Utility of Panoramic Radiographs in the Screening of Individuals with Edentulous Arches: A Need-Analysis Study

Abstract Objective: To evaluate the utility of panoramic radiographs in pre-prosthetic screening of edentulous arches. Material and Methods: Panoramic radiographs taken for three years were retrospectively analyzed. Observations from the radiographs shall be categorized and classified into either of the two categories, namely: 'findings with minimal impact on denture fabrication' and 'findings which affect denture fabrication and require further evaluation.' Anatomic variations, jaw pathologies, and residual ridge resorption patterns were assessed. Results: This study included the initial screening of 23,020 panoramic radiographs, out of which 505 (showing either one or both edentulous arches) were included for the study purpose. The age range of the subjects was from 21 to 94 years. 52.6% of the radiographs showed positive findings. More than half of the radiographs belonged to the males (52.5%). Hyperpneumatization of the maxillary sinus, crestal position of the mental foramen, and retained root fragments were the most common entities noted in the radiographs. Changes in the mental foramen were significantly higher in males than females (p=0.002). Conclusion: Observations from this study showed that panoramic radiographs have high utility for screening edentulous arches, and they should be used in routine clinical practice before denture fabrication.

Radiologic findings of osteonecrosis, osteoradionecrosis, osteomyelitis and jaw metastatic disease with cone beam CT.

PURPOSE: The purpose of this study was to assess CBCT scans of patients with medication related osteonecrosis of the jaws (MRONJ), osteoradionecrosis (ORN), osteomyelitis (OM) and jaw metastatic disease (JM), evaluate the presence and extent of radiologic findings, identify radiologic parameters that may distinguish the four entities and last, introduce a new modified radiographic index (CRIm), in order to contribute to the diagnosis of these conditions. METHODS: Τwo major databases were retrospectively searched for fully documented and diagnosed CBCT scans of MRONJ, ORN, OM and JM from 2006 to 2019. 335 CBCT scans met the inclusion criteria and were assessed under standardized viewing conditions blindly by 2 observers. The CRIm index proposed in this study evaluates: lytic changes, sclerosis, periosteal bone formation, sequestration, non-healing extraction sockets and other findings which included: sinus implication, inferior alveolar canal implication and jaw fracture. Lytic changes, sclerosis, periosteal bone formation, sequestration and non-healing extraction sockets were scored as: absent (0), localized/single (1) and extensive/multiple (2). Each one of other findings were scored individually as: absent (0) and present (1). For statistical analysis t-test, Pearson's r correlation coefficient, one-way ANOVA and Bonferonni were performed. RESULTS: Extensive lytic changes were the most common finding, especially for ORN, where it occurred in all CBCT scans (100%). The mean value of the CRIm index differs significantly between CBCT scans with MRONJ and JM, as well as between those with OM and JM (Bonferroni p < 0.001). CONCLUSIONS: The new modified Composite Radiographic Index introduced in this study, appears to have improved an objective approach to the previously used Composite Radiographic Index by means of cumulative radiologic features. Τhe predominance of certain radiologic features in one or more of these entities may lead the diagnostician towards the correct diagnosis.

Radiological aspects of lymphomas and leukaemias affecting the jaws: A systematic review.

BACKGROUND: This systematic review aimed to investigate the radiological features of lymphomas and leukaemias affecting the jaws. METHODS: A systematic literature review was conducted using the electronic databases of PubMed, Web of Science and Scopus. Articles that contained sufficient radiographic examinations (periapical, panoramic or computed tomography images) for individual cases were included. Additionally, either immunohistochemical or molecular confirmation was required prior to inclusion. Three authors evaluated and described the image quality and radiological features. RESULTS: From an initial 1079 articles screened, 129 cases were included, containing 88 tomographic, 76 panoramic and 26 periapical examinations. The quality of the majority of images was sufficient for evaluation. Diffuse large B-cell lymphoma, Burkitt lymphoma, leukemic infiltration, plasmablastic lymphoma and extranodal Natural killer (NK)/T-cell lymphoma, nasal type were the most common subtypes. Involved teeth presented with mobility in 37.2% of the cases and a provisional diagnosis of inflammatory/infectious dental disease was considered in 49.2% of cases. Computed tomography exams were available for 76% of the cases, with most presented with an osteolytic lesion with ill-defined borders. Periosteal reactions were uncommon. CONCLUSION: Lymphoma/leukaemia infiltrates of the jaw bones are usually of high-grade subtypes and rarely present with periosteal reactions.

Radiomics in bone pathology of the jaws.

OBJECTIVE: To define which are and how the radiomics features of jawbone pathologies are extracted for diagnosis, predicting prognosis and therapeutic response. METHODS: A comprehensive literature search was conducted using eight databases and gray literature. Two independent observers rated these articles according to exclusion and inclusion criteria. 23 papers were included to assess the radiomics features related to jawbone pathologies. Included studies were evaluated by using JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies. RESULTS: Agnostic features were mined from periapical, dental panoramic radiographs, cone beam CT, CT and MRI images of six different jawbone alterations. The most frequent features mined were texture-, shape- and intensity-based features. Only 13 studies described the machine learning step, and the best results were obtained with Support Vector Machine and random forest classifier. For osteoporosis diagnosis and classification, filtering, shape-based and Tamura texture features showed the best performance. For temporomandibular joint pathology, gray-level co-occurrence matrix (GLCM), gray level run length matrix (GLRLM), Gray Level Size Zone Matrix (GLSZM), first-order statistics analysis and shape-based analysis showed the best results. Considering odontogenic and non-odontogenic cysts and tumors, contourlet and SPHARM features, first-order statistical features, GLRLM, GLCM had better indexes. For odontogenic cysts and granulomas, first-order statistical analysis showed better classification results. CONCLUSIONS: GLCM was the most frequent feature, followed by first-order statistics, and GLRLM features. No study reported predicting response, prognosis or therapeutic response, but instead diseases diagnosis or classification. Although the lack of standardization in the radiomics workflow of the included studies, texture analysis showed potential to contribute to radiologists' reports, decreasing the subjectivity and leading to personalized healthcare.

Radiolucent Lesions of the Jaws: An Attempted Demonstration of the Use of Co-Word Analysis to List Main Similar Pathologies.

(1) Background: Many radiolucent jaw lesions exist, and they often show a radiographic resemblance, rendering diagnosis a challenging act. Closely related lesions should be frequently mentioned together in the academic literature, which might be helpful for junior practitioners in determining their differential diagnosis. The usefulness of bibliometric analysis in this respect has yet to be demonstrated. (2) Methods: This study evaluated academic publications on radiolucent jaw lesions, as indexed by the Web of Science Core Collection database. The mentions of radiolucent jaw lesions were extracted from the complete bibliographic records of the publications, and co-word analyses were conducted with the aid of VOSviewer. (3) Results: Based on 1897 papers, visualization maps were synthesized to evaluate co-occurrences of the radiolucent jaw lesions. Ameloblastoma was frequently mentioned together with odontogenic keratocyst, dentigerous cyst, and radicular cyst. Osseous dysplasia was co-mentioned with osteomyelitis, ossifying fibroma, odontoma, fibrous dysplasia, and apical periodontitis. (4) Conclusions: The co-word analysis, a form of bibliometric analysis, could demonstrate a relatedness of radiolucent jaw lesions that could be considered at differential diagnosis.

Craniofacial and Craniocervical Features in Cartilage-Hair Hypoplasia: A Radiological Study of 17 Patients and 34 Controls.

Background: Biallelic mutations in the non-coding RNA gene RMRP cause Cartilage-hair hypoplasia (CHH), a rare skeletal dysplasia in which the main phenotypic characteristic is severe progressive growth retardation. Objective: This study compared the cranial dimensions of individuals with CHH to healthy subjects. Methods: Lateral skull radiographs of 17 patients with CHH (age range 10 to 59 years) and 34 healthy individuals (age range 10 to 54 years) were analyzed for relative position of the jaws to skull base, craniofacial height and depth, as well as vertical growth pattern of the lower jaw, anterior cranial base angle, and the relationship between the cervical spine and skull base. Results: We found that the length of the upper and lower jaws, and clivus were significantly decreased in patients with CHH as compared to the controls. Anterior cranial base angle was large in patients with CHH. Basilar invagination was not found. Conclusion: This study found no severe craniofacial involvement of patients with CHH, except for the short jaws. Unexpectedly, mandibular deficiency did not lead to skeletal class II malocclusion. Clinical Impact: Although the jaws were shorter in patients with CHH, they were proportional to each other. A short posterior cranial base was not associated with craniocervical junction pathology.

Focal Bone-Marrow Defects in the Jawbone Determined by Ultrasonography-Validation of New Trans-Alveolar Ultrasound Technique for Measuring Jawbone Density in 210 Participants.

Ultrasound imaging of the jawbone is not currently used in dental medicine to determine bone density. Bone-marrow defects in the human jawbone (BMDJ/FDOJ) are widely discussed in dentistry owing to their role in implant failures and as sources of inflammation in various immune diseases. The use of through-transmission alveolar ultrasonography (TAU) to locate BMDJ/FDOJ was evaluated in this study using a new TAU apparatus (TAU-n). The objective was to determine whether TAU-n readings accurately indicate the clinical parameters to detect BMDJ/FDOJ. Three parameters were compared with TAU-n measurements: 2-D orthopantomogram, Hounsfield units using digital volume tomography and post-operatively measured levels of RANTES/CCL5 expression in BMDJ/FDOJ samples. Based on the available clinical data, Hounsfield units, RANTES/CCL5 expression and TAU-n color codes yielded consistent results with respect to bone mineral density. Thus, ultrasonography with TAU-n is a reliable and efficient diagnostic method to screen for BMDJ/FDOJ in dentistry.

Deep learning neural networks to differentiate Stafne's bone cavity from pathological radiolucent lesions of the mandible in heterogeneous panoramic radiography.

This study aimed to develop a high-performance deep learning algorithm to differentiate Stafne's bone cavity (SBC) from cysts and tumors of the jaw based on images acquired from various panoramic radiographic systems. Data sets included 176 Stafne's bone cavities and 282 odontogenic cysts and tumors of the mandible (98 dentigerous cysts, 91 odontogenic keratocysts, and 93 ameloblastomas) that required surgical removal. Panoramic radiographs were obtained using three different imaging systems. The trained model showed 99.25% accuracy, 98.08% sensitivity, and 100% specificity for SBC classification and resulted in one misclassified SBC case. The algorithm was approved to recognize the typical imaging features of SBC in panoramic radiography regardless of the imaging system when traced back with Grad-Cam and Guided Grad-Cam methods. The deep learning model for SBC differentiating from odontogenic cysts and tumors showed high performance with images obtained from multiple panoramic systems. The present algorithm is expected to be a useful tool for clinicians, as it diagnoses SBCs in panoramic radiography to prevent unnecessary examinations for patients. Additionally, it would provide support for clinicians to determine further examinations or referrals to surgeons for cases where even experts are unsure of diagnosis using panoramic radiography alone.

Plasmacytoma and plasma cell myeloma affecting the jaws: A multi-institutional collaborative study.

BACKGROUND: Plasma cell neoplasms are characterized by the proliferation of a single clone of plasma cells with production of a monoclonal immunoglobulin. They can manifest as a single lesion (plasmacytoma) or as multiple lesions (multiple myeloma). METHODS: Paraffin-embedded tissue blocks of patients microscopically diagnosed with plasma cell neoplasms in the jaws were retrieved from five pathology files. Data including clinical, radiographic, microscopic and immunohistochemical findings, treatment employed and follow-up status were retrieved from the pathology reports. RESULTS: Fifty-two cases were retrieved (mean age: 59.4 years) without sex predilection. The mandible was the most affected site (67.3%), usually associated with pain and/or paresthesia (53.8%). Lesions in other bones besides the jaws were reported for 24 patients (46.2%). Radiographically, tumours usually presented as poorly defined osteolytic lesions with unilocular or multilocular images, while microscopy revealed diffuse proliferation of neoplastic plasma cells with nuclear displacement and abundant eosinophilic cytoplasm. Two cases were classified as anaplastic, and amyloid deposits were found in two other cases. Immunohistochemistry was positive for plasma cell markers and negative for CD20 and CD3, and monoclonality for kappa light chain predominated. The overall survival rate after 5 years of follow-up was 26.6%. CONCLUSION: Plasma cell neoplasms are aggressive tumours with a poor prognosis and involvement of the jaws may be the first complaint of the patient. Thus, oral pathologists, head and neck surgeons and dentists should be aware of their clinical, radiographic and microscopic manifestations.

Comparison of Vascular Morphometry in Jawbones and Long Bones: Micro-CT Study in a Rat Model Treated with Zoledronic Acid.

The study was aimed at investigating the effect of zoledronic acid on vascular morphometry in jawbones and long bones on a rat model. Twenty-four skeletal mature Sprague-Dawley female rats were administered oncologic dose of zoledronic acid (ZA) or normal saline for 4 weeks and then subjected to tooth extraction on the mandible and maxilla and a bone defect creation on the femur. After the surgical procedures, ZA or saline treatment was continued until sacrifice at week 2, week 4, and week 8 postoperatively. Vascular perfusion with MICROFIL was performed on all the animals. Micro-CT analysis demonstrated a tendency of decreased vessel density and vessel number in ZA-treated groups but no statistical difference. In conclusion, the neovessel formation is suppressed but not significantly by ZA treatment, indicating that angiogenesis inhibition may contribute to the development of MRONJ but does not play a key role.

In-house 3D-printed surgical guides for osseous lesions of the lower jaw: an experimental study.

BACKGROUND: The accuracy of computer-assisted biopsies at the lower jaw was compared to the accuracy of freehand biopsies. METHODS: Patients with a bony lesion of the lower jaw with an indication for biopsy were prospectively enrolled. Two customized bone models per patient were produced using a 3D printer. The models of the lower jaw were fitted into a phantom head model to simulate operation room conditions. Biopsies for the study group were taken by means of surgical guides and freehand biopsies were performed for the control group. RESULTS: The deviation of the biopsy axes from the planning was significantly less when using templates. It turned out to be 1.3 ± 0.6 mm for the biopsies with a surgical guide and 3.9 ± 1.1 mm for the freehand biopsies. CONCLUSIONS: Surgical guides allow significantly higher accuracy of biopsies. The preliminary results are promising, but clinical evaluation is necessary.

[CLINICAL AND RADIOLOGICAL CHARAKTERISTICS OF AMELOBLASTOMAS OF JAWS AND THEIR DIFFERENTIAL DIAGNOSIS].

The purpose of the study is to examine the clinical radiological features of the amtereloblastomas through a comprehensive survey of patients and assess the possibility of conducting differential diagnosis based on the data obtained.Under our observation there were 267 patients with benign tumors of the upper and lower jaws, which were carried out with a clinical examination and surgical treatment with subsequent histological examination of the material. An analysis of the clinical symptoms of ameloblastomas was carried out, the X-ray systematization of cystic forms of this tumor was proposed.The use of a comprehensive clinical examination of patients with tumors and tumor-like formations of jaws (computed tomography, radiological and ultrasound methods of examination) makes it possible to increase the accuracy during their differential diagnosis.

Aspectos descriptivos imagenológicos del osteoma de los maxilares: Revisión de la literatura / Descriptive imagenological aspects of osteoma in the jaws: review of the literature

El osteoma es una lesión osteogénica benigna, derivado de hueso compacto o esponjoso. Se caracteriza por ser de crecimiento lento y aparece con más frecuencia entre los 20 y los 50 años de vida, con una prevalencia mayor en hombres con respecto a las mujeres. Clínicamente asintomáticos, los podemos encontrar en la región craneofacial, particularmente en los senos paranasales y la mandíbula, y pueden presentarse de tres formas: central, periférica y extraósea, siendo más comunes los solitarios, a diferencia de los múltiples que están relacionados con el síndrome de Gardner. El tratamiento de los osteomas es quirúrgico cuando causan complicaciones. Los estudios por imágenes, como la radiografía panorámica y la TCHC, son las modalidades de mayor uso para determinar la ubicación, la extensión y las relaciones anatómicas de la lesión. Las características imagenológicas pueden presentarse como una excrecencia ósea de hueso compacto, esponjoso o mixto. El conocimiento de esta lesión nos permitirá tener mejores propuestas diagnósticas. (AU)

Osteomas are benign osteogenic lesions derived from compact or spongy bone. They are characterized by their slow growth and appear more frequently between 20 and 50 years of age, with a higher prevalence in men than in women. These lesions are clinically asymptomatic and can be found in the craniofacial region, particularly in the paranasal sinuses and the mandible, and may have a central, peripheral or extraosseous presentation. Multiple osteomas are related to Gardner's Syndrome. Treatment of osteoma is surgical when complications develop. Imaging studies such as panoramic radiography and cone beam computed tomography are the modalities most widely used to determine the location, extent, and anatomical relationships of the lesion. Imaging features may present as a bony excretion of compact, spongy, or mixed bone. Adequate knowledge of these lesions allows adequate diagnosis and better treatment planning. (AU)

World Health Organization Classification of Odontogenic Tumors and Imaging Approach of Jaw Lesions.

Tumors of the jaws represent a heterogeneous group of lesions that are classified histologically in the World Health Organization Classification of Odontogenic Tumors (2017). This article provides an update of the current nomenclature. The main role of imaging is to describe the precise location and extent of these lesions. Although characterization of imaging is often difficult due to overlapping characteristics, imaging is helpful to define which lesions should be referred for histologic examination and subsequent treatment planning. Location and density are the cardinal criteria for potential characterization on imaging. Radiologically, lesions may be radiolucent, radiopaque, or of mixed density. Additional criteria include lesion demarcation, morphology, cortical breakthrough, periosteal reaction, and adjacent soft tissue changes. Final lesion characterization is only definitive after interdisciplinary discussion and radiopathologic correlation. Correct diagnosis is obtained by a combination of the patient's age, lesion location, and clinical and radiologic presentation. It is important that all physicians use a uniform nomenclature.

Imaging of Mixed and Radiopaque Jaw Lesions.

Radiopaque lesions and lesions of mixed density are less frequent than radiolucent lesions of the jawbones. They comprise a spectrum of odontogenic and non-odontogenic lesions. The latter group includes inherited and developmental disorders, osteomyelitis, and benign and malignant primary bone tumors and metastases. Most odontogenic radiopaque or mixed lesions are either related to the apex or more rarely to the crown of the tooth, although there are exceptions to this rule. Some lesions, such as a torus mandibularis and torus palatinus, have a characteristic location, whereas others show no relationship to the dentition. This article describes the most characteristic and prevalent radiopaque and mixed lesions of the jaws and their imaging characteristics. Paget's disease, fibrous dysplasia, and rare sclerotic bone diseases of the maxillofacial bones are discussed elsewhere in this issue. Careful correlation of clinical presentation, panoramic radiographs, cone beam computed tomography, and histopathology are the cornerstones for appropriate lesion characterization.

Dental MRI: a road beyond CBCT.

KEY POINTS: • Three-dimensional (3D) imaging coupled with computer-guided surgery planning is the core of the contemporary dental implant practice.• Magnetic resonance (MR)-based dental implant planning can achieve results comparable to those with cone beam computed tomography (CBCT)-based planning.• MR-based dental implant planning without radiation dose could be a potential alternative to CBCT-based planning.

Use of dental MRI for radiation-free guided dental implant planning: a prospective, in vivo study of accuracy and reliability.

OBJECTIVES: To evaluate the accuracy and reliability of dental MRI for static guided implant surgery planning. MATERIALS AND METHODS: In this prospective study, a 0.4-mm isotropic, artifact-suppressed, 3T MRI protocol was used for implant planning and surgical guide production in participants in need of dental implants. Two dentists decided on treatment plan. Surgical guides were placed intraorally during a subsequent reference cone beam computed tomography (CBCT) scan. Inter-rater and inter-modality agreement were assessed by Cohen's kappa. For each participant, dental MRI and CBCT datasets were co-registered to determine three-dimensional and angular deviations between planned and surgically guided implant positions. RESULTS: Forty-five implants among 30 study participants were planned and evaluated (17 women, 13 men, mean age 56.9 ± 13.1 years). Inter-rater agreement (mean κ 0.814; range 0.704-0.927) and inter-modality agreement (mean κ 0.879; range 0.782-0.901) were both excellent for the dental MRI-based treatment plans. Mean three-dimensional deviations were 1.1 ± 0.7 (entry point) and 1.3 ± 0.7 mm (apex). Mean angular deviation was 2.4 ± 1.5°. CBCT-based adjustments of MRI plans were necessary for implant position in 29.5% and for implant axis in 6.8% of all implant sites. Changes were larger in the group with shortened dental arches compared with those for tooth gaps. Except for one implant site, all guides were suitable for clinical use. CONCLUSION: This feasibility study indicates that dental MRI is reliable and sufficiently accurate for surgical guide production. Nevertheless, more studies are needed to increase its accuracy before it can be used for implant planning outside clinical trials. KEY POINTS: • An excellent reliability for the dental MRI-based treatment plans as well as agreement between dental MRI-based and CBCT-based (reference standard) decisions were noted. • Ideal implant position was not reached in all cases by dental MRI plans. • For all but one implant site surgical guides derived from dental MRI were sufficiently accurate to perform implant placement (mean three-dimensional deviations were 1.1 ± 0.7 (entry point) and 1.3 ± 0.7 mm (apex); mean angular deviation was 2.4 ± 1.5°).

Retrospective 3D analysis of bone regeneration after cystectomy of odontogenic cysts.

BACKGROUND/OBJECTIVE: In this retrospective study, we aimed to investigate a new 3D evaluation method for evaluating bone regeneration after cystectomy of odontogenic cysts. METHODS: The study included 26 patients who underwent cystectomies between 2012 and 2017 and had received either fillings or non-fillings with autologous iliac crest. Bony regeneration was analyzed using 3D imaging software and comparing identical regions of interest (ROIs) that were determined by exact overlays of the postoperative cone beam computer tomography (CBCT) or computer tomography (CT) images. Outcome measures, including volume changes according to the defect size and configuration, patient age, the entity and distribution of the cysts, were collected. RESULTS: Twenty-six patients (5 women and 21 men) had 30 defects, including nine keratocysts, seven radicular cysts and 14 dentigerous cysts. A total of 73% of the defects were in the mandible. The mean 3D follow-up time was 12 months. According to the 3D evaluation of bony regeneration, the defect size and configuration showed no significant differences between the groups (filled or non-filled with 15 defects per group). CONCLUSIONS: By establishing a standardized 3D method for evaluating bone regeneration, healing can be better monitored and evaluated.

Condyle modeling stability, craniofacial asymmetry and ACTN3 genotypes: Contribution to TMD prevalence in a cohort of dentofacial deformities.

Craniofacial asymmetry, mandibular condylar modeling and temporomandibular joint disorders are common comorbidities of skeletally disproportionate malocclusions, but etiology of occurrence together is poorly understood. We compared asymmetry, condyle modeling stability and temporomandibular health in a cohort of 128 patients having orthodontics and orthognathic surgery to correct dentofacial deformity malocclusions. We also compared ACTN3 and ENPP1 genotypes for association to clinical conditions. Pre-surgical posterior-anterior cephalometric and panometric radiographic analyses; jaw pain and function questionnaire and clinical examination of TMD; and SNP-genotype analysis from saliva samples were compared to assess interrelationships. Almost half had asymmetries in need of surgical correction, which could be subdivided into four distinct morphological patterns. Asymmetric condyle modeling between sides was significantly greater in craniofacial asymmetry, but most commonly had an unanticipated pattern. Often, longer or larger condyles occurred on the shorter mandibular ramus side. Subjects with longer ramus but dimensionally smaller condyles were more likely to have self-reported TMD symptoms (p = 0.023) and significantly greater clinical diagnosis of TMD (p = 0 .000001), with masticatory myalgia most prominent. Genotyping found two significant genotype associations for ACTN3 rs1671064 (Q523R missense) p = 0.02; rs678397 (intronic SNP) p = 0.04 and one significant allele association rs1815739 (R577X nonsense) p = 0.00. Skeletal asymmetry, unusual condyle modeling and TMD are common and interrelated components of many dentofacial deformities. Imbalanced musculoskeletal functional adaptations and genetic or epigenetic influences contribute to the etiology, and require further investigation.