Figure 5. OKCs in a 22-year-old man. Panoramic reformatted CT image demonstrates cystic lesions with well-demarcated borders (arrows) within the mandible. There is no evidence of adjacent tooth root erosion. Note the slight expansile change and remodeling of the mandibular cortex without bone destruction.
Ghost cells are pale eosinophilic swollen epithelial cells which have lost their nuclei+membrane
; it appears radiographically as a sharply circumscribed ovoid radiolucency between the mandibular canal and the inferior border of the posterior mandible
Figure 22a. Acute suppurative osteomyelitis in a 44-year-old woman. (a) CT scan (bone windowing) demonstrates a nonexpansile, osteolytic lesion (arrow) within the right mandible. Perimandibular soft-tissue inflammatory change (arrowheads) is also present. (b) High-power photomicrograph (H-E stain) reveals loss of osteocytes from lacunae and severe inflammatory cell infiltrates (arrows).
Figure 23. Chronic osteomyelitis in a 47-year-old man. CT scan reveals an osteolytic lesion (arrow) containing a bony sequestrum (arrowhead) within the left mandibular body.
Figure 24. Sclerosing osteomyelitis in a 10-year-old boy. CT scan shows diffuse sclerotic changes with expansion of the left mandibular body (arrows). Note the diffuse soft-tissue swelling (arrowheads).
Put radio pic
Put radio pic
Radiograph shows a large, ill-defined osteolytic lesion in the angle of the mandible (arrows) that causes resorption of an unerupted molar tooth (curved arrow).
Orthopantomogram shows lytic destruction of the left side involving the left first molar bed (arrow) and the root of the 2nd premolar.
“It is an epithelium-lined sac filled with fluid or semi-fluid
material.” (Killey and Kay, 1966)
“A cyst is a pathologic cavity having fluid, semifluid, or gaseous
contents that are not created by the accumulation of pus;
frequently, but not always, it is lined by epithelium.” (Kramer,
Nasopalatine duct (incisive canal) cyst
Median palatine, median alveolar and median mandibular
Simple bone cyst
Aneurysmal bone cyst
CYSTS ASSOCIATED WITH MAXILLARY ANTRUM
Benign mucosal cyst of the maxillary antrum
Surgical ciliated cyst of maxilla
CYSTS OF THE SOFT TISSUE OF THE MOUTH, FACE &
Also called as “follicular” or “pericoronal” cyst
Surround the crown of an unerupted tooth
Usually mandibular 3rd molar and maxillary canine
Cyst wall is attached at the neck of the tooth
Origin is from reduced enamel epithelium, epithelial
lining consists of 2-3 layers of cuboidal cells
OKCs possess destructive potential, with a high
recurrence rate after resection
develop from the dental lamina, which is found
throughout the jaw and overlying alveolar mucosa and
is lined by stratified keratinizing squamous epithelium
can expand cortical bone and erode the cortex
The lesion is multiloculated, often with daughter cysts
that extend to the surrounding bone
Now known as “Keratocystic Odontogenic Tumor”
• Multiple OKCs in a young patient should raise the possibility of basal
cell nevus syndrome (Gorlin-Goltz syndrome).
• Associated findings with this autosomal dominant disorder include
midface hypoplasia, frontal bossing and prognathism, mental
retardation, and calcification of the falx cerebri.
An odontogenic cyst developing from the stellate
Formed in place of the tooth i.e. the tooth is missing.
LATERAL PERIODONTAL CYST
Located between the roots of vital teeth
Lined by a thin, non-keratinizing squamous/cuboidal
epithelium with focal, plaque-like thickenings that
consist of clear cells.
Multilocular variety called as “Botryoid Odontogenic
cyst”, term proposed by Waldron.
1st described by Gorlin in 1962
Unusual and unique lesion with characteristics of a
solid neoplasm and a cyst
Also known as “Keratinizing and/or calcifying
epithelial odontogenic cyst”, “Gorlin cyst”, “cystic
The neoplasm is more aptly termed as “dentinogenic
ghost cell tumor”
GLANDULAR ODONTOGENIC CYST
Also called as “Sialo odontogenic cyst” or
Has both secretory elements and stratified squamous
epithelium. (Sadeghi et al., 1991)
Slight predilection for mandibular anterior region.
Recurrence is common after treatment.
RADICULAR, RESIDUAL and
Radicular cysts are located at the root tips of teeth with
necrotic pulp tissue.
Origin from cell rests of Malassez.
Radicular cyst left behind after removal of the
associated tooth is called residual cyst.
Similar cyst located at the lateral side of the tooth at
the border between enamel and root cementum are
NASOPALATINE DUCT (INCISIVE
Derived from the epithelial remnants of the naso-
Lies in the anterior palate just behind the central
First described by Thoma
Formed at the junction of the globular portion of the
medial nasal process and the maxillary process
SIMPLE BONE CYST
Also known as “Traumatic bone cyst”, “Hemorrhagic
cyst”, “Intraosseous hematoma”, “Idiopathic bone cyst”,
“Extravasation bone cyst”
Not a true cyst as lacks lining.
Probable etiology is trauma.
ANEURYSMAL BONE CYST
Pseudocyst first described by Jaffe and Lichtenstein in
Current opinion is that it is an exaggerated localized
proliferative response of vascular tissue
Contains giant cells which represent an attempt at
repair of a hematoma of bone
Biesecker and his associates postulated etiology being
secondary to primary lesion of bone
STAFNE’S BONE CYST
Also known as “Static bone cyst”, “Lingual mandibular
Stafne bone cyst of the mandible is the only described
destructive bone lesion that is highly localized,
nonprogressive, but nonhealing.
An indentation on the lingual surface of the mandible
within which a portion of the submandibular gland
Odontogenic tumors (modified
I. Odontogenic epithelium without odontogenic
2. Squamous odontogenic tumor
3. Calcifying epithelial odontogenic tumor
4. Adenomatoid odontogenic tumor
II. Odontogenic epithelium with odontogenic
ectomesenchyme with or without hard tissue
1. Ameloblastic fibroma
2. Ameloblastic fibrodentinoma
3. Ameloblastic fibro-odontoma
5. Calcifying odontogenic cyst
6. Complex odontoma
7. Compound odontoma
III. Odontogenic ectomesenchyme with or without
included odontogenic epithelium
1. Odontogenic fibroma
2. Myxoma (myxofibroma)
3. Cementoblastoma (benign cementoblastoma,
The ameloblastoma is the most common clinically
It may develop from cell rests of the enamel organ; from
the developing enamel organ; from the lining of
odontogenic cysts or from the basal cells of the oral
It is typically slow-growing, locally invasive and runs a
H.G.B. Robinson described it as being a benign tumor that
is “usually unicentric, non-functional, intermittent in
growth, anatomically benign and clinically persistent.”
Ameloblastomas occur in 3 different clinico-
radiographic situations requiring different therapeutic
considerations and having different prognoses.
Conventional Solid/Multicystic (86 % of all cases)
Unicystic (13 % of all cases)
Peripheral or Extraosseous (1 % of all cases)
Several microscopic subtypes: follicular, plexiform,
acanthomatous, granular, desmoplastic, basaloid
SOTs occur with about equal frequency in maxilla and
mandible. They are more common in the anterior
regions of the jaws than in the posterior. The lesions
occur in the alveolar process.
CALCIFYING EPITHELIAL ODONTOGENIC
TUMOR (PINDBORG TUMOR)
Pindborg tumor accounts for < 1 % of all odontogenic
It is clearly of odontogenic origin but its histogenesis is
The tumor cells are said to resemble cells of the
Formerly called an adenoameloblastoma, a somewhat
deceptive term that should be discarded, the AOT
represents about 3-7 % of all odontogenic tumors.
This epithelial tumor has an inductive effect on the
odontogenic ectomesenchyme with dentinoid
frequently being produced.
This true mixed odontogenic tumor is more common
in patients in the first and second decades of life with a
mean of 14 years.
It is slightly more common in males than females.
Approximately 70 % of the ameloblastic fibromas
occur in the posterior mandible.
This lesion is defined as a tumor with general features
of an ameloblastic fibroma but containing enamel and
Some investigators believe that this entity is but a
stage in the development of an odontoma; however,
most agree that progressive destructive tumors are
Extremely rare tumor, thus there is little reliable
Patient Age: Has been seen in younger patients.
Gender Predilection: Unknown.
Location: Most cases have been in mandible.
Radiographic Appearance: Lesion is a mixed
radiolucent-radiopaque, ill-defined one.
The odontoma is the most common odontogenic
It is not a true neoplasm but rather is considered
to be a developmental anomaly (hamartoma).
Two types of odontomas are recognized:
Compound: this type of odontoma is composed of
multiple small tooth-like structures.
Complex: this lesion is composed of a conglomerate
mass of enamel and dentin, which bears no anatomic
resemblance to a tooth.
The compound type is more often in the anterior
maxilla while the complex type occurs more often in
the posterior regions of either jaw.
Fewer than 70 cases have been reported in the English
Sixty percent occur in the maxilla where most are located
anterior to the first molar. When in the mandible,
approximately 50 % occur in the posterior jaw.
Slow-growing expansile lesion, often associated with
missing or impacted teeth.
Prominent mucoid intercellular substance is present.
Hyaluronic acid and chondroitin sulfate are produced
by this lesion.
Although benign, behaves aggressively.
The cementoblastoma is a slow-growing lesion that may
cause local expansion of the jaw.
Patient Age: This lesion is most commonly occurs in
the second and third decades.
Gender Predilection: Approximately equal.
Location: The cementoblastoma is associated with the
roots of posterior teeth and is more common in the
mandible than the maxilla.
Less than 1 % of the ameloblastomas show malignant
behavior with the development of metastases.
Malignant ameloblastoma is a tumor that shows
histologic features of the typical (benign) ameloblastoma
in both the primary and secondary deposits.
Ameloblastic carcinoma is a tumor that shows cytologic
features of malignancy in the primary tumor, in recurrence
and any metastases.
Metastases most often occur in the lungs
CLEAR CELL ODONTOGENIC
First reported in 1985 with few cases thus far.
Tumor appears to be of odontogenic origin but its
histogenesis is uncertain.
The term carcinoma is used because most cases have
demonstrated aggressive behavior with invasion of
The clear cells contain small amounts of glycogen.
GHOST CELL ODONTOGENIC
“Is the Gorlin cyst a cyst or is it a tumor that is
Fejerskov and Krogh suggested the term ‘calcifying
ghost cell odontogenic tumor’
Freedman and his associates suggested the name
‘cystic calcifying odontogenic tumor’
The calcifying odontogenic cyst can be classified
mainly into two type:
1. Cystic lesion
2. Solid neoplastic lesion
Currently, WHO classifies the lesion as a benign tumor
and calls it calcifying cystic odontogenic tumor. This is
now defined as “a benign cystic neoplasm of
odontogenic origin, characterized by an
ameloblastoma-like epithelium with ghost cells that
Dr. Gorlin’s recent paper classifies the lesion into four
• Type 1. Simple cystic CCOT. Includes pigmented and
clear cell variants.
• Type 2. Odontoma-associated CCOT.
• Type 3. Ameloblastomatous proliferating CCOT.
• Type 4. CCOT associated with benign odontogenic
tumors other than odontoma.
This lesion is considered the malignant counterpart of
the ameloblastic fibroma in which the mesenchymal
portion shows features of malignancy.
The ameloblastic fibrosarcoma may arise de novo or
there may be a malignant transformation of an
Classification by Waldron CA:
1. Fibrous dysplasia
a. Periapical cemento-osseous dysplasia
b. Focal cemento-osseous dysplasia
c. Florid cemento-osseous dysplasia
3. Fibro-osseous neoplasms i.e. Ossifying fibroma
Asymptomatic, self-limiting developmental regional alteration
of bone in which the normal architecture is replaced by fibrous
tissue and nonfunctional trabeculae-like osseous tissue.
It is self-limiting (thus it is not a true neoplasm)
• Mutation in GNAS 1 gene
Clinical forms of fibrous dysplasia of the jaws
• Monostotic: localized to a single bone
Juvenile and aggressive juvenile
• Polystotic: involves several bones
MONOSTOTIC FIBROUS DYSPLASIA
• 80 – 85% of cases; Jaws most commonly affected
• Painless enlargement of the affected bone
• Diagnosed during 2nd decade
• Maxilla > Mandible; male = females
• Growth stops in late teen or early twenties
• Maxillary lesions usually involve other adjoining bones –
POLYOSTOTIC FIBROUS DYSPLASIA
McCune Albright Syndrome: Associated with skin
pigmentation and endocrine dysfunction
Multiple bone (particularly the craniofacial bones)
Skin lesions - Café-au-lait spots
Endocrine dysfunction – precocious sexual
development, pituitary, thyroid, parathyroid glands
Jaffe Syndrome: Absence of endocrine disturbances
Bone defects dominated by long bone involvement
• Most common fibro-osseous lesion of the jaws
• Occurs in tooth bearing areas
• 3 types: focal; periapical; florid
Periapical cemento-osseous dysplasia
• Periapical region of anterior mandible
• Middle-aged African-American women
• Associated teeth are vital
Focal Cemento-osseous dysplasia
• Single site involvement
• 90% of cases occur in females
• 3-6th decade
• More common in whites
• Posterior mandible
• Asymptomatic and routine X-rays
Florid cemento-osseous dysplasia
• Multifocal involvement
• Both anterior and posterior mandible
• Middle-aged African-American women
• Rarely all 4 quadrants involved
• Both dentulous and edentulous areas
Montgomery, 1927, first used the term.
Composed of fibrous tissue that contains woven as
well as lamellar bone and acellular mineralized
material resembling cementum.
Arises from the periodontal membrane.
Classification was given by El-Mofty S., 2002
JUVENILE TRABECULAR OSSIFYING
Shows bands of cellular osteoid together with slender
trabeculae of plexiform bone lined by a dense rim of
Maybe confused with osteosarcoma
Favors upper jaw.
Characterized by small ossicles resembling
psammoma bodies, hence its name.
This type is usually located in the walls of the
sinonasal cavities but sometimes can be encountered
in the mandible.
CENTRAL GIANT CELL GRANULOMA
• Intraosseous destructive lesions of the jaws
• Far less common than peripheral giant cell
• 10-30 yrs of age; Female > Male
• Mandible > Maxilla; Ant. > Post.
• Mandibular lesions frequently cross the midline
• Asymptomatic or painless expansion
• Nonaggressive and aggressive lesions
• Perforation of the cortical plates and resorption of
Central giant cell granuloma in a 34-year-old man. CT scan (bone windowing)
demonstrates a cystic lesion (arrows) within the mandible. Note the erosion of
the mandibular cortex.
Central giant cell granuloma in a 34-year-old man.
Photograph of the gross resected specimen shows multiple
cystic cavities (arrows). Photomicrography with H-E stain
revealed multinucleated giant cells within the lesion.
• Autosomal dominant
• Facial appearance similar to “cherub”-like
• 2 – 5 yrs of age
• The clinical alterations typically progress until puberty,
stabilize and slowly regress
Benign, self-limiting fibro-osseous disorder characterized
by bilateral expansion of mandible, maxilla or both.
• “Eyes upturned to heaven” appearance – due to
involvement of the infraorbital rim and orbital floor
• Painless bilateral expansion of the post. mandible
• Marked widening and distortion of alveolar ridges
• Tooth displacement and eruption failure
• Most common form of cancer involving bone
• Breast and prostate carcinomas are most common
• Lung and kidney carcinomas also occurs
• >80% of jaw metastasis occurs in mandible
• Variety of symptoms: pain, swelling, loose teeth, paresthesia
• Rarely patients are asymptomatic
• Metastasis found in nonhealing extraction
• Site from which tooth was removed for local pain or mobility
• More often is undifferentiated and does not resemble primary
lesion and difficult to tell primary
• Immunohistochemistry is important
• Prognosis is poor; most patients die within a year
Squamous cell carcinoma arising within the jawbones
which has no initial connection with the oral mucous
membrane, adjoining skin or nasal or antral mucous
Extremely rare tumor. Diagnosis is often made after
metastasis has occurred.
Maybe of three different type (Elzay, 1982):
1. Arising from an odontogenic cyst.
2. Developing from an ameloblastoma.
3. Arising from odontogenic epithelium.
Rare malignant plasma-cell disorder.
The malignancy is more common in men over 50 years
of age, and the jaws are affected in about 30% of cases.
Clinically, it presents with bone swelling, tooth
mobility, pain, and paresthesia.
A painless soft swelling, usually on the alveolar mucosa
and gingiva, may develop as part of the overall disease
• Malignancy of mesenchymal cells that produce osteoid or
• Can arise following radiation - * Intramedullary
• Osteosarcomas of jaws: 6% to 8% of all osteosarcomas 3rd
to 4th decade (roughly 10-15 yrs older than for long bones)
• Swelling, pain, loosening of teeth, paresthesia and nasal
• Half as common as osteosarcomas
• 1% to 3% arise in head and neck area
• Extragnathic lesions: older patients
• Jaw lesions: Younger (<20yrs; mean=41.6 yrs)
• Maxilla > mandible
• Painless mass
Described under small round cell tumors.
Occurs predominantly in children & young adults
between 5-25 yrs, median age of occurrence 13yrs.
Males > females
Episode of trauma often preceeds development.
Pain & bone swelling- earliest sign & symptoms
Jaws were involved in 13% of series of 126 cases
reported by Geschickter and Copeland.
Destructive lesions of bone are reported in some cases
of chronic leukemia, and these may result in
pathologic fracture or osteomyelitis- Shafer
PRIMARY LYMPHOMA OF BONE
Rare malignant neoplastic disorder of skeleton.
Described as distinct clinical condition by Parker and
Pain, palpable swelling & pathologic fracture can be
Diagnostic criteria, (Coley, et al., 1950) by WHO are:
A primary focus in a single bone
At the time of Dx, no evidence of distant soft tissue or
distant lymph node involvement.
High-grade malignant B-lymphocyte lymphoma.
Epstein–Barr virus is closely associated.
The malignancy is prevalent in central Africa (the endemic
form), and usually affects children 2–12 years of age.
Cases have also been observed in other countries (the
nonendemic form), and recently in patients with AIDS.
The jaws are the most common site of lymphoma (60–
Clinically, it presents as a rapidly growing hard swelling
that causes bone destruction, tooth loss, and facial
deformity. Pain, paresthesia and large ulcerating or non-
ulcerating masses may also be seen.
PAGET’S DISEASE (OSTEITIS
Uncoordinated increase in bone turnover (osteoblastic and
osteoclastic activity) producing large but weak bone, increased
serum alkaline phosphatase and urinary hydroxyproline
Patients older than 40 yrs of age
• More common in Western countries
• Men > Women
• Bone pain, fractures and bowing deformity – “simian stance”
• Progressive increase in head circumference
• Jaw involvement (17% of patients)
• Maxilla > mandible – “lionlike facies”
• Gradual enlargement of the jaw and generalized spaces between
• Compression of the cranial nerves and spinal cord leading to
paralysis and loss of hearing and sight
LANGERHAN’S CELL HISTIOCYTOSIS
Rare disease involving clonal proliferation of Langerhans
cell. Manifestations range from isolated bone lesions
to multisystem disease.
Traditionally divided into 3 groups:
Unifocal – Eosinophilic granuloma
Multifocal unisystem- Hand-Schüller-Christian triad
Multifocal multisystem- Letterer-Siwe disease
Can be monostotic or polyostotic
No extra-skeletal involvement
Seen mostly in children
Characterized by fever, bone lesions & diffuse euptions
usually on scalp & in ear canals
50% cases involve pituitary stalk-> diabetes insipidus
Triad: diabetes insipidus, exopthalmos & lytic bone
Rapidly progressing disease in which Langerhans cells
proliferate in many tissues
Mostly seen in children <2 yrs of age
Also known as “Marble bone disease”, “Albers-Schönberg
disease”, “osteosclerosis fragilis generalisata”
Defect in osteoclasts to resorb bone.
3 distinct forms:
Radiation-induced pathologic process characterized
by chronic & painful infection & necrosis accompanied
by late sequestration & sometimes permanent
Mandible > maxilla
Intractable pain, surface ulceration & pathologic
fracture are common presenting features.
Autosomal dominant disorder that is the most
common cause of short limb dwarfism
As the skull base forms by endochondral ossification
whereas the skull vault by membranous ossification
there is a marked discrepancy in relative size as the
skull vault, brain and cord grow normally whereas the
skull base remains small.
Red marrow hyperplasia causes widening of the
diploic space, and the outer table thins or is completely
When the hyperplastic marrow perforates or destroys
the outer table, it proliferates under the invisible
periosteum, and new bone spicules are laid down
perpendicular to the inner table.
Seen in patients with thalassemia major, iron
deficiency anemia, sickle cell disease, and
Abnormal, direct communications between arteries
Rare, may occur within the ramus and posterior
Identification is important owing to potential fatal
hemorrhage after tooth extraction
Radiography shows multiloculated lesions are cystic in
Angiography maybe necessary for Dx and Rx planning.
AVM in a 28-year-old man. (a) Contrast-enhanced CT scan reveals multiple
dilated and tortuous vessels (arrow) within the right masseter muscle. Note the
abnormal enhancement (arrowhead) within the marrow of the mandible. (b)
Axial T1-weighted MR image demonstrates a slightly expansile lesion (arrow)
within the right mandibular angle and body. Multiple flow voids are present within
the right masseter muscle. Note the loss of normal fatty marrow (arrowhead)
within the mandible.
PSEUDOTUMOR OF HEMOPHILIA
First described in 1918 by Starker
Pseudotumors are found almost exclusively in men
between 20 and 70 years of age
Encapsulated, chronic, slowly expanding hematoma
Many patients recall sustaining an injury prior to
development of the pseudotumor
Pseudotumors that occur in muscles with broad
tendon insertions readily progress to cause severe
pressure erosion of adjacent bone
TUMOR OF INFANCY
Rare benign tumor of neural crest origin that was first
described by Krompecher in 1918
Maxilla > mandible
More common in anterior region
Rapidly growing, non-ulcerated, darkly pigmented
lesion. Blue-black in color.
Lab Dx- high urinary level of VMA.
Rare disorder that occurs after trauma or surgery &
involves the peripheral nerve.
Exaggerated response to injury consisting of reactive
hyperplasia of nerve tissue, usually at the proximal
Common intra-oral locations are mental foramen,
lower lip & tongue. Intraosseous neuroms are very
Neurilemmoma, a benign neoplasm derived from
Schwann cells was first described by Verocay in 1910.
The intrabony lesions account for less than 1% of the
Benign tumor, 1% of all lipomas
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