Differential Diagnosis of Oral and Maxillofacial lesions 1

Differential Diagnosis of Oral and Maxillofacial lesions 1. Solitary cystlike Radiolucencies not necessarily contacting teeth 2. Multilocular radiolucencies 1. 顎骨中未必接觸牙齒之單一囊狀放射線透射性病灶 2. 多房性放射線透射性病灶 王文岑 助理教授 高雄醫學大學 牙醫學系 高醫大附設醫院S 棟 2 樓 口腔病理影像診斷科 07 -3208284; wcwang@kmu. edu. tw Wen. Chen Wang

學習目標 | 複習顎骨中的單囊狀及多房性放射線透射 病灶之疾病與成因，並學習其相關之鑑別 診斷。 學習資源及主要圖片引用: 1. Differential diagnosis of oral lesion. Wood, Gooz(Mosby), 5 th ed. , 1997. 2. Neville and Damm et al: Oral & maxillofacial patholgy, 3 rd ed. 3. 口腔病理科門診臨床記錄 Wen. Chen Wang

Radiopaque Bony Lesions Radiolucent mixed with radiopaque Radiolucent Contacting tooth Not contacting tooth Inter-radicular Periapical ★ Solitary cystlike Pericoronal ★ Multilocular Solitary-ragged Multiple, separate Generalized. Wen. Chen rarefaction Wang

Cystlike lesion Dark radiographic image , circular in outline and usually smoothly contoured with well-defined borders | Ref. 1 Wen. Chen Wang

Marrow spaces Ref. 1 Wen. Chen Wang

Maxillary sinus Ref. 1 Wen. Chen Wang

Ref. 1 Wen. Chen Wang

Early stage of tooth crypt Ref. 1 Postextraction socket Wen. Chen Wang

Residual cyst -Cyst remained after its associated tooth has been lost -Age >20 y/o -Surgical intervention Ref. 1 Wen. Chen Wang

Traumatic bone cyst Classically: | Above the mandibular canal | Vital tooth, scallpoed appearance | Solitary (majority) or multiple (bilateral) | post. Mandible, ramus | <30 y/o | 95% containing fluid or empty | Surgical curettage | May coexist with fibro-osseous lesion Ref. 1 Wen. Chen Wang

Q: A 40 y/o male, a tooth removed due to hypermobility, what were the possible diagnosis ? Ref. 1 Wen. Chen Wang

Ref. 2 Multilocular RL, bony Wen. Chen expansion Wang

Lingual mandibular bone defect Stafne cyst; static bone cyst - A well-defined RL in the post. Region under mandibular canal Ref. 1 Wen. Chen Wang

Odontogenic keratocyst | | A well-defined multilocular (or unilocular) radiolucency Most common in post. mandible Resorb and /or move teeth, vital Multiple lesions in Gorlin syndrome Ref. 2 Wen. Chen Wang

Ameloblastoma-unicystic Ref. 1 | | Mean age: 23 y/o 90% in mandible, posterior region Wen. Chen Wang

practice | | | 21 y/o male 2 x 1. 5 cm cystlike RL lesion over an edentulous 3 rd molar region of the mandible asymptomatic, masndibular canal inferiorly displaced Less likely diagnosis: • Benign nonodontogenic tumor • Cemento-ossifying fibroma • Giant cell granuloma • Fissure cysts • 3 rd molar tooth crypt Ref. 3 More likely diagnosis: • Residual cyst • Traumatic bone cyst • Primordial cyst • OKC (Primordial type) • unicystic ameloblastoma • Odontogenic myxoma Wen. Chen Wang

Surgical defect Ref. 1 Wen. Chen Wang

Central giant cell granuloma | | Unilocular or multicular R-L Cortical bone expansion Well defined, corticated or not ; some are poorly defined Displace tooth follicle & roots, root resorption, lamina dura of adjacent teeth resorbed. Ref. 2 Ref. 1 Wang Wen. Chen

| | | Range 2 -80 y/o; 70% < 30 y/o Mandible : maxilla = 2: 1 More in mand. ant. to 1 st molar, 21% cross midline Painless swelling Multilocular RL, Vital mobile teeth bony expansion right angles to the outer expanded border Ref. 2 Central giant cell granuloma Wen. Chen Wang

Giant cell lesion Hyperparathyroidism | Diagnosis based on history and laboratory findings Ref. 2 Wen. Chen Wang

Chronic Renal Failure Phosphate Retention ↑ active Vit. D 3 calcium production↓ resorption ↓ Hypocalcemia PTH↑ Secondary Hyperparathyroidism Wen. Chen Wang

Fibroosseous lesion | | Early : Unilocular RL Later : Mixed RL with RO or RO Early stage of a COF Wen. Chen Wang

Incisive canal cyst | Enlargement of the Incisive foramen & canal , > 1 cm Ref. 1 Ref. 2 Wen. Chen Wang

Midpalatine cyst; median palatal cyst Ref. 1 Wang Wen. Chen

Benign nonodontogenic tumors as radiolucencies in the jaws Lipoma |Salivary gland tumors |Amputation neuroma |Neurofibroma, schwannoma |Leiomyoma |Fibroma | Ref. 1 Wen. Chen Wang

Ref. 1 Metastatic bronchogenic carcinoma Wen. Chen Wang

Aneurysmal bone cyst Unilocular RL Ref. 2 Multilocular RL, bony expansion Ref. 2 Ref. 1 | | | 90% < 30 y/o; Md. > Max. Proliferative response of vascular tissue R-L, expansile osteolytic process Wen. Chen Wang

Typical locations of odontogenic and nonodontogenic cysts Ref: Essentials of Dental Radiography and Radiology, 4 th edition, 2007 Summary Wen. Chen Wang

Multilocular radiolucencies Soap bubble Ref. 1, 3 Honeycomb Tennis racket Wen. Chen Wang

Maxillary sinus Ref. 1 Wen. Chen Wang

Marrow spaces Ref. 1 Wen. Chen Wang

Multilocular cysts | Odontogenic cyst: Dentigerous cyst Odontogenic keratocyst Lateral periodontal cyst Primordial cyst Glandular odontogenic cyst | Nonodontogenic cyst(pseudocyst): Aneurysmal bone cyst Traumatic bone cyst Wen. Chen Wang

Glandular odontogenic cyst Ref. 2 | middle-aged adults, mean=49 y/o；rarely before the age of 20 – 85％ in mandible. –strong predilection for the anterior region, cross midline Wen. Chen Wang

Ameloblastoma-conventional type | | | Wide age range, mean=39 y/o, rare in young children > 80% in mandible, molar-ramus Painless swelling or expansion the bone, benign but local invasive non-encapsulated and destructive seldom causes paresthesia may cause loosening of teeth or resorption Ref. 1 Ref. 2 Wen. Chen Wang

Ref. 3 32 y/o male, ameloblastoma Wen. Chen Wang

Ameloblastic fibroma | | | younger age gr. , not commonly over 21 y/o painless, asymptomatic, slow expansion of the cortical plates of the premolar and molar areas, more frequently in mandible Smooth, well-outlined cyst-like or radiolucency, cannot be differentiated from unilocular ameloblastoma, or multilocular Ref. 3 Wen. Chen Wang

Odontogenic myxoma Ref. 2 | | | 10 -50 y/o, without any sex predilection and slight preference for the mandible (3/4) Multilocur radiolucency of varying sizes separated by straight (tennis racket) or curved bony trabeculae (soap bubble appearance) May be unilocular RL or an i. II-defined RL Wen. Chen Wang

Ref. 2 Odontogenic myxoma, tennis racket appearance Wen. Chen Wang

Cherubism | | | Inherited developmental abnormality, only affects the jaws, cherubic appearance Age: 2 -20 y/o Multiple multilocular RL Ref. 2 Wen. Chen Wang

Vascular malformations(VM) and central hemangioma(CH) of bone | | | 35% VM occur in bone, CH rare 10 -20 y/o 50% multilocular, some are unilocular; well- or poor defined border Resorption of roots, some phleboliths may present Pulsation, occasionally parthesia; local hemorrhage Ref. 1 Wen. Chen Wang

Central Odontogenic Fibroma l l large lesion: multilocular radiolucencies. Many lesions have sclerotic border, root resorption or root divergence Ref. 2 Wen. Chen Wang

Ref. 1 16 y/o boy, severe hemophilia 23 y/o, hemophilia, condyle, ramus, coronoid process Wen. Chen Wang

Ref. 1 Intrabony neurilemoma Wen. Chen Wang

Summary Multilocular radiolucencies | | | Anatomic patterns Odontogenic cysts Odontogenic tumors ] ] | | | | Ameloblastoma Odontogenic myxoma Central giant cell grnuloma Giant cell lesion of hyperparathyroidism Cherubism Simple bone cyst Aneurysmal bone cyst Metastatic tumors to the jaws Vascular malformations and central hemangioma of bone Rarities Wen. Chen Wang