Dentomaxillofacial Radiology (2009) 38, 23-27
© 2009 British Institute of Radiology
doi: 10.1259/dmfr/20664232
Ultrasonography and Doppler ultrasonography in the evaluation of intraosseous lesions of the jaws
AP Sumer*,1,
M Danaci2,
E Özen Sandikçi3,
M Sumer3 and
P Celenk1
1Ondokuz Mayis University, Faculty of Dentistry, Department of Oral Diagnosis and Radiology, Samsun, Turkey; 2Ondokuz Mayis University, Faculty of Medicine, Department of Radiology, Samsun, Turkey; 3Ondokuz Mayis University, Faculty of Dentistry, Department of Oral and Maxillofacial Surgery, Samsun, Turkey
*Correspondence to: Dr A Pinar Sumer, Ondokuzmayis University, Faculty of Dentistry, Department of Oral Diagnosis and Radiology, 55139 Samsun, Turkey. E-mail: psumer1970{at}yahoo.com
Received 26 November 2007;
revised 4 February 2008;
accepted 12 February 2008
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Abstract
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Objectives: To evaluate the efficacy of ultrasonography and colour and power Doppler ultrasonography for diagnosis of intraosseous lesions of the jaws and to correlate the contents of the lesion with the histological findings.
Methods: This study included 20 patients referred to the oral surgery clinic for treatment. All patients had intraosseous jaw lesions in the maxilla or mandible. Ultrasonographic examinations were performed and, according to the ultrasonography findings, the jaw lesions were classified into three groups: cystic, semisolid and solid. Additionally, colour and power Doppler ultrasonography examinations were performed to evaluate blood flow in all patients. After the ultrasonography examination, the patients underwent surgical treatment. The correlation between ultrasonography and Doppler ultrasonography findings of the lesions and histological findings was investigated.
Results: 22 lesions were identified in 20 patients. Of the five lesions with histological findings of inflammatory granulation tissue, ultrasonography identified four of them that showed a solid appearance. Vascularization was detected in both internal and external areas of these lesions with colour and power Doppler ultrasonography. Of the 17 odontogenic cystic lesions, the ultrasonography examination showed a simple cystic appearance in 5 lesions, a complex cystic appearance in 3 lesions, a semisolid appearance in 6 lesions and a solid appearance in 1 lesion. Two lesions were inconclusive on ultrasonographic examination.
Conclusions: Ultrasonography can provide accurate information on the content of intraosseous lesions of the jaws before any surgical procedure. Additionally, Doppler ultrasound can show vascularization of the lesion. However, there was no correlation between the ultrasound findings and the definitive histological diagnosis.
Keywords: ultrasound, colour power Doppler, jaws, diagnosis
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Introduction
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The jaw is a common anatomical site for the development of odontogenic and non-odontogenic lesions. Because of the wide variation of these lesions, the diagnosis is complex.1 Conventional radiographs play an important role in the detection, treatment and follow-up of bone lesions.
As technology improves, CT has been used occasionally to aid in diagnosis of conditions in the bone. However, routine use of CT is associated with high radiation doses, even though dose reduction methods have been established.2 Low dose cone beam CT has recently been developed specifically for use in the dental and maxillofacial regions. MRI is another specialized imaging modality that does not involve the use of ionizing radiation and is important in imaging intracranial and soft tissue lesions. It has proved useful in differentiating between normal and abnormal tissues. However, equipment is very expensive and tends to be claustrophobic, scanning time can be long and it is contraindicated in patients with certain types of surgical clips, cardiac pacemakers and cochlear implants.3 The use of ultrasound is of importance in evaluating the solid and cystic components of jaw lesions.1, 4 Although ultrasound imaging technology, a safe and minimally invasive procedure, has been in use in medicine for many years, its use in dental medicine has been limited and mainly restricted to soft tissue applications.4, 5
Recent studies have focused on potential applications of ultrasound for periodontal assessment,4 imaging of the temporomandibular joint6, 7 and mandibular fracture evaluation.8 The number of studies investigating the role of ultrasound in the diagnosis of bone lesions of the jaw is limited. Lauria et al1 first evaluated the role of ultrasound as a complementary examination in the diagnosis of intraosseous lesions of the jaws. However, power and colour Doppler ultrasound was not used in their study. In 20029 and 200310 Cotti et el, and in 2006 Gundappa et al11 reported positive findings using ultrasound in the differential diagnosis of periapical lesions. The use of Doppler ultrasound allows blood flow to be detected. For the differentiation of lesions in the other parts of the body, the Doppler index (resistive index, pulsatility index) could have been used.
The purpose of this study is to evaluate the efficacy of ultrasound and colour and power Doppler ultrasound for diagnosis of intraosseous lesions of the jaws and to correlate the contents of the lesion with the histological findings.
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Materials and methods
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20 patients referred to the oral surgery clinic for treatment were evaluated. All patients had intraosseous jaw lesions in the maxilla or mandible, based on their symptoms, clinical and panoramic radiographic findings. After the confirmation of an intraosseous lesion, an ultrasound examination was performed in all patients to detect the lesions and to evaluate their content, size, and the relationship with anatomical structures. All patients were informed about the study and signed an informed consent.
All patients underwent Doppler ultrasound evaluation by the same radiologist and the images were analysed at the same time the examination was done. The examinations were performed with a colour-coded duplex scanner (Toshiba Aplio 80; Toshiba, Tokyo, Japan) with a 7.5 MHz linear-array transducer. There was no histological result at the time of the examination and the radiologist did not have access to the radiographs before ultrasound examination. The ultrasound probe was positioned outside the mouth on the skin overlying the intraosseous lesion. Its position was changed several times to obtain good quality transverse, oblique and longitudinal scans.
According to the ultrasound findings, the jaw lesions were classified into three groups: cystic, semisolid and solid. The cystic definition was made based on posterior enhancement and anechoic area where no reflection occurs. Cystic lesions were also classified into two groups; totally anechoic lesions with limited or without internal echoes were defined as simple cysts and the lesions containing dense internal echoes or high echo-intensity were defined as complex cysts. The semisolid definition was made when cystic and solid areas were combined in the same lesion. Solid lesions had no liquid component and posterior enhancement and had a moderate echo pattern.
After ultrasound examination, colour and power Doppler ultrasound examinations were performed to evaluate blood flow within or surrounding the examined lesion in all patients. The filter settings were chosen to evaluate and determine the slow blood flow.
After the ultrasound examination, the patients underwent surgical treatment and the specimens were submitted for routine histopathologic examination. After obtaining histological results of the lesions, the correlation between ultrasound and Doppler ultrasound findings of the lesions and histological findings were investigated.
No discomfort was experienced by the patients when the ultrasound examination was performed.
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Results
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22 intraosseous lesions from 20 patients were evaluated in this study. 11 lesions were located in the posterior region of the mandible and 11 were in the anterior region of the maxilla. All lesions had a radiolucent appearance with well-defined borders in panoramic radiographs, except one lesion. This lesion, histologically diagnosed as an odontogenic keratocyst, had a multilocular appearance with panoramic radiography. Of the 22 lesions, the ultrasound examination was inconclusive in three lesions because of the thick cortical vestibular bone plate.
The lesions' ultrasonographic and Doppler findings and histological diagnosis are shown in Table 1
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Odontogenic cyst was diagnosed by histological examination in 17 specimens (4 odontogenic keratocysts, 7 radicular cysts, 4 residual cysts, 2 dentigerous cysts), and 5 specimens were inflammatory granulation tissue. Of the 17 odontogenic cystic lesions, the ultrasound examination showed a simple cystic appearance in 5 lesions (Figure 1), complex cystic appearance in 3 lesions (Figure 2), semisolid appearance in 6 lesions (Figure 3), solid appearance in 1 lesion. Of the other two lesions, ultrasound examination was inconclusive due to the thick vestibular bone palate. Vascularization was not detected at the colour and power Doppler ultrasound in 14 odontogenic lesions. One solid lesion of the odontogenic cysts was a radicular cyst and internal vascularization was detected within this lesion.
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Figure 1 A case of radicular cyst shows simple cystic appearance. (a) Panoramic radiograph showing a radiolucent lesion on the right of the maxilla. (b) Ultrasound image showing anechoic lesion without internal echoes. (c) Schematic drawing of this lesion
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Figure 2 A case of odontogenic keratocyst shows complex cystic appearance. (a) Panoramic radiograph showing a radiolucent lesion on the left of the mandible. (b) Ultrasound image showing complex cyst with dense internal echoes. (c) Schematic drawing of this lesion
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Figure 3 A case of radicular cyst shows semisolid appearance. (a) Panoramic radiograph showing a radiolucent lesion on the right anterior maxilla. (b) Ultrasound image showing semisolid lesion. (c) Schematic drawing of this lesion
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Of the five lesions with histological findings of inflammatory granulation tissue, the ultrasound showed four of them as a solid appearance (Figure 4). Vascularization was detected at both the internal and the external areas of these lesions at colour and power the Doppler ultrasound (Figure 5). In one case, the ultrasound finding was inconclusive because of the thick cortical bone plate.
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Figure 4 A case of inflammatory granulation tissue shows solid appearance. (a) Panoramic radiograph showing a radiolucent lesion on the right posterior mandible. (b) Ultrasound image showing solid lesion. (c) Schematic drawing of this lesion
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Figure 5 Colour and power Doppler ultrasound image of inflammatory granulation tissue shows both internal and external vascularization
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Discussion
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In 1996, Lauria et al1 reported positive findings using ultrasound in the differential diagnosis of bone lesions of the jaw. They evaluated the ultrasonographic aspects of 72 jaw lesions and proposed the use of ultrasound as a complementary examination for the diagnosis of intraosseous lesions of the jaws. Clinical studies demonstrated that ultrasound imaging was a promising diagnostic technique that had the potential to be used in the assessment of periradicular lesions of endodontic origin.9–11 It was reported that there was a definitive correlation between the echostructure of the periapical lesions and histopathological features.11
Ultrasound imaging will facilitate the differential diagnosis between solid and cystic lesions, but not establish the definitive diagnosis.1 No adverse effects of ultrasound waves have been reported in the tissues.12 Additionally, colour and power Doppler ultrasound can provide information about the presence of blood flow within or around the examined tissue. However, the presence of intact and thick vestibular cortical bone, the occurrence of infected cysts and solid areas within cystic lesions can cause pitfalls in the interpretation of ultrasonograms.1
In the five cystic lesions defined as a simple cyst on ultrasound, the findings of ultrasound and Doppler ultrasound were compatible with the content of the lesions. Based on the results of a previous study the ultrasound aspect was compatible with the histological finding in 73.9% of the cystic lesions.1
In three lesions, histologically diagnosed odontogenic keratocysts, ultrasound examination showed complex, dense cystic content with no evidence of internal vascularization. This finding is consistent with and confirms findings made by Lauria et al.1 In their study, a dense, cystic content was identified in ultrasound examination in seven of nine cases. The ultrasound aspect was important for odontogenic keratocysts because odontogenic keratocysts have the highest recurrence rate of any odontogenic cyst. For surgical treatment, more attention should be devoted to the complete removal of the cyst walls to reduce the chance of recurrence. Also, it is important to make periodic post-treatment radiographic examinations.13
A radicular cyst was solid on ultrasound and it had internal vascularization on colour and power Doppler ultrasound. Histopathologic reports of this lesion showed simple cysts containing extensive active and chronic inflammation. Ultrasound findings were compatible with lesion content and these findings were explained on the basis of the associated inflammatory process and the thick capsule of the lesions.1
Six other odontogenic cysts having different histopathology were semisolid on ultrasound and they had no vascularization on Doppler ultrasound.
Although ultrasound examination showed odontogenic cysts and their content, there was no correlation between ultrasound findings and the histological result. Three radicular cysts had different ultrasound findings. Radicular cysts were seen on ultrasound as a simple cyst, semisolid or solid.
The four cases in which the ultrasound images displayed lesions with solid content and a rich internal and external vascularity were described as infected granulomas from a histological standpoint. In one study, 11 periapical lesions that were assessed based on their contents and the lesions histologically classified as periapical granulomas showed a vascularization that varied from rich to scattered on colour power Doppler examination.10
In conclusion, ultrasound can provide accurate information on the content of intraosseous lesions of the jaws before any surgical procedure. It is non-invasive, low cost and recommended as a complementary imaging modality for intraosseous lesions of the jaw. Additionally, the use of colour and power Doppler ultrasound allows the detection of vascularization within or around the examined tissue. However, there was no correlation between the ultrasound findings and the definitive histological diagnosis. Therefore, ultrasound did not eliminate the necessity of routine use of biopsy or surgery to obtain the final diagnosis for intraosseous lesions with similar radiologic images. Our study was composed of a limited number of patients. There were no malignant lesions and great number of different benign lesions. Further studies for the multiple differential diagnosis of intraosseous lesions of the jaws are necessary to clarify ultrasound and Doppler ultrasound findings.
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References
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- Dula K, Mini R, van der Stelt PF, Lambrecht JT, Schneeberger P, Buser D. Hypothetical mortality risk associated with spiral computed tomography of the maxilla and mandible. Eur J Oral Sci 1996;104:503–510.[Medline]
- Whaites E. Essentials of dental radiography and radiology (4th edn). London: Churchill Livingstone, Elsevier, 2007.
- Tsiolis FI, Needleman IG, Griffiths GS. Periodontal ultrasonography. J Clin Periodontol 2003;30:849–854.[Medline]
- Imbeau J. Introduction to through-transmission alveolar ultrasonography (TAU) in dental medicine. Cranio 2005;23:100–112.[Medline]
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- Gundappa M, Ng SY, Whaites EJ. Comparison of ultrasound, digital and conventional radiography in differentiating periapical lesions. Dentomaxillofac Radiol 2006;35:326–333.[Abstract/Free Full Text]
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- White SC, Pharoah MJ. Oral radiology principles and interpretation (4th edn). Philadelphia, PA: Mosby, Inc, 2000.
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Abstract
Introduction
