Radiolucent Multiple Separate Lesions

Front 1

Gorlin-Goltz Sydndrome/Nevoid Basal Cell Carcinoma Syndrome

Back 1

Multiple Keratocysts (1mm to several cm) + Basal Cell Carcinomas
5-30yrs
Small, flat, flesh/brwon papules on skin, bifid rib
Skeletal Abnormalities
Autosomal Dominant
Mandible - posterior
Epicenter - above IAN
Corticated unles infected
Round, Oval, Scalloped
Smooth border
RL
May have internal septa
Grows along internal aspect of Jaw
MINIMAL expansion (ramus and coronoid process may expand)
DDX:
Presence of a cortical boundary and other cystic characteristics differentiate basal cell nevus syndrome from other multiple RL abnormalities.
1. Cherubism
- bilateral multilocular
- has significant jaw EXPANSION (not characteristic GGS)
- pushes posterior teeth anteriorly (characteristic for cherubism)
2. Multiple dentigerous cysts
- DC are more expansile

Front 2

Cementoma (stage 1)/Periapical Cemental Dysplasia

If teeth are extracted "cemental dysplasia"

Back 2

Teeth VITAL
Middle age (39yrs)
F 9x>M
Black 3x > white (also increased in Asians)
Usually mandibular anteriors (rare: maxillary)
Epicentre - over apex (rarely higher: over the apical 1/3rd)
Well defined
Overall round, or oval, or irregular
RadioLUCENT BORDER surrounded by band of SCLEROTIC BONE (reaction)
Most multiple and bilateral
INTERNALLY (lesion mature from inside out):
- Early: RL (what we are talking about in this deck)
- Mixed stage: RO tissue (cementum, abnormal bone) in the RL structure. Rarely RO with abnormal trabecular.
- Mature stage: Totally RO without an obvious pattern. Usually a thin RL margin (occasionally not apparent).
Normal LD lost (PDL space seems wider or less apparent)
Root resorption is rare.
Occasionally hypercementosis occurs
Small lesions - no expansion of jaw
Larger lesions - may cause expansion that undulates (always bordered by a thin, intact outer cortex)

No history of pain
Can get large - can expand alveolar process

Localised changes in bone metabolism. Cencellous bone replaced with fibrous tissue and cementum-like material, or abnormal bone, or a mixture.

DDX Stage 1:
1. Periapical rarefying osteitis (?inflammatory)
- vitality testing

DDX Solitary mature stage:
1. Benign cementoblastoma (tumour)
- especially when lesion is periapical to the mandibular first molar
- Usually attached to root -> partly resorbed)
- peripheral soft tissue capsule is better defined
- may have unique radiating internal structure
- Expansion is more concentric, less undulating
- presence or absence of clinical symptoms.

Front 3

Histiocytosis X/Langerhan's Cell Histiocytosis
Two types
1. Alveolar
2. Intraosseous (jaw)

Back 3

Mandible>Maxilla
Posterior>Anterior
1. Alveolar usually multiple lesions
- often start at midroot -> progresses in a circular shape. Once it includes part of the superior border of alveolar process-> appears 'scooped out'
2. Intraosseous usually single lesion (often in ramus)
- irregular, oval or round

RL lesion
Moderate to well-defined
NO cortication
Smooth or somewhat irregular margins
Periphery - sometimes appears punched out
Destruction! cortical bone, Bone, LD ->Teeth 'hanging in the air'
NO DISPLACEMENT of teeth (may be mobile from loss of bone)
MINOR root resorption
Can stimulate new periosteal bone formation (esp type 2)

Lesions form quickly - may cause dull, steady pain
Bony swelling in jaws
Loosening or sloughing of teeth after destruction of alveolar bone

DDX for Alveolar Type (multiple).
1. Squamous cell carcinoma
- borders of LCH are typically better defined
- multiple lesions in younger age group (0-30yrs) are more likely to be LCH
- SCC typically appears as single lesion in mid->old age
2. Periodontal disease
- Epicentre in LCH is midroot -> scooped out
- Perio: alveolar bone -> apically

DDX for solitary intraosseous lesion:
1. Metastatic malignant neoplasia
2. Malignant tumours from adjacent soft tissue
- Well-defined borders and periosteal reaction in histiocytosis

Front 4

Hyperparathyroidism

Back 4

Loss of ALL Lamina Duras
Remodelling in preference of osteoclastic resorption - Increased serum Ca
Primary (tumour in parathyroid gland) = 0.1%
Secondary (response to hypocalcemia)
F 2-3x> M
Demineralisation/thinning of cortical boundaries
Density of jaws decreases -> teeth stand out in contrast
Normal trabecular pattern may appear as ground-glass
Brown tumours - may be multiple within a bone, cortical expansion, variably defined margins
10% have loss of LD
Mature teeth are immune to demineralisation

Front 5

Multiple Myeloma

Back 5

Punched out RL
Smooth borders

Front 6

Metastatic tumour

Back 6

RL with/without history of malignant disease elsewhere