PMC4045108_01
Clinical presentation of the patient. Root fragments in the areas of #19 and 30 can be seen. However, no evidence of bone exposure or fistula formation is present.
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F1
Upon examination, there were multiple carious and fractured teeth that were sensitive to palpation including teeth 4 and 14, with only root tips present of 5, 12, 19, and 30 (Fig 1).
A) Panoramic radiograph of patient at the time of presentation. B) and C) magnified areas of the panoramic radiograph focusing on the posterior right and left mandible, respectively. White arrows point to the root fragments, while black arrows show areas of increased bone density.
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F2
The panoramic radiograph revealed multiple grossly carious teeth (Fig 2, white arrows) with widening of the periodontal ligament (PDL) space and loss of lamina dura, suggestive of periapical disease. In particular, increased alveolar bone density was observed around teeth # 19 and 30 (Fig 2B and C, black arrows).
Axial (A, D), cross-sectional (B, E) and sagittal (C, F) cone beam CT (CBCT) slices of the patient's right (A, B, C) and left (D, E, F) posterior mandible. White arrows point to root fragments, black arrows to areas of increased trabecular density and loss of trabecular architecture, and white arrowhead to radiolucent areas.
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F3
The CBCT scans showed the root fragments of teeth 19 and 30 (Fig 3, white arrows) and increased trabecular density of the alveolar ridge with loss of trabecular architecture (Fig 3, black arrows). Multiple small areas of osteolysis were also observed (Fig 3, white arrowheads).
Axial (A), cross-sectional (B) and sagittal (C) CBCT slices through the area of the lingual cortical plate of the posterior right mandible. White arrowheads delineate the sequestrum outline.
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F4
This bone fragment extended from the distal surface of # 30 to the distal surface of # 32 (Fig 4, white arrowheads), highly suggestive of a bone sequestrum.
4X (A), 10X (B), and 20X (C) magnification of H&E stained histologic sections of the bone fragment. Blue arrows point to empty osteocytic lacunae, while green arrows point to neutrophil rimming of the bone. No osteoblasts, osteocytes or osteoclasts are seen.
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F5
Hematoxylin and eosin staining revealed complete osteonecrosis with empty osteocytic lacunae (Fig 5, blue arrows) and rimming by neutrophils (Fig 5, green arrows) throughout the full extent of the bone fragment.