Clinical History:
31-year-old female with history of left facial swelling adjacent to nose.
Figure A |
Figure B |
Figure 1C
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Figure 1D |
Radiographic Findings:
There is a 2 cm mass in the soft tissue on the anterior aspect of the left
maxilla and adjacent to the nose (Image
A). On the bone window, one can appreciate a 2 mm round calcific
density within the portion of the mass which is immediately adjacent to
the maxilla (Image
B). If one compares this to the normal right side, one will realize
that this is actually the root apex of the canine tooth. The normal right
canine has bone surrounding the root apex, while the abnormal left side
demonstrates loss of bone and radiolucency around the root apex.
Discussion:
Any time there is a soft tissue mass or swelling in the region of the
mandible or maxilla, don't forget about dental pathology (and in particular
dental infection) as a possible cause. A periapical dental abscess most
frequently arises from dental caries. If the decay is deep enough, the
bacteria can enter the pulp chamber (radiolucent central portion of tooth
crown containing the neurovascular structures) and travel down the root
canal (radiolucent central portion of root containing neurovascular structures)
to the apical foramen (foramen at root apex where neurovascular bundle
enters root). Here the infection propagates and gradually erodes the bone
around the root apex creating a periapical radiolucency. (Images
C & D).
If one looks for them, these periapical radiolucencies will frequently
be seen on routine CTs that image the mandible and maxilla (i.e. neck
CT, C-spine CT). Since the tooth cannot expand, the swelling and increased
pressure within the pulp chamber causes decreased perfusion and finally
death of the tooth. Periapical radioluciencies are therefore usually associated
with a non-vital tooth.
Treatment consists of a root canal procedure, whereby the endodontist
drills out the root canal to allow the infection to drain. The apical
foramen is then sealed and the root canal filled with a radiopaque material.
A crown is typically placed on the tooth to avoid discoloration associated
with non-vital teeth.
On Image C, from a patient with trauma from an automobile collision,
the left central incisor appears to be missing. If one looks at the coronal
section (Image
D), one will notice that this actually represents a periapical
radiolucency from endodontal disease. Note how the lucency surrounds the
root apex. These periapical abscesses usually remain within the confines
of the bone, but occasionally they break through to the soft tissues as
in images A & B.
Diagnosis:
Periapical abscess (endodontal disease) of left canine extending into
soft
References:
- Abrahams JJ, Berger SB. Inflammatory Disease
of the Jaw: Appearance on Reformatted CT Scans. Am
J Roentgenol1998;170(4):1085-91. tissue
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