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(BQ) Part 1 book Diagnostic imaging oral and maxillofacial presents the following contents: Oral cavity, nose and sinuses, temporal bone, base of skull, cervical spine, suprahyoid neck, teeth, oral cavity, mandible and maxilla.
Diagnostic Imaging Oral and Maxillofacial Diagnostic Imaging Oral and Maxillofacial Table of Contents Diagnostic Imaging - Oral and Maxillofacial Cover Authors Dedication 11 Preface 12 Acknowledgements 12 Part I - Anatomy 13 Section - Oral Cavity 13 Teeth 13 Dental Restorations .24 Dental Implants 31 Maxilla 44 Mandible 51 Tongue 59 Retromolar Trigone .63 Sublingual Space 68 Submandibular Space 73 10 Oral Mucosal Space - Surface 78 Section - Nose and Sinuses .81 11 Sinonasal Overview 81 12 Ostiomeatal Complex 96 13 Pterygopalatine Fossa .101 Section - Temporal Bone 107 14 Temporomandibular Joint .107 15 External, Middle, and Inner Ear .113 Section - Base of Skull 120 16 Anterior Skull Base 120 17 Central Skull Base 127 18 Styloid Process and Stylohyoid Ligament 134 Section - Cranial Nerves 140 19 Cranial Nerve 140 20 Cranial Nerve 153 Section - Cervical Spine 162 21 Craniocervical Junction 162 Section - Suprahyoid Neck 173 22 Suprahyoid Neck Overview 173 23 Parapharyngeal Space .180 24 Nasopharynx and Oropharynx 185 25 Masticator Space .192 26 Parotid Space 197 27 Carotid Space 202 28 Retropharyngeal Space 207 29 Perivertebral Space 212 30 Lymph Nodes 217 31 External and Internal Carotid Arteries 222 Part II - Diagnoses 230 Section - Teeth .230 I Developmental Alterations in Size and Shape of Teeth .230 32 Hypodontia 230 33 Hyperdontia 233 34 Macrodontia, Gemination, and Fusion 236 Diagnostic Imaging Oral and Maxillofacial 35 Microdontia 239 36 Concrescence 240 37 Talon Cusp 242 38 Dens Invaginatus 243 39 Enamel Pearls 245 40 Taurodontism 246 41 Dilaceration 248 42 Supernumerary Roots 249 II Developmental Alterations in Structure of Teeth .251 43 Amelogenesis Imperfecta 251 44 Dentinogenesis Imperfecta 257 45 Dentin Dysplasia 261 46 Regional Odontodysplasia 262 III Acquired Alterations of Teeth and Supporting Structures 264 47 Attrition .264 48 Abrasion 267 49 Erosion 269 50 Abfraction 270 51 Turner Dysplasia 272 52 Internal and External Resorption 274 53 Hypercementosis 280 IV Trauma 282 54 Concussion 282 55 Luxation 284 56 Root Fractures .289 V Infection - Inflammation 293 57 Dental Caries .293 58 Periapical Rarefying Osteitis 298 59 Periapical Sclerosing Osteitis 305 60 Periodontal Disease .308 VI Miscellaneous 317 61 Gubernaculum Dentis 317 Section - Oral Cavity .320 I Congenital - Genetic 320 62 Submandibular Space Accessory Salivary Tissue 320 63 Lingual Thyroid 323 64 Dermoid and Epidermoid Cysts 326 65 Lymphatic Malformation .333 66 Submandibular Gland Aplasia-Hypoplasia 339 67 Foregut Duplication Cyst in Tongue .343 II Infection 346 68 Oral Cavity Soft Tissue Infections 346 III Inflammation 352 69 Ranula 352 70 Submandibular Gland Sialadenitis 358 71 Oral Cavity Sialocele 362 72 Submandibular Gland Mucocele 365 IV Neoplasm, Benign 368 73 Sublingual Gland Benign Mixed Tumor .368 74 Submandibular Gland Benign Mixed Tumor 371 75 Palate Benign Mixed Tumor 375 V Neoplasm, Malignant 378 76 Oral Cavity Minor Salivary Gland Malignancy .378 77 Sublingual Gland Carcinoma 381 Diagnostic Imaging Oral and Maxillofacial 78 Submandibular Gland Carcinoma 385 79 Submandibular Space Nodal Non-Hodgkin Lymphoma 388 80 Oral Tongue SCCa 391 81 Floor of Mouth SCCa 398 82 Gingival SCCa .401 83 Retromolar Trigone SCCa .404 84 Submandibular Space Nodal SCCa 408 85 Buccal Mucosa SCCa 411 86 Hard Palate SCCa 414 VI Miscellaneous - Idiopathic 417 87 Motor Denervation CN12 417 88 Submandibular Sialoliths .421 Section - Mandible and Maxilla 424 I Normal Variants 424 89 Buccal and Palatal Exostoses 424 90 Torus Mandibularis 427 91 Torus Palatinus 430 92 Accessory Mandibular Canal 433 93 Mandibular Salivary Gland Defect 436 94 Mandible-Maxilla Idiopathic Osteosclerosis 442 II Congenital - Genetic 445 95 Clefts 445 96 Cleidocranial Dysplasia 448 97 Pierre Robin Sequence 452 98 Treacher Collins Syndrome 455 III Trauma 458 99 Mandible Fracture .458 100 Nasoethmoid Complex Fracture .464 101 Complex Midfacial Fracture .468 102 Zygomaticomaxillary Complex Fracture .471 103 Trans-facial Fracture 474 IV Infection - Inflammation 479 104 Mandible-Maxilla Osteomyelitis .479 105 Mandible-Maxilla Osteoradionecrosis 485 106 Mandible-Maxilla Osteonecrosis 491 V Cysts, Odontogenic 498 107 Dentigerous Cyst .498 108 Lateral Periodontal Cyst .504 109 Residual Cyst .508 110 Buccal Bifurcation Cyst 511 VI Cysts, Nonodontogenic 517 111 Mandible-Maxilla Aneurysmal Bone Cyst 517 112 Nasopalatine Duct Cyst 523 113 Nasolabial Cyst 530 114 Mandible-Maxilla Simple Bone Cyst 533 VII Fibro-osseous Lesions .539 115 Periapical Cemental Dysplasia 539 116 Florid Cemento-osseous Dysplasia .546 117 Cemento-ossifying Fibroma .552 118 Mandible-Maxilla Fibrous Dysplasia 558 119 Paget Disease 564 120 Cherubism 570 VIII Neoplasm, Benign, Odontogenic 577 121 Odontoma 577 Diagnostic Imaging Oral and Maxillofacial 122 Adenomatoid Odontogenic Tumor 583 123 Ameloblastoma 586 124 Ameloblastic Fibroma 592 125 Ameloblastic Fibro-odontoma 598 126 Calcifying Epithelial Odontogenic Tumor 601 127 Calcifying Cystic Odontogenic Tumor 604 128 Cementoblastoma .607 129 Odontogenic Myxoma .611 130 Central Odontogenic Fibroma 614 131 Keratocystic Odontogenic Tumor .617 132 Basal Cell Nevus Syndrome 624 IX Neoplasm, Benign, Nonodontogenic 627 133 Central Hemangioma 627 134 Osteoid Osteoma .630 135 Osteoblastoma 634 136 Mandible-Maxilla Osteoma 637 137 Nerve Sheath Tumor 640 138 Neurofibromatosis Type 646 139 Desmoplastic Fibroma .653 X Neoplasm, Malignant, Odontogenic 656 140 Malignant Ameloblastoma and Ameloblastic Carcinoma 656 XI Neoplasm, Malignant, Nonodontogenic 659 141 Mandible-Maxilla Metastasis .659 142 Mandible-Maxilla Osteosarcoma .668 143 Mandible-Maxilla Chondrosarcoma 674 144 Primary Intraosseous Carcinoma 680 145 Central Mucoepidermoid Carcinoma 683 146 Burkitt Lymphoma .686 147 Non-Hodgkin Lymphoma 692 148 Multiple Myeloma .698 149 Ewing Sarcoma 705 150 Leukemia 711 XII Tumor-like Lesions 715 151 Mandible-Maxilla Central Giant Cell Granuloma .715 152 Langerhans Histiocytosis 721 Section - Temporomandibular Joint 728 I Congenital Disorders 728 153 Condylar Aplasia 728 154 Hemifacial Microsomia 731 II Developmental Acquired Disorders 737 155 Condylar Hyperplasia 737 156 Coronoid Hyperplasia 747 157 Condylar Hypoplasia 750 158 Fibrous Ankylosis .756 159 Bony Ankylosis 759 III Trauma 762 160 TMJ Fracture 762 161 Dislocation .765 162 Bifid Condyle .768 163 TMJ Osteochondritis Dissecans 774 IV Inflammatory Disorders 777 164 TMJ Rheumatoid Arthritis 777 165 TMJ Juvenile Idiopathic Arthritis 780 166 TMJ Pigmented Villonodular Synovitis .786 Diagnostic Imaging Oral and Maxillofacial V Degenerative Disorders .789 167 TMJ Degenerative Disease 789 168 TMJ Synovial Cyst 795 169 Condylysis 798 VI Disc Derangement Disorders 807 170 Disc Displacement with Reduction .807 171 Disc Displacement without Reduction 811 172 Adhesions 814 VII Neoplasm, Benign 817 173 TMJ Osteoma 817 174 TMJ Osteochondroma 820 VIII Tumor-like Lesions 826 175 TMJ Calcium Pyrophosphate Dihydrate Deposition Disease .826 176 TMJ Synovial Chondromatosis 833 IX Neoplasm, Malignant .839 177 TMJ Osteosarcoma 839 178 TMJ Chondrosarcoma 842 179 TMJ Metastasis 848 X Miscellaneous 851 180 TMJ Simple Bone Cyst 851 181 TMJ Aneurysmal Bone Cyst 854 Section - Maxillary Sinus and Nasal Cavity 857 I Normal Variants 857 182 Deviated Nasal Septum 857 183 Concha Bullosa 859 184 Accessory Ostia 860 II Developmental 863 185 Hypoplasia-Aplasia 863 III Inflammation 869 186 Mucus Retention Pseudocyst .869 187 Sinonasal Mucocele 873 188 Sinonasal Wegener Granulomatosis 879 189 Sinonasal Polyposis 885 190 Acute Rhinosinusitis 892 191 Chronic Rhinosinusitis 898 192 Odontogenic Sinusitis 904 193 Allergic Fungal Sinusitis 907 194 Invasive Fungal Sinusitis 910 195 Mycetoma 916 196 Invasive Pseudotumor .920 IV Neoplasm, Benign 923 197 Sinonasal Inverted Papilloma .923 198 Sinonasal Ossifying Fibroma .929 199 Sinonasal Osteoma 935 V Neoplasm, Malignant 941 200 Sinonasal Squamous Cell Carcinoma 941 201 Sinonasal Adenoid Cystic Carcinoma 945 202 Nasopharyngeal Carcinoma .948 203 Sinonasal Malignant Melanoma 954 VI Tumor-like Lesions 958 204 Sinonasal Fibrous Dysplasia .958 Section - Masticator Space .964 I Normal Variants 964 205 Pterygoid Venous Plexus Asymmetry 964 Diagnostic Imaging Oral and Maxillofacial II Infection 967 206 Masticator Space Abscess 967 III Degenerative 973 207 Masticator Muscle Atrophy 973 IV Neoplasm, Benign 980 208 Masticator Space CNV3 Schwannoma 980 209 Fibromatosis 983 V Neoplasm, Malignant 989 210 Masticator Space Chondrosarcoma 989 211 Masticator Space Sarcoma 993 212 Masticator Space CNV3 Perineural Tumor 999 VI Miscellaneous - Idiopathic 1005 213 Benign Masticator Muscle Hypertrophy 1005 Section - Parotid Space 1009 I Inflammatory 1009 214 Parotid Sialadenitis 1009 215 Parotid Sialoliths 1012 216 Benign Lymphoepithelial Lesions-HIV 1015 II Neoplasm, Benign 1021 217 Parotid Benign Mixed Tumor 1021 218 Warthin Tumor 1027 219 Parotid Schwannoma 1033 III Neoplasm, Malignant 1037 220 Parotid Malignant Mixed Tumor 1037 221 Parotid Mucoepidermoid Carcinoma 1040 222 Parotid Adenoid Cystic Carcinoma 1046 223 Parotid Non-Hodgkin Lymphoma 1049 224 Metastatic Disease of Parotid Nodes 1055 IV Autoimmune 1061 225 SjoGren Syndrome 1061 Part III - Differential Diagnoses 1064 Section - Teeth 1064 I Alterations in Tooth Number 1064 226 Extra Teeth 1064 227 Missing Teeth 1069 II Alterations in Tooth Morphology - Shape 1073 228 Crown Changes 1073 229 Root Changes 1077 Section - Mandible and Maxilla 1085 I Alterations in Supporting Structures of Teeth 1085 230 Periapical Radiolucencies 1085 231 Periapical Radiopacities and Mixed Lesions 1093 232 Floating Teeth 1097 233 Widened Periodontal Ligament Space 1101 234 Lamina Dura Changes 1106 II Radiolucencies 1113 235 Well-defined Unilocular Radiolucencies 1113 236 Pericoronal Radiolucencies without Radiopacities 1121 237 Pericoronal Radiolucencies with Radiopacities 1126 238 Multilocular Radiolucencies 1131 239 Ill-defined Radiolucencies 1138 240 Generalized Rarefaction 1148 III Radiopacities 1156 241 Well-defined Radiopacities 1156 Diagnostic Imaging Oral and Maxillofacial 242 Ground-Glass and Granular Radiopacities 1164 243 Generalized Radiopacities 1171 IV Periosteal Reactions 1176 244 Periosteal Reactions 1176 Section - Oral Cavity 1186 I Anatomically Based Lesions 1186 245 Submandibular Space Lesions 1186 246 Parotid Space Lesions 1194 247 Sublingual Space Lesions 1202 248 Oral Mucosal Space-Surface Lesions 1209 249 Root of Tongue Lesions 1217 II Miscellaneous 1224 250 Soft Tissue Calcifications 1224 Section - Temporomandibular Joint 1232 I Changes in Condylar Size and Function 1232 251 Small Condyle 1232 252 Large Condyle 1240 253 Limited Condylar Translation 1248 II Mass Lesions 1255 254 TMJ Radiolucencies 1255 255 TMJ Radiopacities 1259 III Miscellaneous 1264 256 TMJ Articular Loose Bodies 1264 Section - Maxillary Sinus and Nasal Cavity 1268 I Nasal Lesions 1268 257 Perforated Nasal Septum 1268 258 Nasal Lesion without Bony Destruction 1272 259 Nasal Lesion with Bony Destruction 1280 260 Sinonasal Fibro-osseous and Cartilaginous Lesions 1287 II Sinus Lesions 1291 261 Paranasal Sinus Lesions without Bony Destruction 1291 262 Paranasal Sinus Lesions with Bony Destruction 1299 III Miscellaneous 1307 263 Displaced Dental Structures into Antrum 1307 Index 1312 A 1312 B 1313 C 1314 D 1317 E 1318 F 1319 G 1320 H 1320 I 1321 J 1321 K 1322 L 1322 M 1323 N 1327 O 1328 P 1332 Q 1335 R 1335 S 1336 Diagnostic Imaging Oral and Maxillofacial T 1341 U 1343 V 1343 W 1343 Z 1343 Diagnostic Imaging Oral and Maxillofacial Diagnostic Imaging - Oral and Maxillofacial Cover Authors Authors Lisa J Koenig BChD, DDS, MS Associate Professor Program Director, Oral Medicine and Oral Radiology Marquette University School of Dentistry Milwaukee, WI C Grace Petrikowski DDS, MSc, FRCD(C) Associate Professor Department of Oral Radiology Faculty of Dentistry University of Toronto Toronto, Canada Dania Tamimi BDS, DMSc Oral and Maxillofacial Radiology Consultant Private Practice Orlando, FL Diagnostic Imaging Oral and Maxillofacial (Left) Panoramic reformat CBCT of the same patient shows a minimally corticated tooth follicle that is displaced occlusally Crestal alveolar bone is present , simulating periodontal disease not usually present in children (Courtesy M Noujeim, DDS.) (Right) Cross section CBCT of the same patient shows widened periodontal ligament space and minimal lamina dura These findings are also found during orthodontic tooth movement; a bracket is seen in the image Note apical lytic lesion on maxillary incisor (Courtesy M Noujeim, DDS.) P.187 TERMINOLOGY Synonyms Acute lymphoblastic leukemia (ALL), acute nonlymphoblastic leukemia (ANL), chronic myelocytic leukemia (CML), chronic lymphocytic leukemia (CLL) Definitions Diverse spectrum of hematopoietic malignancies of stem cells IMAGING General Features Best diagnostic clue Acute: Lytic, blastic, or mixed lesion with ill-defined margins Effaced dental lamina dura with widened periodontal ligament spaces Chronic: Osteolytic lesions < 3% CT Findings Bone CT Acute: Ill-defined margins with lytic, blastic, or mixed tumors; may simulate periodontal disease Diffuse osteopenia; similar appearance to osteoporosis/osteopenia Decreased density; thin cortices Effacement of dental lamina dura and dental follicle cortices; widened periodontal ligament spaces May simulate rarefying periapical osteitis and occlusal displacement of tooth follicles “Hair on end” pattern of new bone growth Chronic: < 3% have lytic lesions of bone, usually in femur and humerus Imaging Recommendations Best imaging tool Panoramic or intraoral radiograph, bone CT, CBCT, nuclear medicine (NM) DIFFERENTIAL DIAGNOSIS Neuroblastoma 713 Diagnostic Imaging Oral and Maxillofacial Primary cases: Very rare in jaws Metastatic cases: Jaw involvement primarily in mandibular molar area May have rapid growth/swelling with moderate pain One of most common childhood malignancies Lymphoma Developing teeth may be displaced occlusally Difficult to distinguish from periapical rarefying osteitis Lesions spread along fat layers in soft tissue spaces and along bone surfaces Metabolic Disorders Osteoporosis or osteopenia Generalized osseous rarefaction Thin cortices PATHOLOGY General Features Genetics Nonrandom chromosomal abnormalities are common Acute: Malignant blast cells displace normal marrow cells Extend into peripheral blood circulation with spread to liver, spleen, lymph nodes, CNS, kidneys, and gonads Chronic: Massive appearance of mature lymphocytes in blood, bone marrow, and lymphoid organs Staging, Grading, & Classification Acute vs chronic based on cell maturity Acute: Undifferentiated cells; chronic: Mature cells CLINICAL ISSUES Presentation Most common signs/symptoms Acute: Sudden onset of malaise, weakness, fever, bone pain, pallor, spontaneous bleeding Hepatomegaly, splenomegaly, lymphadenopathy Paresthesia of lower lip Oral symptoms commonly absent but variable (8-18% reported), e.g., petechiae, ulceration, loose teeth, and edematous gingiva Chronic: Usually few or no symptoms Other signs/symptoms Rarely, pathologic mandibular fractures (0.47%) Demographics Age ALL (3-5 years), ANL (all ages), CML (> 10 years; median: 45 years), CLL (median is 60 years in 75% of cases) Gender No gender predilection in ALL, ANL, or CML M:F ratio is 2-3:1 in CLL Treatment Chemotherapy ± bone marrow transplantation DIAGNOSTIC CHECKLIST Consider Radiographically detectible lesions in 50-70% of children and < 10% of adults Image Interpretation Pearls May simulate periodontal disease Radiographic signs may signal relapse SELECTED REFERENCES Benson RE et al: Leukaemic infiltration of the mandible in a young girl Int J Paediatr Dent 17(2):145-50, 2007 Ruprecht A et al: Involvement of the mandible in leukemia Dentomaxillofac Radiol 7(1):27-30, 1978 714 Diagnostic Imaging Oral and Maxillofacial Stern MH et al: Radiographic changes in the mandible associated with leukemic cell infiltration in a case of acute myelogenous leukemia Oral Surg Oral Med Oral Pathol 36(3):343-8, 1973 XII Tumor-like Lesions 151 Mandible-Maxilla Central Giant Cell Granuloma > Table of Contents > Part II - Diagnoses > Section - Mandible and Maxilla > Tumor-like Lesions > Mandible-Maxilla Central Giant Cell Granuloma Mandible-Maxilla Central Giant Cell Granuloma Susanne Perschbacher, DDS, MSc Key Facts Terminology Definition: Reactive intraosseous lesion of jaws Imaging General imaging findings Loculated, often poorly corticated, expansile lesion with granular, wispy septa Mandible > maxilla: Anterior to 1st molar Root resorption Bone CT findings Undulating expansile margin Septations at right angle to periphery Best imaging tool: Contrast-enhanced CT Top Differential Diagnoses Ameloblastoma Odontogenic myxoma Aneurysmal bone cyst Brown tumor of hyperparathyroidism Cherubism Pathology Unknown etiology Reactive granuloma vs benign neoplasm Spectrum of behavior: Aggressive vs nonaggressive Clinical Issues Presentation: Swelling, ± pain Age < 30 years, F > M Recurrence common Surgical excision treatment of choice: Calcitonin, intralesional steroids may be adjuncts Diagnostic Checklist Report cortical perforation Root resorption = sign of ↑ aggressiveness 715 Diagnostic Imaging Oral and Maxillofacial (Left) Cropped panoramic radiograph shows a faintly corticated multilocular lesion extending from the mandibular right 1st molar to the left canine Note inability to appreciate any expansion in this view (Right) Periapical radiograph of the same patient shows faint septa and mild external root resorption The occlusal radiograph, though subtle, shows prominent buccal expansion with wispy septa internally (Left) Axial bone CT slice near the apices of the teeth of the same patient better demonstrates the granular, wispy septa within the lesion Notice that the peripheral cortex is very faint and grainy (Right) Axial NECT of the same patient demonstrates the undulating expansile, corticated periphery Note the septa oriented at right angle to the outer corticated border, which is a characteristic feature of CGCG P.189 TERMINOLOGY Abbreviations Central giant cell granuloma (CGCG) Synonyms Giant cell reparative granuloma Definitions Reactive lesion of jaws with benign tumor-like behavior IMAGING General Features 716 Diagnostic Imaging Oral and Maxillofacial Best diagnostic clue Multilocular lesion with granular, wispy septa Location Mandible > Maxilla Most commonly anterior to 1st molar May extend across midline Size Expansile: May become large before detection Imaging Recommendations Best imaging tool Contrast-enhanced CT Protocol advice Thin-section CECT Bone CT shows extent and internal characteristics Radiographic Findings Radiography Unilocular or multilocular when large Periphery well defined but poorly corticated Undulating expanded margins Wispy, faint septa or granular bone deposits Root resorption seen in ˜ 1/3 of lesions Tooth displacement common CT Findings CECT May see soft tissue involvement Mild enhancement internally Bone CT/CBCT Cortical expansion creates undulations Septa form at right angles to outer boundaries Varying amounts of granular bone internally, may form irregular septations MR Findings T1/T2WI Hypo- to isointense T1WI C+ Heterogeneous enhancement DIFFERENTIAL DIAGNOSIS Ameloblastoma Predominately 3rd-5th decade (older than CGCG) More likely to present posteriorly Septations tend to be coarser than CGCG Odontogenic Myxoma Older average age at presentation See straighter and sharper septa Generally less expansile than CGCG Aneurysmal Bone Cyst Majority of lesions in posterior mandible Same radiographic characteristics as CGCG CT: Low density of large vascular spaces MR: Fluid-fluid levels on T2 sequence Brown Tumor of Hyperparathyroidism Radiographic appearance often identical to CGCG Occurs in older patient than true CGCG Patients with diagnosis of CGCG histologically should be routinely tested for hyperparathyroidism Cherubism 717 Diagnostic Imaging Oral and Maxillofacial Radiographic pattern may be identical to CGCG Bilateral lesions with epicenter posteriorly Autosomal dominant condition; young children PATHOLOGY General Features Etiology Unknown: Controversy over reactive lesion vs benign neoplasm Histopathology overlaps with giant cell tumor Associated abnormalities Giant cell granulomas of jaws found in cherubism, Noonan syndrome, & neurofibromatosis type Staging, Grading, & Classification Some divide as aggressive vs nonaggressive Aggressive features: Pain, paresthesia, root resorption More likely to recur in younger patients Microscopic Features Stroma cellular to loose; spindle or ovoid fibroblasts Heterogeneous clumps of multinucleated giant cells Hemorrhage and osteoid; no necrosis CLINICAL ISSUES Presentation Most common signs/symptoms Asymptomatic swelling; can have pain Demographics Age Wide age range but majority < 30 years old Gender F:M = 2:1 Natural History & Prognosis High recurrence rate (11-50%) Treatment Surgical excision: Treatment of choice Systemic calcitonin and intralesional steroid injections SELECTED REFERENCES De Lange J et al: Clinical and radiological features of central giant-cell lesions of the jaw Oral Surg Oral Med Oral Pathol Oral Radiol Endod 99(4):464-70, 2005 P.190 Image Gallery 718 Diagnostic Imaging Oral and Maxillofacial (Left) Cropped panoramic radiograph in the maxillary right premolar and canine region shows that the periphery of this CGCG is not clearly corticated; however, a scalloped border extends into the maxillary sinus Faint granular bone deposits and irregular wispy septa are seen internally (Right) Occlusal radiograph of the same patient shows faint, wispy internal septa with straight septa extending perpendicular to the periphery The noncorticated periphery is also seen (Left) Cropped panoramic radiograph of the left posterior mandible shows a CGCG that developed after extraction of a 3rd molar The periphery is irregular but well defined Faint, granular internal structure is seen The molars are displaced anteriorly (Right) Axial CECT, bone window, of the same patient shows prominent expansion of the mandible with undulating expanded margins Loculations are seen internally; however, the septa are not as coarse or defined as in an ameloblastoma 719 Diagnostic Imaging Oral and Maxillofacial (Left) Axial bone CT of a CGCG in the anterior mandible of a 15-year-old female shows that the expanded cortices are faint and irregular Note minimal internal structure (Right) Axial bone CT of the same patient months later, with no treatment, shows that the lesion has grown considerably and crossed the mandibular midline Septa are extending at right angles from the lesion periphery Irregular bone deposits are also seen internally The buccal cortex is still faint (Courtesy C Schatz, MD.) P.191 (Left) Axial CECT, bone window, shows a very expansile CGCG in the right maxilla The periphery is wispy and undulating , and there are granular bone formations internally (Right) Axial bone CT shows a large CGCG extending across the mandibular midline Multiple islands of granular bone are seen internally One short septum is seen extending perpendicular from the buccal cortex 720 Diagnostic Imaging Oral and Maxillofacial (Left) Axial CECT, bone window, shows a large, expansile lesion in the right maxilla The periphery is not well corticated but the surrounding fat planes are preserved Some irregular internal septa are seen within the lesion (Right) Axial CECT through the maxillary sinus of the same patient shows the lesion displacing the lateral wall of the nose The anterior and posterolateral walls of the maxillary sinus are also resorbed and expanded There is mild contrast enhancement of the lesion (Left) Axial T1WI MR of the same patient shows that the lesion has a low to isointense internal signal The periphery is well defined (Right) Axial T1WI C+ FS MR of the same patient shows heterogeneous internal enhancement of the lesion , similar to the signal from the left inferior concha 152 Langerhans Histiocytosis > Table of Contents > Part II - Diagnoses > Section - Mandible and Maxilla > Tumor-like Lesions > Langerhans Histiocytosis Langerhans Histiocytosis Lisa Koenig, BChD, DDS, MS Key Facts Terminology Definition: Group of lesions affecting reticuloendothelial system and characterized by proliferation of Langerhans cells Imaging Well-defined or “punched-out” radiolucency without corticated border Bone lesions found in skull, femur, jaws, ribs, long bones, vertebrae, and pelvis 721 Diagnostic Imaging Oral and Maxillofacial Mandible > maxilla; posterior > anterior Bone may appear “scooped out” Teeth may appear to be “floating” Periosteal reaction parallel to cortex may be evident Skull lesions may be irregular: “Geographic skull” Top Differential Diagnoses Localized aggressive periodontitis Squamous cell carcinoma Osteomyelitis Metastasis Pathology Acute disseminated (Letterer-Siwe disease): Multiple organ involvement Chronic disseminated (Hand-Schüller-Christian) Triad: Multiple bone lesions, diabetes insipidus, exophthalmos Chronic localized form (eosinophilic granuloma): Monostotic or polyostotic bone lesions without visceral involvement Clinical Issues Mobility of teeth; intraoral mass/swelling; pain Overall prognosis is related to age at onset and degree of organ dysfunction (Left) Periapical radiograph shows a lesion of eosinophilic granuloma , the localized form of Langerhans cell histiocytosis, appearing similar to localized aggressive periodontitis Note total loss of alveolar crest and interproximal bone (Right) Lateral oblique radiograph shows extensive bone loss in the posterior mandible in a patient with eosinophilic granuloma Note the 1st molar appears to be “floating.” The radiolucencies at the apices of the 2nd molar are the follicles of the developing tooth roots 722 Diagnostic Imaging Oral and Maxillofacial (Left) Panoramic radiograph shows a fairly well-defined radiolucent lesion of eosinophilic granuloma distal to the developing mandibular right 3rd molar Note that the external oblique ridge is intact, which helps differentiate from pericoronitis or periodontal disease (Right) Panoramic radiograph shows a large irregular lytic lesion in the left posterior mandible Note how lesion curves back to meet the crest anteriorly, giving a somewhat “scooped out” appearance typical of bone loss in eosinophilic granuloma P.193 TERMINOLOGY Abbreviations Langerhans cell histiocytosis (LCH) Synonyms Histiocytosis X, idiopathic histiocytosis, Langerhans cell disease, Langerhans cell granulomatosis, Langerhans cell granuloma, eosinophilic granuloma (EG) Definitions Group of lesions affecting reticuloendothelial system & characterized by proliferation of Langerhans cells (LC) IMAGING General Features Best diagnostic clue Well-defined or “punched-out” radiolucency without corticated border In alveolar process, teeth may appear to be “floating in air” Location Bone lesions found in skull, femur, jaws, ribs, long bones, vertebrae, and pelvis 50% of all bone lesions found in skull & facial bones In oral cavity: Jaw lesions > oral soft tissues (2:1) Jaws involved in 10-20% of all cases Mandible > maxilla Posterior > anterior; especially mandibular body and ramus Size From small (“punched-out”) to large irregular lesions Morphology Round or oval lesions at onset As lesions progress, they may become irregular or coalesce Radiographic Findings Intraoral and extraoral plain film 723 Diagnostic Imaging Oral and Maxillofacial Bone loss around root or whole tooth May mimic periodontal disease; the following help differentiate Periodontal disease begins at alveolar crest; epicenter of LCH lesion usually mid-root Bone may appear “scooped out” unlike periodontal disease Teeth may appear to be “floating” Periosteal reaction parallel to cortex may be evident on panoramic images Cephalometric images Will demonstrate skull lesions Lesions may be “punched-out” and relatively well defined Lesions may have irregular shape and be larger: Appearance sometimes referred to as “geographic skull” CT Findings Bone CT and CBCT Will show extent of osteolytic lesions in maxilla and mandible Depending on field of view (FOV), CBCT may demonstrate presence of skull lesions Periosteal reactions are better detected MR Findings T1WI Isointense to muscle; moderately enhancing T2WI Hyperintense Nuclear Medicine Findings Lesions show avid uptake of Tc-99m: Useful for determining extent of disease DIFFERENTIAL DIAGNOSIS Localized Aggressive Periodontitis Aggressive form of periodontal disease affecting localized areas 1st molars and incisors most commonly Bone loss may form arc pattern in interproximal space Young patients, teenage years Squamous Cell Carcinoma (SCCa) Solitary ill-defined radiolucency Presence of multiple lesions rules out SCCa Destruction of bone around tooth roots may cause teeth to become mobile May have associated soft tissue mass Usually older age group Osteomyelitis Ill-defined radiolucent or mixed lesions Often source of infection can be identified Sequestra is “hallmark” Periosteal reactions may be present Metastasis Ill-defined radiolucency May grow within periodontal ligament space Usually history of known primary Lymphoma Ill-defined radiolucency Preferential growth in periodontal ligament space May destroy developing tooth follicle Histologically lymphoma may resemble EG if few eosinophils present Leukemia Multifocal radiolucencies Widening of periodontal ligament space Fever, malaise PATHOLOGY 724 Diagnostic Imaging Oral and Maxillofacial Staging, Grading, & Classification Acute disseminated form (Letterer-Siwe disease): Multiple organ involvement Hepatomegaly, splenomegaly, hemorrhage, anemia, lymphadenopathy, involvement of thymus and bone marrow, cutaneous lesions Most likely represents malignant neoplastic process 10% of all cases of LCH P.194 Chronic disseminated form (Hand-Schüller-Christian disease) Triad: Multiple bone lesions, diabetes insipidus, exophthalmos 20% of all cases of LCH Chronic localized form (eosinophilic granuloma): Monostotic or polyostotic bone lesions without visceral involvement Polyostotic forms usually involve 2-4 bones Eosinophilic granuloma accounts for 60-70 % of all cases of LCH Microscopic Features Aggregation of eosinophils interspersed with histiocyte-like cells Plasma cells, lymphocytes, and multinucleated giant cells sometimes seen Identification of Langerhans cells needed for diagnosis Langerhans cells: Dendritic mononuclear cells found primarily in epidermis and bone marrow Present antigens to T lymphocytes Contain Birbeck granules in cytoplasm Differentiates LCs from other mononuclear phagocytes Immunohistochemistry: CD1a strongly positive; S100 positive CLINICAL ISSUES Presentation Most common signs/symptoms Mobility of teeth Sockets of lost teeth not heal normally Intraoral mass/swelling Pain Other signs/symptoms Gingivitis/bleeding Ulcers Impaired healing Halitosis Demographics Age Acute disseminated: Infants < years Chronic disseminated: 1st decade Localized (eosinophilic granuloma): Older children → adults Gender M = F, although some report male preponderance for localized form (2:1) Epidemiology 2-5 cases per 1,000,000 50% are < 15 years old Natural History & Prognosis Overall prognosis is related to age at onset and degree of organ dysfunction Localized form: Prognosis is good Spontaneous remission of eosinophilic granuloma following biopsy reported Chronic disseminated: Prognosis is fair Progression to lethal dissemination may occur (10%) Acute disseminated: Prognosis poor 725 Diagnostic Imaging Oral and Maxillofacial Invariably fatal in early infancy Prognosis improves slightly after age years Treatment Eosinophilic granuloma: Localized lesions of mandible/maxilla Surgical curettage Low dosage radiation therapy ± chemotherapy for inaccessible lesions Concern for malignancy induction with radiation therapy in younger patients Radiation dose usually < 10 Gy Recurrence from 1.6-25% Recurrence may be less for surgery + radiation compared to surgery alone Intralesion injection of corticosteroid reported successful in some lesions Chronic disseminated Chemotherapy: Vinblastine sulphate, vincristine, etoposide ± corticosteroid (prednisone) Prednisone thought to help decrease recurrence Acute disseminated: Multiple chemotherapeutic agents DIAGNOSTIC CHECKLIST Consider Although lesions of multiple myeloma (MM) are also described as “punched-out,” MM occurs in much older age group SELECTED REFERENCES Esen A et al: Treatment of localized Langerhans’ cell histiocytosis of the mandible with intralesional steroid injection: report of a case Oral Surg Oral Med Oral Pathol Oral Radiol Endod 109(2):e53-8, 2010 Neville B et al: Oral and Maxillofacial Pathology 3rd ed St Louis: Saunders, 2009 Baltacioğlu E et al: Clinical, pathological and radiological evaluation of disseminated Langerhans’ cell histiocytosis in a 30-month-old boy Dentomaxillofac Radiol 36(8):526-9, 2007 dos Anjos Pontual ML et al: Eosinophilic granuloma in the jaws Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104(6):e47-51, 2007 Schroff J Eosinophilic granuloma of bone: case report of eosinophilic granuloma of mouth (jaws et al: 1948 Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100(2 Suppl):S37-41, 2005 Kessler P et al: Langerhans cell granulomatosis: a case report of polyostotic manifestation in the jaw Int J Oral Maxillofac Surg 30(4):359-61, 2001 Namai T et al: Spontaneous remission of a solitary eosinophilic granuloma of the mandible after biopsy: a case report J Oral Maxillofac Surg 59(12):1485-7, 2001 Asaumi J et al: Two cases of polyostotic eosinophilic granuloma Dentomaxillofac Radiol 29(6):382-5, 2000 Watzke IM et al: Multifocal eosinophilic granuloma of the jaw: long-term follow-up of a novel intraosseous corticoid treatment for recalcitrant lesions Oral Surg Oral Med Oral Pathol Oral Radiol Endod 90(3):317-22, 2000 10 Ardekian L et al: Clinical and radiographic features of eosinophilic granuloma in the jaws: review of 41 lesions treated by surgery and low-dose radiotherapy Oral Surg Oral Med Oral Pathol Oral Radiol Endod 87(2):238-42, 1999 P.195 Image Gallery 726 Diagnostic Imaging Oral and Maxillofacial (Left) PA radiograph shows lesions of LCH in the frontal bone, a smaller round well-defined lesion and a larger irregular lesion This appearance gave rise to the term “geographic skull.” Lesions are also present in mandible (Right) Lateral oblique radiograph in same patient shows round “scooped out” appearance of lesion around mesial root of developing 1st mandibular molar The patient had the chronic disseminated form and presented clinically with exophthalmos (Left) Lateral cephalometric radiograph shows typical small “punched-out” radiolucencies in the skull of a young patient with the chronic disseminated form of LCH (Right) Coronal bone CT shows a small welldefined lesion of eosinophilic granuloma in the right mandibular ramus of a 28-year-old woman Note that the buccal cortex is thinned but not perforated The lesion extends buccally around the mandibular canal , which lies superiorly 727 ... 13 12 A 13 12 B 13 13 C 13 14 D 13 17 E 13 18 F 13 19 G 13 20 H... Nonodontogenic 517 11 1 Mandible-Maxilla Aneurysmal Bone Cyst 517 11 2 Nasopalatine Duct Cyst 523 11 3 Nasolabial Cyst 530 11 4 Mandible-Maxilla Simple Bone... 10 12 216 Benign Lymphoepithelial Lesions-HIV 10 15 II Neoplasm, Benign 10 21 217 Parotid Benign Mixed Tumor 10 21 218 Warthin Tumor 10 27 219