Differential diagnosis and clinical management of periapical radiopaque/hyperdense jaw lesions

SILVA, Brunno Santos Freitas; BUENO, Mike Reis; YAMAMOTO-SILVA, Fernanda P.; GOMEZ, Ricardo Santiago; PETERS, Ove Andreas; ESTRELA, Carlos

doi:10.1590/1807-3107BOR-2017.vol31.0052

Brunno Santos Freitas SILVA

Universidade de Anápolis, School of Dentistry, Department of Oral Diagnosis, Anápolis, GO, Brazil.

Mike Reis BUENO

Universidade de Cuiabá – UNIC, School of Dentistry, Department of Stomatology, University of Cuiabá, Cuibá, MT, Brazil

Fernanda P. YAMAMOTO-SILVA

Universidade Federal de Goiás – UFG, School of Dentistry, Department of Stomatologic Sciences, Goiânia, GO, Brazil.

Ricardo Santiago GOMEZ

Universidade Federal de Minas Gerias – UFMG, School of Dentistry, Department of Oral Surgery and Pathology, Belo Horizonte, MG, Brazil.

Ove Andreas PETERS

University of the Pacific, Arthur A. Dugoni School of Dentistry, Department of Endodontics, San Francisco, CA, United States of America.

Carlos ESTRELA

Universidade Federal de Goiás – UFG, School of Dentistry, Department of Stomatologic Sciences, Goiânia, GO, Brazil.

Corresponding Author: Carlos Estrela. E-mail: estrela3@terra.com.br

Declaration of Interest: The authors certify that they have no commercial or associative interest that represents a conflict of interest in connection with the manuscript.

Figures (4)
Tables (1)

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Figure 1
Reactional osteogenesis: Cone beam computed tomography (CBCT) images showing a hyperdense irregularly shaped structure (arrow head) in the right maxillary sinus (A-B), associated with an inflammatory hypodense periapical lesion (arrow) (C). Condensing osteitis (CO): CBCT presenting a diffuse hyperdense lesion in the apex of a mandibular molar (arrowhead) (D), adjacent to an inflammatory periapical lesion (arrow) (E). Chronic osteomyelitis: CBCT views show a mixed hypodense/hyperdense lesion (F) with evident sclerotic changes (arrow head) in the periapical region of a mandibular right molar, and with the presence of an inflammatory hypodense periapical lesion (arrow) (G). Idiopathic osteosclerosis (IO): In CBCT images, it is observed as a hyperdense round lesion (arrowhead) located under the apex of an apparently non-infected tooth (H). IO lesion is clearly separated from the root of the adjacent tooth by a visible periodontal membrane (I).

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Figure 2
Periapical cemento-osseous dysplasia (periapical COD): Panoramic images showing hyperdense round lesions in the periapical region of a mandibular anterior sound tooth (arrowhead) (A). Cross-sectional images showing periapical COD lesions markedly separated from the adjacent normal bone and also separated from the root of the anterior tooth (arrowhead) (B). Florid COD: In CBCT images, hyperdense multiple lesions are observed that involve the mandible bilaterally (arrow head) and bone sequestration in left mandible (arrow) (C). In (D), hyperdense elliptical lesions are seen clearly separated from the root of a mandibular tooth (arrowhead).

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Figure 3
Fibrous dysplasia: CBCT views showing a homogeneous hyperdense lesion in the right maxilla merging into the normal bone margins, and having a ground-glass appearance (A). Craniocaudal expansion and tooth displacement can also be observed (A). Histologically, FD presenting thin osteoid trabeculae with “Chinese-figure” characteristics in a hypercellular fibroblastic stroma (B). In cross-sectional views, it is observed as a narrowing of periodontal ligament space and ill-defined lamina dura of the affected teeth (C). Central osteoma: Panoramic image shows a well-defined round hyperdense mass in the maxillary sinus, associated with the apex of a maxillary tooth (arrow head) (D). Histopathological examination revealing mature, compact and trabecular bones with sparse fibrous-adipose tissue (E). Cementoblastoma: CBCT images showing a well-defined hyperdense round lesion attached to the root of supernumerary mandibular tooth (arrow head) (F) with a surrounding hypodense rim (arrow) (G).

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Figure 4
Compound odontoma: CBCT showing multiple hyperdense tooth-like structures lateral to the maxillary anterior tooth (A). Tooth-like structures presenting a fine radiolucent line that demonstrates a clear separation from the normal bone (B). Complex odontoma: Presence of a hyperdense amorphous structure with a thin radiolucent peripheral zone adjacent to the left maxillary lateral incisor (C-D). Calcifying cystic odontogenic tumor (CCOT): Coronal views showing a hypodense unilocular lesion with irregular hyperdense calcified structures in the periphery (arrowhead) and an associated odontoma (arrow) (E). Histopathological evaluation showing a cyst wall lined by ameloblastomatous odontogenic epithelia (arrowhead) associated with the formation of eosinophilic ghost cells (arrow) (F). Adenomatoid odontogenic tumor (AOT): In CBCT images, a mixed hypodense/hyperdense lesion is noted between the roots of the maxillary second premolar and first molar (arrow head) (G). In cross-sectional views, a preserved periodontal ligament space of the related tooth can be seen. There are also heterogenous calcified deposits in the lesion center (arrowhead) (H). In a radiographic exam, a sclerotic to a mixed radiolucent/radiopaque image in posterior mandible is observed, associated with a parosteal osteogenic reaction “sunray pattern” (arrowhead) (I).

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Table
Clinical, radiographic and epidemiological features of radiopaque/hyperdense lesions.

Lesion	Etiology	Decadess of life/Age	Gender/Race	Clinical/Radiographic characteristics	Anatomical site	Histopathological characteristics	Pulp vitality	Management
Condensing osteitis	I	3rd–7th	NP	Asymptomatic/ Diffuse radiopaque /Ill-defined nonexpansile sclerotic image	Associated with the apex of an infected tooth/Alveolar – premolar or molar region	Dense layers of compact bone replacing fibrofatty bone marrow and cancellous bone	N	Root canal therapy
Reactional osteogenesis	I	5th–7th	F	Asymptomatic/Ill-defined, dome-shaped, radiopaque/Thickening/Hyperdense, well-defined lesion with irregular to round to ovoid shape	Maxillary sinus associated with the apex of an infected molar	Bone tissue, concentric layers and haversian systems. Mature fibrofatty tissue, marrow and inflammatory cell infiltrate	N	Root canal therapy/Surgical treatment
Primary chronic osteomyelitis	I	Adolescence	NP	Varies from an isolated disease to a broader lesion comprising the entire hemi-mandible/Variable symptomatic intensity, mandibular enlargement, lasting from a few days to several weeks, and sometimes accompanied by variable jaw opening limitation/Mixed radiolucent/radiopaque area with periosteal reaction, subperiosteal bone formation followed by sclerotic changes in later stages	Mandible>maxilla	Necrotic bone tissue with presence of bacterial colonies	UC	The same treatment used for acute osteomyelitis
Secondary chronic osteomyelitis	I	NP	NP	Infection foci and suppuration are more evident/Intra and extraoral fistula	Mandible>maxilla	Necrotic bone tissue with presence of bacterial colonies	UC	The same treatment used for acute osteomyelitis
Osteomyelitis with proliferative periostitis	I	NP	NP	Localized slow-growing swelling/Radiopaque concentric parallel layers of new bone deposition in periosteal region/No cortical perforation	Inferior border and buccal cortex of the mandible in the molar region	Irregular reactive woven bone, with marked osteoblastic rimming and possibly inflammatory cells	N	Remove the cause of infection/Surgical remodeling may be indicated
Idiopathic osteosclerosis	NI	NP	NP	Asymptomatic non-expansile localized radiopaque lesion/Well-defined bony radiopaque, round, elliptical or irregular mass/	Alveolar process of posterior regions/ Periapical region of the lower first molar, first and second premolar, underlying the apex or separated from the tooth	Dense lamellar bone/No inflammation	P	Follow-up
Focal cemento-osseous dysplasia	NI	30–40 years	> Black	Asymptomatic single lesion/Varies from a completely radiolucent to a radiopaque lesion	Usually in the posterior quadrant of the jaw, near tooth root or edentulous area	Presence of a varied pattern of calcified structures/In the early stage - formation a vascular fibrous stroma with osteoid and some basophilic cementoid structures/In the later stages - the stroma becomes more fibrotic; a more obvious osteoid trabeculae formation is observed with the presence of thicker curvilinear bony trabeculae and the occurrence of prominent cementoid masses	P	Follow-up
Periapical cemento-osseous dysplasia	NI	> 50 years	Female >Black	Asymptomatic/Varies from a completely radiolucent to a radiopaque lesion	Adjacent to a tooth-bearing area associated with one or more vital mandibular anterior teeth	The same histological presentation of focal cemento-osseous dysplasia	P	Follow-up
Florid cemento-osseous dysplasia	NI	> 50 years	Female >Black	Asymptomatic/Well-defined radiolucent rim around the radiopaque areas	Involves 2 or more quadrants/Mandible bilaterally	The same histological presentation of focal cemento-osseous dysplasia	P	Follow-up
Fibrous dysplasia (monostotic form)	NI	1st–3rd	NP	Single bone lesion/ Asymptomatic/ Could present expansion of the buccolingual and inferior cortical bone/ Root and tooth displacement, root resorption, dislocation of the inferior mandibular canal and malocclusion/ Could vary from a radiolucent to an entirely radiopaque lesion with ground glass appearance	Maxilla	Thin osteoid anastomosing trabeculae in a hypercellular fibroblastic stroma – “Chinese figure”	P	Cosmetic recontouring surgery/ Follow-up
Osteoma (central type)	BNL	NP	NP	Asymptomatic or not/ Persistent slow growth/ Well-defined round radiopaque mass with no radiolucent halo	Posterior mandible	Mature bone with compact and/or trabecular bone	P	Surgical excision
Osteoblastoma	BNL	2nd–3rd	M	Asymptomatic/ Solitary round or oval radiolucent lesion with foci of radiopaque structures	Mandible/ Could be near the root apex	Osteoid and bone trabeculae permeating a vascularized connective tissue stroma	P	Surgical excision
Osteoid osteoma	BNL	2nd-3rd	M	10-20 mm in size/ Low growth potential/ Severe pain/ Lytic lesion with a radiopaque central nidus surrounded by a sclerotic bony margin	Mandible	Fused trabeculae within a vascularized stromal tissue, and prominent rim of osteoblasts	P	Surgical excision
Cementoblastoma	BNL	2nd-3rd	NP	Connected to the tooth root/Pain/Swelling of the alveolar ridges/Round demarcated radiopaque mass connected to a tooth root surrounded by a thin radiolucent rim/Root resorption	Mandibular permanent first molar	Dense masses of acellular cementum-like material with basophilic reversal lines in a fibrous stroma/ The lesion mass merges with the tooth	P	Surgical excision and related tooth extraction
Central ossifying fibroma	BNL	2nd-4th	F	Swelling and cortical expansion/ Asymptomatic/ Round unilocular radiolucency, well-demarcated mixed radiolucent-radiopaque content	Mandible	Spindle fibroblast-like cells with deposition of cementicles, osteoid and woven bone	P	Curettage and enucleation
Odontoma	OTM	Children and adolescents	NP	Slow growing/ Rarely presents clinical signs and symptoms/ Usually an incidental radiographic finding/ Associated with delayed tooth eruption/ Compound odontomas – multiple radiopaque tooth-like structures surrounded by a thin radiolucent line (10-20 mm in diameter)/ Complex odontoma – amorphous radiopaque structure with a fine radiopaque periphery surrounded by a radiolucent zone	Tooth bearing areas/ Compound – anterior maxilla/ Complex – posterior mandible	Capsule of connective tissue with strands or islands of odontogenic epithelium and the formation of tubular dentin and enamel matrix	P	Surgical excision
Calcifying cystic odontogenic tumor/ Calcifying odontogenic cyst	BOT	2nd – 3rd	NP	Rare/ Painless slow-growing lesion which could present bone expansion, and, in some cases, be associated with an unerupted tooth (involvement with the tooth crown)/ Well-defined unilocular radiolucent lesion that occasionally presents an irregular radiopaque material with varying degrees of radiodensity/ In some cases, could mimic apical periodontitis, presenting as a well-defined radiolucent round lesion in the periapical region	Anterior region of maxilla and mandible, especially in incisor and canine region	Cyst wall composed of connective tissue and lined with thin odontogenic epithelial cells with ameloblastomatous features/ Formation of ghost cells, and calcification in some areas/ Eosinophilic dentinoid or dysplastic dentin could be observed in some lesions	P	Enucleation
Adenomatoid odontogenic tumor	BOT	2nd	F	Swelling, tooth impaction or tooth displacement/ Follicular type – associated with the crown of an unerupted tooth/ Extrafollicular type – periapical region of the anterior mandible/Radiographically, initial AOT could be a well-defined unilocular radiolucency/ Usually present in an intact periodontal ligament space and lamina dura/ Presence of fine calcifications in the interior of the radiolucent lesion	Canine tooth crown or present in the intraradicular region of a tooth, lateral to the root, or in the apex area	Odontogenic epithelial cells with cuboidal or columnar features forming nests or rosette-like structures/ Duct-like spaces, lined by a row of columnar cells with polarized nuclei, and amorphous nodules containing amyloid-like and calcified substances/ Dysplastic structures or calcified osteodentin may be found in these lesions	P	Surgical excision
Ameloblastic fibro-odontoma	BOT	Between 5 and 17 years old	NP	Painless swelling/ Delayed tooth eruption/ Displacement or even tooth loosening/ Well-defined radiolucent area containing variables sizes and forms of radiopaque material	Crown of an unerupted tooth or even in the periapical region/ Posterior mandible or posterior portion of the maxilla	Cell rich primitive ectomesenchyme resembling dental papilla, permeated cords and nests of odontogenic epithelium with ameloblastic differentiation/ Dentinoid and enamel matrix structures with different degrees of maturation	P	Curettage/ Enucleation
Osteosarcoma	MBT	Between 10 and 20 years	M	Swelling, pain, loosening of teeth or paresthesia/ Sclerotic to a mixed radiolucent/radiopaque image/ In the initial stage of the tumor, a widened periodontal ligament could be the only radiographic sign of the lesion/ Some osteosarcomas are related to the loss of visualization of the periodontal space and the destruction of the cortical plate/ Sunray pattern could be seen	Maxilla and mandible/ Mandibular tumors tend to occur in molar region/ Could occur in periapical region	Osteoblastic osteosarcoma - osteoid surrounded by irregularly arranged fibroblast-like cells/ Chondroblastic subtype - lobules of tumor cells with a feathery appearance, and atypical chondrocytes in lacunae. Fibroblastic osteosarcoma - spindle-shaped tumor cells arranged in herring bone pattern and areas of osteoid formation	P	Surgical resection/Radiotherapy/Chemotherapy
Chondrosarcoma	MBT	4th	M	Slow growing painless swelling/ Varying from a complete osteolytic lesion to a poorly defined radiolucent area with calcified radiopaque foci/ The calcified areas could have a mottled appearance with regions of varied density	Anterior portion of the maxilla and in the mandible, especially in symphysis, coronoid and condylar processes	These tumors are composed of round to oval cells in lacunae, permeating a chondroid matrix with occasional myxoid changes	P	Surgical resection/Radiotherapy/Chemotherapy
Renal osteodystrophy	BMD	NP	NP	Painless, diffuse or localized enlargement of the maxilla and mandible, radiographically characterized by a mixed radiolucent/radiopaque lesion presenting an altered trabecular configuration/ A diffuse ground-glass pattern and loss of lamina dura are also noted	Maxilla and mandible	Composed of trabeculae of woven bone, numerous osteoblasts on the bone surface, and osteoclastic resorption lacunae/ Fibrous tissue around the trabecular woven bone	P	Surgical recontouring/ Parathyroidectomy

[1] Corresponding Author: Carlos Estrela. E-mail: estrela3@terra.com.br

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Differential diagnosis and clinical management of periapical radiopaque/hyperdense jaw lesions

Abstract