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Clinical Radiology xxx (2014) 1e16

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Clinical Radiology
journal homepage: www.clinicalradiologyonline.net

Review

A radiological approach to benign and malignant


lesions of the mandible
M. Harmon a, *, M. Arrigan a, M. Toner b, S.A. O’Keeffe a
a
Department of Radiology, St James’s Hospital, Dublin, Ireland
b
Department of Histopathology, St James’s Hospital, Dublin, Ireland

art icl e i nformat ion


There is a wide range of pathological conditions that affect the mandible. Although some lesions
Article history: demonstrate characteristic imaging features, many of the pathological processes encountered in
Received 30 May 2014 the mandible often exhibit similar imaging appearances resulting in uncertainty for the
Received in revised form reporting radiologist. Many mandibular lesions remain impossible to distinguish without his-
8 October 2014 tological analysis. Therefore, this review aims to reassure the radiologist that although imaging
Accepted 22 October 2014 findings may not always lead to a specific diagnosis, they narrow the differential diagnosis and
guide further work-up. In this regard, we aim to provide a clinically useful framework and
approach for radiologists to use when they encounter lesions within the mandible.
Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction margins of the lesion, size of the lesion and solid or cystic
nature of the lesion; all aid in narrowing the differential
Primary mandibular lesions include neoplasms (benign or diagnosis.2 Ultimately however, biopsy is required in many
malignant), tumour-like lesions and cysts arising from the instances to make the diagnosis. The role of imaging
odontogenic apparatus. The classification was published by therefore lies in narrowing the differential diagnosis,
the World Health Organization (WHO) in 2005 and sub- assessing the extent and complexity of a lesion, and helping
divides lesions by the predominant odontogenic tissue to guide further patient management.
involved.1 Other lesions in the mandible include cystic le- The purpose of this article is to review the most
sions, solid benign and malignant lesions; infectious and in- commonly encountered cystic and solid lesions of the
flammatory processes; and vascular and tumour-like lesions.2 mandible to help radiologists familiarise themselves with
Although some mandibular lesions will display typical commonly encountered jaw diseases. Rather than providing
features on imaging studies, many lesions will demonstrate an exhaustive review of all conditions affecting the mandible
similar, almost indistinguishable imaging findings despite by their tissue of origin, we will divide the lesions into the
the considerable differences in the underlying disease that broad and clinically useful categories: common radiolucent
they represent. Information regarding the age and gender of lesions, common radio-opaque lesions, and conditions with
the patient, along with pertinent imaging findings such as mixed radiolucenteradio-opaque appearances.
the location within the mandible, relationship to the tooth,
Radiolucent lesions of the mandible

The majority of pathological processes affecting the


* Guarantor and correspondent: M. Harmon, Department of Radiology, St
James’s Hospital, Dublin, Ireland. Tel.: þ353 86 8205728, þ1 604 356 3250;
mandible manifest radiologically as radiolucent lesions.
fax: þ353 1 410 3455. These include cystic lesions, solid benign and malignant
E-mail address: dr.markharmon@gmail.com (M. Harmon). lesions, metastases, and inflammatory and infectious

http://dx.doi.org/10.1016/j.crad.2014.10.011
0009-9260/Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Harmon M, et al., A radiological approach to benign and malignant lesions of the mandible, Clinical Radiology
(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
2 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16

Table 1 usually asymptomatic. Typically, periapical cysts are asso-


Differential diagnosis of a well-defined radiolucent ciated with carious teeth. Infection from caries leads to pulp
mandibular lesion.
necrosis; this then passes through the root resulting in an
CYSTIC apical periodontitis and either an abscess or granuloma.
Periapical (radicular) cyst
Beyond this stage, the disease typically becomes latent and
Dentigerous (follicular) cyst
Odontogenic keratocystic tumour
a periapical (radicular) cyst develops.2
Residual cyst Radiographically, a periapical cyst is a well-
Traumatic (solitary) bone cyst circumscribed radiolucency, usually 1e2 cm, which arises
Aneurysmal bone cyst from the root/apex of the tooth and is associated with a thin
sclerotic rim (Fig 1).4 Large lesions can expand cortical bone,
SOLID
Ameloblastoma displace tooth structures, and cause slight tooth erosion.5
Odontogenic myxoma
Giant cell granuloma
Dentigerous (follicular cysts)
Giant cell tumour
Brown tumour of hyperparathyroidism A dentigerous cyst is the second most common odonto-
Myeloma metastasis genic cyst after the periapical cyst2; it is the commonest
Early-stage cemento-ossifying fibroma
Early-stage cementoblastoma
developmental odontogenic cyst.3 Dentigerous cysts form
Early-stage periapical cemental dysplasia around the crowns of unerupted teeth, most commonly the
third molar. The typical situation is that the tooth crown
projects into the cystic cavity with the walls of the cyst
conditions. Radiolucent lesions of the mandible may be converging at the cemento-enamel junction. The cysts
well-defined (Table 1) or ill-defined (Table 2). develop when enamel epithelium surrounding the crown
proliferates and fluid collects between the layers; thus the
Cystic lesions tooth will never erupt.
Radiographically, dentigerous cysts appear as well-
Mandibular cysts typically appear as well-circumscribed, circumscribed, unilocular, radiolucent lesions that incorpo-
lucent lesions within the bone. Most cystic mandibular le- rate the crown of a tooth (Fig 2). Lesions vary greatly in size
sions will have a sclerotic rim, although this can become ill- and may cause expansion of the jaw and displacement of
defined in the presence of severe secondary inflammation.3 teeth. Apical resorption of tooth elements however is rare.
Cysts are classified according to their cell of origin, with the Radiographically, it can be difficult to differentiate the peri-
majority of mandibular cystic lesions arising from odonto- coronal lucency of a small dentigerous cyst from the dental
genic elements.1 Cysts not arising from odontogenic ele- follicle of a “normal” impacted tooth. Although some authors
ments include inflammatory and post-traumatic cysts. have described microscopic dentigerous cysts in almost one-
The most commonly encountered cystic lesions in the third of the pericoronal lucencies <2.4 mm associated with
mandible are periapical (radicular) cysts, dentigerous impacted third molars,6 a working definition is that a den-
(follicular) cysts, and keratocystic odontogenic tumours tigerous cyst exists when the distance between the crown
(odontogenic keratocysts).2,3 Other cystic lesions include and the dental sac on orthopantomogram is >2.5e4 mm.7e9
solitary bone cysts and aneurysmal bone cysts. Static bone
cavities (Stafne cysts) are not true cysts, but are generally
included in this category.

Periapical/radicular cysts

Periapical (radicular) cysts are the most common type of


odontogenic cyst.1,2 Although they can arise at any time
during life, there is a peak incidence between 30 and 50
years of age with a slight male preponderance; they are

Table 2
Differential diagnosis of an ill-defined
radiolucent mandibular lesion.

Squamous cell carcinoma


Mucoepidermoid carcinoma
Lytic metastasis
Suppurative osteomyelitis
Osteoradionecrosis
Osteonecrosis
Plasmacytoma
Leukaemia
Figure 1 Radiograph demonstrating a carious left first molar (thin
Lymphoma
Sarcoma
arrow) with a periapical cyst (open arrow) surrounding the mesial
root.

Please cite this article in press as: Harmon M, et al., A radiological approach to benign and malignant lesions of the mandible, Clinical Radiology
(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
M. Harmon et al. / Clinical Radiology xxx (2014) 1e16 3

Figure 2 Radiograph demonstrating an unerupted right lower molar


with an associated dentigerous cyst (open arrow). Note the walls of the
cyst are converging at the cemento-enamel junction (thin arrows).

Large cysts may show radiographic appearances that are


similar to other odontogenic lesions such as keratocystic
odontogenic tumours and ameloblastomas.
Dentigerous cysts do not contain soft-tissue elements,
but in rare instances ameloblastomas, mucoepidermoid
carcinomas and squamous carcinomas may develop in the
walls of the cysts.2,10 At MRI, the thin lining of the cysts
normally demonstrate mild contrast enhancement. The cyst
contents are typically T2-hyperintense and variable in-
tensity on T1-weighted imaging.

Keratocystic odontogenic tumours (odontogenic


keratocysts) Figure 3 (a) Radiograph demonstrating a large lucent mandibular
lesion with a scalloped border. (b) CTof the lesion demonstrates a lesion
Odontogenic keratocysts have been renamed keratocys- expanding and thinning the cortex, but without extension into adja-
tic odontogenic tumours because of their locally aggressive cent soft tissues (thin arrow). Histology confirmed the lesion as a ker-
behaviour.11 They account for 5e15% of all jaw cysts.12,13 atocystic odontogenic tumour. The lesion initially appears similar to the
These cysts occur in patients of all ages, but have a peak ameloblastoma in Fig. 5(d), but note that the odontogenic cyst displaces
the roots of adjacent teeth and demonstrates only mild root erosion.
in the second and third decades. The cysts develop from the
dental lamina, which is found throughout the jaw and
Multiple keratocystic odontogenic tumours are a feature
overlying alveolar mucosa; thus the cysts occur throughout
of basal cell naevus syndrome (GorlineGoltz syndrome). In
the tooth-bearing regions and occur twice as often in the
this autosomal dominant syndrome, multiple jaw cysts
mandible as in the maxilla. These cysts may recur, possibly
develop in early childhood (Fig 4).14 Associated features
related to the presence of small adjacent daughter cysts or
include: midface hypoplasia, frontal bossing, intellectual
to the ability of the cyst epithelium to proliferate.
disability, and calcification of the falx cerebri. Nevoid basal
Radiographically, the cysts manifest as radiolucent le-
cell carcinomas tend to appear later than the cysts, but
sions that may be loculated; they can have a smooth or a
before 30 years of age.2
scalloped border. They are typically located in the ramus or
body of the mandible and similar to dentigerous cysts may Primordial cyst
be associated with an impacted tooth. The cysts grow along
the length of the mandible and may expand the cortical Primordial cysts are considered to arise from a degen-
bone and erode the cortex. They may displace the roots of erated enamel organ and are found in place of a missing
teeth, but should not cause significant root erosion (Fig 3). tooth. They are well-defined, non-expansile lucent lesions
CT and MRI can be helpful in characterizing the lesions. At without an associated tooth.15 Although the term is now
CT the cyst contents are higher attenuation than water usually synonymous with keratocystic odontogenic lesions,
owing to the keratinized material; this accounts for the some believe they represent a separate entity.2
“cheesy” appearance of the cyst contents. At MRI, the cyst
contents demonstrate variable T1 and mixed T2 signal Residual cyst
characteristics depending on the proteinaceous content of
the fluid. Ultimately, the diagnosis is independent of the A residual cyst is the term for a cyst that remains after the
cyst’s location and radiographic appearance and is depen- removal of a carious tooth. They are therefore usually per-
dent on the cyst’s microscopic features at histopathology. iapical (radicular/inflammatory) in aetiology.

Please cite this article in press as: Harmon M, et al., A radiological approach to benign and malignant lesions of the mandible, Clinical Radiology
(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
4 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16

appearances on both imaging techniques varies depending


on the maturity of the blood products within the cavity.

Solid lesions

Solid lesions in the mandible can present as well-defined


or ill-defined radiolucencies. Well-defined lesions include
ameloblastomas, odontogenic myxomas, vascular lesions
such as giant cell granulomas and early-stage cemental
dysplasias. Multiple myeloma can present as well-defined
lesions, but malignant lesions are more commonly ill-
defined. The most common malignant lesions affecting
the mandible are squamous cell carcinomas invading from
the adjacent oral mucosa; mucoepidermoid carcinomas,
lymphoma, leukaemia and metastatic lesions can also
occur. Infection/osteomyelitis will also usually present as an
ill-defined lucent lesion. Less common solid lucent lesions
affecting the mandible include Langerhan’s cell histiocy-
tosis and metabolic processes such as hyperparathyroidism
with brown tumours.

Well-defined solid lesions

Ameloblastoma

Ameloblastomas are primary odontogenic tumours that


arise from the embryonic enamel forming cells that fail to
regress during development. They have a peak incidence in
Figure 4 (a) Radiograph demonstrates multiple radiolucent lesions
the third and fourth decades and have no sex predilection. It is
(thin arrows), many associated with carious teeth. (b) However, the estimated that they represent 10e18% of odontogenic tu-
lesions are large and CT demonstrates expansion of the cortex and mours and are the second most common odontogenic tumour
displacement of adjacent teeth. Resection confirmed multiple kera- after odontome. They occur mainly in the mandible.2,17
tocystic odontogenic tumours in this patient with Gorlin’s syndrome. Approximately 5% arise from the epithelial lining of dentig-
erous cysts.17 Ameloblastomas are usually benign but locally
Stafne cyst aggressive lesions that typically present as a slow-growing,
painless mass. Malignant behaviour is rare, but occurs in
A Stafne cyst, also known as a static bone cavity, is a two forms: ameloblastic carcinoma, which demonstrates
pseudocyst caused by inward bowing of the medial frankly malignant histology; and malignant ameloblastoma,
mandibular cortex into the medullary cavity. Radiographi- which metastasizes despite well-differentiated histology,
cally they manifest as a well-defined, ovoid or round radio- usually following repeated surgery and is thought to repre-
lucent lesion within a cortical defect on the medial surface of sent tumour seeding rather than true metastases.
the posterior mandible; often near the angle of the mandible. Radiographically, ameloblastomas appear as expansile,
They typically contain fat or submandibular salivary gland.13 radiolucent lesions, most commonly in the posterior
mandible. They can be unilocular or multilocular with a
“soap-bubble” appearance that is characteristic, but not
Traumatic bone cyst (solitary/simple/haemorrhagic bone pathognomonic (Fig 5). Loss of the lamina dura and erosion
cyst) of the roots of adjacent teeth is a distinctive feature
reflecting the locally aggressive characteristics of the le-
Traumatic bone cysts, also known as solitary/simple or sions.18 The tumour also has a tendency to break through
haemorrhagic bone cysts, are not true cysts, as they do not the cortex of the bone with tumour extension into the
have an epithelial lining. The exact aetiology of these le- adjacent soft tissues.17,19
sions is not clear; either trauma resulting in intramedullary Although multiple subtypes of ameloblastoma exist,
haematoma or degeneration of another benign tumour are most cannot be distinguished on imaging. A histopatho-
thought to be the most likely causes.2,16 The end result is a logical diagnosis is required to provide definitive subtype
haemorrhagic, unilocular cavity, which appears radiologi- diagnosis and to determine any carcinomatous change. The
cally as an irregular, scalloped, and sometimes expansive desmoplastic ameloblastoma subtype, however, has more
lucency, which extends between the roots of adjacent teeth. distinguishing features of coarse internal calcifications with
CT and MRI can occasionally help in further diagnosis, but poorly defined borders due to surrounding cortical

Please cite this article in press as: Harmon M, et al., A radiological approach to benign and malignant lesions of the mandible, Clinical Radiology
(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
M. Harmon et al. / Clinical Radiology xxx (2014) 1e16 5

Figure 5 This figure demonstrates the varying appearances of benign ameloblastomas. (aec) Patient 1 has a multiloculated ameloblastoma. (a)
Radiograph demonstrates a multiloculated lucent lesion with a “soap-bubble” appearance within the right body of mandible (open arrows). (b)
CT confirms a multiloculated lesion that is also expanding the cortex (thin arrow). (c) A specimen radiograph demonstrates adequate resection
margins radiographically. (def) Patient 2 had a unilocular ameloblastoma. (d) Radiograph demonstrates a unilocular, expansile lesion in the right
body of mandible. On initial inspection, the lesion could be a keratocystic odontogenic tumour, but note the erosion of the roots of the teeth
(asterisk) that distinguish it as an ameloblastoma. (eef) CT imaging confirms the expansile soft-tissue lesion within the mandible eroding the
roots of adjacent teeth.

destruction. It results in a mixed radiolucenteradio-opaque difficult, but large, enhancing solid components, extra-
appearance and may be mistakenly diagnosed as a fibro- osseous extension, and papillary projections represent
osseous lesion.19 more aggressive features and should raise concern for ma-
CT is useful in assessing the extent of lesions, sites of lignant behaviour (Fig 6).18 MRI is also useful in assessing
cortical perforation, and involvement of the adjacent soft the extent of disease with solid components, septa, and any
tissues.17,19 Preoperative diagnosis of malignant disease is papillary projections demonstrating vivid post-contrast

Please cite this article in press as: Harmon M, et al., A radiological approach to benign and malignant lesions of the mandible, Clinical Radiology
(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
6 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16

enhancement.21,22 The malignant forms of the tumour


demonstrate strong FDG avidity on PET/CT, which can be
useful in assessing disease extent, treatment planning, and
postoperative surveillance.23

Odontogenic myxoma

Odontogenic myxomas are benign, but locally aggressive


and rapidly growing primary odontogenic tumours.2
Radiographically, they appear as multiloculated radiolu-
cent lesions with internal trabeculae, which are often
straight. They can be indistinguishable from amelo-
blastomas and may also simulate lesions such as giant cell
granulomas and haemangiomas. They occur most
commonly in the second and third decades.

Giant cell granuloma

Giant cell granulomas (also known as central giant cell


granulomas and giant cell reparative granulomas) are
believed to form part of a spectrum of histologically similar,
but clinically distinct, vascular and reactive conditions
affecting the mandible. The other clinically distinct entities
within this category include giant cell tumours, brown tu-
mours of hyperparathyroidism, and cherubism.2,24 Giant
cell granulomas show a female predominance (2:1), with
most lesions occurring in patients <30 years. They are most
commonly situated in the anterior mandible.2,25e27
In the early stages of development, a giant cell granuloma
may manifest radiologically as a small, unilocular radiolu-
cency, and may be mistaken for an odontogenic cyst. As le-
sions progress, they become multilocular and can take on a
honeycomb appearance due to small bony septa that may
traverse the lesions. The lesions can be expansile, remodel-
ling and thinning the cortex (Fig 7). The cortex usually re-
mains intact, but perforation can occur. Large lesions can
displace and erode adjacent teeth.2,3,24e26 CT and MRI find-
ings are non-specific; the lesions can be indistinguishable
from odontogenic cysts, aneurysmal bone cysts, amelo-
blastoma, odontogenic myxoma, and odontogenic fibroma.25
Differentiating the lesions from the similar appearing brown
tumours can usually be achieved when patient demographics
and laboratory parameters are available.

Ill-defined solid lesions

Squamous cell carcinoma

These tumours usually arise within the oral cavity and


secondarily invade the mandible. Initial osseous involve-
ment is seen as an erosive lesion at the alveolar ridge; in the
early stages of disease, this may be well-defined and
Figure 6 (a) Radiograph demonstrates a large radiolucent lesion with mistaken for periodontal disease. Tumour progression will
a scalloped border expanding the left ramus of the mandible. This appear as an ill-defined radiolucent lesion within the
could represent an ameloblastoma or a keratocystic odontogenic mandible, usually without periosteal reaction or bony
tumour. (b) Contrast-enhanced CT was performed which shows sclerosis. A “moth-eaten” pattern will be seen in some cases.
marked cortical expansion (thin arrows) and large solid enhancing Advanced disease will demonstrate a “floating teeth”
components (open arrow). Ameloblastic carcinoma was confirmed appearance on panoramic radiography (Fig 8). Importantly,
histologically. the roots of adjacent teeth are not resorbed. CT, MRI, and

Please cite this article in press as: Harmon M, et al., A radiological approach to benign and malignant lesions of the mandible, Clinical Radiology
(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
M. Harmon et al. / Clinical Radiology xxx (2014) 1e16 7

responsible pathogen. Suppurative osteomyelitis typically


has an acute presentation with constitutional symptoms.
Radiographs are usually normal in the initial stages (8e10
days), but later show irregular radiolucencies with poorly
defined margins.28 Bone scintigraphy and MRI are both
useful in assessing patients with suspected osteomyelitis
and will both demonstrate features similar to those of
osteomyelitis elsewhere in the body.29,30 Chronic suppura-
tive osteomyelitis has a variable appearance, which includes
lytic, sclerotic, and mixed lytic/sclerotic lesions. The pres-
ence of bony sequestra is best assessed using CT. Periosteal
reaction is rare, except in children who may demonstrate
laminar periosteal new bone.31 Low-grade infections induce
a proliferative reaction of the bone, which manifests as
sclerosing osteomyelitis. This will be discussed separately
with the radio-opaque lesions.

Mucoepidermoid carcinoma

Mucoepidermoid carcinomas typically arise in salivary


glands and the sinonasal cavities, but infrequently they can
arise centrally within the mandible itself. They are twice as
common in females and usually occur in the fifth decade.32
Radiographically, the lesion may appear as a multiloculated
cystic area or an ill-defined radiolucency; it is often indis-
tinguishable from squamous cell carcinoma and biopsy is
required. CT and MRI help to assess the extent of disease and
determine soft-tissue or nodal involvement.

Osteoradionecrosis

Osteoradionecrosis is a chronic, painful necrotic process


that may develop months to years following radiotherapy;
the findings will vary depending on the radiation dose and
the duration of therapy. Endothelial death and vessel
thrombosis from radiation effects is progressive and even-
tually leads to necrosis and sequestration of the bone.
Although radiographs can be normal in the early stages of
the process, this will progress to poorly defined radiolucent
areas with enlarged, irregular trabecular spaces containing
bony sequestra. The bone often has a moth eaten appear-
ance.2 It is often indistinguishable from chronic
osteomyelitis.

Metastatic disease

The jaw may be affected by metastatic disease, some-


Figure 7 (a) Radiograph demonstrates a well-defined radiolucent
lesion with containing a bony septum within the left mandible (thin times as the first clinical manifestation of an occult primary
arrows). (b) A CT demonstrates multiple bony septa traversing the tumour. Radiographically, metastases are usually ill-defined
lesion, expansion of the bone, and thinning and remodelling of the radiolucent lesions, often in the posterior or angle of the
cortex. The lesion was excised and diagnosed as a giant cell granuloma. mandible.33 Common tumours metastasizing to the
mandible include breast, lung, renal, gastric, and thyroid.
PET/CT imaging are more sensitive for early mandibular Prostate cancer can also affect the mandible, but usually as a
involvement and are used in treatment planning to assess blastic lesion.
the extent of local disease and any metastatic spread. Multiple myeloma can present a single lesion, although
usually it appears as multiple “punched out” lesions or
Suppurative osteomyelitis diffuse bony destruction. The “punched-out” lesions of
myeloma appear as regular, round or ovoid radiolucent le-
The imaging appearances of osteomyelitis vary depend- sions without a sclerotic rim. If the disease burden is large,
ing on the chronicity of the infection and the grade of the the entire bone may be destroyed.

Please cite this article in press as: Harmon M, et al., A radiological approach to benign and malignant lesions of the mandible, Clinical Radiology
(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
8 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16

Figure 8 (a) Radiograph demonstrates a large lucent lesion (open arrows) destroying the body of the mandible and encasing the roots of the
teeth. Note that, importantly, the roots are not resorbed. This results in a “floating teeth” appearance. (b) CT confirms the bony destruction and
(c) contrast-enhanced MRI demonstrates a large, enhancing soft-tissue mass (thin arrows) surrounding the teeth. Histology confirmed a
squamous cell carcinoma.

Other ill-defined radiolucencies

Lymphoma, leukaemia, and Ewing’s sarcoma can all Table 3


Differential diagnosis of a radio-opaque
affect the mandible; they have similar imaging findings of
mandibular lesion.
moth-eaten, permeative destruction of the bone. The
characteristic periosteal reaction of Ewing’s sarcoma may FOCAL
Enostosis
be absent when it presents in the mandible.2 Loss of the Odontoma
lamina dura may be an early finding in leukaemia of the Osteoma
mandible. Other sarcomas can also present as ill-defined Exostosis
radiolucent lesions. Cementoblastoma (cementoma)
Blastic metastasis
Osteosarcoma
Radio-opaque lesions of the mandible
DIFFUSE
Sclerosing osteomyelitis
Pathological conditions affecting the mandible may also Osteonecrosis
present as increased density (Table 3). Diffuse radio-opacity Osteoradionecrosis
is usually the result of osteosclerosis, thickening of the Diffuse blastic metastases
Fibrous dysplasia
cortex, or inflammation. Radio-opaque lesions are most
Paget’s disease
frequently due to fibro-osseous lesions, tumours, and

Please cite this article in press as: Harmon M, et al., A radiological approach to benign and malignant lesions of the mandible, Clinical Radiology
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M. Harmon et al. / Clinical Radiology xxx (2014) 1e16 9

cemental masses. These lesions are usually best differenti-


ated using a combination of plain film and CT.

Focal radio-opaque lesions

Enostoses

Enostoses, also known as benign bone islands or idio-


pathic osteosclerosis, are the most common focal radio-
density encountered in the mandible, occurring in up to 6%
of the population.34 They are developmental intra-osseous
anatomical variants comprising of focal areas of increased
bone production. They typically appear as round or elliptical
radiodensities and can occur at root apexes, between the
roots, or in a separate location away from the teeth, pri-
marily in the premolar/molar region (Fig 9). Size typically
varies from 2e3 mm to 1e2 cm, but rarely they can be
larger. There is no age or sex predilection and they are
asymptomatic. They require no treatment.

Odontoma

Odontomas are the most common benign odontogenic


tumour of the mandible; they are comprised of the various
components that occur in teeth and may be thought of as
odontogenic hamartomas. The presence of enamel within a
lesion is essentially pathognomic of an odontoma. They
usually present in the second and third decades of life. They
occur in two forms and are associated with an unerupted
tooth in approximately half of cases (Fig 10).3
Complex odontomas occur predominantly in the posterior
mandible and account for 24% of odontomas.35,36 Dental
tissue in complex odontomas is arranged in a disordered
pattern with no morphological resemblance of normal or

Figure 10 (a) Radiograph and (b) coronal CT demonstrate a large


maxillary odontoma (open arrow) associated with an unerupted right
upper molar (thin arrow).

rudimentary teeth. Radiographically, they are well-


demarcated radio-opaque masses containing amorphous
calcifications, often associated with an unerupted tooth.
Compound odontomas occur more often in the anterior
mandible and represent the majority of odontomas. The
dental tissue in compound odontomas is arranged in a more
structured pattern, and therefore, they have identifiable
tooth components. Radiographically, they are typically seen
in the incisorecanine region and more commonly in the
maxilla.2 They appear as multiple small, well-defined,
malformed or rudimentary teeth known as denticles, sur-
Figure 9 Radiograph demonstrating a focal radio-opaque lesion rounded by a radiolucent zone (the fibrous capsule).
associated with the distal root of the left first molar tooth consistent Odontomas are usually well encapsulated, and therefore,
with an enostosis (idiopathic osteosclerosis). easily enucleated. Recurrences are rare.

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(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
10 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16

Ameloblastic fibro-odontomas Cementoblastoma

Ameloblastic fibro-odontomas are, as their name sug- Also known as a true cementoma, this is a rare, benign
gests, a mixture of ameloblastic tissue and odontomas; they neoplasm of cementoblasts. It has a male predominance and
are not a form of ameloblastoma. They are rare and most is typically located in the pre-molar and molar region of the
frequently encountered in children. Radiographically, they mandible.37 Initially they are radiolucent, but become dense
appear as either a solid mass or multiple small radio- as the cementum is deposited. Radiographically, they appear
opaque masses. They are surrounded by a well- as a dense sclerotic lesion with a thin radiolucent rim and are
circumscribed radiolucent rim and are indistinguishable attached to the root of a tooth; the radiolucent rim repre-
from other odontomas. sents non-mineralized tissue (Fig 11). As they increase in

Figure 11 (a) Radiograph and (b) coronal and (c) axial CT images demonstrating a sclerotic lesion involving both the mesial root of the right
second molar and the distal root of the right first molar. The lesion was histologically confirmed as a benign cementoblastoma following excision.

Please cite this article in press as: Harmon M, et al., A radiological approach to benign and malignant lesions of the mandible, Clinical Radiology
(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
M. Harmon et al. / Clinical Radiology xxx (2014) 1e16 11

size, they may expand cortical bone. In themselves, they are decade, but mandibular osteomas are more common in the
usually asymptomatic, but may present with dull pain that is second decade. The need for intervention and management
typically relieved by non-steroidal anti-inflammatory is determined by clinical symptoms.
drugs.38,39 It is important to be aware that extraction of the Radiographically, mandibular osteomas appear as well-
involved tooth may be difficult or impossible.37 circumscribed, dense, sclerotic bony masses, which are
attached to the underlying bone by a broad base or pedicle
Osteoma (Fig 12).2 At CT, compact (ivory) osteomas will appear as
dense mature bone with scant marrow and cancellous os-
Osteomas are benign neoplasms formed of compact teomas will demonstrate lamellar trabeculae with abun-
(ivory osteomas) or cancellous bone. Common sites include dant marrow.
the paranasal sinuses, skull vault, and mandible. They most The presence of multiple osteomas should prompt
commonly occur in an endosteal or periosteal location and screening for Gardner’s syndrome, as the development of
vary greatly in size. They are more common in women.40 In osteomas often precedes the onset of colonic polyps.2
general, osteomas occur most frequently in the sixth
Exostoses

Exostoses, or tori, are localized bony protuberances on


the surface of the mandible or maxilla. Compact exostoses

Figure 12 (a) Radiograph and (b) axial CT image demonstrate a Figure 13 (a) Axial and (b) coronal CT images in the same patient
dense, well-defined, exophytic lesion involving the left mandibular demonstrating bilateral maxillary exostoses (thin arrows) arising
ramus. CT demonstrates a wide base that extends into the bone. Bi- from the lingual surface of the maxilla and a torus palatinus (open
opsy confirmed a mandibular osteoma. arrow).

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12 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16

are uniformly radiodense, whereas those that contain as lytic, destructive lesions (osteolytic type), sclerotic le-
marrow cavity will contain trabeculae. They resemble os- sions (osteoblastic type) or with a mixed pattern. The
teomas and are differentiated based on their typical loca- osteoblastic type is most common in the mandible.2 They
tion. Three patterns occur: torus mandibularis is seen as an may be poorly assessed with radiographs and are better
outgrowth of bone along the lingual surface of the evaluated with cross-sectional imaging techniques
mandible, just above the mylohyoid line and is bilateral in (Fig 14).
about 80%; torus palatinus is seen as a nodular exostosis
arising centrally along the hard palate; and multiple exos-
toses of the maxilla are small nodular masses arising from Diffuse radio-opaque lesions
the buccal or lingual surface of the maxilla, usually in the
molar region (Fig 13).2 Sclerosing osteomyelitis
Tori are removed if they are constantly traumatized, if
they interfere with function and swallowing or if required Chronic or sclerosing osteomyelitis of the mandible may
for fitting a denture or prosthesis. present as a focal or diffuse radiodensity. It is believed to be
due to a proliferative reaction of the bone to chronic low-
Malignancy grade infection, which results in thickening of the cortex
and trabeculae. Diffuse periosteal reaction and sequestra-
Blastic metastases, typically from breast or prostate tions of necrotic bone are commonly seen in chronic oste-
carcinoma, can present as a focal or diffuse radiodense omyelitis. CT, MRI, and bone scintigraphy are useful in
lesion of the mandible. Osteogenic sarcoma of assessing the disease, but differentiation of osteomyelitis
the mandible usually presents in the third decade of life (a from other sclerosing lesions, osseous dysplasias, and a
decade later than elsewhere). They typically present with number of malignant lesions can remain a challenge; thus
pain and swelling. Radiographically, they may appear bone biopsy is occasionally required.2

Figure 14 (a) Radiograph demonstrates subtle, asymmetrical increased density in the right body of the mandible (open arrows). (b) CT, (c) PET/
CT, and (d) MRI demonstrate the extent of this osteosarcoma.

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M. Harmon et al. / Clinical Radiology xxx (2014) 1e16 13

Osteonecrosis metastases, and Paget’s disease; biopsy can result in path-


ological fracture and should only be considered if there is a
Bisphosphonate-associated osteonecrosis of the jaw is a strong suspicion of malignancy. The differentiation of
relatively new entity encountered over the past decade.41,42 osteonecrosis from sclerosing osteomyelitis can be difficult
Clinically, it usually manifests as an area of exposed bone both clinically and histologically, and both will often co-
that has been present for more than 8 weeks, commonly at a exist; therefore, management will often be dictated based
site of a previous dental extraction. It may present with pain on clinical grounds.48,50
and swelling, loosening of teeth or superimposed infection. As the imaging findings at CT, MRI, and scintigraphy are
Occasionally, the changes may be present without bone generally non-specific,48,49 the primary role of imaging is to
exposure.43,44 The diagnosis requires a history of bisphosph- demonstrate the extent of disease prior to any surgical
onate usage and the absence of a history of radiotherapy. intervention and to assess for any complications such as
There is also increasing evidence of osteonecrosis associated pathological fracture.
with RANKL (receptor activator of nuclear factor-kappa B
lignand) inhibitors such as denosumab.4547 Fibrous dysplasia
The appearance of osteonecrosis of the jaw at radiog-
raphy and CT is variable and includes ill-defined areas of Fibrous dysplasia of the mandible will present with the
lucency or low attenuation, a permeative appearance, same clinical and radiographic appearances as elsewhere in
cortical destruction, bony sequestrum, periosteal reaction, the body. Fibrous dysplasia will typically appear as homo-
or sclerotic changes.48 The most commonly encountered geneously dense, expanded bone that results in the typical
appearance is diffuse osseous sclerosis (Fig 15),49 but peri- “ground-glass appearance” (Fig 16). However, similar to
osteal reaction and bony sequestration may predominate elsewhere in the body, it can also appear as a radiolucent
late in the disease process.50 The imaging differential in-
cludes chronic sclerosing osteomyelitis, osteoradionecrosis,

Figure 16 (a) Radiograph demonstrates subtle increased density in


Figure 15 (a) Radiograph and (b) CT image demonstrate the diffuse the right body of the mandible (open arrows). (b) CT demonstrates
sclerotic appearance of bisphosphonate-induced osteonecrosis in this expansion of the bone and a “ground-glass” type matrix (open ar-
patient who was receiving high-dose intravenous bisphosphonates. rows). The abnormality was confirmed as fibrous dysplasia.

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14 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16

lesion. It seldom progresses beyond the third decade and Calcifying epithelial odontogenic tumour (Pindborg
symptoms usually relate to deformity or mass effect. tumour)
Fibrous dysplasia may result in superior or inferior
displacement of the mandibular canal. Some authors have These are composed of islands of epithelial odontogenic
suggested that upward displacement of the mandibular cells with small calcified bodies, within a fibrous stroma.
canal is pathognomic of fibrous dysplasia.51,52 Cherubism The mean age at diagnosis is 40 years. About half of the
was previous thought to be a form of polyostotic fibrous lesions are associated with the crown of an impacted tooth.2
dysplasia of the mandible, but is now considered a distinct The tumour will appear as a radiolucent mass with scat-
entity.53e55 tered calcific densities. It is usually multilocular, but may be
unilocular. It is often expansile with poorly defined and
irregular margins; thus reflecting the locally aggressive
Paget’s disease
behaviour of the lesion. The internal scattered calcifications
will often differentiate it from ameloblastomas.
The radiographic appearances of Paget’s disease will
vary with the stage of disease activity. In the later stages of Cemental dyplasias
disease, it will appear as thickened, expanded, and scle-
rotic bone. It is more common in the maxilla than the Periapical cemental dysplasia always occurs at the root of
mandible.2 a tooth and is due to proliferation of connective tissues
within the periodontal membrane. They are most common
in middle-aged women, usually presenting with pain; they
Mixed radiolucenteradio-opaque lesions of are often multifocal. Radiographic appearances depend on
the mandible the stage of disease: early lesions appear as well-
circumscribed radiolucencies at the root of a tooth. As
Mixed density lesions of the mandible can occur for a they progress, they appear as mixed radiolucent/radio-
number of reasons including: the presence of two or more opaque lesions and finally mature lesions will appear as a
tissues with differing radiographic densities, varying de- mineralised radio-opaque mass surrounded by a narrow
grees of inflammatory soft tissue within a lesion, or local- radiolucent halo.2,3 A diffuse form of the condition is known
ised resorption of bone from within a lesion. as florid cemental dysplasia. The diagnosis is usually ob-
A number of the radiolucent and radio-opaque lesions tained with plain film and occasionally CT; other imaging
and processes already discussed can have variable appear- methods are usually not helpful.2
ances and will often fall within this category (Table 4).
These include malignant/metastatic lesions, osteomyelitis, Cemento-ossifying fibromas
osteonecrosis, osteoradionecrosis, Paget’s disease, and
fibrous dysplasia. Cementomas may also appear mixed in Cemento-ossifying fibromas are benign lesions
their early stages. Other lesions that result in a mixed comprising of fibrous tissue and varying amounts of tra-
appearance include the cemental dysplasias and immature beculated bone. As the lesions mature, they become more
fibro-osseous lesions. radio-opaque and have appearances that are very similar to
fibrous dysplasia. Unlike fibrous dysplasia however, they are
usually well demarcated and often encapsulated. A rare
Table 4 more aggressive form in children younger than 15 is known
Differential diagnosis of a mixed radiolucent-radio-opaque as a juvenile ossifying fibroma. It is more commonly found
lesion of the mandible. in the maxilla.2
FOCAL
Calcifying epithelial odontogenic tumour (Pindborg
Adenomatoid odontogenic tumour
tumour)
Cemento-ossifying fibroma A rare benign lesion that typically occurs in the second
Adenomatoid odontogenic tumour decade. It is more common in girls, and approximately
Calcifying cystic odontogenic tumour
twice as common in the maxilla as the mandible. Typically
Periapical cemental dysplasia
Desmoplastic ameloblastoma the lesion involves the crown of an unerupted tooth; thus
Intermediate stage cementoblastoma mimicking a dentigerous cyst. The lesions appear as well-
Haemangioma circumscribed radiolucencies with varying amounts of
punctate calcifications. They are slow growing and can
DIFFUSE
either displace or prevent the eruption of teeth.
Osteomyelitis
Osteonecrosis
Osteoradionecrosis
Calcifying cystic odontogenic tumour (Gorlin cyst)
Florid cemental dysplasia
Fibrous dysplasia This is a rare odontogenic tumour comprised of both
Paget’s disease solid and cystic elements; it can occur at any age. Radio-
Ewing’s sarcoma
graphically, it will appear as a uni- or multilocular lucent
Lymphoma
lesion with well-defined margins, containing scattered

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M. Harmon et al. / Clinical Radiology xxx (2014) 1e16 15

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Please cite this article in press as: Harmon M, et al., A radiological approach to benign and malignant lesions of the mandible, Clinical Radiology
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