
•
Shape – Unilocular or multilocular,
May occur in a pericoronal position
mimicking like Dentigerous cyst
•
Size – In initial stage –
Anterioposterior dimention is more
than bucco-lingual direction
•
•
Internal structureUniformly radiolucent, can have
curved trabeculae or septa.
•
Effects on adjacent structure may displace the root/tooth,
inferior alveolar canal or cause
root resorption, In maxilla
encroches antrum.
•
Number – if multiple OKC are
detected in Jaw ,should rule out
Nevoid Basal cell carcinoma
syndrome(NBCC)
•
Consistency: Depending on cortical
plates thickness it may be bony hard, if
thin – Tennis ball consistency, futher
thinning results in egg shell crackling
and if completely destroyed then soft and
fluctuant cystic consistency.
•
Aspiration : straw colored fluid with
flecks of keratin or thick yellow cheesy
keration.
Differential Diagnosis
• Ameloblastoma
• Giant cell lesions of Hyperparathyroidism
• Odontogenic myxoma
Management
• Enucleation
• Marsupialization
cauterizing solution
with
chemical
Aneurysmal Bone Cyst
 Definition – it’s a reactive bone
lesion.
It
represents
an
exaggerated
proliferative
response of vascular tissue in
bone.
•
•
Age – In less than 30 yrs
•
Sex - common in female patient.
•
Seen as
swelling.
•
Pain is an occasional complaint &
involved area is tender on
palpation
•
Intra-operative finding – appear as
blood soaked sponge with large
pores
representing
cavernous
spaces of lesion
It was separated as a distinct
entity by Jaffe & Lichenstein in
1942.
•
Aneurysmal bone cysts (ABC) are
expansile osteolytic lesions with
thin wall cystic cavities without
epithelial lining.
a
fairly
rapid
bony
Radiographic Features
•
Location -Mandibular molar and ramus is
more involved
 Periphery – well defined, circular in shape
 Internal Structure – initial lesions are
radiolucent – multilocular with internal septa.
 Surrounding Structures – extreme
expansion of outer cortical plate – displace
and resorb teeth.
Differential Diagnosis
• Traumatic bone cyst
• Central giant cell granuloma – ocuur in
anterior reion of mandible
• Ameloblastoma – occurs in older age
Management
• Surgical curettage – autogeneous bone
graft.
Central Giant Cell Granuloma
 Synonyms – giant cell reparative
granuloma, giant cell lesions &
Giant cell tumor
•
Introduced by Waren – 1837
•
Described by Jaffe – 1953 – Giant
Cell Reparative Granuloma
 Definition – reactive lesion to
unknown stimulus
 not a true neoplastic lesion
 Cane be associated with
Hyperparathyroidism
Clinical features
•
Age - 2nd decade.
•
Male to Female ratio = 1: 2
•
Mandible > Maxilla
•
Anterior region > Posterior region
•
Painless – Rapid growing swelling –
with tenderness on mild palpation
•
Overlying mucosa is bluish – brown
in color
Radiographic Features
 Location – mandible – anterior to
1st molar or anterior to cuspids
lesions cross midline.
 Periphery – well defined lesions
borders
 Internal Structure – subtle
granular pattern of calcification –
ill defined wispy septa.
 Surrounding Bone
- Causes expansion of cortical
bone in maxilla cortical plate is
destroyed more easily
– displace and resorb teeth,
missing lamina dura, displaces
inferior alveolar canal inferiorly.
Differential Diagnosis
• Ameloblastoma
•
Odontogenic Myxoma
•
Aneurysmal Bone Cyst
Management
Medical Managment
• Corticosteroid injections –
– Exact mechanism is not known –
inhibit bone resorption
 Calcitonin – causes increased influx of
Ca in bones – antagonist to
parathyroid.
•
Synthetic Salmon Calcitonin – nasal
spray (osteospray)
•
Interferon – differentiate mesenchymal
stem cells into osteoblasts , thereby
enhancing bone formation in CGCG.
Surgical excision with recurrence rate of
11 – 49%
Ameloblastoma
•
It is a true benign neoplasm of
Odontogenic epithelium
•
Locally invasive
•
More common in males
•
It is the most common
odontogenic tumor
•
Age prdilection – 40 yrs
•
Grows slowly with expansion of
jaw producing facial asymmetry
•
It can cause migration, tipping,
mobility and root resorption.
•
Painless, No paresthesia
•
Initially bony hard in cosistency
later may have egg shell crackiling
and cystic consistency
•
In multi cystic variant aspiration
may yield fluid.
•
Arises from reminents of dental
lamina or dental organ
•
Types
•
–
Solid / multicystic
–
Unicystic
–
Desmoplastic
Bone resorption is mediated by
Interleukin 1 and Interleukin 6
mainly synthesized in stellate
reticulum like cells
Clinical Features
Radiographic appearance
•
•
•
•
•
•
Location –
80% in mandible Molar ramus
area
Borders –
well defined with cortical border
and may show scalloping
Shape –
– Unilocular or multilocular
– Soap bubble / honey comb
– Pericoronal also.
Internal structure –
– Uniformly radiolucent
– Curved septa / trabeculae
– Desmoplastic type shows
irregular sclerotic raioopaque
mass.
Effect on adjacent structure
•
•
•
•
Root resorption, displacement
Displacement of tooth, inferior
alveolar canal
Cortical bone expansion is seen.
Maxilla is rarely involved but
dangerous as the cortical plates
are thin and mayextend to sinus,
nasal walls and orbital floor
•
Differential Diagnosis –
– Odontogenic keratocyst
– Central giant cell granuloma
•
Treatment – enbloc surgical
resection
Thank you
Any questions???