CDA Essentials 2019 • Volume 6 • Issue 4

36 | 2019 | Issue 4 S upporting Y our P ractice observation; one could see them in osteogenic sarcoma but usually doesn’t and one almost always sees more destruction with osteosarcomas and tumour (malignant) bone. I don’t see either here. So the differential diagnosis is osteomyelitis, the narrowest of differentials. These findings have to be integrated into the clinical findings and the history; if you are particularly worried, you could biopsy it. This case should probably be managed by an oral and maxillofacial surgeon since amelioration of it will be difficult.   Observations • The right and left condylar processes of the mandible are malpositioned in the articular fossae and are also misshapen. The condylar necks are short. The coronoids are normal. • The inferior border of the mandible is lost in the first permanent molar/second premolar area. We are missing the first permanent molar in the right mandible. • Let’s focus on the mandible: The right vertical ramus of the mandible shows a few things: - It is almost entirely radiopaque. - It is difficult to see where the trabecular bone ends and the cortical bone begins. - These findings continue in towards the posterior horizontal ramus of the mandible. The region of interest is a mixed lucent opaque one that is poorly demarcated, not corticated, not encapsulated. It extends from the right condylar head to the right mandibular permanent cuspid and top to bottom in the mandible. It is centred in the mandibular right first permanent molar region. This may be where this issue began. The internal structure is “leftovers” or residual, but there are notable areas of significant bone destruction in the inferior border, around the apex of the mandibular right third molar and within the right posterior mandible. Do you see anything in the right mandible between the premolars and molars? There could be a discontinuity, a band of lucency between the posterior portion of the mandible and the anterior parts. • Turning to the internal structure, there is residual bone and also areas of dense radiopacity surrounded by radiolucency. These most certainly are sequestra and sclerosing osteitis in the whole of the right mandible. • Effect on adjacent structures: the mandibular canal cortices are lost throughout parts of the region of interest, there may be widening of the periodontal ligament space on the mesial of the second molar, there is definite discontinuity of the inferior mandibular cortex; the alveolar bone is ratty. Case 3: Patient presents after being treated for base of tongue cancer, following a crack-like sound when he opened wide to yawn. He now has trismus. The soft tissues are normal and he has been cancer-free for eight years. A panoramic radiograph was taken. ( Figure 3 ) Fig. 3 continued on p. 38