Differential Diagnosis of Unilocular RL Lesions Wood and Goaz Classification Radiolucencies Mixed (RL-RO) Radiopacities ► Periapical ► Periapical • Periapical ► Pericoronal ► Pericoronal • Not necessarily ► Inter-radicular ► Not necessarily contacting the ► Solitary cyst-like contacting the teeth lesions teeth • Multiple ► Multilocular • Generalized ► Ill defined ► Multiple separate ► Generalized rarefaction .RL lesions .Contacting tooth .Not contacting tooth periapical Inter radicular pericoronal Solitary well defined multilocular Solitary ill defined Multiple-separate Generalized rarefaction .RL lesions .Contacting tooth .Not contacting tooth periapical Inter radicular pericoronal Solitary well defined Solitary ill defined Periapical RL Periapical RL 1. Pseudoperiapical RL (Anatomical landmarks) 2. True periapical RL lesions • Periapical RL as a sequalae of pulpitis • Dentigerous cyst • Periapical cementomas • Periodntal diseases • Traumatic bone cyst • Non radicular cyst • Malignant tumors Pseudoperiapical RL ► Anatomical landmarks misinterpreted as pathology (1) In mandible (2) In maxilla .Mental foramen .Nasolacrimal canal .Lingual foramen .Incisive foramen .Submandibular gland fossa .Wide marrow spaces .Maxillary sinus (1) In mandible Mental foramen Lingual foramen Submandibular gland fossa .Wide marrow spaces (2) In maxilla Incisive foramen Nasolacrimal canal Maxillary sinus ►Comparison with the other side (identical situation) ►Tube shift technique True periapical RL: 1. periapical RL as a 2. Dentigerous cyst sequalae of pulpitis: 3. Periapical Granuloma cementomas Radicular cyst 4. Periodntal diseases Periapical Scar 5. Traumatic bone cyst Surgical defect 6. Non radicular cyst Ch and acute DA 7. Malignant tumors abscess 8. Eosinophilic osteomyelitis Granuloma Non vital tooth vital tooth 1- periapical granuloma Small rounded periapical RL (Less than 1.5 cm) * Asymptomatic * Non vital tooth 2- Radicular cyst • Well defined RL may be surrounded with RO border •Asymptomatic •Non vital tooth • May cause expansion & displacement •Larger in size than periapical granuloma •+ve aspiration 3- periapical scar •Asymptomatic •Endodontically treated 4- surgical defect •Asymptomatic •History of surgery or apicectomy 5- periapical abscess . ill def ragged borders . Aspiration Pus 6- osteomyelitis •Severe signs of infection •Mandible >maxilla •less extensive than periapical abscess B- PCD (early stage) ♀ Black middle age vital teeth Radiographically: .MD>Mx ant .Multiple occ. Solitary .Well defined .Early: RL-Mixed- Mature: RO .loss of LD .Root Resorption, .hypercementosis C- Periodontal diseases ► Associated with alveolar bone resorption ► Characterizes with increased width of PL pace around apex D- Traumatic bone cyst •young age •post. Mand •rare expansion •scallopped borders •no root resorption, •Aspiration E-Non radicular cysts F-Malignant tumors •pain or rapid swelling with no demonstrable dental cause •Loosened teeth over a short time G-Eosinophilic Granuloma •Young age •Swelling •Loose teeth •Gingivitis •MD>Mx •Bone destruction •onion skin •Teeth float in space Pericoronal RL (Related to the crown of unerupted or impacted tooth) Follicular space Dentigerous cyst AB and Unicystic AB (Mural AB) OKC AOT CEOT Calc. odontogenic cyst AB fibroma Pericoronitis 1- Follicular space (enlarged) • Appear as homogenous RL halo with thin cortical border • Young children • Only considered if eruption is delayed, tooth displaced in the crypt, bone expansion or surrounding cortical border is destructed 2-Dentigerous cyst •Surrounds the crown of unerupted tooth at the CEJ (Circumferential type) •Aspiration •Bone expansion 3- Ameloblastoma and Mural ameloblastoma •Parathesia (AB) •Age (Mural) •Aspiration •Bone expansion 4- Adenomatoid odontogenic tumor (AOT) ► More in females ► Young age ► Maxilla> mandible ► Anterior region ► Rare root resorption ► Tends to surrounds more than just the crown of the tooth 5- Odontogenic Keratocyst(OKC) •MINIMAL Expansion In the mandibular body in a BL direction while severe expansion occur in the ramus •Root Resorption less than AB and Dentigerous cyst •ASPIRATION (keratin) •High recurrence rate 6- Ameloblastic fibroma ► 2nd decade ► ♀ = ♂ ► Mand. Molar - premolar ► Outwards growth from the follicle ► Aspiration 7- Calcifying odontogenic cyst ► Wide age range ► Maxilla=mandible ► Well defined RL ► Later contains RO foci ► Expansion + Erosion ► Aspiration ► Tends to surround more than just the crown of the tooth 8- Calcifying epithelial odontogenic tumor (CEOT) • 40 y. • Males • Mand. Molar Ramus area • Bone Expansion • Teeth Displacement, Resorption • Aspiration • Later Calcific foci are numerous closely located to the crown (DRIVEN SNOW) 9- Pericoronitis - RL adjacent to crown with ill-defined sclerotic border enlarging the follicular space - In extensive cases, new bone at inferior cortex and posterior border of ramus Inter radicular RL Anatomic RL. ► Tooth crypt. ► Mental foramen and canal. ► Maxillary sinus. ► Incisive foramen. ► Lateral fossa. ► Bone marrow pattern. ► Nutrient canal Pathologic RL. ► Furcations involvement by a periodontal disease. ► Lateral radicular cyst. ► Lateral periodontal cyst. ► periodontal abscess. ► Traumatic bone cyst. ► Incisive canal cyst. ► OKC ► Residual cyst Normal landmarks Lateral fossa Nutrient canal Bone marrow pattern Incisive foramen (6mm) (Asymtomatic – compare with other side) Tooth crypt. Maxillary sinus. Young children (Bilateral appearance) Lateral periodontal cyst Well defined RL between the roots adjacent to root surface with lost LD Small dome shaped swelling in the attached gingiva Vital tooth associated with pocket Lateral radicular cyst ► Restricted to a small area adjacent to root surfaces ► Non vital tooth Traumatic bone cyst ► Mandible ► (Premolar-molar)(Anterior)region ► Vital teeth ► Minimal BL expansion ► Around and between roots of teeth ► Intact LD ► Aspiration .Furcation .Bony defects involvement •Clinically (Gingiva) •Mobility Incisive canal cyst •salty taste •Numbness •heart shape •root divergence •root resorption Residual cyst •History of extraction •Previous radiograph Odontogenic Keratocyst •Vital teeth •aspiration •MINIMAL Expansion In the mandibular body in a BL direction while severe expansion occur in the ramus •Root Resorption less than AB and Dentigerous cyst •ASPIRATION (keratin) •High recurrence rate Solitary cyst like RL Post extraction socket Residual cyst (History, Max., Straw-amber aspirate) Traumatic bone cyst (<25, Mand., -ve aspirate) Latent bone cyst ( Below IDC mol.area, Assympt., NO enlargement, Thick clear viscous aspirate) Odontogenic keratocyst ( Thick, cheesy yellow aspirate, Mand.) AB (uni cystic) ( Straw amber aspirate, 40, M., Mand.) Focal osteoporotic defect Surgical defect (Permenant, Assympt., History) 1. Residual cyst 2. Traumatic bone cyst 3. Odontogenic keratocyst 4. Ameloblastoma 5. Central giant cell granuloma 6. Odontogenic fibroma 7. Central hemangioma 8. Adenomatoid odontogenic tumor 9. Ameloblastic fibroma 10. Latent bone cyst 11. Brown tumor of hyperparathyroidism 12. Metastatic tumors 13. Incisive canal cyst 14. Odontoma (early stage) (rare) 15. Calcifying epithelial odontogenic tumor (rare) 16. Gorlin cyst (rare) 17. Aneurysmal bone cyst (rare) Normal anatomy .Marrow spaces .Max sinus .Tooth crypt .Post extraction socket Residual cyst On the alveolar bone related to missing or extracted tooth On edentulous ridge Thin bulging periosteal May interfere with new bone layer denture wearing Latent bone cyst features ► Below the ID canal with a corticated periphery ► Does not increase in size ► sialography Odontogenic keratocyst Ameloblastoma In midline of maxilla Nasopalatine canal cyst Swelling in midline of palate rise the palatine Rounded or pear papilla shaped RL in midline of palate Central giant cell granuloma Traumatic bone cyst Odontogenic fibroma Central hemangioma Metastatic tumors Adenomatoid odontogenic tumor Ameloblastic fibroma Solitary RL with ragged borders 1. Osteomyelitis 2. Carcinoma (Sq. c. c.) 3. Osteogenic sarcoma (osteolytic type) 4. Fibrous dysplasia (early lesion) 5. Metastatic tumor of the jaw 6. Residual infection 7. Peripheral lesions 8. Periodontal disease causing bone loss 9. Fibrosarcoma 10. Ewing's sarcoma 11. Chronic Dento-alveolar abcess. 12. Osteoradionecrosis 13. Eosinophilic Granuloma 14. Malignant Lymphoma 15. Ameloblastoma (rarely) 16. Odontogenic fibroma (rarely) 17. Odontogenic myxoma (rarely) 18. Central Hemangioma (rarely) Chronic osteomyelitis Squamous cell carcinoma ► Metastatic carcinoma Osteosarcoma Fibrous dysplasia (early lesion) Fibrosarcoma Ewing's sarcoma Malignant Lymphoma .