( 17 )

INFLAMMATORY
LESIONS OF
THE JAWS
LECTURE OBJECTIVES
By the end of this lecture you should
be able to know the following :
1 ) Periapical inflammatory lesions
2 ) Pericoronitis
3 ) Osteomyelitis
4 ) Osteoradionecrosis
 Effects on surrounding structures
• The periodontal ligament space will be
widened.
• With chronic infections, root resorption may
occur.
• Inflammatory exudate can penetrate the
cortex, lift up the periosteum, and stimulate
the periosteum to produce new bone.
 ( I ) Periapical inflammatory
lesions
• A periapical inflammatory lesion is
defined as a local response of the
bone around the apex, that occurs
secondary to necrosis of the pulp or
by extensive periodontal disease.
 Radiographic features
• Very early lesions may not show any
radiographic changes.
• Chronic lesions may show lytic or
sclerotic change, or both.
Location
• Usually the epicenter is found at the
apex.
• Early lesion involving the pulp of the
second premolar (arrow)
• Note that in both cases the epicenter of
bone destruction is located at the apex of
the root
 Internal structure
• The earliest change is loss
of bone density.
• Later, a mixture of
sclerosis and rarefaction of
bone occurs.
• When most of the lesion consists
of increased bone formation, the
term periapical sclerosing osteitis
is used.
• When most of the lesion is
undergoing bone resorption, the
term periapical rarefying osteitis is
used.
• Several examples of a mixture of
rarefying and sclerosing osteitis
• Periapical sclerosing osteitis
associated with the first molar
 Effects on surrounding structures
• 1 ) Periapical inflammatory lesions may stimulate either
the resorption of bone or the manufacture of new bone.
• 2 ) The lamina dura around the apex usually is lost.
• 3 ) In chronic cases external resorption of the apical
region of the root may occur.
• 4 ) If the lesion is long-standing, the pulp canal may
appear wider than adjacent teeth.
• 5 ) Production of inflammatory periosteal reaction, in the
adjacent cortical boundaries.
• A, laminated type of periostitis (arrow).
B, periostitis and mucositis. The mucositis is
characterized by a slight radiopaque band
(arrow).
• A, Radiolucent apical scar left after successful endodontic
treatment. B, Healing periapical inflammatory lesion. Note
the radiating, spoke like pattern of new bone forming from
the periphery of the lesion.
 ( II ) PERICORONITIS
(OPERCULITIS)
• It refers to inflammation of
the tissues surrounding the
crown of a partially erupted
tooth
 Radiographic features
• Can range from no changes (when
confined to the soft tissues),  to
localized rarefaction and sclerosis,  to
osteomyelitis in the most severe cases.
• In extensive cases evidence of periosteal
new bone formation may be seen.
• Pericoronitis. Note the sclerotic bone reaction
(black arrow) and the periosteal reaction (white
arrow)
 ( III ) Osteomyelitis
• Osteomyelitis is an inflammation of bone.
• The inflammatory process may spread
through the bone to involve the marrow,
cortex, cancellous portion, and
periosteum.
• The hallmark of osteomyelitis is the
development of sequestra.
Examples of sequestra
 Periosteal Reaction
• An inflammatory exudate can lift the
periosteum and stimulate bone formation.
• Radiographically, this appears as a thin,
radiopaque line almost parallel to surface
of the bone. A radiolucent band
separates this line from the bone
surface.
Osteomyelitis of the mandible with a
periosteal reaction located at the inferior
cortex
• As the lesion develops into
a more chronic phase this
process may continue and
may result in several lines
(an onion-skin appearance)
Onion-skin appearance
 ( 1 ) Acute phase osteomyelitis
• Early in the disease, no radiographic
changes may be identifiable.
• The first radiographic evidence of the
acute form is a slight decrease in
the density of the involved bone.
 ( 2 ) Chronic phase osteomyelitis
• Diffuse sclerosing osteomyelitis
refers to chronic osteomyelitis in
which the balance in bone
metabolism is tipped toward
increased bone formation
 Radiographic features
• Most of the lesion usually is composed of
the more radiopaque or sclerotic bone
pattern.
• In more chronic lesions the internal bone
density can be equivalent to cortical bone.
• A close inspection may reveal sequestrum
within the center.
• CT is superior for revealing the internal
structure and sequestra.
 Chronic diffuse sclerosing osteomyelitis
• Most of the body and ramus of the right
mandible is involved
 Effects on surrounding structures
• Chronic osteomyelitis often stimulates the
formation of periosteal new bone
(Onion-skin appearance).
• Chronic lesions may develop a draining
fistula, which may appear as a well-
defined break in the outer cortex or in
the periosteal new bone.
• A fistulous
tract extending
inferiorly from
the apex of
the first molar
to the inferior
cortex of the
mandible
 ( IV ) Osteoradionecrosis
• Osteoradionecrosis refers to an
inflammatory condition of bone
(osteomyelitis) that occurs after
the bone has been exposed to
therapeutic doses of radiation
• Doses above 50 Gy usually are
required to cause this irreversible
damage.
• The radiographic features have
many similarities to those of
chronic osteomyelitis  The
History.
 Osteoradionecrosis of the maxilla
• A, Before radiotherapy. B, within 6 months of
receiving the radiation.