HTC (COMBINED) Flashcards

Question

Which cyst has been associated w/ enamel extensions into furcation areas of the involved teeth?

Answer 1

**Paradental Cyst**

Answer 2

**Extraction** of the _tooth along with the lesion_

Answer 3

Paradental Cyst

Answer 4

Paradental Cyst

Answer 5

_Similar to **a paradental cyst**_ ‐ **EXCEPT**: location is _central on the buccal of mandibular first molars_

Answer 6

The eruption of ***the permanent first molar***

Answer 7

seen as * swelling * tenderness of soft tissue over involved area

Answer 8

▪ Radiolucency best seen with **an occlusal radiograph**

Answer 9

**Buccal Bifurcation Cyst** *as seen in occlusal radiographs*

Answer 10

**Buccal Bifurcation Cyst** *as seen in occlusal radiographs*

Answer 11

▪ **Enucleation** **of cyst**; tooth extraction unnecessary ▪ Some cases _resolve w/o surgery_ ▪ Some resolve _w/ daily irrigation_ of buccal pocket with saline/hydrogen peroxide

Answer 12

**Follicular Cyst**

Answer 13

**Dentigerous Cyst**

Answer 14

*_Originates_*: by **the separation** of the _follicle_ from the _crown of an unerupted tooth_ *_Pathogenesis_*: **accumulation of fluid** between the tooth and the _reduced enamel epithelium_

Answer 15

▪ Small cysts typically asymptomatic and picked up on routine radiographic exam ▪ Large lesions may show expansion of bone ▪ Cysts may become infected, especially if partially erupted tooth

Answer 16

* Mostly **mandibular 3rd molars** (rarely unerupted deciduous teeth) * Most commonly present in **2nd and 3rd decades**

Answer 17

* **Attached to the tooth at the CEJ**

Answer 18

**enlarged/hyperplastic follicle** Rule of thumb: * If 4‐5mm or more of radiolucency ► _dentigerous cyst_ * If \<4mm of radiolucency► can be _hyperplastic follicle_

Answer 19

_dentigerous cys_t b/c **\*attachment at CEJ**

Answer 20

**Dentigerous Cyst**

Answer 21

**dentigerous cyst**

Answer 22

**dentigerous cyst**

Answer 23

**dentigerous cyst**

Answer 24

Grossly image of Dentigerous Cyst

Answer 25

* **Decompression**: Try to open window in the jawand put tube into cyst lumen and have pt irrigate a few times a day for a few weeks ► release pressure and allows bone to grow back ► **cyst will shrink** * If get rid of whole area surgically► c_an risk_ _fracturing the jaw_

Answer 26

Eruption Cyst

Answer 27

_eruption hematoma_

Answer 28

* Results from accumulation of fluid in the follicular space when the tooth has erupted over the alveolar bone **\*NOT in bone\***

Answer 29

▪ Usually seen in **1st decade** *(children)* ▪ Most often involves **1st permanent molar** and **maxillary incisors**

Answer 30

Frequently _normal mucosal color_, BUT surface trauma (ex. chewing) may result in bleeding into the cystic space► may look **purple or blue** ▪ Usually **soft** or **fluctuant**(like a balloon) _upon palpation_

Answer 31

* Unless symptomatic, no treatment required, cysts resolve upon eruption of teeth

Answer 32

**Eruption Cyst**

Answer 33

**Eruption Cyst**

Answer 34

**Palatal cysts** or **Gingival cyst**

Answer 35

**‐ Bohn’s nodules:** scattered over HP (hard palate), often junction of HP and SP (soft palate) **‐ Epstein’s pearls:** along median palatal raphe

Answer 36

* Seen in 60‐80% of neonates

Answer 37

* 1‐3 mm cream to white papules (keratin filled cysts) ## Footnote **\*NOT in bone\***

Answer 38

**No treatment is required** ‐ Resolve (degenerate or rupture) on their own in a few months ‐ Once baby eats solid foods, will go away

Answer 39

Cysts of the Newborn: Palatal cysts

Answer 40

**Dental lamina cysts**

Answer 41

* Found superficially on the **alveolar ridge mucosa** * **MX** \> MD * Rarely seen after 3 mos. of age

Answer 42

▪ No treatment is necessary ▪ Spontaneously resolve (degenerate or rupture)

Answer 43

* 1‐3 mm creamy white papule (keratin filled cysts) * \*NOT in bone\*

Answer 44

Gingival cyst of the newborn/ Dental lamina cysts/Cysts of the Newborn-gingival

Answer 45

**Gingival Cyst of the Adult**

Answer 46

Derived from dental lamina rests **‐ Rests of Serres**

Answer 47

**▪Uncommon lesion** ▪ 60‐75% **mandibular canine/premolar area** ‐ most common location on the _facial or buccal aspect_ ▪ **5th and 6th decade** most common

Answer 48

* Painless, dome‐like swellings up to 5 mm in diamete * Often with a bluish or grayish hue

Answer 49

**lateral periodontal cyst**

Answer 50

* **simple surgical excision** * _Unlikely_ to recur/come back

Answer 51

**Gingival Cyst of the Adult**

Answer 52

Gingival Cyst of the Adult

Answer 53

Gingival Cyst of the Adult notice the _bluish hue_

Answer 54

**gingival cyst of the adult?**

Answer 55

* Developmental cyst believed to arise from **dental lamina rests**

Answer 56

* **an inflammatory origin cysts** or t**he diagnosis of odontogenickeratocyst** _have been excluded_

Answer 57

▪ Commonly **asymptomatic** and _found on routine radiographic exam_ ▪ Associated teeth tests **vital/responsive with electric pulp test**

Answer 58

‐ **If pulp alive**► **lateral periodontal cyst** or ***Lateral Okc ( if huge lesion)*** ‐ If pulp dead► **lateral radicular cyst**

Answer 59

▪ Most likely found after age 30 ▪ Males\>Females **▪ ~65% mandibular canine/premolar area** ‐ Can also be seen _between canine and lateral incisor_

Answer 60

Present as **well circumscribed**, **unilocular** _radiolucencies between 2 teeth,_ located **lateral to tooth root** ▪ Most often **0.5‐1.0 cm** in diameter ▪ Radiographic features are **NOT** diagnostic

Answer 61

* * Could be differential for lateral Odontogenic keratocyst, except this does not grow in size * Lateral radicular cysts from an accessory canal if tooth is non vital * or it could be Lateral Periodontal Cyst if tooth is vital!

Answer 62

**Lateral Periodontal Cyst**

Answer 63

**Lateral Periodontal Cyst**

Answer 64

* consists of **conservative enucleation**

Answer 65

**Botryoid Odontogenic Cyst**

Answer 66

shows **a grape‐like cluster** of small individual cysts

Answer 67

▪ Either unilocular or multilocular on radiographs, depending on size of the lesion ▪ Cyst lining similar to lateral periodontal cyst

Answer 68

**Botryoid Odontogenic Cyst** well circumscribed, between 2 teeth (similar to lateral odontogenic cyst), multilocular

Answer 69

**Botryoid Odontogenic Cyst**

Answer 70

* **A rare odontogenic cyst** which exhibits features of _glandular differentiation within the epithelium_ * Presumably **represents the pluripotentiality of odontogenic epithelium**

Answer 71

▪ Wide age range from 2nd to 9th decades **‐** *_mean age 49_* **▪ ~ 80% of cases in mandible ▪ Anterior lesions** ‐ More common ‐ _May cross the midline_

Answer 72

▪ Uni‐ or (more often) multilocular radiolucency ▪ **Well‐defined** with **a sclerotic border**

Answer 73

(~ 25% recurrence rate) Can be locally aggressive

Answer 74

▪ Usually asymptomatic unless inflamed

Answer 75

**mucoepidermoid carcinoma** (salivary gland tumor)

Answer 76

**“Primordial” Cyst** Assuming histologically it is *different from OKC*

Answer 77

* lesion, *was actually some other type of cyst* * * it is now thought that most of the reported Primordial cysts were actually **OKCs**

Answer 78

**keratocystic odontogenic tumor (KOT)** -2005 WHO _but now it's back to **OKC**_

Answer 79

* **Growth and expansion** of this lesion due not only to osmotic effects/pressure, but to _unusual gene expressions_

Answer 80

* _Expresses **Ki‐67**_ (high rate of cell proliferation) * O_verexpression of **Bcl‐2**_ (antipoptotic protein) * _Overexpression of **MMP’s 2 and 9**_ (thought to allow growth into connective tissue) * _Mutation of **PTCH**_, a tumor suppressor gene * when PTCH is non‐functional → cell proliferation

Answer 81

* ~ **60%** present in **2nd and 3rd decade**, but can occur at any age * **Mandible** affected in 60‐80% of cases * tendency to occur in **posterior mandible and ramus** * **25‐40% of cases involve an unerupted tooth** * ‐ **5%** of patients have **_multiple cysts_**

Answer 82

**Odontogenic Keratocyst (OKC) :**grows in anterior to posterior manner before causing cortical expansion *while* **Meloblastoma:** causes **cortical expansion _early_**

Answer 83

**Odontogenic Keratocyst (OKC)**

Answer 84

**nevoid basal cell carcinoma syndrome**(*_**Gorlin syndrome**)_*

Answer 85

Most of OKC in posterior region

Answer 86

* **HIGH Recurrence Rate** * **Benign**, but _locally aggressive biologic behavior_ * _Solitary OKCs have_ ~**10% recurrence rate with appropriate treatment** * _Multiple OKCs hav_e ~ **30% recurrence rate**

Answer 87

**Syndrome OKC \> Multiple OKC \> Solitary OKC \> Conventional odontogenic cysts**

Answer 88

* Usually **a well‐circumscribed** *_radiolucency_* with **smooth, often** **corticated margins** ▪ Cysts may be ‐ **Unilocular** (most common) ‐ **Multilocular** (larger lesions)

Answer 89

▪ **Small cysts** are typically **asymptomatic** and picked up on routine radiographic exam ▪ **Larger cysts** may or may not be asymptomatic ▪ \*Cysts tend to grow in an antero‐posterior direction prior to lateral growth ►_therefore cysts are usually quite large when they start to expand the cortical plate_

Answer 90

* dentigerous cyst * ameloblastoma * and others

Answer 91

▪ **Marsupialization** (decompression) ▪ **Peripheral ostectomy** ‐ Carnoy’s solution ▪ **Resection** ▪ **Medications targeted to PTCH** ▪ ***Long term follow‐up***

Answer 92

**Odontogenic Keratocyst OKC**

Answer 93

**Odontogenic Keratocyst OKC**

Answer 94

**Odontogenic Keratocyst OKC**

Answer 95

**Odontogenic Keratocyst OKC**

Answer 96

similar to *lateral periodontal cyst* but is actually **OKC**

Answer 97

**Basal Cell Nevus or Bifid Rib Syndrome** or **Gorlin syndrome**

Answer 98

**Odontogenic Keratocyst “OKC”**

Answer 99

**_Autosomal dominant_ inheritance**

Answer 100

**Nevoid Basal Cell Carcinoma Syndrome**

Answer 101

* _Mutation_ of **PTCH** (tumor suppressor gene) * in the **Sonic Hedge Hog pathway**

Answer 102

■ Prognosis _depends on progression of skin tumors_

Answer 103

✎Surgery (typically MOHS) ✎Sometimes curette them ✎ Radiation therapy (RT) is typically not the first line of therapy with small lesions RT ✎Cryotherapy which means they just use a little liquid nitrogen and freeze them ✎Photodynamic therapy with photosensitizer and topical medications ■ New medication: **Vismodegib _inhibits sonic hedgehog pathway by binding smoothened (SMO)_** * *suppressive rather than curative cause it seems to work for short time and after ~7-8 months ..may also helps _suppress growth of OKC_*

Answer 104

✎A patient who has **Nevoid Basal Cell Carcinoma Syndrome** ✎We can see **multiple cystics** areas and lesions in _the jaws, maxillary and mandible_ ✎**Both 3rd molar displaced** in the maxilla because of the cyst

Answer 105

✎**Multiple lesions**, impacted 3rd molar in mandible and displaced 3rd molar up into the sinus, ✎These too many lesions hard to manage the issue with a surgery ✎This large area on the left mandible – good example of why we do decompression because if you just remove this lesion and the entire area is left open, this would be an area risk for fracture

Answer 106

✎An example of the **pitting** that can be seen **palmar and plantar** ~ This is a side of a hand ✎This is an early stage of basal carcinoma which never goes on (like it is aborted)

Answer 107

* **thousands of basal cell carcinoma** is developing on the skin -very difficult to manage with surgery, ~ That’s why they remove the larger ones, the deeper ones ~ They leave the one that’s less as an issue until they get to a larger size to be removed

Answer 108

It’s not the lesion themselves causing metastasis that’s the issue, it’s the lesion growing deeply and in affecting adjacent structures that really is the issue with basal carcinoma

Answer 109

**Basal Cell Carcinoma (BCC)**

Answer 110

* 2-3 million cases a year * About 3 out of 4 skin cancers are basal cell carcinomas

Answer 111

- Develop in the **lowest layer of the epidermis**, called the **basal Laye**r - Develops on sun-exposed areas: _cumulative DNA Damage_ **- Slow-growing** • If not treated, basal cell c**ancer can grow into nearby areas and invade the bone or other tissues beneath the skin**

Answer 112

within 5 years of being diagnosed with BCC►**35%-50%** of people _develop a new skin cancer_

Answer 113

* **Calcifying Cystic Odontogenic Tumor** * **_Gorlin Cyst_ ( don't confuse it with Gorlin syndrome)** * **Ghost Cell Tumor** *

Answer 114

1. **■ Cystic Unilocular COC** * COC with odontoma (~ 20%) * Extraosseous/peripheral – present in _older patients_ 2. **■ Solid COC (odontogenic ghost cell tumor)** * Often demonstrate _a more aggressive behavior_ * WHO once considered them all CCOT now back to COC 3. ■ **Odontogenic ghost cell carcinoma** * _very rare lesion_

Answer 115

* where you see **_both features_ of ameloblastoma with COC** or **adenomatoid odontogenic tumor with COC**

Answer 116

* **Odontomas** (a benign tumour linked to tooth development) * **Ameloblastomas** (rare, noncancerous (benign) tumor) * **Adenomatoid odontogenic tumor** (rare tumor of epithelial origin that is benign, painless, noninvasive, and slow-growing)

Answer 117

■ Peak in _second decade_, most **before age of 40** ■ Frequently presents **anterior to molars** ■ ~ **20% extraosseous (peripheral)**, found in **older age group** (~ 50 years of age) ■ Female \> Male ■ **~ 70% occur in MX** ■ One third are associated with **unerupted teeth**, usually a **canine**

Answer 118

■ Usually **a well-circumscribed unilocular radiolucency,** _infrequent multilocular cases_ ■ **One third to one half** show _radiopaque structures within the radiolucency_ ■ When you see **calcifications** within a lesion, you don't use the term uni or multi locular anymore, but they are called **_mixed radiolucent/radiopaque lesions_** ■ May cause **resorption or displacement of roots** **■** **_One third_** are associated with **unerupted** **Canine**

Answer 119

``` **Calcifying Odontogenic Cyst (COC)** ``` * _in the mandible_ and you can see it **well circumscribed radiolucency** * a little bit of blunt root resorption in this area * _No calcifications_ in this one yet ►so this is still **unilocular radiolucency**

Answer 120

* Clinical finding for this patient was **Obliteration of the vestibule space**, because the mandible is showing expansion * radiographically:we see radiolucency going as far as the first molar * This is a **mixed radiolucent radiopaque lesion** in developing calcifications. * This is an example of **Calcifying** **Odontogenic Cyst (COC)**

Answer 121

**_Ghost cells_** They have that sort of polygonal shape or roundish shape with the pink that looks like the cytoplasm, but in the location where the nucleus would have then, there's an empty spot

Answer 122

**_ameloblastic epithelium_**

Answer 123

■**Enucleation with peripheral ostectomy** ~ Very similar to odontogenic keratosis ■ **Follow up is long term** because s_ome of the solid tumors have a more aggressive behavior_ **■ Peripheral lesions are treated with excision**

Answer 124

■ the treatment is based on **the more aggressive tumor** **~** So you would treat the _ameloblastoma_. ~You wouldn't treat conservatively the COC though

Answer 125

❑ Nasolabial cyst ❑ Globulomaxillary cyst (historic) ❑ Nasopalatine (incisive canal) cyst ❑ Incisive papilla cyst ❑ Median palatal cyst ❑ Median mandibular cyst (historic)

Answer 126

aka Nasoalveolar cyst

Answer 127

(1) That's the nasopalatine, which is sort of up in the labial nasal fold and it's in the soft tissue. (2) Sort of where the nasal alveolar cyst would occur. (3) Where the globular maxillary cyst would occur between the canine and the lateral sometimes between the lateral and the first premolar (4) The nasopalatine in the cyst of the nasopalatine papilla (5) Is the median palatal

Answer 128

■ Thought to be caused by: * either **epithelial remnants of the nasolacrimal duct** * or **cells left after fusion of the maxillary, medial and lateral nasal processe**s during _development of the midface_

Answer 129

_Rare_ **soft tissue cyst of the upper lip**, lateral to the midline (right under the ala of the nose) \*NOT in bone\* ■ Clinically see a swelling which can cause elevation of the ala of the nose ■ Intraorally see a swelling in the maxillary vestibule lateral to the midline (usually sort of in the canine area or just a little bit distal to the canine area) ■ Pain is uncommon, unless cyst becomes infected

Answer 130

■Clinically we see a **swelling** which _can cause elevation of the ala of the nose_ ■ Intraorally see **a swelling in the maxillary vestibule lateral to the midline** (usually sort of in the canine area or just a little bit distal to the canine area) ■ **Pain is uncommon,** _unless cyst becomes infected_

Answer 131

■ Peak in **4th and 5th decades** ■ **3 to 4 times** _more common in **females**_ ■ ~ **10%** of cases are **bilateral**

Answer 132

* **Surgical Excision** via i**ntraoral approach**, * usually do not recur ~ **very low risk of occurrence**

Answer 133

Nasolabial Cyst The lesion here just below the nose and you can tell that it's sort of raising the edge of the nose slightly

Answer 134

**Nasolabial Cyst** the lesion raising the edge of the nose slightly

Answer 135

either in the **sinus** or in the **nasopalatine ducts**

Answer 136

* we can see the **displacement of the root** * A **teardrop or pear shaped** radiolucency between the lateral and the canine * **Well circumscribed** maybe leaving **a little sclerotic edge** up here * ended up being in **a odontogenic keratocyst (OKC)**

Answer 137

~ it is kind of **a teardrop or pear shaped size** ~Little less well differentiated in this particular instance but again **unilocular radiolucency between the roots of two teeth** This one ended up being an **OKC**

Answer 138

* it's in quotations, because really there is no such thing as a globulomaxillary cyst * because it was thought that this was remnants _after fusion of the globular portion of the nasal process with the maxillary process,_ and now we know that **these two processes are always united from the start and that there is no fusion** * When biopsied these cysts are **odontogenic in origin**

Answer 139

✎This is term used to **describe a cyst in a particular anatomic location** _it is not a diagnosis_ ✎An odontogenic cyst (inflammatory cyst, lateral periodontal or even sometimes OKC) that forms in the area **between the maxillary lateral incisor and the canine roots** ~ It's really associated with a_n anatomic location **not** with any particular cyst._ ✎So it can be any of the odontogenic lesions such as **lateral granulomas or cysts, OKCs, COCs, etc.**

Answer 140

## Footnote ✎Presents as a **“inverted pear”** shaped **well-circumscribed radiolucency** ✎Frequently causes **displacement of the roots**

Answer 141

* *A**. It can either be _the cyst totally within bone_ * *B**. It can actually cause _widening of the orifice and causing the soft tissue expansion in this way_

Answer 142

**Nasopalatine Duct Cyst**

Answer 143

**incisive canal cyst** **nasopalatine canal cyst**

Answer 144

**Nasopalatine Duct Cyst** ## Footnote ✎This person is edentulous ✎ **an inverted pear shape** ✎The nasal spine is superimposed on your radiolucency ► **a heart shape**

Answer 145

**Nasopalatine Duct Cyst** ✎Between the roots of the two teeth, a well circumscribed radiolucency, not showing any changes to the adjacent structures ✎could be an enlargement of the incisive canal due to variation in size ~ **early lesions can be hard to diagnose** ✎**the treatment in such cases**: a follow up with another radiograph in six months to see if there's been any change in size **✎ No surgical intervention until you see the cyst expanding**

Answer 146

This is showing you the how the papilla can be enlarged if it's only in soft tissue or if there's a partial soft tissue partial bone expansion *Nasopalatine Duct Cyst*

Answer 147

* arise **from epithelial remnants of the nasopalatine duct** which, _embryologically, connects the oral and the nasal cavities_

Answer 148

**Median Palatine Cyst**

Answer 149

* Peak presentation in the **4th to 6th decades**, _but can occur at any age_ ~ *because it takes a little bit of time for the cyst to grow within the bone* * commonly found on the **anterior palate** ~ typically in the _nasal area of the papilla._

Answer 150

Remember ## Footnote _Median Mandibular Cyst_ is a term used to describe a cyst in a **anterior mandible** not a definitive diagnosis So, this turned out to be an early ameloblastoma. It wasn’t a cyst The lesion radiolucency in the anterior mandible and again

Answer 151

■ present with **swelling** o_f the anterior palate_ (in the nasal area of the papilla) ■ Most are **asymptomatic**, but _they may have pain or drainage_

Answer 152

■ a **well-circumscribed unilocular** **radiolucency** on _the midline of the anterior hard palate_ _between and apical to the central incisors_ ■ The radiolucency often have an oval or inverted pear shape with a sclerotic border ■ Superimposition with the nasal septum can create an appearance of the classic **“heart” shape**

Answer 153

Is a **soft tissue cyst** (no bone involvement) located in the same area as the **Nasopalatine Duct Cyst** _on the midline of the anterior hard palate between and apical to the central incisors_ . They may be symptomatic or asymptomatic and usually are not seen radiographically. some consider them to be uncommon variants of the nasopalatine duct cysts

Answer 154

**Surgical Ciliated Cyst of the Maxilla** In this premolar shot (middle image) you can see a **well-circumscribed lesion** ✎Because the maxillary sinus is **radiolucent**, it almost looks like this is **radiopaque** but it's not ✎ If you did a CBCT you would see that **it's an empty space within the bone of the maxilla.** It's not actually radiopaque

Answer 155

* **surgical excision** * **recurrence is rare**

Answer 156

**nasopalatine duct cyst** * it represents a more **posteriorly** placed nasopalatine duct cyst * ~ It's probably due to some sort of anatomic variation in the patients; that their palatine duct is just placed more posteriorly * So **instead of being between the roots of these two teeth, it's placed more posteriorly**

Answer 157

* **A controversial cysts** whose existence is questioned ~ similar to **the globulomaxillary cyst** ■ Originally *thought to arise from the fusion of the “halves” of the mandible, but current embryology finds that the mandible forms from a single bilobed process, therefore, no epithelial remnants would be found* ■ Now, it is thought that cysts in this area represent **odontogenic cysts or tumors** * **Median Mandibular Cyst is a** term used **to describe a cyst in a particular anatomic location not a definitive diagnosis** * ~ It is other lesions that occur in that particular location * **The Anterior Mandible**

Answer 158

■ Occurs after trauma or sinus surgery (iatrogenic - reactive not neoplastic)

Answer 159

■a portion of the sinus lining is **separated** from the sinus and forms an epithelial lined cavity in bone ■ Cavity f**ills with mucin** produced by the _mucous cells of the cyst lining_ ■ These cysts **enlarge** as the _intraluminal pressure increases_, causing **destruction of bone**

Answer 160

* after **a Caldwell-Luc procedure** * *sometimes with **difficult maxillary extractions***

Answer 161

**Surgical Ciliated Cyst of the Maxilla** In this premolar shot (middle image) you can see a **well-circumscribed lesion** ✎Because the maxillary sinus is **radiolucent**, it almost looks like this is **radiopaque** but it's not ✎ If you did a CBCT you would see that **it's an empty space within the bone of the maxilla.** It's not actually radiopaque

Answer 162

* **They have no epithelial lining.** * They’re called cysts by convention just because that's what everybody is used to * **They're not true cysts.**

Answer 163

* Aneurysmal Bone Cyst * Antral Pseudocyst * Simple Bone Cyst * Osteoporotic Bone Marrow Defect * Stafne Bone Cyst

Answer 164

■ Most common site in the body is **long bones *or* vertebrae** _■ In the jaw_s, most frequently seen in the **1st and 2nd decade** **■ MD \> MX** ## Footnote *it's a pesudocyst*

Answer 165

* swelling, frequently a rather rapid swelling * often with **pain** and/or **paresthesia** (signs which can be suggestive of the presence of _a malignant or aggressive lesion_)

Answer 166

* Etiology is **unclear**, may result from **trauma** or a **vascular malformation** * most agree that it is a _**reactive** and ***not*** a neoplastic lesion_

Answer 167

■ **a radiolucency** which can be either **unilocular or multilocular** in appearance ■ **Borders are variable**, *often irregular in shape* and may be **ill-defined** (again, giving the suggestion of malignancy) ■ **Teeth may be displaced** ■ we may see **cortical expansion and thinning** ~ the cortex itself can become quite thin

Answer 168

- you might think that he has an odontogenic infection but he didn't. You can see that there's a pretty significant swelling on the left side of his face This is a **Aneurysmal Bone Cysts**

Answer 169

Aneurysmal Bone Cyst you can see that there is kind of a **multilocular radiolucency** in this particular area

Answer 170

**Aneurysmal Bone Cyst** ## Footnote ✎ There's a **radiolucency** involving _the second molar_ that's going as far anterior as the first molar and back to the third molar ✎ There is a little bit of **spiking root resorption** and _that's one of the signs that we associate with malignancy_ ✎ It's a little bit **ill-defined** *~ hard to say exactly where it begins and ends*

Answer 171

**Aneurysmal Bone Cyst** ✎ It looks like **a blood soaked sponge** ✎ There’s these **open sinusoidal spaces** and then fibrous connective tissue surrounding them. *✎The sinusoidal spaces can vary in size; some of them are fairly small and others are large*

Answer 172

**✎ Central giant cell granuloma** **✎ Cherubism** **✎ Brown tumor of hyperparathyroidism**

Answer 173

■ Treatment is **surgical enucleation and curettage** ■ **lesions can recur** ~ Usually the recurrence is because you didn't get the entire thing out the first time around ■ Some surgeons follow **enucleation** with **cryotherapy** ■ **Irradiation** is _contraindicated_

Answer 174

■ No, **vascularity is predominantly “low flow”**, therefore not as much concern for bleeding upon surgical removal ■ As compared with **central hemangioma** where there is a concen for bleeding

Answer 175

**Antral Pseudocyst** * a **Dome-shape** **swelling** on the floor of the sinus. * _They can sometimes_ be **fairly subtle** **Antral Pseduocyst** are **NOT Mucoceles** **Mucoceles** would have more of **meniscus-like appearance**where it would come up to**the edge of the sinus**

Answer 176

They are different than **surgical ciliated cyst** in their lining, etiology, location and appearance!

Answer 177

**Aneurysmal Bone Cyst** ## Footnote ✎ A **dome shape swelling on the floor of the sinus** that’s associated with some _sort of inflammation of tooth of t_he **premolar** caused inflammation underneath the apex of the bone (right) and then that leads to accumulation of fluid which causes the sinus lining to elevate off the bone and fill with fluid ✎ After root canal therapy and once the infection gets under control, these will typically resolve on their own

Answer 178

_Not epithelial lined spaces_

Answer 179

Not within the bone **but are in the sinus**

Answer 180

develop a**s an accumulation of an inflammatory exudate** (often serum) _between the sinus epithelial lining and the bone_ -It develops because of an **inflammatory event in the jaw,** usually the **maxilla**, often from the roots of the maxillary teeth that cause inflammation

Answer 181

Appears as **a dome shaped elevation** _of the floor of the sinus_

Answer 182

aka **traumatic bone cyst**

Answer 183

**Simple Bone Cyst** ## Footnote ✎**A well-circumscribed with cortication** in the **body of the mandible**, affecting _the posterior aspect (premolars and the molars )_ ✎Note the **scalloping** that happens up **between the roots**. It doesn't cause root resorption and actually the lesion will grow up between the roots of the teeth

Answer 184

**Simple Bone Cyst** * **A well-circumscribed**showing **the scalloping up between the roots of the teeth radiolucency**

Answer 185

**Simple Bone Cyst** ## Footnote ✎Big lesion example: It’s going back to the molar area here. ✎You can see that the lesion extends _over to the canine on the other side_ ✎Most lesions are usually **in the anterior mandible**

Answer 186

* **A benign**, empty or fluid filled, cavity in bone which is devoid of an epithelial lining – **a pseudocyst** * Thought to be **reactive**, NOT *neoplastic*

Answer 187

_Etiology_ **ununcertain**, theories include: * **trauma** * **ischemic necrosis of medullary space** * **cystic degeneration of a primary bone lesion**

Answer 188

* In jaws, most likely in the **2nd decade** * Almost **exclusively the mandible** * **Twice** as common in **males**

Answer 189

* a **well-circumscribed radiolucency** with **an irregular outline** * Tendency to **“scallop” around and between roots** *_(highly suggestive_*, but *_not diagnostic of this lesion_*)

Answer 190

* **exploration** and **curettage** of space to create bleeding. Clot will organize and allow bone repair * **Recurrence** is **_rare_**

Answer 191

* You can see there's a little bit of radiolucency. * There happened to actually still be teeth in the area, but * when it was _biopsied_ it showed that it was a * **hematopoietic** or **osteopoietic bone marrow defect**

Answer 192

■ An **asymptomatic** focal _concavity_ of the cortical bone on the _lingual aspect of the MD_ ■ A *pseudocyst*, not a true cyst

Answer 193

■ _Uncommon finding_ ■ \> 75% of cases are in **females** ■ ~ 70% occur in the **posterior MD**, often in _an edentulous area_ it's a *pesydocyst*

Answer 194

* **Etiology unclear** * may be **hyperplasia of marrow** due to need for RBCs or * **abnormal regeneration of bone** after **an extraction or persistence of fetal marrow**

Answer 195

**Stafne Bone Cyst** _This is the classic look._ - a **well-circumscribed corticated radiolucency** - **below the inferior alveolar nerve**, away from the teeth. - They can be either **oval**, like this, or **round** in appearance

Answer 196

**Stafne Bone Cyst** Less common location Check if the teeth were vital with vitality test Get a CBCT in that area to see what was going on first and then once you saw the CBCT you'd be able to make the diagnosis.

Answer 197

* it's a pesydocyst * a **radiolucency** in an area typically where tooth has been removed. Instead of filling in with bone, it fills in with marrow. * When we biopsy it, you’re seeing the hematopoietic elements. (fat, early stages of (the -blasts of) red cells, white cells. * We see basic **bone forming marrow** **content**

Answer 198

_Stafne Bone Cyst_ What we see on biopsy: ✎It's just **salivary gland tissue** b_ecause the salivary glands grow into that space_ ✎ **It’s an empty space** that they can grow into and that's what they do; they just expand into that location**. It's not that the salivary gland is causing it**

Answer 199

**Hematopoietic bone marrow defect**

Answer 200

■ Typically **asymptomatic** and found on _routine_ radiographic exam

Answer 201

* **Irregularly shaped radiolucency** with _either_ **a well-defined or ill-defined border** (It can be in the _differential diagnosis with malignancy_)

Answer 202

■ **Must biopsy** to make a definitive diagnosis ■ **No further treatment is then necessary** ~ You don't have to remove it; you can just leave it as it is

Answer 203

**static bone cyst, Stafne defect**

Answer 204

* Most commonly found near **the angle of the mandible** **below the inferior alveolar nerve** (but also _seen in the anterior MD)_ * **\> 80% in Males** * usually noted **only in adults**

Answer 205

Oval round well-circumcribed radilucency Below the Inferior Alveolar Nerve

Answer 206

* Believed to be **developmental** in origin, *but usually noted only in **_adults_***

Answer 207

* lesions in the posterior MD are usually pathognomonic * **no further treatment is necessary**

Answer 208

* **Benign** developmental cystic lesion * Considered a form of teratoma Remember: _Teratomas_ have **all four embryologic** **layers** and so you can see these cysts that have **teeth, bone, hair, muscle, and nerves.** **Dermoid cyst** is sort of a lesser version of a teratoma in that **it just has dermis, rather than all the other layers**

Answer 209

* Depending on whether the cyst is above or below the mylohyoid muscle►the lesion will cause **swelling into the oral cavity elevating the tongue** or **under the chin in the submandibular area**, _respectively_ * Usually **found on the midline** * **Painless** and **slow growing,** _if not infected_ * _Upon palpation, cyst feels **doughy or rubbery**_ * _Usually **roundish to oval-ish swelling**_

Answer 210

* Most common in the 1st and 2nd decade ( young pts) * Can be found anywhere, but in the oral cavity they are ususally located i**n the anterior floor of the mouth (FOM) -** *usually* ***on the midline***

Answer 211

* **surgical excision** * _recurrence_ is ***rare***

Answer 212

_Dermoid Cyst_ a **dome shaped swelling**in _the floor of the mouth._ If these were left long enough, they could _cause issues with swallowing_

Answer 213

**Dermoid Cyst** ## Footnote ✎This is **a larger lesion on the floor of the mouth**, causing elevation of the tongue ✎If you let this go/grow, it would be similar to **Ludwig’s angina** where you would basically **eventually obstruct the airway** ✎**The difference** is this is **very slow growing** while **Ludwig’s happens** rather quickly. with **fever and other symptoms.**

Answer 214

**Dermoid Cyst** * This is showing you when they occur below the **mylohyoid muscle.** * You get **an elevation under the chin.** * This is **a fairly small on**e but they can get much larger

Answer 215

**infundibular cyst** **epidermal inclusion cyst** **“sebaceous” cyst** (laymen’s term, not really sebaceous) ~

Answer 216

* A very common skin cyst

Answer 217

similar to the dermoid cyst, except we don't see those **adnexal structures**

Answer 218

* Often occur after _***inflammation*** of a hair follicl_e

Answer 219

■ **_Males_** \> *Females* ■ **Young adults** _more likely to have cysts of the_ **fa**ce ■ **Older adults** _have cysts of the_ **back**

Answer 220

Associated with **Gardner’s syndrome** **Gardner syndrome** is associated with **polyps in the intestine**. **Gardner syndrome** is associated with **epidermoid cysts.**

Answer 221

Epidermoid Cyst **A dome-shaped swelling.** There’s **no change** in the overlying skin color, no redness, no pain

Answer 222

■ **Subcutaneous** ***nodular***, ***firm to fluctuant,* _papule_** ~ It tends to be **a subcutaneous, dome-shaped nodule that can be either firm to fluctuant**, _depending on how much stuff is within the lumen_

Answer 223

* The key difference between a dermoid and * epidermoid cyst, **is that there's no adnexal structures in an epidermoid cyst. _There are adnexal structures in a_** **_dermoid cyst._** * The adnexal structures are: **sebaceous glands, sweat glands, hair follicles, etc.**

Answer 224

■ Treatment is **_excision_** ■ _Recurrence_ is ***rare***

Answer 225

Thyroglossal Duct Cyst This is **NOT** a goiter. It looks like an enlargement of the thyroid, but this ended up being just a cyst, so they had a thyroglossal duct cyst

Answer 226

* _A developmental cyst_ that develops **from epithelial remnants of a tract which forms when the thyroid anlage descends into the neck** _from an area that later forms **the foramen caecum**_ * Follows a path that goes **anterior to the hyoid bone and ends below the thyroid cartilage**

Answer 227

■ Cysts are typically **painless fluctuant swellings,** _unless infected_ ■ **If the cyst remains attached to the hyoid bone or the tongue ►** i_t will move up and down when swallowing or protruding the tongue_ ■ **~ 1/3 will present with a fistulous tract** ~ _so they'll be draining._

Answer 228

■ **surgical excision** ■ _recurrence_ are ***not uncommon*** ■ *Rare cases* of **thyroid carcinoma** developing in these cysts have been reported

Answer 229

■ **60-80% of cysts** are _below the hyoid bone_ ■ **Most commonly present in the first 2 decades** (~ 50% prior to 20 years of age) ■ Cyst classically **forms at the midline** ■ _The most common developmental cyst of the neck_

Answer 230

Thyroglossal Duct Cyst

Answer 231

Branchial Cleft Cyst **a small one in a child.** You can see that there's a small cystic lesion here on the neck

Answer 232

**Branchial Cleft Cyst** Then you can see it in an older person; this is getting to be maybe 4-5 centimeters at least in size. He left his for a little bit longer

Answer 233

**cervical lymphoepithelial cysts**

Answer 234

■ Most commonly presents in the **3rd to 5th decades** ■Located on the **lateral aspect of the neck**, usually **anterior to the sternocleidomastoid muscle** ■**2/3** of the reported lesions have been **on the left side** ■Although cyst are uncommon in the parotid gland, can see multiple lymphoepithelial cysts bilaterally in **HIV positive patients** ■These cases present as painless uni- or bilateral swellings of the parotid glands

Answer 235

* presents as a **soft fluctuant swelling** ranging from **1 to 10 cm** _in diameter_

Answer 236

**Oral Lymphoepithelial Cyst** **A pale dome-shape swelling in the floor of the mouth. **because the lesion is so close to the surface; you're seeing _little capillaries of the mucosa lining the lesion_

Answer 237

Etiology is _disputed_ * Some think it is _from_ **remnants of the branchial cleft** * Others think it is _cystic change of parotid gland epithelium_ which **became entrapped in a cervical lymph node during development**

Answer 238

We can see _multiple Branchial Ceft cysts_ bilaterally on the parotid gland Painless swelling bilaterally or unilaterally on the parotid gland

Answer 239

surgical excision, recurrence is rare

Answer 240

■ **Uncommon lesion** ■ **The Most frequent location is _the floor of the mouth (FOM)_** (\> 50%)

Answer 241

■ Usually **less than 1 cm** _in diameter_ ■ May feel **firm or soft** _on palpation_ ■ Typically **creamy to yellow** _in color_ ■ **Painless** _unless infected_

Answer 242

* **Surgical Excision** * _Reccurance_ is ***Rare***

Answer 243

**Oral Lymphoepithelial Cyst** **A pale dome-shape swelling in the floor of the mouth. **because the lesion is so close to the surface; you're seeing _little capillaries of the mucosa lining the lesion_

Answer 244

the more aggressive the biologic behavior, the higher risk of recurrence, and the longer the follow up needed for the patient

Answer 245

Things that have a very low rate of recurrence when you do a conservative excision or a nucleation ►they're going to be very benign and they're not going to be likely to be recurrent: ▪ **Odontoma and radicular cysts** are way down here near the benign side ▪ **AOT** (Adenomatoid Odontogenic Tumor) is benign. ▪ **COCs** (Calcifying odontogenic cyst) are benign. ▪ **OKCs** (Odontogenic keratocyst) ‐ they’re benign. ▪ Even **Ameloblastomas** are benign

Answer 246

But eventually you get over to the side over here where you can have something like an ***Ameloblastic carcinoma*** ‐ truly malignant --\> W*e know that it can metastasize and it can lead to death* ▪ Lesions like **Ameloblastomas and CEOTs** will need to be _managed more aggressively._ (**Not just curettage, aka surgical scraping or cleaning**) o You have **a resection ‐ either a portion of the mandible is removed or a segment of the mandible is removed.**

Answer 247

1. **Epithelial** 2. **Mesenchymal** 3. **Mixed**

Answer 248

**▪ Ameloblastoma ▪ Adenomatoid odontogenic tumor ▪ Calcifying epithelial odontogenic tumor ▪ Squamous odontogenic tumor** ▪ **Odontogenic keratocyst** (aka Keratocystic odontogenic tumor)

Answer 249

**▪ Odontogenic myxoma ▪ Central Odontogenic fibroma ▪ Cementifying fibroma ▪ Cementoblastoma ▪ Granular cell odontogenic tumor**

Answer 250

**▪ Odontoma** (complex and compound) **▪ Ameloblastic fibroma/odontoma ▪ Primordial odontogenic tumor ▪ Dentinogenic ghost cell tumor ▪ Calcifying cystic odontogenic tumor**(aka COC, ghost cell tumor)

Answer 251

* **An epithelial odontogenic neoplasm (**Tumor of Epithelial Origin) * with a close histologic **resemblance to the enamel organ**

Answer 252

**_Potential sources of epithelium include:_** **o Enamel organ** – look like they’re about to deposit a substance but never do **o Odontogenic rests (Malassez, Serres)** **o Reduced enamel epithelium** **o Epithelial lining of odontogenic cysts** ‐ can actually have an ameloblastoma arise within a dentigerous cyst

Answer 253

**-Osteolytic tumor** **(radiolucent – no hard tissue formed)** - **Well-circumscribed uni**- or **multilocular radiolucency** - Often with **sclerotic** or **corticated borders** - May see **blunt root** **resorption** and **displacement of teeth** - Frequently seen **in association with unerupted teeth**

Answer 254

* Rather **slow growing tumor** * Larger lesions present as ***painless*** ***expansion*** or ***swelling*** of bone * Smaller ones are ***asymptomatic***, can be seen on routine imaging * **Buccal and lingual cortical expansion is common** * May perforate cortical plate and invade surrounding soft tissue * Can arise in a dentigerous cyst (see transition from stratified * squamous to ameloblastic epithelium)

Answer 255

Conventional/multicystic/solid/ (~ 80%) * **Unicystic** (~6-15%) need entire specimen (excision) to know * **Desmoplastic** * **Peripheral** * **Malignant**

Answer 256

▪ **11‐18% of non‐cystic lesions** of the _maxillofacial bones_ ▪ **4th and 5th decade most common,** but occurs over a broad age range *(rare in first decade*) o Usually starts 2nd decade, can go up to 80‐90s. **Late 30s/early 40s are usually the peak** **▪ \> 80% occur in the mandibl**e _(most in molar/ramus area)_

Answer 257

**Ameloblastoma** _(after odontoma)_ o although ***odontomas*** are more _like hamartomas_

Answer 258

**Ameloblastoma** (we see transition from stratified squamous to ameloblastic epithelium)

Answer 259

▪ Almost 80% or a little over 80% (of ameloblasts) are down in the mandible. ▪ And the vast majority are in the posterior mandible ▪ Do occur in maxilla but at lower rate

Answer 260

**Unilocular and unicystic** ‐ An example of **a unilocular ameloblastoma** that is not associated with an impacted tooth ▪ Is between roots of two teeth, may be confused with lateral periodontal cyst. **Well‐circumscribed radiolucency**

Answer 261

▪ Typical appearance for **ameloblastoma** **Multilocular**, **very well‐circumscribed,** _associated with impacted tooth_. Can see bowing of _inferior aspect of mandible_ _lateral oblique radiograph.was used here_

Answer 262

**Ameloblastoma** **clinically:** Have expansion of the buccal plate, obliterating the vestibule in this area. **Radiographically:** Root resorption of molar, unilocular radiolucency in mandible

Answer 263

**Ameloblastoma** * **Small lesion** distal to impacted tooth. * **Unilocular radiolucency** with _elevation of alveolar ridge + some expansion of soft tissue_

Answer 264

**Ameloblastoma** ▪ **Well‐circumscribed radiolucency** with **a sclerotic or corticated margin**. ▪ If you had a CBCT, it would probably show you that there was a thin septa in this area of residual bone trabeculae. ▪ **Fracture could be caused by very large cysts.** ▪ **Resolve by decompressing unless with odontogenic tumor** – need to remove the mandible **1cm+** on either side of lesion

Answer 265

▪ Over expression of **Bcl‐2 (**anti‐apoptotic protein) ▪ **Expression of fibroblast growth factor (FGF)** ▪ **Over expression of matrix metalloproteinases (MMPs 9 and 20**) – like in OKC, allowing tumor to grow into surrounding area ▪ Surprisingly, _no significant increase in Ki‐67 expression_ (cell proliferation marker) **– ameloblastomas do NOT turn over rapidly**

Answer 266

▪Left mandible, **multilocular radiolucency associated with impacted tooth** ▪ It's **well circumscribed,** edge may be a little **bit sclerotic or corticated** ▪ It has _displaced an impacted tooth down_ towards the inferior aspect of the mandible ▪ Appears to be expanding the cortex of the mandible in areas ▪ There's **blunt resorption of the teeth adjacen**t (PMs and molar) **Ameloblastoma**

Answer 267

**Conventional/Solid Ameloblastoma**

Answer 268

▪ **Unicystic** (Simple or luminal) * lumina- confined to the surface lining of the cystic space ▪ **Plexiform** (intraluminal) * intralumina-one or more areas of the ameloblastic epithelial lining, proliferate into the lumen of the cystic space ▪ **Mural** – hard to distinguish from conventional, so pathologists think they should NOT be treated the same as unicystic (which would be a more conservative treatment) ▪ **Ameloblastoma arising in a cyst** ‐ can usually be treated in a similar way ***as unicystic ameloblastoma.***

Answer 269

**Unicystic Ameloblastoma** but could be **Dentigerous Cyst** based on clinical presentation! So radiograph is not diagonstic

Answer 270

Desmoplastic Ameloblastoma * **Spherical growth**. Within it, has both radiodense and radiolucent areas (is * **mixed radiolucent‐radiopaqu**e)– similar appearance to *_benign fibro‐osseous lesions._* * **Well‐circumscribed, corticated**.

Answer 271

* **Resection** (treatment depends on extent of the lesion and anatomy of involved bone) * **Segmental** * **Composite** * **Long term (decades) follow up** is needed for these patients

Answer 272

**Peripheral Ameloblastoma**

Answer 273

▪ **Younger initial presentation** (~ 50% in ***2nd decade***) ▪ **90% in MD (mandibular)** ▪ Typically _asymptomatic and found on routine radiographic exam_

Answer 274

* Commonly **a well‐circumscribed radiolucency** that _surrounds the crown of an unerupted tooth_ * Commonly accompanied by **_root resoprtion_**

Answer 275

* Radiographically can be confused with **dentigerous cyst** * **Presence of root resorption** should _increase your suspicion of ameloblastoma_

Answer 276

* Treatment is typically **enucleation and curettage** * Reports of lower rate of recurrence (10‐20%) than conventional ameloblastoma (50‐90%) with similar treatment * Some recommend decompression prior to surgery * Use of **Carnoy's solution** ***after enucleation- resulted in a recurrence rate _lower_***

Answer 277

* **Anterior jaws** (particularly **maxilla**)

Answer 278

* looks **“fibro‐osseous”** due to **mixed radiolucentradiopaque** **appearance** * Mineralization of **dense collagen** * **Well‐circumscribed**, _corticated_.

Answer 279

Calcifying Epithelial Odontogenic Tumor (CEOT) **Clinically:** we see **a little expansion** on _inferior aspect of mandible + lingual_ too Radiographically: we see **well‐circumscribed**, **a little corticated/sclerotic edge**, **impacted tooth** ▪ we can see bowing of inferior aspect of mandible ▪ Within areas of radiolucency, see areas of opacity **(calcified lesions = classic CEOT)** ▪ _When smaller► could have looked ***unilocular***_

Answer 280

**Calcifying Epithelial Odontogenic Tumor(CEOT)** * **flecks of calcifications.** * **Calcifications** all around crown is common

Answer 281

**Calcifying Epithelial Odontogenic Tumor(CEOT)** * **Multilocular radiolucency with calcifications**. * **an expansion** *up to PMs and back to 2nd molar* * as well as **bowing of mandible.**

Answer 282

**Calcifying Epithelial Odontogenic Tumor(CEOT**) * ***Fewer calcifications here***, **well‐circumscribed and corticated, impacted** tooth. * **periosteal reaction** _causing elevation_ at the bottom of image!

Answer 283

**Calcifying Epithelial Odontogenic Tumor(CEOT)** * **well‐circumscribed radiolucency with calcifications** *_in lower anteriors_*

Answer 284

* Thought to arise from **epithelial rests or basal cells in the gingiva** * *Uncommon* * **Does not invade underlying bone** * *Histology is the same as _conventional type_*

Answer 285

* Found on **gingiva or alveolar mucosa (**\*that's why it's named *peripheral* or extraosseous)

Answer 286

1. **Malignant ameloblastoma** 2. **Ameloblastic carcinoma**

Answer 287

* thought to arise from ***remnants of the dental lamina in the gubernacular cord /canal***

Answer 288

* **a primary lesion** has _atypical poorly‐differentiated_ * _neoplastic_(malignant) histology * **may metastasize**

Answer 289

**well‐circumscribed radiolucency at crown of an impacted canine** _Hard to tell if attaches at CEJ._ If further down, *less likely **a dentigerous cyst*** and more likely **AOT, ameloblastoma, or OKC**

Answer 290

we see **calcifications** forming, with both radiolucent and radiolucent areas. *▪ Dentingerous cyst, ameloblastoma, and OKC are NO LONGER in the* **differential diagnosis.** **_This is clearly AOT_** **_(_Adenomatoid odontogenic tumor)**

Answer 291

Adenomatoid odontogenic tumor (AOT) **Swelling in maxillary vestibule**

Answer 292

**Adenomatoid odontogenic tumor** **(AOT)** fibrous capsule of AOT is at least partially encapsulated. Easy to remove; “popped right out”.

Answer 293

**Adenomatoid odontogenic tumor** **(AOT)** An expansion _into lingual area_ as well as _into vestibule_

Answer 294

_Adenomatoid odontogenic tumor_ _(AOT)_ **Snowflake‐like calcifications** within ***mixed, well‐circumscribed radiolucency***

Answer 295

Adenomatoid odontogenic tumor (AOT) * **Teardrop shape / inverted pear** _between roots of teeth_. * **Well-circumscribed, corticated margin** & **snowflake‐like calcifications** *within*

Answer 296

▪ Malignant ameloblastoma o Primary lesion and metastasis have normal welldifferentiated ameloblastic (benign) histology o Most commonly to lung

Answer 297

**Pindborg Tumor**

Answer 298

▪ Uncommon (~1% of odontogenic tumors) ▪ Does not have inductive effect

Answer 299

o **2nd to 10th decade**s, peak **~ 4th decade** o **MD (mandibular) 2 : 1 MX (maxillary)** o Usually ***posterior mandible***

Answer 300

* Presents as **painless slowly expanding swellings** * sessile swellings **of the gingiva or alveolus** *( 2 times more on mandible than maxilla* * **Peripheral lesion** may be seen, but are **rare**

Answer 301

* *May be **unilocular***, but **most commonly as a multilocular lesion** * ***May be entirely radiolucent*** or ***a mixed radiolucent-radiopaque lesion*** * **Often associated with an unerupted tooth** * *MD third molar most common* * **Calcifications** in the lesion, if present, are typically *prominent around the crown of the impacted tooth.*

Answer 302

In addition to *fracture*, there is **semilunar loss of bone around the molars ►** (SOT) **Squamous Odontogenic Tumor**

Answer 303

**SOT** **Squamous Odontogenic Tumor** * ***Semilunar** loss of bone*. * **Alveolar bone** is gone due to **impacted canine** that is visible

Answer 304

* CEOT clinically is similar to **ameloblastoma** * Also**, CEOT** has potential _to be locally invasive_, if in the right anatomic location, *but has **a less aggressive biologic behavior** compared to **ameloblastoma***

Answer 305

▪ **Enucleation** _with peripheral ostectom_y ▪ **Resection** _with rim of normal bone_ ▪ _Recurrence_ rate is ***~12%*** ▪ **~ 2%** demonstrate *malignant transformation*

Answer 306

Central odontogenic fibroma (COF) * **well‐circumscribed radiolucency** *posterior to molar*

Answer 307

Central odontogenic fibroma (COF) round mass of opacity due to FCT. **Ground glass‐like appearance**

Answer 308

▪ 2/3 **anterior jaws** ▪ 2/3 **females** ▪ 2/3 associated with **an impacted canine** ▪ 2/3 **MX** ▪ 2/3 **2nd decade** – kids and teenagers\ That's why it's known as **the tumor of two thirds** ▪ ~ 3‐7% of all odontogenic tumors *New research showing more in **_ant md_** though*

Answer 309

* Frequently ***_asymptomatic_***, discovered upon routine radiographic exam or when lesion becomes large enough to expand bone * Tumor of *Epithelial Origin*

Answer 310

▪ ***~ 75%*** are **well‐circumscribed unilocular radiolucency** involving the **crown of an unerupted tooth** o ***less often,*** they are **found between the roots of teeth** **▪** ***Mixed radiolucent/radiopaque appearance*** is likened to **“snowflake” calcifications** *▪ May be totally radiopaque in some cases* **▪ Divergence of roots** _is frequently seen_

Answer 311

**a dentigerous cyst.**

Answer 312

**Odontogenic Myxoma** * Classic example of **enlargement of the mandible** caused by **multilocular radiolucency.** * Enlarged into oral cavity ‐ **alveolar ridge elevated**

Answer 313

**Odontogenic Myxoma**

Answer 314

**Clinically**: obliteration of vestibule on patient’s left mandible **Radiographically**:lesion running from posterior by third molar all the way anterior to canine. Well‐circumscribed, multilocular radiolucency is scalloping up between teeth, causing some root divergence **Grossly**: gelatinous appearance of myxoma makes it hard to remove **After treatment:** post‐surgery; had excised all the way to right 2nd PM This is **Odontogenic Myxoma**

Answer 315

* Treatment is usually **_enucleation_** * _recurrence_ is ***rare***

Answer 316

**CEMENTOBLASTOMA (True Cementoma)** * First molar has **tumor attached to the root.** * Mostly **radiopaque but has some less radiodense areas within** = *_classic for cementoblastoma._* * **Radiolucent halo** around region.

Answer 317

**Cementoblastoma** **Grossly** continuous growth from tumor to the root of the tooth. Brownish areas were more vascular. **Histologically:** tubular dentin in tooth, attached to mass of tissue with calcifications

Answer 318

▪ Typically _involves alveolar ridge_ **▪ Anterior \> Posterior jaws** ▪ Seen from 2nd to 7th decade (mean 40 years of age)

Answer 319

* Tumor of *Epithelial Origin* * ***Rare*** * Usually ***asymptomatic***, but _may present with tooth mobility and slight pain_ * **Multiquadrant** ~ 20-25% * A couple reported cases *in families*

Answer 320

* **Well‐circumscribed radiolucency** , often ***a semilunar radiolucency of alveolar ridge*** * Can mimic _periodontal disease_

Answer 321

* Thought to arise ***from epithelial rests (Malassez) in the periodontal ligament space***

Answer 322

* Treatment is **conservative local excision** * _Recurrence_ is ***rare***

Answer 323

* **Ameloblastoma** * **Squamous cell carcinoma (SCCa)**

Answer 324

**Compound Odontoma** * Mature normal appearing pulp, enamel and dentin * Organization like teeth, with enamel surrounding dentin which surrounds pulp ( Well developed rudimentary “tooth” forms) * appear as small tooth‐like structures in the Anterior jaws (esp. MX) **Complex Odontoma** * Mature pulp, enamel and dentin * No organization, mass of dentin and enamel matrix and pulp tissue (\*\*Poorly developed mass of calcified deposits) * appear as masses of radiopaque material with * variable densities in the Posterior jaws (esp. MD)

Answer 325

Classic appearance of **Odontoma** * **multiple tooth‐like shapes** *aggregated together* * Typically with some sort of **radiolucent halo around them**

Answer 326

**Compound Odontoma** _little teeth‐like structures_ blocking canine eruption

Answer 327

**Complex Odontoma** * _2‐2.5cm mass overlaying the molar_. * ***radiolucent rim/halo*** that is **mixed**, *mostly* **radiopaque**

Answer 328

* *Odontogenic Fibroma (central) **

Answer 329

- Tumors of Mesenchymal Origin - Some believe represents **the counterpart to the peripheral ossifying (odontogenic) fibroma** *(in soft tissue)*

Answer 330

* **MX ≈ MD** * lesions in **MX** tend to be **anterior to first molar** * those in **MD** **anterior ≈ posterior** * **1/3** associated with an **unerupted tooth**

Answer 331

Primordial Odontogenic Tumor (POT) **unilocular radiolucency**

Answer 332

*_-Small lesion_* tend to be **asymptomatic** -*_Larger lesions_* can cause **cortical expansion and tooth mobility**

Answer 333

* *Small lesions* tend to be **well-circumscribed unilocular radiolucencies** * **often periradicular** * can mimic periapical granulomas and cysts * *Larger lesions* tend to be **well-circumscribed multilocular radiolucencies** * ***Borders*** are usually **sclerotic** * **Root resorption** or **divergence** may be seen * ***~ 10- 15%*** will show **radiopaque flecks** _within the radiolucency_

Answer 334

* **Enucleation** with **curettage** or **excision** * usually d**on’t recur**

Answer 335

**Ameloblastic Fibroma (AF)** 1‐3 potential locules, no impacted tooth associated

Answer 336

**o Desmoplastic fibroma** ‐ *a more aggressive lesion* o **Fibromyxoma *‐*** *variant of odontogenic myxoma with abundant collagen* **o Hyperplastic tooth follicle** *‐ typically loose immature stroma, but when hyperplastic can have abundant collagen*

Answer 337

**Ameloblastic Fibro-odontoma (AFO)** * _well‐circumscribed radiolucency_ * ***corticated edg***e + **calcification**

Answer 338

**Ameloblastic Fibro-odontoma (AFO)** has expansion into oral cavity. Flecks of calcification in lesion with impacted tooth = odontoma

Answer 339

* Tumors of *Mesenchymal Origin* * Thought to arise from ***the tooth follicle or dental papilla***

Answer 340

* **~3-5%** of all odontogenic tumors * Wide age range, but **3rd decade most common** * Found anywhere in the ***MD or MX***

Answer 341

* *Small lesions* present as **asymptomatic radiolucencies** found upon routine exam * *Larger lesions* can cause **painless expansion of bone** * All are **radiolucent lesions**, but the appearance can vary from **well‐ circumscribed to irregular and diffuse** * ***Unilocular*** to, **more commonly, multilocular** _(“soap bubble” or “honeycomb”) radiolucency_ * **Borders** are often **scalloped**, can see sc_alloping around the roots of teeth_ * But can cause **displacement of teeth and resorption of the roots of teet**

Answer 342

* the tumor is described as **loose**, **soft** and **gelatinous**

Answer 343

**Ameloblastic Fibrosarcoma** in the mandible developed after two years from AF

Answer 344

* **Surgical excision** or **resection** * Because the lesion is not encapsulated and has a gelatinous loose consistency► it is difficult to remove completely * this is thought to be why myxoma **has a fairly high recurrence rate** * _**Maxillary posterior lesions** should be treated more aggressively_

Answer 345

* Tumor of *Mesenchymal* origin * **Benign tumor** of *cementoblasts*

Answer 346

* **2/3** of cases have **pain and swelling** * Can cause **cortical expansion *_if large enough_***

Answer 347

* **Radiopaque mass** _fused to_ *the root of the affected tooth* * Usually has a **thin radiolucent halo or rim** _surrounding the radiopacity_

Answer 348

* **surgical extraction** _of the involved tooth with attached tumor_ * **Root amputation (with attached tumor) and endo** is an option *_for smaller lesions_* * _Recurrence_ is ***unlikely***

Answer 349

**osteoblastoma** Difference is Osteoblastoma is **NOT** a_ttached to the root of a tooth_ (whereas cementoblastoma must be)

Answer 350

They are tumors in which the _odontogenic epithelial componen_t causes **induction** of the _mesenchymal component_ **to produce a product** **Examples:** * Odontomas * Ameloblastic fibroma * (and Ameloblastic fibrosarcoma) * Ameloblastic fibro-odontoma

Answer 351

* Odontogenic Tumors of Mixed Origin (Epithelial and Mesenchymal * They are **_hamartomas_** *rather* than _true neoplasms_ * They are **_masses of enamel and dentin_** *with variable amounts* ***of*** **_pulp and cementum_**

Answer 352

**Odontoma**

Answer 353

▪ **First 2 decade** *_most common_* (mean age of ***14***) Location is based on *the type of Odontoma* * **Compound Odontoma** * _Anterior jaws (esp. MX)_ * \*\***Well developed rudimentary “tooth” forms** * **Complex Odontoma** * _Posterior jaws (esp. MD_) * **\*\*Poorly developed mass of calcified deposits**

Answer 354

* Often associated with _an unerupted tooth_ * Lesions **may prevent eruption of teeth** * Usually ***small* in size,** but ***rare cases of \> 6cm reported*** * *large lesions* **can cause bone expansion**

Answer 355

▪ Radiographically see **a radiopaque structure(s)** *surrounded by* **a radiolucent rim** ▪ As with any calcified lesion, those found *early in development* may appear _totally or *predominantly radiolucent*_ ▪ **Compound odontomas** *appear as* **small tooth‐like structures** ▪ **Complex odontomas** *look like* **masses of radiopaque material** *with* **variable densities**

Answer 356

▪ **Simple excision** or **enucleation** ▪ **Unlikely** *to* **recur**

Answer 357

* Tumor of mixed origin * Very rare! first reported in 2014 -**less than 30 cases so far**

Answer 358

* Most common in **1st and 2nd decades** * Mean age **12.5 years** * **MD:MX 6:1**

Answer 359

- **Asymptomatic** found on routine imaging - Can cause **tooth displacement** and **cortical expansion**

Answer 360

* **Well-defined radiolucency** _associated with_ **an impacted tooth** * Most commonly **a third molar**

Answer 361

* **conservative excision/enucleation** * So far ***no recurrence***

Answer 362

* _Uncommon_ ***benign* mixed** odontogenic neoplasms. * **Considered together b**ecause it is thought they are _variations of the same process_

Answer 363

* Typically presents in **first 2 decades** * mean is 12 years of age * **~ 70%** occur in **the posterior mandible** * **~ 75%** associated with **unerupted teeth**

Answer 364

* **Small lesions** are **asymptomatic** and found on routine exam * **Large lesions** _can cause bone expansion_ * **Smaller lesions are unilocular Radiolucencies** * **Large ones are multilocular radiolucencies** * **Border** is **well defined and often sclerotic** * ***Untreated***, _can grow to very large size_

Answer 365

- Clinical features similar to **Ameloblastic Fibroma AF** *(Small lesions are asymptomatic and found on routine exam & Large lesions can cause bone expansion)* Radiographically, we see **a mixed radiolucent/radiopaque lesion** _because of the formation of odontomas_

Answer 366

* **Conservative surgical excision** or **curettage**, _easily_ _removed from surrounding bone_ * _Prognosis_ is **excellent**, _recurrence_ is ***unusual*** * ▪ **Rare cases** reported of **development of ameloblastic fibrosarcoma** _in area of AF or AFO_

Answer 367

* _Malignant counterpar_t of **ameloblastic fibroma** * **Rare lesion** which may arise in the site of a previous AF/AFO or arise de novo

Answer 368

* **1.5 times** _more common_ in **males** * ~ **80% MD**

Answer 369

* **Pain**, **swelling** and **rapid growth** are *common presenting signs*

Answer 370

* presents as an **ill-defined destructive radiolucency** *with* **irregular borders**

Answer 371

- **Radical surgical excision** as the tumor is ***very aggressive*** *and* ***infiltrative*** - _Prognosis_ is *dependent on* **complete removal of tumor**

Answer 372

-**Ameloblastic carcinoma** **-Primary intraosseous carcinoma, NOS** **-Sclerosing odontogenic carcinoma** **-Clear cell odontogenic carcinoma** **-Ghost cell odontogenic carcinoma** All fairly rare lesions!

Answer 373

**MOCHA** * **M odontogenic **_M_**yxoma** * **O **_O_**dontogenic keratocyst** * **C **_C_**entral giant cell granuloma** * **H Central **_H_**emangioma** * **A _A_meloblastoma** **Others:** * Aneurysmal bone cyst * early CEOT * ameloblastic fibroma AF * central MECa

Answer 374

**Rapidly growing and infiltrative** –finger-like extensions into surrounding anatomy Remember: in some instances, a benign lesion can mimic a malignant one. Therefore we should be wary of all the information that is available.

Answer 375

ill-defined invasive borders followed by bone destruction

Answer 376

Destruction of the cortical boundary (floor of maxillary antrum) with an adjacent soft tissue mass (arrows)

Answer 377

Tumor invasion along the periodontal membrane space causing irregular thickening of this space

Answer 378

Multifocal lesions located at root apices and in the papilla of a developing tooth destroying the crypt cortex and displacing the developing tooth in an occlusal direction (arrow)

Answer 379

Four types of effects on cortical bone and periosteal reaction, from top to the bottom: •**cortical bone destruction** *without* **periosteal reaction** ***•laminated periosteal reaction*** *with* **destruction of the cortical bone and the new periosteal bone** **•destruction of cortical bone** *with* **periosteal reaction at the periphery** *forming* **Codman's triangles** **•a spiculatedor sunray** _type of periosteal reaction_

Answer 380

Bone destruction around existing teeth, producing an appearance of teeth floating in space.

Answer 381

**Chondrosarcoma** * its consistent widening as opposed to seen in periodontitis and inflammatory disease

Answer 382

**Chondrosarcoma** * Ill defined lesion of anterior maxilla * Areas of radiolucency * Classic area of moth‐eaten look * Circular area of radiolucency with trabecular * pattern * Patient left without surgery, not heeding medical advice Then patient came back ▪ Someone was willing to do the dentures for her ▪ CC‐ denture was not fitting ▪ Expansion of cortical plate ▪ Hyperkeratotic because of denture rubbing ▪ Still has malignancy ▪ Advise for surgery ▪ Refused again Then the lesion kept on Lesion still growing ▪ Metastasize to lungs ▪ Admitted to breathing issues ▪ About 5 ½ years from initial dx to pt passing away

Answer 383

**Chondrosarcoma** * Alveolar process and floor of mouth affected * **Limitations of movement of the tongue**

Answer 384

Can see in the anterior region there’s an elevation histology shows it's not chondrosarcoma because it contained **_Cutright lesion_** **papule or nodule on alveolar ridge** * Osseous and/or chondromatous metaplasia within the soft tissue of the gingiva o **Lesion is NOT central in bone or connected to bone** *_▪ NOT a malignant lesion_* o Thought to be **reactive metaplasia due to a poorly fitting denture**

Answer 385

* *Chondroma –** benign * *Chondrosarcoma**‐ malignant * Both are listed here _because_ * _a benign cartilaginous tumor central In the jaw is extremely rare_ (or may not exist) * _Lesions tend to recur many times_ and **eventually metastasize *( Basically chondromas are not really benign)***

Answer 386

* **Malignant tumor** that _forms cartilage_ * **10%** of all primary bone tumors, but ***rare in the jaws***

Answer 387

**Osteosarcoma** ## Footnote ▪ Swelling on left side of face ▪ Difficult opening

Answer 388

**Osteosarcoma** * See something in the operculum * Infection in third molar?

Answer 389

**Osteosarcoma** * AP Plain Film * Most of jaw was missing * Radiolucency affecting entire ramus and condyle

Answer 390

**Osteosarcoma** * Classic _sunburst pattern_ * **Fuzzy appearance** _on outer edges of cortex_

Answer 391

**Osteosarcoma** * _cloudy bone formation_ on surface of cortex on facial and lingual aspect

Answer 392

**Osteosarcoma** a patient with swelling with side of face

Answer 393

**Osteosarcoma** ▪ _Lytic lesion_ ▪ *Slightly* **ill defined** ▪ **Loss of bone** in the _inferior aspect of mandible_

Answer 394

* Patient’s chief complaint is **painless swelling,** *may be associated with tooth mobility* * **Symmetric widening of the PDL space** * Can be _initial presentation with chondrosarcoma and osteosarcoma_ * **Along radicular surface of the tooth** there is the _same rate of widening all the way down the tooth_ * ***In contrast to periodontal disease***, where there is _a triangular shaped loss of space_

Answer 395

* **Poorly defined radiolucency**, often with ***scattered radiopaque foci*** * Radiopaque foci can be seen since the cartilage in the tumor can ossify

Answer 396

* **Radical surgical excision** _on initial treatment_ * _Maxillectomy/Mandibulectomy_ * If anterior region they remove the entire anterior portion of the jaw * These lesions *don’t respond to radiation or chemotherapy* * ***Although used as adjuncts for lesions that can’t be treated surgically*** * *For example **a posterior sinus** **lesion** _since that is the base of the skull_* * *These patients have **poorer prognosis** than those with more accessible sites such as the mandible* * **Prognosis is poorer** *than for osteosarcoma* (which contrasts with the prognosis in extragnathicsites) * **Treatment failure** (and ***mortality***) is usually **due to uncontrolled local disease** *not metastasis*

Answer 397

* **Since 20% of chondrosarcomas of the jaw are initially misdiagnosed as chondromas** ► any diagnosis of chondromain the jaws should be viewed with suspicion * **All cartilaginous tumors arising in the jaws should be excised widely** * (\>60% of cartilaginous tumors of the jaw recur and ~7% metastasize to the lung and/or bone )

Answer 398

* **Most common malignant bone tumor in the jaws** is _metastatic disease_ * **Most commonly primary** (meaning started at this location) **malignant bone tumor in patients under 40 years old** * 2nd most common overall after *multiple myeloma* * _Mean age at presentation for jaw lesions_ is **33 years old,** *10‐15 years older than that for long bones* *

Answer 399

* **Swelling and pain** are the common presenting symptoms **(25% have “toothache”)** * Can also have ***loosening of teeth,** **paresthesia of lip** and **nasal obstruction*** * **Symmetric widening of the PDL** is often _an early radiographic change_ * Lesions vary from ***dense sclerotic, mixed sclerotic*** *and* ***radiolucent*** *to* ***all radiolucent***

Answer 400

* _Important to distinguish from chondrosarcoma as treatments are different_ * **_Osteosarcoma_** is currently treated with **pre-op multi-agent chemotherapy followed by surgery** * ***Radiation therapy*** alone is ***insufficient*** for cure * **_Favorable jaw site – MD symphysis_** * **_Worst site – MX sinus_** * **5 year survival is ~ 20%** (***_up to 80% if caught early_*** and *_treated with radical resection)_*

Answer 401

**Langerhans Cell Disease** Infant with _Acute disseminated type_ ▪ See lesions on head/ear

Answer 402

Langerhans Cell Disease we see _lesions on maxilla_

Answer 403

**Langerhans Cell Disease** ▪ Older child ▪ Chronic disseminated form ▪ Alveolar ridge involvement ▪ Lot of bone loss and mobility ▪ Painful to brush

Answer 404

**Langerhans Cell Disease** Torus and molar involvement

Answer 405

**Eosinophilic Granulations** Erythematous area

Answer 406

▪ Child with _disseminated form_ ▪ **Punched out radiolucency** in the skull

Answer 407

▪ Child with bone loss surround the teeth ▪ Floating teeth _disseminated form_

Answer 408

▪ Floating teeth ▪ Only attached by soft tissue due to extensive bone loss _disseminated form_

Answer 409

**Eosinophilic granuloma**

Answer 410

* **Arise on the surface of the bone** (vs. medullary site for usual forms of osteosarcoma) * Usually **long bones**

Answer 411

**parosteal** – *_well differentiated_*, but will **recur** with less than an en bloc or radical surgery **periosteal** – _higher grade_ with prominent **cartilaginous** component

Answer 412

o **Mushroom like growth** on bone surface o **No** *elevation of periosteum* o **No** *new bone formation* o **Low grade**

Answer 413

o Usually **sessile** **growth** on bone surface o **Elevation of periosteum** o **New bone fills in** space under periosteum o **Prognosis is _better_** *than medullary osteosarcoma* ***but worse than**parosteal type*

Answer 414

* **Histiocytosis X (old name**) * **Langerhans cell granuloma** * **Eosinophilic granuloma** * **_Langerhans cell histiocytosis_**

Answer 415

Etiology unclear o Demonstration that LCH cells are **clonal**, along with the recent discovery of **activating BRAF mutations in LCH cells**, ►**strongly suggests that LCH is a neoplastic disease**

Answer 416

* **Males**\>\>\> Females * More than half of cases seen **under the age of 10** * **Jaw** affected in **10 ‐20% of cases**

Answer 417

**_Clinically:_** Common sites: **skull, rib, vertebrae, and mandible** ▪ Often have associated **pain or tenderness** **_Radiographically:_** ▪ In jaws we see loss of alveolar bone in molar area o Mimics severe periodontitis

Answer 418

* **Punched out** radiolucency * **Lytic** radiolucency *without cortication* MM Multiple Myeloma

Answer 419

* more punched out radiolucency in iliac crest in the image * Bone marrow biopsy usually done in this area since it’s frequently involved multiple Myeloma MM

Answer 420

Multiple Myeloma ## Footnote ▪ Radiolucency without sclerotic border ▪ Multiple and separated

Answer 421

Swelling of gingiva ## Footnote **▪ Plasmacytoma**

Answer 422

**▪ Acute disseminated form (Letterer‐Siwe disease) ▪ Chronic disseminated form (Hand‐Schuller‐Christian Disease, ▪ Eosinophilic Granuloma (chronic localized)**

Answer 423

* **Multisystem** (bone, skin, liver spleen and lymph nodes) * **Infants** * **high mortality** * **rapidly progressive**

Answer 424

* **Unisystem** (frequently *bone*, but _also skin and viscera)_ * **Children** * ***fairly* high mortality** * ***more* chronic progression**

Answer 425

* **Solitary or multiple bone lesions** *without visceral involvement* * **Adults** * **very low mortality** * Some reports of **association with smoking marijuana** * In these cases ***the lungs are involved***

Answer 426

**Ewing Sarcoma** ## Footnote ▪ Long bone ▪ Large expansion

Answer 427

**Ewing Sarcoma** * an _expansion of tissu_e * **Dissolution of bone** in that area

Answer 428

Site of involvement depends on clinical form * Neoplastic proliferation of Langerhans cells * Langerhans cells * Dendritic mononuclear cells normally *found in the epidermis and mucosa* * Antigen presenting cells to T lymphocytes

Answer 429

Metastatic Carcinoma to Jaw Bones ▪ A. Metastatic breast carcinoma surrounding the apical half of the second and third molar roots and extending inferiorly. It has destroyed the inferior border of the mandible.

Answer 430

Metastatic Carcinoma to Jaw Bones B. Bilateral metastatic lesions from the lung destroying the mandibular rami.

Answer 431

Metastatic Carcinoma to Jaw Bones D. Destruction of the left mandibular condyle (arrows) from a thyroid metastatic lesion

Answer 432

Metastatic Carcinoma to Jaw Bones A. Partial panoramic image of prostate metastatic lesions involving the body and ramus; note the sclerotic bone reaction (arrows).

Answer 433

Metastatic Carcinoma to Jaw Bones B. Occlusal image of prostate lesions causing sclerosis and spiculated periosteal reaction (arrows)

Answer 434

Metastatic Carcinoma to Jaw Bones C. Periapical image of a metastatic lesion of breast carcinoma; note the irregular widening of the periodontal membrane spaces and patchy sclerotic bone reaction, especially around the roots of the molars

Answer 435

* **Exophthalmus** * **Diabetes insipidus** * **Lytic defects of bone**

Answer 436

Clinically: * we see _mobility of teeth_ Radiographically: * picture of child with **“teeth floating in air”** * **Sharply punched out radiolucent lesion**s, *ill- defined radiolucency in some cases*

Answer 437

* **Elderly men** often present with **lung lesions** *_(increased incidence with smoking)_* * **Localized lesions,** usually affecting **one bone** * If found to be a*n accessible solitary lesion,* **treatment** is usually **curettage and possibly low dose RT** * in some instances it can be **initial presentation of systemic disease** – but that would _typically be in children or young adults_

Answer 438

**Birbeck granules**

Answer 439

**o Juvenile periodontitis** **o Langerhans cell histiocytosis** **o Papillon‐Lefevre syndrome** **o Cyclic neutropenia/agranulocytosis** **o Burkitt’s Lymphoma**

Answer 440

**Monoclonal Expansion of malignant plasma cells** * Plasma cells make a lot of immunoglobulin ► So we will see a lot of immunoglobulin

Answer 441

* Most common in **40‐70 year old** * Means 63 years old * Bones most commonly involved include **ribs, vertebrae and skull** * **70‐90%** will have ***_jaw involvement at some point_***

Answer 442

* Present with **bone pain (\>70%)** and **pathologic fractures** * ***Anemia, thrombocytopenia and neutropenia*** _due to crowding out of normal cells within bone marrow by proliferating malignant cells_ * _50‐60%_ have **Bence‐Jones proteins in urine** (light chains, usually kappa)

Answer 443

**▪ Solitary plasmacytoma** * *Individual lesion **in bone*** * When affecting oral cavity, ~95% of the cases are ramus and angle of the mandible * In many cases p_rogress to more systemic disease_ **Extramedullary plasmacytoma** * *individual **soft tissue** lesion* (not central In bone) **Multiple myeloma** * ***multifocal*** *disseminated disease*

Answer 444

* **“punched out” radiolucencies** (no sclerotic margin) often _with an irregular outline_

Answer 445

* **Elevated M spike in serum** * *Elevation of immunoglobulin in serum* (**hyperglobulinemia**) most **commonly IgG** * *Deposition of amyloid in tissues* (**macroglossia**)

Answer 446

Treatment can include : * **chemotherapy** _with or without Radtiaion Therapy_ * bone marrow transplant * interferon * antibodies made against tumor cells * thalidomide * Even with treatment, many patients do not survive more than 18‐24 months, however treatment modalities are improving * Older patients are treated less aggressively

Answer 447

▪ Highly malignant, undifferentiated, small round cell tumor/small blue cell tumor o The cell of origin is in question, may be of neural crest origin

Answer 448

* **Primarily a disease of children and adolescents (**90% of patients are between 5 and 30 years old) ▪ **\>60% males** ▪ * _Twice as common_ **in mandible** * **Caucasians\>\>\>\>Blacks and Asians** * Make up **~6% of primary malignant bone tumors** * In the jaws, the ratio of primary tumor to metastasis is 14 to 1 * **50%** of cases i**n the femur and pelvic bones** * **~1%** occur in the **jaw bones**

Answer 449

* Patients often present with **pain, swelling, fever and elevated ESR** (similar to signs of inflammation) * May be misdiagnosed as **an infection or osteomyelitis** * **Paresthesia** and **loosening of teeth** are _common findings with jaw lesions_

Answer 450

* **an irregular lytic lesion** *with* i**ll‐defined margins** * **Root resorption** _may be seen_ * May see **thickening of the periosteum** with a characteristic **“onion skinning” pattern** (like with peripheral periostitis) * seen more in long bones

Answer 451

* **Combined therapy with multi‐agent chemotherapy, radiation therapy and surgery** has led to 40% ‐ 80% survival rates * **Gnathic Ewing sarcoma** has *_a lower mortality rat_*_e_ than all other primary sites

Answer 452

The most common carcinomas to jaw: **B**reast **L**ung **T**hyroid and **C**olon **K**idney **P**rostate ▪ “B. L. T. and Cold Kosher Pickle”

Answer 453

Metastatic tumors to the jaw are more common than primary lesions ## Footnote ● Think osteosarcoma, chondrosarcoma, or osteoblastic metastasis (breast or prostate) if lesion radiographically looks malignant and has radiopaque internal pattern ● Ewing’s sarcoma is clinically accompanied by signs of inflammation ●Multiple myeloma characteristically presents as multiple, well‐ defined, punched‐out radiolucencies ● Bone affected by Non‐Hodgkin’s lymphoma radiographically appears to be dissolving ● Langerhans cell histiocytosis characteristically presents as scooped‐ out radiolucencies at the mid‐root level ● Remember to include metastatic carcinoma to jaw as a radiographic differential diagnosis for malignant lesions

Answer 454

_What is it?_ * **Excess of circulating parathyroid hormone important in formation of osseous structures** * Increase bone remodeling but tips the balance of osteoblastic and osteoclastic activity in favor or osteoclastic resorption * it's a systemic endocrine disease _What are its types?_ **o Primary hyperparathyroidism Type** 1 ▪ Uncontrolled parathyroid hormone production by parathyroid neoplasm (adenoma \>\> hyperplasia \> adenocarcinoma) **o Secondary hyperparathyroidism Type 2** ▪ Continuous parathyroid hormone production in response to chronic low serum calcium levels ▪ Renal osteodystrophy

Answer 455

Hyperparathyroidism Here we see we see * _a granular appearance of the max and mand bone everywhere,_ it is **not localized**. * There is a **loss of bone density** and **the loss of definition of cortical bone.** * Here we see a **loss of definition of lamina dura** as well _because it is now granular, and is not as clear._

Answer 456

**Hyperparathyroidism**; this is the **brown tumor** which is sometimes **well or ill defined,** **multi or unilocular radiolucency** with **granular septation.** If you have a patient that is younger than 15-20 years old that has **a central giant cell granuloma** ► you have to check that patient for hyperparathyroidism, because it could be a brown tumor.

Answer 457

This is another medical CT scan. You see the granular appearance of the maxilla, skull, and well-defined multilocular radiolucency with granulation. We call this a brown tumor because it is associated with **hyperparathyroidism.** **( s**ystemic endocrine diseases)

Answer 458

Hyperparathyroidism ## Footnote On our intraoral radiographs, we see **loss of definition of lamina dura** because the bone now has **a granular appearance** which extends to the lamina dura. The teeth are usually normal, but there is a loss of lamina dura around the teeth. These teeth are not mobile.

Answer 459

a medical CT scan of a patient with **secondary hyperparathyroidism.** We see a **lack of cortical bone** – no normal cortical bone. Inside the skull we have **a granular appearance**, with **radiolucent and radiopaque dots**, we call this **a salt and pepper dots**. This is why we call this a salt and pepper appearance, _there is no normal cortical bone._ *( systemic endocrine diseases)*

Answer 460

we have 2 Pas of patients **with pseudohypoparathyroidism**. * hypoplasia of enamel, tooth material * hypoplastic tooth bud ( hypoplastic means arrested development) * delayed eruption, * external root resorption.

Answer 461

Acromegaly (Hyperpituitarism) * enlargement of the mandibular bone with a high degree of enlargement * a class III appearance * enlargement of sella tursica because of the pituitary gland enlargement

Answer 462

Dwarfism * hypopituitarism* * We see* multiple dental anomalies: **hypodontia, radicular fusion,** fused roots of left lateral incisor and left canine **and impacted permanent teeth.** * (from google)*

Answer 463

▪ **Stones, bones, moans, and groans** ▪ **Radiolucent appearance** (_generalized osteopenia_) What we see in the bones is one of the earliest radiographic features that we see = sudden erosions in the phalanges in the bones of the hands followed by mineralization of the skeleton including max and mand, skull base. As a result, you have generalized osteopenia. **10% of these patients have brown tumors** ▪ **Brown tumors:** Brown tumors are the same as central giant cell granulomas. When they are associated with hyperparathyroidism, we call them brown tumors. ▪ **Punctate or nodular calcifications** in the joints and kidneys =stones ▪ **Entire calvaria** has _a granular appearance_ classically known as the **“salt and pepper”** skull as a result of the generalized osteopenia, we have this granular appearance in the skull

Answer 464

_Osteoporosis_ * **reduction in bone density,** * **larger bone marrow spaces.** We **need more tests to confirm osteoporosis** besides dental radiographs.

Answer 465

What is Hypoparathyroidism: ## Footnote _Insufficient secretion of PTH o Damage or removal of the parathyroid glands during thyroid surgery_ Principal radiographic change: calcification of the basal ganglia Sometimes we have **pseudohypoparathyroidism.** This happens when we have a normal amount of PTH, but there is something wrong with the response of the target tissue. So, we have normal PTH but abnormal response to PTH. **dental enamel hypoplasia, external root resorption, delayed eruption, or root dilaceration**

Answer 466

medical CT scan with a patient with **osteopetrosis**- very dense. Not a nice definition of the cortical bone. We see decreased in size of skull foramina.

Answer 467

pt with Osteopetrosis we see **Hypovascular bones** so they are *more prone to osteomyelitis*. This is a sign of sequestrum which is a sign of osteomyelitis.

Answer 468

pt with Osteopetrosis * **Generalized increase in bone density,** increased trabeculation, loss of large bone marrow spaces. * These patients are more prone to **osteomyelitis** _because they are Hypovascular_. * We have to be careful in **extractions** because they don’t have the same vascularity as other healthy patients have. * We see an **onion skin appearance** by the white arrow.

Answer 469

_What is it?_ * Hyperfunction of the anterior lobe of the pituitary gland caused by a benign functioning tumor of the anterior lobe * it's a systemic endocrine disease _What is its types ?_ ▪ Types based _on age of onset_ * **Gigantism** happens in ***children***, **generalized overgrowth of most long bones, hard and soft tissue**. These patients are usually very tall. Proportion in these patients may be normal, but very large appearance. * **Acromegaly** Increased hyperfunction in **adult patients**. In these patients, the epiphysis of the long bones already closed, **you can see in the mand or max.** One of the observable features is **enlargement of the whole mandible/skull/sinuses/soft tissue.** Patients usually present with _“My hat is not fitting anymore, my denture is not fitting anymore”_

Answer 470

**▪ General features** * _Enlargement_ (ballooning) of the **sella turcica** * _Enlargement_ of the **paranasal sinuses** (especially the **frontal sinus**) * _Thickening_ of the outer table of the **skull** **▪ Jaws** * _Enlargement of the **jaws**,_ most notably the **mandible** * **Class III skeletal** as a result of the mandible enlargement with growth centering in the condylar head **▪ Teeth and associated structures** * _Spacing of the teeth, enlargement of tongue_, it could result in spacing of teeth in the anterior region o **Hypercementosis the forces** are higher now * so you may see H**_ypercementosis_** * Hypercementosis is **excessive deposition of non-neoplastic cementum over normal root cementum,** which alters root morphology. This cementum may be either hypocellular or cellular in natur*

Answer 471

Ricket / Osteomalacia hyperplasia or thinning of mineralization of teeth. We can see hyperplasia of enamel in patients.

Answer 472

_What is it?_ Reduced secretion of pituitary hormones it's a systemic endocrine disease _What is it called?_ **Dwarfism** _How it appears radiographically?_ ▪ Finding of the jaws o **Normal eruption of primary dentition** but _delayed exfoliation_ o **Small jaws -**\> crowding and malocclusion because there is not enough space for the teeth to erupt

Answer 473

**Renal Osteodystrophy 1** *Presentation is variable*. Sometimes you see **denser or granular appearance of bone.** You see _increase here_ but you sometimes will also see loss of definition of lamina dura, sometimes a sclerotic appearance and trabeculation.

Answer 474

**Renal Osteodystrophy 2** sometimes you see: * **increase in bone density** * **loss of definition of lamina** * **dura and cortical bone**

Answer 475

_What is it?_ ▪ **_Generalized decrease in bone mass_ i**n which the histologic appearance of bone is normal, it is a metabolic bone diseases (MBD) _Why it happens?_ * **Aging process (postmenopausal women)** bone mass usually increases until 30 years of age, and then there is a gradual decrease- about 8% loss in females and 3% loss in males * **Nutritional deficiencies** * **Hormonal imbalance** * **Inactivity** * **Corticosteroid or heparin therapy** _What the bone are like?_ ▪ **More prone to fracture** (distal radius, proximal femur, ribs, and vertebrae)

Answer 476

Hypophosphatasia

Answer 477

large root canal structures, large root chambers, premature loss of teeth = **hypophosphatasia.**

Answer 478

_What is it?_ **Defect in the differentiation and function of osteoclast**s, (osteoclasts that are used to resorb bone in the bone modeling process. They are not functioning properly ►so we have an increase in bone density.) It is a metabolic bone diseases (MBD) _How is the bone like?_ Bone is **dense, fragile, and _susceptible to fracture_** _and **infection ►**_we now have a_n osseous structure but small bone marrow spaces_ _What are the effects on other structures?_ It compromised vascular structures and cranial nerves

Answer 479

**Hypophosphatemia** * Periapical lesions with radiolucency but no caries on the crown. * There is loss of definition of cortical bone. * On the teeth, you have: * large pulp chambers * hypoplasia of enamel and dentin * periodontal and periapical lesions.

Answer 480

* Compression of the cranial nerves as they pass through the narrowed skull foramina -\> **blindness, deafness, vestibular nerve dysfunction, and facial nerve paralysis.** * Compromises hematopoiesis Poor vascularity -\> **osteomyelitis**

Answer 481

Progressive Systemic Sclerosis (scleroderma) ## Footnote sharp areas of resorption in the bones near muscles attached to the angle of the mandible= masseter and medial pterygoid. You see resorption at the coronoid process at the attachment of the temporal bone as well.

Answer 482

**Progressive Systemic Sclerosis (scleroderma)** * presence of **widening of the PDL space everywhere** around the root of the tooth.

Answer 483

***_What happens?_*** They are metabolic bone diseases (MBD) Inadequate serum and extracellular levels of ***calcium*** and ***phosphate***, ***failure of normal activity of vitamin D.*** There are different levels in the conversion from I,12- dihydroxy vitamin D that can have errors, not just the consumption of vitamin D. ***_Differences_*** **Rickets**: disease affects the growing skeleton in i**nfants and children** **Osteomalacia**: disease affects the **mature skeleton in adults** **Effects on bones:** A softening and weakening of bones

Answer 484

On a **sickle cell anemia** patient, you see: * **loss of this cortical bone area** * **the hair-on-end appearance on the skull**

Answer 485

Sickel Cell Anemia enlargement of bone marrow spaces, less trabeculation, more osteoporotic bone. You see periapical pathology associated with teeth with no obvious reason. You see the radioluscencies around the apex of the mandibular teeth.

Answer 486

o Lack of vitamin D in the diet o Gastrointestinal malabsorption problems o Lack of exposure to UV light o Liver disease o Kidney disease o Defect in the intestinal target cell response

Answer 487

_Rickets_ o Growth retardation o Short stature o **Bowing of long bones** of the legs, waddling gait o **Radiograph manifestations in the teeth** (especially \<3 years of age) **and jaws** _Osteomalacia_ o Weak fragile bone structure _o Diffuse skeletal pain_ o Susceptible to fracture with minor injury o _Radiographic manifestations in the jaws_ **are uncommon** o you may see **hyperplasia** *or* **thinning of mineralization of teeth. You can see hyperplasia of enamel in patients.**

Answer 488

**Thalassemia** * **osteopenic bone (***loss bone mass and bones get weaker*) * **radiolucent appearance of bone** * thinning of cortical bone around the mandible and maxilla. * Usually there is **hypoplasia of the paranasal sinuses.**

Answer 489

_What is it?_ **Chronic renal failure** produces **bone changes** by _interfering with the hydroxylation of vitamin D in the kidneys_ -\> _hypocalcemia_ -\> **inhibit the normal calcification of bone and teeth** *(it is a metabolic bone disease)* _what can it lead to?_ (secondary hyperparathyroidism) **level of calcium is low** leads to having **hyperparathyroidism secondary to osteodystrophy**

Answer 490

**_What is it?_** * Rare metabolic bone disease due to **lack of tissue-nonspecific alkaline phosphatase** **_What are its types?_** **Four types: prenatal, infantile, childhood, adult** * _The younger the age of onset, the more severe the_ * _manifestations_ * It may have premature loss of these patients because loss of function of the lungs in these patients

Answer 491

Common factors? * _Low levels_ of **tissue-nonspecific alkaline phosphatase** * **High** blood and urinary **phosphoethanolamine** * **Rickets-like skeletal malformations** Dental manfestations? * _Premature shedding_ of **primary incisors** * **Enamel hypoplasia** * _Enlarged_ **pulp chambers** and **root canals**

Answer 492

_What is it?_ * A **rare**, **heterogeneous** group of **inherited** metabolic disorders characterized by **decreased phosphate reabsorption** _in the distal renal tubules_

Answer 493

_Clinical Manifestations_ * **Rickets-like skeletal malformations** _Dental Manifestations_ * **Enlarged pulp chambers** and **root canals** * **Periapical and periodontal abscesses** of no obvious cause * **Enamel hypoplasia**

Answer 494

_What is it?_ * **Excessive collagen deposition** resulting in **hardening (sclerosis) of the skin and other tissues** can have involvement of _GI tract, heart, kidney,etc_ _Demographics?_ * Middle aged female

Answer 495

_Clinical Presentation_ * Thickened, leathery quality skin * joint pain * exaggerated response to cold (Raynaud's disease) * heartburn. * more prone for heart problems and respiratory insufficiencies, _Oral Manifestations_ * microstomia (small mouth) * Xerostomia (dry mouth) * telangietasia ("spider veins") * Increased decayed, missing and filled teeth. * higher Gingivitis scores (usually) * Deeper Periodontal Pockets

Answer 496

Treatment for generalized symptoms may involve: * **corticosteroids** * **immunosuppressants, such as methotrexate or Cytoxan** * **nonsteroidal anti-inflammatory drugs** Depending on your symptoms, treatment can also include: * blood pressure medication * medication to aid breathing * physical therapy * light therapy, such as ultraviolet A1 phototherapy * nitroglycerin ointment to treat localized areas of tightening of the skin *(from google)*

Answer 497

_What is it?_ **Chronic hemolytic blood disorder** _What causes it?_ ▪ **Abnormal hemoglobin, resulting in anemia** -\> by increasing the production of red blood cells -\> **requires compensatory hyperplasia of the bone marrow**

Answer 498

* loss of this cortical bone area * See the hair-on-end appearance on the skull * enlargement of bone marrow spaces * less trabeculation, more osteoporotic bone * periapical pathology associated with teeth with no obvious reason

Answer 499

What is it? * **Defect in hemoglobin synthesis** What causes it? * **RBC with reduced hemoglobin content** and _short life span_

Answer 500

* **Hyperplasia of the bone marrow** **component** of the bone which results _in fewer trabeculae per unit area and can **change the overall shape of the bone**_ * **Protrusive premaxilla** * **Radiographic appearance** very similar to _Sickle Cell Anemia_

Answer 501

generalized decrease in bone density of jaws (thin cortices; granular cancellous bone; loss of lamina dura). * Refer to physician for lab tests to make the diagnosis

Answer 502

o Localized focus of radiolucency► **think brown tumor and hyperparathyroidism** o Mandibular prognathism and incisor flaring► **think acromegaly** o Premature shedding of primary incisors► **think hypophosphatasia** o Enamel hypoplasia, enlarged pulp chambers and periapical abscesses of no obvious cause► **think hypophosphatemia**

Answer 503

1. Fibrous Dysplasia 2. Cemento-osseous Oysplasia 3. Ossifying Fibroma

Answer 504

Type of Bone Dysplasia

Answer 505

Benign neoplasm

Answer 506

** Monostotic  Polystotic  McCune‐Albright Syndrome  Craniofacial  Mazabraud Syndrome**

Answer 507

Monostotic

Answer 508

a Fibrous dysplasia involving **one bone** o Ex: when only the mandible involved or only the maxillae (Most common type (70%)

Answer 509

a Fibrous dysplasia involving **more than one bone**

Answer 510

Polystotic Fibrous dysplasia

Answer 511

** Jaffe Type  McCune‐Albright Syndrome** (involving multiple bones with endocrine abnormalities)

Answer 512

-a Fibrous dysplasia limited to **Skull and Facial Bones.**..

Answer 513

-Fibrous dysplasia with **intramuscular myxomas**

Answer 514

an aberrations in osteoblastic/osteoclastic function ► normal bone turn over affected ► normal bone structure will be affected!

Answer 515

Developmental lesion characterized by substitution of normal bone by poorly organized woven bone and fibrous tissue.

Answer 516

**_GNAS1 gene mutation_** in fibrous dysplasia is a potential diagnostic adjuvant, as it is not found in normal bone tissue (etiolog

Answer 517

* No gender predilection * commonly seen in pediatric patients and young adults

Answer 518

* Clinically, it causes **bone expansio**n and **asymmetry** * most typical presentation of monostotic fibrous dysplasia is **a slow growing painless enlargement in the affected area.** * so the patient may notice a slight asymmetry that won’t bother them intially, but over time~months to years ►they’ll notice that this area is slowly and steadily growing more and more ( slow and painless)

Answer 519

• Most common sites of FD include the **ribs, femur, tibia, maxillae and mandible**  the **Maxillae** is affected more than the mandible

Answer 520

**FD** Radiographically: you have altered trabecular pattern Clinically: Painless mass slowly growing over time is is typical presntation of Fibrous Dysplasia

Answer 521

**Fibrous Dysplasia** * ill‐defined radiolucent/radiopaque/mixed radiolucent‐radiopaque entities that blend with normal bone. * The left side is affected. Left body of the mandible and the ramus. * The cortical outlines have been expanded near the inferior border of the mandible.

Answer 522

**• Maxillae affected more than mandible** • **Ill‐defined borders, blends in with the surrounding bone (not necessary to be corticated)** • **Variable density and orientation of the trabecular pattern** (radiolucent, radiopaque or a combination) * *• Ground‐glass appearance** (common) * *• Peau d'orange (surface of an orange)** (common) * *• Cotton wool appearance** (common) * *• Fingerprint pattern** ( uncommon pattern) • Typically the lesionss in the **maxillae are more homogenous and radiopaque,** whereas they may appear **more heterogenous and mixed in the mandible.** *\*typically you’ll see the ground glass appearnce and Peau d’orange on the maxilla as they are homogenous the cotton wool appearance more commonly found in the mandible since it is heterogenous.*

Answer 523

**Fingerprint pattern** The arrow indicating the inter‐radicular area of this molar. You can see the trabecular bone has been altered into a fingerprint pattern. This is a case of localized fibrous dysplasia. Very uncommon.

Answer 524

**Cotton wool appearance** Irregullary shaped and outlined radiopacities blending in with adjacent bone

Answer 525

**Peau d'orange** surface of an orange – the bone shows a “pitting” appearance.

Answer 526

**Ground Glass Pattern** it appears granular in nature. (Grainy)

Answer 527

**Fibrous dysplasia on the right mandible.** Note the superior displacement of the IAN Canal This is not odontogenic ( as they are usually above the canal) **Anything below th canal ►think of it as originiating from the bone itself**

Answer 528

Fibrous Dysplasia in the left of the maxillae. Always compare both side left and right * We see granular/glass appearance of the bone ( blue arrow) and compare it to the contralateral maxillae. The trabucular pattern has changed signficantly. * Also compare the maxillary sinus space. The left maxillary sinus appears radiopaque. * That is because the maxillae has been enlarged to the point where it is pushing the floor of the maxillary sinus superiorly and reducing the total volume of the sinus. * The purple arrows indcate the displaced floor of the maxillary sinus.

Answer 529

**FD** Note the normal left maxillary sinus and the obliterated space of the right maxillary sinus ( blue arrows). **A ground glass appearing entity** (humogenous radiopaque lesion) has obliterated the space secondary to expansion of the right maxilla. These findings are consistent and quiet common in **advanced cases Firbous dysplasia**

Answer 530

* **May have no effect** ( especially if it hasn’t reached the cortical outlines) * **Expansion and thinning of cortical walls** * **Displacement of teeth** ( espically in advanced cases) * One of the few entities that cause **SUPERIOR displacement** of the mandibular canal

Answer 531

Periapical COD green arrow Simple bone cysts may develop in regions of COD ( periapical or florid type) So look for areas void of trabucular bone and has scalopping of the lesion. red arrow

Answer 532

mature Periapical COD Coronal cross section of the posterior mandible in the region of the premolar ~ mixed radiolucent/radiopaque entity, the center is radiopaque and the periphery is radiolucent.

Answer 533

mature Periapical COD You can have these lesions in endentulous areas as well. So this is is an endeulous area, but if there was a tooth here, this would be in the periapicel region or near it with mixed radiolucent/radiopaque entity  the differential diagonsis of this area could include Periapical COD.

Answer 534

mature Periapical COD You see a nice radiolucent rim and radiopaque center  so mixed radiolucent/radiopaque entity in the periapical region of tooth #31  most likely diagonsis would be Periapical COD.

Answer 535

A very mature Periapical COD ( purple arrow) Well‐defined radiopacity in the periapical region. Sometimes you may or may not be able to differentiate a very thin radiolucent line as in this case. you might include ddx of other lesions which might present with radiopacity in the preapical region There are certain tests you can do clinically to differentiate too. or do clinical tests

Answer 536

Periapical COD Sagital cross section of the anterior Mandible. Mixed radiolucent/radiopaque area (green circle)

Answer 537

Early & mature Periapical COD **Preapical radiographs of the anterior mandible of the same patient at different times.** Note the differnece in density between the two radiolecency: Note the internal structure of the radiopacity is quite radiolucent ( purple arrow) The Preapical radiographs of the same region taken at a later time shows a more radiopaque internal structure (pink arrow). This reflect the maturing of the COD lesion. The lesion with Pink arrow can be described as well‐defined mixed radiolucent/radiopaque entity. ( because you have radioleucent part and radipaque part)

Answer 538

Early Periapical COD well defined radiolucency surrounding the apeces of these two central When looking at such cases, it is also imporant to: 1. look at the crowns to look for carious lesions. If there is no restorations or no evidence of caries, it is likely that these lesions are arising from the bone and not secondary to pulpal involvement. 2. It also important to look at the PDL and Lamina dura, typically in COD lesions they should be visisulized and intact ( but because this is a 2D image and this area may superimpose on this region and obsecure the visulizing of the lamina dura and the PDL) **what’s the difference between COD and Inflammatory lesion?** COD won’t have effect on the PDL space itself, because it orginates from the bone! Vitality testing can help us differntiate between inflmmatory lesion and something that happeing inside of the bone.

Answer 539

Florid COD Axial section of the mandible. * Notice **mixed radiolucent/radiopaque entity on the patient right side**. And **on the left the area is more radiopaque centrally and has a thin radioluceny around it.** * The arrows indicate **well‐defined radiopacities immedietly surrounded by radiolucent rims.** * Note that **the radiolucent rim on the left side is thin when compared to the lesion on the right. This likely means that the lesion on the left is more mature** ( more time has passed for the entity to produce more woven bone).

Answer 540

Florid COD ## Footnote Two periapical radiographs of the left and right posterior mandible of the same patient.  In this case, note **the areas of radiolucency and radiopacity are rather ill defined but widepsread** to affect most of the teeth. Most of the teeth noted here are restored.  So even if the radiographs suggest a cemento‐osseous process, it is important to keep an eye for these teeth in term of vitality and prevent a periapical infections which would otherwise **secondarily infect** the altered bone of COD.

Answer 541

Florid COD Multiple regions of COD. Notice the wide areas of scelortic/radiopaque areas on mandible and also on maxillae

Answer 542

**Generalized FD** * Metabolic bone diseases (hyperparathyroidism) (any disease that incrase trabacular bone density) * Paget's disease **Localized FD** * Osteomyelitis * Osteosarcoma

Answer 543

* Consultation with an OMFR is advisable. Monitoring of the area is also advised. * Typically treatment is not needed unless there are clinical symptoms or patients present with cosmetic concerns if clinical symptoms are severe * Implants and surgical intervention should be avoided when possible as these areas are void of blood supply

Answer 544

There are two types: **classic and juvenile form** -**juvenile** seen in younger patients and tend to be more aggressive in nature ( both radiographically and clinically aggressive features) • Young adults and females affected mostly • Bony expansion and displacement of teeth can be seen in many cases ( not suprising since it acts like a neoplasm) • _More commonly_ seen i**n the mandible and in posterior regions**

Answer 545

**Cemento‐ossifying Fibroma** ## Footnote Note **the internal granular appearance of the trabucular bone** ( black arrows) The purple arrows shows the wall of the expanded buccal/facial and lingual cortical plates caused by the neoplastic entity. This was a confirmed cased of **ossifying fibroma\*** mainly because of two things: **1. siginficant cortical expansion on buccal and lignual side 2. altered trabacular pattern.** **ddx of fibrous dysplasia b**ut you should look for a radiolucent rim if you can and if not, they maybe considered under the same differential diagosnsis. Note that may help you in differentiating : **** The **maxilla** is affected more in **_Fibrous dysplasia_** **** The **mandible** is affected more in **_Ossifying fibroma_**

Answer 546

Cemento‐ossifying Fibroma Axial section of the mandible * The granular radiopacity immediately surrounded by a radiolucent rim ( purple arrow) * **Also note the extent of the expansion of the buccal and lingual cortical plates, a feature which is common of ossifying fibroma.** * This is more clear radiographically where we see a radiolucent rim surrouding a mixed radiolucent/radiopaque center and there is a siginficant expansion of the buccal and lingual plates. ► **very common in ossifying fibroma**

Answer 547

Classified as **a benign neoplasm** ## Footnote Because _it acts like a benign neoplasm_. Once you examine it under microscope, you’ll see features _resmeble_ **benign fibrous osseous lesions.** You’ll see: ** Fibrous connective tissues  cementum like material  even altered bone material (woven bone)**

Answer 548

* **Well‐defined, round or oval lesion** * **Periphery of the lesion is corticated** and may **exhibit a radiolucent periphery** (sometimes referred to as **a soft tissue capsule**) * Internally, the lesion is typically **granular or radiopaque** but may show variations (**mixed radiolucent/radiopaque**) * _Strong tendency to_ **displace teeth and cortical outlines**

Answer 549

Cropped Panaromic showing **a case of** Cemento‐ossifying Fibroma * Appreciate the **radiolucent rim** indicated by the black arrows. * Also note the internal structure of the trabucular bone and compare it to adjacent unaffected areas. It is **more granular and radopaque** compared to adjacent areas. * Another important feature to appreciate is **the displacement of the anterior teeth** **(diverging roots)** * These features are usually seen **in lesions with benign neoplastic characterstics.**

Answer 550

Dysplastic lesions that are confined to the jaws.

Answer 551

**Cleido-Cranial Dysplasia** **Treatment:** For children, facial reconstructive surgery on the bones of the face to reshape the forehead or cheekbones. Spinal fusion procedures to support the spinal column. Lower leg surgery to correct knock knees (knees that bend inward toward the center of the body)

Answer 552

Gardner's Syndrome Synonym: Familial Multiple Polyposis. Remember this:  GarDENse Bone Island.  GARDEN-FOREST:  F- Familial adenomatous polyposis.  O- Osteomas.  RE- Retinal epithelial hypertropy.  ST- Supernumerary teeth. Treatment: Because people with Gardner’s syndrome have a higher risk of developing colon cancer, treatment is usually aimed at preventing this. Medications such as an NSAID (sulindac) or a COX2 inhibitor (celecoxib) may be used to help limit the growth of colon polyps. Treatment also involves close monitoring of the polyps with lower GI tract endoscopy to make sure they do not become malignant (cancerous). Once 20 or more polyps and/or multiple higher risk polyps are found, removal of the colon is recommended in order to prevent colon cancer. If dental abnormalities are present, treatment may be recommended to correct problems.

Answer 553

**Osteopetrosis** **Osteomyelitis** is a complication in patients with **osteopetrosis** as can be seen in pan image! Treatment: Bone marrow transplant (to stimulate osteoclast formation).

Answer 554

Paget's disease stages ## Footnote Early Linear lines: The bone is being resorbed in a very distinct pattern \> linear patterns of trabeculation Middle -MAY see the "cotton wool" appearance (but this is more pronounced in the third stage) -the trabecular pattern may or may not be slightly affected Late - There is MORE bone deposition -the "cotton wool" appearance is very very clear in this stage! Also-hypercementosis and spacing of teeth.

Answer 555

Paget's Disease Also Known As: **Osteitis Deformans.** **Skeletal disorder involving osteoclasts** **_Treatment:_** Osteoporosis drugs (bisphosphonates) are the most common treatment for Paget's disease of bone

Answer 556

Cherubism **Treatment**: Usually not needed as the cyst-like lesions fill in with granular bone during adolescence- conservative surgical procedures may follow for cosmetic reasons.

Answer 557

Idiopathic Osteosclerosis AKA: Dense Bone Island  Not associated with any dysplastic, neoplastic, inflammatory or systemic disorder.  **Common incidental finding.**  Slow growing, typically stops growing by the time of skeletal maturity.  Peak prevalence in the third decade of life. ** No treatment required; monitoring is suggested.**

Answer 558

**PCOD** ## Footnote **Differentiating factor:** Radiolucent zone surrounding the radiopacities of COD lesions. No such radiolucent areas for idiopathic osteosclerosis.  Important: The root of the tooth #28 appears to be resorbed but is likely not. Look at the root of #29. These teeth are still undergoing development in a young patient.  Left is showing dense bone island.  Right is showing Periapical COD- this is intermediate stage, not fully mature. You should see a radiolucent rim.  Another more obvious radiographic feature: you see radiolucent areas surrounding in both images, the common feature is: because PCOD and dense bone island do not affect the PDL spaces – you should be able to see the PDL spaces.  Sometimes it’s not the case. Look for the PDL, look for radiolucent area surrounding possible central radiopacity, idiopathic osteosclerosis can cause resorption; PCOD hasn’t been associated with root resorption.

Answer 559

**_Hypercementosis_** ## Footnote  **Differentiating Factor:** A well-defined radiolucent border that is continuous with the PDL of the tooth, in the case of hypercementosis. This means that whatever is happening is within the confines of the tooth-bearing region. In this case, the cementum.  Hypercementosis- Cementum is overraeacting, so there’s enlargement of cementum.  If cementum is larger, it should be pushing the PDL out (black arrow). So the PDL is enlarged meaning you should be able to see a radiolucent rim around the area. And the radiolucent rim should be continuous with the PDL of the remaining root structure.

Answer 560

**Cementoblastoma** ## Footnote ** Differentiating Factor:** A well-defined radiolucent border that is continuous with the PDL of the tooth, similarly seen in the previous case of hypercementosis. (sometimes it is difficult to differentiate hypercementosis and cementoblastoma, in this case, the beige arrow indicates the resorbed root surface, which normally occurs in benign neoplastic cases, such as cementoblastoma.  Cementoblastoma is more of a heterogenous radiopacity- meaning you may see gaps, like radiolucent voids, in between the areas.  See radiolucent rim.  But more common feature include root resorption because it’s a neoplastic condition. It should act like a neoplasms in which it’s destroying some of the root structure.

Answer 561

 For condensing osteitis, look for heavily restored or carious teeth. Condensing osteitis typically surrounds the initial rarefying osteitis lesion. The teeth in these cases are non-vital as they represent a condition that is secondary to pulpal necrosis.  Open necrosis, eventual PDL space widening and then once the infection reaches the bone, you have bone loss.  Now you have an overreaction or inflammatory reaction surrounding the initial inflammation.

Answer 562

**Focal Osteoporotic Marrow Defect** A large marrow defect that may mimic a cystic/neoplastic radiolucency in the jaw. common incidental finding a variation of normal anatomy within trabecular bone.

Answer 563

Simple Bone Cyst Also known as  1.) Solitary Bone Cyst.  2.) Traumatic Bone Cyst.  3.) Idiopathic Bone Cyst.  4.) Hemorhhagic Bone Cyst. Remember radiographic feature tend to Scalop between teeth  Treatment includes surgical curettage- spontaneous healing has been reported.

Answer 564

Sometimes, simple bone cysts should be differentiated from odontogenic keratocysts (OKCs)

Answer 565

brown tumor.

Answer 566

central giant cell granuloma CGCG

Answer 567

Aneurysmal Bone Cyst

Answer 568

**Mucositis** Thickening of the mucous of the sinus - normally we don’t see mucosa because it is very thin membrane 10 to 15 times thicker. Most common incidental findings that we can see on radiographs

Answer 569

**Sinusitis** Sinus mucosa becomes inflamed and thickened from infection or allergen, which may lead to ciliary dysfunction, retention of sinus secretions and blockage of sinus drainage ● 10% of maxillary sinusitis are related to dental infections

Answer 570

**Sinusitis** In this cone beam CT scan, we can see opacification of the sinus + sometimes we see gaseous bubbles. It is fluid that is forming inside the sinus.

Answer 571

**Sinusitis** Sinusitis can be secondary to oral antral communication (communication between maxillary sinus and oral cavity) this can happen due to extraction

Answer 572

``` Antral Pseudocyst (Retention Pseudocyst) ``` Localized, submucosal accumulation of fluid forming a sessile, domeshaped swelling along a sinus border ● Common incidental radiographic finding on panoramic ● Well-defined, non-corticated and dome shape radiopacity mostly along the floor of maxillary sinus

Answer 573

``` Antral Pseudocyst (Retention Pseudocyst) ```

Answer 574

``` Antral Pseudocyst (Retention Pseudocyst) ```

Answer 575

**Antrolith** ## Footnote Deposition of mineral salts (calcium phosphate/carbonate/magnesium) around an exogenous or endogenous (due to blood, pus or mucous) nidus ● Pediatric and adult population ‐ **Small antroliths** – incidental radiographic finding ‐ **Large antroliths** – sinus obstruction, sinusitis, nasal discharge, pain ● Mostly adjacent to the floor of the maxillary sinus ● We see combination of radiopacity and radiolucency due to layers of calcification.

Answer 576

One of the ways to differentiate antral pseudocyst from radicular cyst is by the presence of cortication. ‐ Reticulosis is a cystic lesion that happens around the apex of the nonvital tooth. ‐ They have a round and domed shaped appearance too, but they are from a different origin 􀀀 happening inside the alveolar processes

Answer 577

**Antrolith** ## Footnote Deposition of mineral salts (calcium phosphate/carbonate/magnesium) around an exogenous or endogenous (due to blood, pus or mucous) nidus We see a presence of radiopacity which is antrolith inside the maxillary sinus

Answer 578

**Foreign Body in Maxillary Sinus**

Answer 579

Foreign Body in Maxillary Sinus

Answer 580

**Periostitis** ## Footnote **•**Lamellar, periosteal reaction **from periapical inflammatory disease** •**Exudate** from infected tooth diffuses through the cortical bone, (elevation of periosteum) lifts and stimulates the periosteal lining to produce layer(s) of new bone **•Floor of maxillary sinus** •Inferior, buccal, lingual mandibular cortices

Answer 581

1) Periapical COD 2) Focal COD ( not covered) 3) Florid COD Two types of COD instead of three Perapical COD & Florid COD

Answer 582

cancellous bone is replaced with fibrous tissues & cementum‐like material.

Answer 583

* Typically **asymptomatic**, almost always captured as incidental finding * Generally, no bony expansion but is not uncommon in the florid type

Answer 584

• Commonly seen in middle‐aged patients female predilection * more commonly seen in the **Black population** * also frequently seen in **Asian population**

Answer 585

* Usually **well‐defined borders** in perapical type (may be ill‐defined in florid type). * **Early lesions show radiolucent features** in the periapical area of the teeth _As times progresses, the lesion matures =_t**he entity may become radiopaque.** ‐ as a result there is also **an intermideate mixed phase** **• The lesions mature from the center outwards** ‐ as a result, **_a radiolucent rim surrounding the lesion is commonly noted._** • Typically **the periodontal ligament space** of affected areas are intact but my not be _visualized_ because _they are superimposed over the region._

Answer 586

Widespread form of periapical COD ## Footnote There is some discreppency on how to consider a lesion a florid COD Some people say the radiopacity entities have to be on at least 2 qudarants And other says if you have the radiopacity entities crossing the midline of the bone. If it is in 3 quadrant ► then you can defentitly say it’s the Florid type, but even if you see itone bone and it has crossed the midline ► you may consider it Florid COD

Answer 587

Florid COD ## Footnote  **Rarefying osteitis** (radiolucent lesions) ( it would differentiate in the more early stages of the COD ( the radiolucent stage)  **Condensing osteitis** (considered in the differential when the lesion is more mature and more radiopaque lesions)  **Cementoblastoma** ( benign neoplasm of the cementum so we should be able to see certain features that reflect benign neoplastic lesions )  **Dense bone islands** ( a common differential when considering COD)

Answer 588

* **Paget's disease** ( t generalized areas) * **Osteomyelitis** ( localized area because we have mixed radioluecent/radiopaque areas)

Answer 589

* Typically, no treatment is required **unless these regions show clinical/radiographic evidence of secondary infection** * Ex if patient complain of some pain of that area –\> we want to follow up that region * **Surgery** within the dense bone has a high risk of causing **osteomyelitis** * **Patients should be seen regularlyfor preventive treatment** Want tooth supported rather than tissue supported RPD and CD

Answer 590

* Surgical excision ( need to send to **biopsy** in order to confirm the diagosnsis of that) * Wider resection with bone maybe necessary in soma larger or more clincally aggressive cases.

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