1. Solitary cystlike Radiolucencies not necessarily contacting teeth 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

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。 3.口腔病理科門診臨床記錄 學習資源及主要圖片引用: 1. Differential diagnosis of oral lesion. Wood, Gooz(Mosby), 5th ed., 1997. 2. Neville and Damm et al: Oral & maxillofacial patholgy, 3rd ed. 3.口腔病理科門診臨床記錄

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

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

Marrow spaces Ref. 1

Maxillary sinus Ref. 1

Ref. 1

Early stage of tooth crypt Ref. 1 Postextraction socket

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

Traumatic bone cyst Ref. 1 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

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

Multilocular RL, bony expansion Ref. 2 Multilocular RL, bony expansion

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

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 Ref. 2 Ref. 2

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

practice Ref. 3 Less likely diagnosis: Benign nonodontogenic tumor 21 y/o male 2x1.5 cm cystlike RL lesion over an edentulous 3rd molar region of the mandible asymptomatic, masndibular canal inferiorly displaced Ref. 3 Less likely diagnosis: Benign nonodontogenic tumor Cemento-ossifying fibroma Giant cell granuloma Fissure cysts 3rd molar tooth crypt More likely diagnosis: Residual cyst Traumatic bone cyst Primordial cyst OKC (Primordial type) unicystic ameloblastoma Odontogenic myxoma

Surgical defect Ref. 1

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. 2 Ref. 1

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

Giant cell lesion Hyperparathyroidism Diagnosis based on history and laboratory findings Ref. 2

Secondary Hyperparathyroidism Chronic Renal Failure Phosphate active VitD3 calcium Retention ↑ production↓ resorption ↓ Hypocalcemia PTH↑ Secondary Hyperparathyroidism

Fibroosseous lesion Early : Unilocular RL Later : Mixed RL with RO or RO Early stage of a COF

Enlargement of the Incisive foramen & canal , > 1cm Incisive canal cyst Enlargement of the Incisive foramen & canal , > 1cm Ref. 1 Ref. 2

Midpalatine cyst; median palatal cyst Ref. 1

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

Metastatic bronchogenic carcinoma Ref. 1 Metastatic bronchogenic carcinoma

Multilocular RL, bony expansion 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

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

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

Maxillary sinus Ref. 1

Marrow spaces Ref. 1

Nonodontogenic cyst(pseudocyst): 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

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

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. 2 Ref. 1

32 y/o male, ameloblastoma Ref. 3 32 y/o male, ameloblastoma

Ameloblastic fibroma Ref. 3 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

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 iII-defined RL

Odontogenic myxoma, tennis racket appearance Ref. 2 Odontogenic myxoma, tennis racket appearance

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

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

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

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

Intrabony neurilemoma Ref. 1 Intrabony neurilemoma

Multilocular radiolucencies 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