1. Dr. Bouquot, Oral Injuries
Fall, 2011
Residual (ghost) Sockets
Radiographic features & histopathology
of poor healing in 76 cases
J.E. Bouquot,* W.P. Glaros,** S. Zarghouni *
* University of Texas, Houston
** Private Practice, Houston, Texas
Dr. J. E. Bouquot, Professor & Chair
Department of Diagnostic Sciences. Room 3.094b
University of Texas School of Dentistry
6516 M.D. Anderson Blvd., Houston, TX 77030 ;

2. Residual sockets Background
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets Background
When a tooth is extracted a great deal happens:
PDL necrosis
Lamina dura disappears
New crestal cortex forms
Mucosa covers defect
Inflammation/granulation tissue
Blood vessels heal
Fibroplasia
Nerves regenerate/heal
Socket fills with new bone
-- Starts from periphery
New bone remodels
But does it?

3. Residual sockets Background
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets Background
Alveolar bone remodels after extraction to accommodate altered physiologic stresses
Result: loss of socket outline in 3-9 months
However: outlines of poorly remodeled or residual (ghost) sockets are not uncommon in patients, even decades after extraction
Very few have explanatory disease or meds
Remain indefinitely? Probably
Laminar rain

4. Residual sockets Background
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets Background
1850s: Poor healing of sockets in phosphorus toxicity (“phossy jaw”)
1860s; chronic osteitis (ischemic bone disease)
1952: Box: 1,120 hollow 3rd molar sockets
2003: BRONJ in metastatic cancer
-- Bisphosphonates (Zometa, Aredia)
-- Poor healing of sockets
-- Chronically exposed bone, pain
-- Micro = acute osteomyelitis
-- Considerable interest in bone physiology,
healing, bone turnover, etc.
Phossy jaw,
circa 1860
BRONJ
(above photos = same patient)

5. Residual sockets Background
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets Background
2006: BRONJ in osteoporosis (Fosamax, etc.)
2007: First report of BRONJ-like exposed alveolar bone *
2009: 1st report of BRONJ (Zometa Rx for breast cancer) with numerous residual sockets remaining after 18 months **
No characterization yet of residual sockets
BRONJ-like osteonecrosis, unknown etiology
BRONJ with sockets remaining after 18months
Same patient as above
* Bouquot J, Moore E. Osteonecrosis of the jaws – exposed bone without the bisphosphonates. Proceedings, annual meeting,
American Academy of Oral Medicine
** Shetty K, Bouquot J. Residual (ghost) sockets in bisphosphonate use. Gen Dent 2009; 57:

6. Residual sockets Objective & methods
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets Objective & methods
Objective:
To report the surgical and microscopic appearance of a series of radiographically
visible residual sockets biopsied years and
decades after extraction
Methods:
76 cases identified from 3 biopsy services
over a 22 year period
Information from biopsy request form:
-- Demographic information
-- Lesion location
-- Historical information
-- Clinical signs & symptoms
-- Surgical description
This is a convenience sample; no frequency rates can be suggested
IRB approval from the University of Texas Health Sciences Center at Houston

7. Residual sockets demographics, location, ETC. (N =76 cases)
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets demographics, location, ETC. (N =76 cases)
Average age at biopsy was 54 years
-- Age range: years
Onset of socket: decades since extractions (none < 5 years)
No known etiologic factor
81.6% (n = 62): in females
84.2% (n = 64): in mandible
97.4% (n = 74): molar/premolar area
35.5% (n = 27): ghost marrow of
nearby bone *
* Ghost marrow (see photos): faint ground glass
appearance; evidence of ischemic damage; term is
derived from orthopedic/radiology literature

8. Residual sockets clinical features (N =76 cases)
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets clinical features (N =76 cases)
38.2% (n =29): pain/tenderness
No mention of clinical saucerization
No mention of decreased alveolar
height or width
5.3% n = 4): sharp socket rim
18.4% (n = 14): multiple sockets
7.9% (n = 6): bilateral
Sharp (unremodeled?) socket rim
Bilateral residual sockets
(above 2 photos = same patient)

9. Residual sockets radiology (N =76 cases)
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets radiology (N =76 cases)
77.6% (n = 57): socket-shaped outline
% (n = 34) = complete outline
% (n = 23) = partial outline (usually <50%)
22.4% (n = 17): rounded radiolucencies
-- 12 = poorly demarcated
= well demarcated
= Eagle’s nest
= small lamina dura at edge
1.3% (n =1): osteosclerosis nearby
17.1% (n = 13): radiolucencies nearby
35.5% (n = 27): ghost marrow nearby
Complete socket
Round radiolucency
Eagle’s nest
Eagle’s nest
Partial sclerotic rim

10. Residual sockets radiology (N =76 cases)
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets radiology (N =76 cases)
Fiber filled socket
Ghost marrow
Ghost marrow

11. Residual sockets Surgical appearance (N =76 cases)
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets Surgical appearance (N =76 cases)
32.9% (n = 25): covered by crestal bone
67.1% (n = 51): covered by fibrous scar
67.1% (n = 51): hollow, “air-filled”
13.2% (n = 10): filled with fatty marrow
10.5% (n = 8): filled with fibrous scar
-- 4 = chronic inflammatory cells in socket
9.2% (n = 7): unremodeled bone
Cortex so thin perio probe can perforate it
Fibrous scar; fibrous
“cortex”
Hollow socket
Hollow socket
Hollow sockets
Hollow socket with exposed nerve
Necropsy example: Adams WR, Spolnik KJ, Bouquot JE. J Oral Pathol Med 1999.

12. Residual sockets Hollow socket (n = 51)
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets Hollow socket (n = 51)
67.1% = Cavitated
Debris & fibrosed marrow
Cavitation
Edges:
Bare bone
Thin fibrous layer
Thin layer of new bone
Thin layer of fatty marrow
Partially nonviable
(n = 18 of 51)
Ischemic myelofibrosis
Case 17
Cavitation
Cavitation
Inactive new bone
Partially nonviable lamina dura
Case 17
Case 17

13. Residual sockets marrow-filled socket (n = 10)
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets marrow-filled socket (n = 10)
13.2% =
Fatty Marrow
Marrow fibrosis
Features:
Bare bone
Thin fibrous layer
Thin layer of new bone
Thin layer of fatty marrow
Partially nonviable
(n = 18 of 61)
Marrow fibrosis
Inactive new bone
Does this represent many of the
focal osteoporotic marrow defects?

14. Residual sockets marrow-filled socket, with nerve
1 case: apical nerve remains
Nerve

15. Residual sockets intramedullary fibrous scar (n = 8)
10.5% =
Fibrous Scar
Intramedullary fibrous scar:
Dense, avascular collagen
Focal regions with lymphocytes
Viable bone on edges
Normal PDL

16. Residual sockets chronic fibrosing osteomyelitis (n = 4)
Moderately loose fibrosis of marrow
Few remaining adipocytes
Chronic inflammatory cells
Viable bone
Often: osteoblastic activity

17. Residual sockets chronic fibrosing osteomyelitis (n = 4)
Moderately loose fibrosis of marrow
Few remaining adipocytes
Chronic inflammatory cells
Viable bone
Often: osteoblastic activity

18. Residual sockets unremodeled bone (n = 7)
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets unremodeled bone (n = 7)
9.2% = Unremodeled Bone
Case 42
Case 8
Lamina dura
Socket:
New bone
No active osteoblasts
Fatty marrow in background
Medullary congestion
Microcracks
Lamina dura
Lamina dura
Case 42
Case 8
Medullary congestion
Case 8
Microcrack
Lamina dura
Case 42

19. Residual sockets unremodeled bone (n = 7)
Microcrack
Case 26
Case 26
Case 26
Case 26

20. Bone& marrow outside the sockets

21. Residual sockets Cone beam CT may show adjacent pathology
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets Cone beam CT may show adjacent pathology
Residual socket
Residual socket
Regional ischemic osteoporosis
(variant of bone marrow edema)
RIO
Ghost marrow

22. Residual sockets fibrosis outside socket
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets fibrosis outside socket
Intramedullary fibrous scar, outside socket:
Dense, avascular collagen
Focal regions with lymphocytes
Viable bone on edges

23. Residual sockets abnormal bone/marrow outside socket
Bone marrow edema outside sockets:
Ischemic myelofibrosis
Medullary congestion
Focal hemorrhage
(microinfarction)
Oil cysts
Granular adipocytes
Viable bone
59.2% (n = 45) = ischemia or inflammation
of surrounding bone marrow
Ghost marrow; cavitation

24. Residual sockets in situ case: unremodeled bone inside socket
Ghost marrow outside sockets =
bone marrow edema
Ischemic myelofibrosis
Viable bone
Medullary congestion
Plasmostasis
Microinfarction
Oil cysts, mast cells
Few inflammatory cells
Case 8
Case 8
Case 8
Outside sockets: bone marrow edema
Case 8
Case 8
Inside sockets: unremodeled bone

25. Residual sockets bone marrow edema inside/outside socket
Case 21
Case 21
Ischemic myelofibrosis
Viable bone
Medullary congestion
Plasmostasis
Microinfarction
Oil cysts, mast cells
Few inflammatory cells
Case 21

26. Residual sockets in situ case: chronic fibrosing osteomyelitis
Why is this socket inflamed 14 years after extraction?
How can this happen?
New infection?
Fibrosis keeping out the immune system?
A sign of the devil?

27. Residual sockets conclusions
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets conclusions
Residual sockets represent poor bone healing or remodeling, probably from chronic ischemia, low grade inflammation or an unidentified systemic disorder that affects bone growth and repair
Most examples are asymptomatic and may not need surgical treatment
May act as “red flag” to alert the surgeon or dentist to potential healing problems in subsequent surgery, implant placement or trauma of alveolar bone

28. Residual sockets Surgical appearance: Hollow space
© Photo(s): Dr. J.E. Bouquot, University of Texas, Houston,: presented at AAOM annual meeting, 2012
Residual sockets Surgical appearance: Hollow space
Case 65
Case 65
Ghost marrow
67% = cavitated
How can this be?
Variant of traumatic bone cyst?
Variant of ischemic cavitation?
Poor circulation from early life?
Sockets in dried mandible