49 David Sutton•TEETH AND JAWS

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

Fig. 49.2 Early periapical infection beneath the lower second molar in youth of 16. The lamina dura is destroyed round the apical thirds of it roots with widening of the dark line around the roots. Compare with the normal first molar and the incompletely formed roots of the third molar.

Fig. 49.3 There is a granuloma at the apex of the second premolar surrounded by a thin halo of bone formed by the antral mucoperiosteum. There is a similar pattern over the mesial root apex of the first molar.

Fig. 49.6 Irregular bone destruction in

the mandible of a man of

41 some 6 weeks after

onset of osteomyelitis.

Fig. 49.8 Radiation damage to the mandible and teeth is evident in this 25-year-old patient who was irradiated at the age of 6 months for cutaneous haemangioma. The mandible is hypoplastic, many of the teeth have not formed, and a few dwarfed deciduous teeth may be seen.

Fig. 49.9 Radiation necrosis. A pathological fracture has occurredthrough an area of bone necrosis.

Fig. 49.10 Apical bone resorption with loss of the lamina dura is associated in this patient with hypercementosis and obliteration of the root canals.

Fig. 49.11 Cementoma. A well-demarcated radiolucent lesion extends to the alveolar margin and shows irregular calcification within it. This does not happen with radicular cysts.

• Fig. 49.12 Reactive sclerosis is related to the chronic apicitis. Note the bone resorption around the molar teeth. The inferior dental canals stand out in sharp relief.

• Fig. 49.13 A well-defined radicular cyst is related to the right lower canine. Benign sclerosing osteitis is seen between the right lower 5 and the right lower 6.

• Fig. 49.14 Compound odontome. A large aggregate of rudimentary dental elements prevents eruption of a normal tooth.

• Fig. 49.15 Fibrous dysplasia. (A) The radiograph shows expansion with altered bone texture in the left ascending ramus and mandible. A ground-glass pattern is demonstrated. Similar changes are seen in the left antrum. (B) The radio-isotope bone scan shows the extent of the facial, antral and mandibular disease.

• Fig. 49.16 Paget's disease. The mandible shows expansion, loss of corticomedullary differentiation, and a coarsened texture throughout. These appearances are typical of Paget's disease.

• Fig. 49.17 Extensive external root resorption in a man of 62. This erosion reaches into the crown as well as halfway down the root, but the outline of the pulp persists, although it must have been breached. Infection from the gingival margin has reached the pulp and led to an apical abscess.

• Fig. 49.18 Fracture of both upper central incisor roots occurred 1 week before this film was taken in a girl of 14. The pulp survived in both portions of each tooth, as it often will in young jaws.

• Fig. 49.19 Two years later, the vital but damaged pulps have partly calcified up in root as well as in crown portions of the teeth. A layer of bone has formed between the root ends, separated by a dark line like periodontal membrane from the root and with an intact lamina dura beyond this.

• Fig. 49.20 Supernumerary upper 9s. Note how small and conically shaped these teeth are.

• Fig. 49.21 Bilateral mesiodentes with normal eruption.

• Fig. 49.22 Dens in dente. The tooth is also carious and shows apical bone resorption, with loss of the lamina dura due to ascending infection.

• Fig. 49.23 Cleft palate. The occlusal view demonstrates the defect and shows the resulting dental anomalies.

• Fig. 49.24 Stafne cyst. The lesion represents salivary gland inclusion in bone.

• Fig. 49.25 Cretin, showing gross retardation of dental maturity.

• Fig. 49.26 Hyperparathyroidism. A brown tumour is associated with resorption of the lamina dura.

• Fig. 49.27 Cherubism. Fibro-osseous lesions of the mandible prevent the formation of some teeth and displace others.

• Fig. 49.28 Cleidocranial dysplasia. (A,B) There is persistence of wormian bones with maxillary hypoplasia, and a large number of primary and unerupted secondary teeth with supernumerary tooth formation. (C) A midline defect is present at the symphysis mentis.

• Fig. 49.29 Ectodermal dysplasia. Much of the secondary dentition is absent.

• Fig. 49.30 Gardner's syndrome. Multiple osteomas are seen on the mandible and in the paranasal air sinuses, together with areas of sclerosis in the mandible.

• Fig. 49.31 Gorlin syndrome. Multiple dentigerous cysts are seen in the mandible.

• Fig. 49.32 Neurofibromatosis. The right side of the mandible is enlarged. The right condyle is scalloped due to a local neurofibroma, while the origin of the inferior dental canal is widened-also because of the local neurofibroma.

• Fig. 49.33 Thalassaemia. The mandible is enlarged, the cortex thinned and the trabeculae resorbed. The paranasal air sinuses contain marrow.

• Fig. 49.34 Eosinophilic granuloma. Arrows point to the multiple osteolytic lesions which are well defined.

• Fig. 49.35 The three common types of dental cyst. (A) Radicular cyst. The tooth is carious, the cyst sits at the apex of the bone and absorbs the local lamina dura. (B) Dentigerous cyst. The cyst is related to the crown of an unerupted tooth. (C) A large cyst which is not related to a dental element - a primordial cyst.

• Fig. 49.36 Cyst of the antrum. (A) The dental lesion expands into the antrum and has a well-corticated superior margin. (B) Aspiration of contents and installation of contrast medium confirms the true nature of the cyst.

• Fig. 49.37 Odontogenic keratocyst. A large cystic lesion extends to the base of the condyle and expands the bone. It is not related to caries or to the crown of an unerupted tooth.

• Fig. 49.38 Dentigerous cyst. The cyst is related to the crown of an unerupted tooth.

• Fig. 49.39 Residual cyst. A well-defined cyst is all that remains of a radicular cyst following dental extraction. Note reactive sclerosis elsewhere.

• Fig. 49.40 Midline mandibular cyst. This could be a radicular cyst but the local teeth are normal radiologically and vital.

• Fig. 49.41 Dens in dente and globulomaxillary cyst.

• Fig. 49.42 Fibrous dysplasia and resulting degeneration into aneurysmal bone cyst. (A) The initial radiograph shows an expansile, well-demarcated lesion displacing teeth; there is a mixed pattern of lysis and sclerosis. These changes are typical of fibrous dysplasia. Subsequently expansion took place (B) and the lesion became more cystic. (C) The bone scan at this time shows a mixed pattern with a central cold area. (D) The CT scan shows the expanded mandible and the now essentially cystic nature of the lesion. (E) MRI confirms the change in the nature of the lesion from a solid to a fluid-filled tumour.

• Fig. 49.42 Fibrous dysplasia and resulting degeneration into aneurysmal bone cyst. (A) The initial radiograph shows an expansile, well-demarcated lesion displacing teeth; there is a mixed pattern of lysis and sclerosis. These changes are typical of fibrous dysplasia. Subsequently expansion took place (B) and the lesion became more cystic. (C) The bone scan at this time shows a mixed pattern with a central cold area. (D) The CT scan shows the expanded mandible and the now essentially cystic nature of the lesion. (E) MRI confirms the change in the nature of the lesion from a solid to a fluid-filled tumour.

• Fig. 49.43 Boy aged 8. An occlusal view of a large giant-cell lesion expanding the right maxilla which has displaced several teeth.

• Fig. 49.44 Carcinoma of the maxillary antrum. (A) The radiograph shows a soft-tissue mass invading the floor of the right antrum. (B) CT confirms the change and shows the highly invasive nature of the tumour.

• Fig. 49.45 Ameloblastoma. (A) The radiograph shows a well-defined multilocular lesion which characteristically reaches the alveolar margin and erodes teeth. This latter feature is unusual in lesions other than ameloblastoma. (B) The CT scan demonstrates the marked expansion caused by these tumours in the axial plane.

• Fig. 49.46 Ameloblastoma. A multilocular cystic lesion erodes the root of a molar but also prevents eruption of a wisdom tooth. The ameloblastoma may be secondary to a dentigerous cyst.

• Fig. 49.47 Osteogenic sarcoma in a 26-year-old man. (A) Panoramic view shows a large bone-forming tumour affecting the right hemi mandible and crossing the midline. (B) CT scan confirms the extent of involvement. (C) Radioisotope bone scan also delineates the affected area.

• Fig. 49.47 Osteogenic sarcoma in a 26-year-old man. (A) Panoramic view shows a large bone-forming tumour affecting the right hemi mandible and crossing the midline. (B) CT scan confirms the extent of involvement. (C) Radioisotope bone scan also delineates the affected area.

• Fig. 49.48 Ewing's tumour. These lesions are uncommon in the mandible. (A) In this patient an osteolytic lesion is present in the left ascending ramus and condyle; it is expansile and shows slight residual trabeculation. (B) The CT scan shows a large soft-tissue mass associated with bone destruction in the left ascending ramus.

• Fig. 49.49 Carcinoma of the breast with metastases to the mandible. The initial film shows gross bone resorption of the left hemimandible. The lower illustration shows the appearances following radiotherapy.

• Fig. 49.50 Rheumatoid arthritis. (A) Erosion of the condyle is marked. (B) Injection of the lower joint space shows the hypertrophic synovium associated with rheumatoid arthritis.

• Fig. 49.51 Hyperparathyroidism in renal osteodystrophy with medullary and cortical bone resorption. (Courtesy of Dr R. Dick, Royal Free Hospital, London.)

• Fig. 49.52 Deformity of the meniscus is shown at injection of the lower compartment. There is a large anterior meniscal mass. The condyle passes over it with an audible 'clunk'.

• Fig. 49.53 TMJ malfunction syndrome (A-C). The preliminary tomogram shows narrowing of the posterior portion of the joint with widening of the anterior. This usually implies anterior displacement of the meniscus. These changes are confirmed at arthrotomography and the deformed anteriorly displaced meniscus prevents significant forward movement of the condyle.

• Fig. 49.54 The anteriorly displaced meniscus is shown on MRI as a low signal mass anterior to the bright signal of the condyle.

• Fig. 49.55 Fracture of mandible. (A) As is often the case, the mandible has fractured in two places. One fracture extends through the wisdom tooth. (B) The AP view demonstrates normal alignment at the angle of the mandible.

• Fig: 49.56. Condylar Fracture. (A) The right condyle now overlaps the ascending ramus in part. Te subsequent film (B) shows union with malalignment.