JBR–BTR, 2006, 89: 81-99.

PROCEEDINGS OF THE SYMPOSIUM ON MKA BEELDVORMING OF

DECEMBER 10-11, 2004, ANTWERP – PART TWO

TUMORS AND TUMOR-LIKE LESIONS OF THE JAW:

RADIOLUCENT LESIONS
A. Bernaerts1, F.M. Vanhoenacker1, 2, J. Hintjens3, K. Chapelle3, R. Salgado1, B. De Foer4, A.M. De Schepper1

Radiolucent lesions within the jaws represent a whole variety of lesions. Generally, they can be classified into two
categories. The first category comprises well circumscribed lesions, either unilocular, multilobular or multilocular.
They may be further subdivided into odontogenic or nonodontogenic lesions. The key feature that distinguishes
these two subgroups is the relationship with the underlying dentition. Poorly circumscribed radiolucent lesions are
the second category and consist of acute infectious disease and primary or metastatic malignancies.
Although many of these lesions may present with non-specific imaging characteristics, careful analysis of a combi-
nation of imaging parameters may suggest a presumptive diagnosis. This article discusses the imaging features on
different imaging techniques that may be useful in the characterization of these lesions.

Key-words: Jaws, neoplasms – Jaws, CT – Jaws, MR.

Radiolucent lesions within the jaw

bones are often incidentally discov-
ered on a plain radiography, CT scan
or an MR examination, performed
for other indications. Furthermore,
the radiologist will be frequently
consulted to guide the clinician in the
selection of the imaging method of
choice, when these lesions are
encountered in the clinical practice.
Although the radiological diagno-
sis of these lesions is not always
straightforward, this article aims to
familiarize the radiologist with those
Fig. 1. — Schematic drawing of site-specific unilocular cystic
imaging features that may assist in lesions. A: nasopalatine duct cyst; B: lateral periodontal cyst;
the (differential) diagnosis of these C: dentigerous cyst or dentigerous origin odontogenic kerato-
lesions. cyst; D: immature cementoblastoma; E: radicular cyst or dental
granuloma; F: residual cyst; G: static bone cyst.
Well-circumscribed radiolucent
lesions

The majority of jaw lesions are and relationship to a tooth is very graphically, both lesions present as
radiolucent (> 80%) (1). Well-defined important, because it is a key fea- well-circumscribed, unilocular radi-
unilocular radiolucencies generally ture in the differential diagnosis of olucent lesions around the apex of a
represent a cystic or benign neo- different cystic lesions (Fig. 1). nonvital tooth. Radicular cysts are
plastic lesion. Multilocular radiolu- less common and often larger than
Radicular cyst
cencies, generally accompanied by dental granulomas (> 1 cm). There is
cortical expansion, are encountered The periapical cyst is the most a high prevalence for the anterior
in benign, yet aggressive, tumors common odontogenic cyst, result- maxillary region and extension into
and reactive processes. ing from proliferation, expansion the maxillary sinus may be
Cysts are commonly seen in den- and cystification of a dental granulo- observed (Fig. 2). Root resorption
tal practice. A cyst is defined patho- ma. Dental granulomas represent may be observed in long standing
logically as an epithelial lined cavity foci of chronic granulation tissue lesions (1-6).
that may contain fluid or semifluid that develop around the apex of a Failure to remove all of the
material (2). The precise location root after pulpal death. Radio- epithelial soft tissue lining within
the cyst wall at the time of tooth
extraction and curettage can result
From: 1. Department of Radiology, Universitair Ziekenhuis Antwerpen (University of in recurrent epithelial proliferation
Antwerp), Edegem, 2. Department of Radiology, 3.Department of Oral and Maxillo- and the formation of a new cyst
facial Surgery, AZ St-Maarten, Campus Duffel, Duffel, 4. Department of Radiology, AZ known as “residual cyst”. Residual
Sint-Augustinus, Wilrijk, Belgium. cysts are radiographically indistin-
Address for correspondence: Dr F.M. Vanhoenacker, M.D., Department of Radiology, guishable from a number of other
Universitair Ziekenhuis Antwerpen (University of Antwerp), Wilrijkstraat 10, B-2650 well-circumscribed radiolucent jaw
Edegem, Belgium. lesions; therefore, the clinical histo-
82 JBR–BTR, 2006, 89 (2)

Fig. 3. — Residual cyst. Panoramic view of the mandible

Fig. 2. — Periapical cyst. Panoramic view of the mandible
reveals a sharply defined, corticated, cystic lesion around the
apex of the upper right second molar tooth with expansion into
the right antral cavity (arrowheads).
reveals a corticated, cystic lesion in a patient with a history of
the extraction of the right lower first molar associated with peri-
apical lesion.

ry is a key in making the diagnosis
(Fig. 3) (1).
Dentigerous (follicular) cyst
The dentigerous cyst forms with-
in the lining of the dental follicle
when fluid accumulates between
the follicular epithelium and the
crown of the developing or unerupt-
ed tooth (6, 7). It is the second most
common odontogenic cyst after the
radicular cyst. These lesions usually
occur between 10 and 30 years of
age, and occur primarily in the
mandibular and maxillary third
molar or maxillary cuspid regions
(1, 3, 7).
On imaging, a dentigerous cyst is
a well defined, unilocular radiolu-
cency associated with the crown of
an unerupted tooth. Dentigerous
cysts vary greatly in size, ranging
from less than 2 cm in diameter to
cysts that cause marked expansion
of the jaw. The tooth may be dis-
placed: it is not unusual to see teeth
displaced to the condylar neck, the
nasal fossa, the orbital floor, the lat-
eral sinus wall or even within the
sinus ostium causing opacification
and expansion of the antral cavity.
The adjacent teeth may be partly
eroded (Fig. 4) (1, 3-6, 8).
A pericoronal lucency associated
with an impacted crown is usually
the key diagnostic feature. However,

C
Fig. 4. — Dentigerous cyst. A, A panoramic radiograph shows
a large, multilobular corticated cyst that involves the right
mandibular body and ramus (arrowheads). The mesial floor of
the cyst is associated with the crown of the adjacent third
molar. B, A part of a panoramic radiograph demonstrating a
dentigerous cyst associated with an impacted lateral maxillary
incisor. Note the resorption of the distal root of the central max-
illary incisor. C, Dentigerous cyst of the maxilla with extension
into the left atrium. Coronal CT section demonstrates a tooth in
the ostium of the left maxillary sinus causing sinus obstruction
with opacification and a mild expansion of the maxillary sinus.
B Cortical bowing and thinning is noted.
 MKA BEELDVORMING — DECEMBER 10-11, 2004, ANTWERP 83

A
Fig. 5. — Keratocyst in the left angle and ascending portion of
the mandible. A, Panoramic view reveals a multiloculated cystic
lesion in the ascending ramus of the left mandible (black arrow-
heads). Note also the presence of an incidental periapical cyst
around the apices of the second mandibular molar (white
arrowheads). B, Coronal CT section (bone window setting)
reveals a longitudinal expansile lesion in the ascending ramus
and body of the mandible with cortical thinning and some loss
of bone in medial aspect of the cyst.
B

odontogenic keratocysts may be
associated with a tooth and there-
fore indistinguishable from a
dentigerous cyst (25% to 40% of
cases). Furthermore, a small num-
ber of ameloblastomas, often
referred to as “mural ameloblas-
tomas” may arise from the pluripo-
tential cells located within the
epithelium-lining dentigerous cysts.
Radiographically, they are similar to
the cystic lesions from which they
arose (1, 7).
Odontogenic keratocyst
The odontogenic keratocyst
(OKC) is the most aggressive and
recurrent of all odontogenic cysts
constituting 2% to 11% of all jaw
cysts. The cyst occurs in patients of
all ages, with a peak incidence in the
second and third decades of life (4,
7). They occur in children as part of
the basal cell naevus syndrome
(Gorlin’s syndrome). Components of
this syndrome include multiple OKC,
skin basal cell carcinomas, various
skeletal abnormalities, and lamellar
falx calcifications (9). The name OKC
is derived from the presence of ker-
atin within the cystic content (10).
Most (60%) arise from dental lamina
rests (epithelial structure found in
the primitive oral mucosal epitheli-
um responsible for tooth formation)
or from the basal cells of oral epithe-
lium and are thus “primordial-ori-
gin” OKC. The remaining 40% arise
from reduced enamel epithelium of
the dental follicle and are thus
“dentigerous-origin” OKC (4, 7).
Radiographically, the OKC may
be unilocular in smaller lesions but
tends towards multilocularity in
larger lesions (Fig. 5). These cysts
are characteristically located in the
body and ramus of the mandible
and may occur in conjunction with
an impacted tooth mimicking a
dentigerous cyst (1, 8).
CT and MR imaging have an
important role in differentiating OKC
from ameloblastomas and other
cystic lesions in the maxillo-
mandibular region, which is impor-
tant because of high recurrence rate
of OKC (Table 1). Because of its
pastelike consistency, OKC may
show high attenuation areas on CT
or a low to intermediate intensity on
T1-weighted images and low signal
intensity on T2-weighted images (2,
11-14). Another feature of many OKC
that can be useful in differentiating
them from other lesions is the ten-
dency for them to grow within the
medullary space in a predominant
anteroposterior (mesiodistal) direc-
tion while causing minimal – if any –
cortical expansion. On the contrary,
a predominant buccal-lingual ex-
pansion is seen in ameloblastomas
(1, 15). Another differential diagnos-
tic parameter is the enhancement
pattern on MRI. In keratocysts, there
is no enhancement except for a thin
peripheral rim, whereas a nodular
enhancement pattern of the cyst
wall suggests rather an ameloblas-
toma (2, 11, 12, 16).
Ameloblastoma
The ameloblastoma is the most
common clinically significant odon-
togenic tumor constituting 18% of
all odontogenic tumors. Amelo-
blastomas may occur over a wide
age range, with a mean age in the
mid 30s (17, 8). About 80% of tumors
arise in the mandible, especially in
the molar-ramus area. In the maxilla

Table I. — Differential diagnosis of odontogenic keratocysts versus ameloblastoma.

Odontogenic Keratocyst Ameloblastoma
Expansion mesiodistal buccolingual
Signal intensity areas of low SI on T1-WI and T2-WI heterogenous
~ keratinaceous debris ~ solid and cystic components
Enhancement pattern rim like peripheral papillary and septal enhancement
84 JBR–BTR, 2006, 89 (2)

A
Fig. 6. — Unilocular ameloblastoma. A, Axial CT image
through the maxilla (bone window setting) demonstrates an
expansile radiolucency involving the floor of the nose. Cortical
pressure resorption and perforation are noted. B, Coronal fat
suppressed SE T1-Weighted MR image after gadolinium con-
trast administration shows another histologically proven B
unilocular ameloblastoma within the left maxillary molar region
with extension in the maxillary sinus and nasal fossa. Note the
marked enhancement of the solid components.

the most common location is the
maxillary tuberositas (Fig. 6B) (18).
Ameloblastomas originate from
residual odontogenic epithelium
that is involved with tooth forma-
tion. They also arise from the
reduced enamel epithelium after
crown formation and therefore may
mimic a dentigerous cyst or arise
from the epithelial lining of a
dentigerous cyst (7). Its clinical
behaviour is usually benign but fre-
quently locally invasive and may
occasionally exhibit malignant
behaviour. Metastases from malig-
nant ameloblastomas have been
reported in the lung (75%), cervical
lymph node (15%) and spine (15%)
(19). There is a high recurrence rate,
especially in maxillary lesions and
the radiographically multilocular
type (17, 20).
On radiographs and CT, an
ameloblastoma is radiolucent and
either unilocular (Fig. 6) or multiloc-
ular (Fig. 7). The more frequent mul-
tilocular form often has been
described as having a honeycomb
or bubble-like appearance.
Significant buccal-lingual cortical
expansion with cortical pressure
resorption is usually present in larg-
er lesions (Fig. 7). Large tumors may
even break through the cortex, with
subsequent tumor extension into
the adjacent soft tissues. Loss of the Globulomaxillary cyst
lamina dura, erosion of the tooth
Throughout the 1970’s, the term
apex and displacement of the teeth
“globulomaxillary cyst” was used to
are commonly seen. Malignant
describe the so-called classic fissur-
behaviour is characterized by rapid
al cyst that was believed to be
growth, bone destruction, or distant
caused by entrapment of epithelium
metastases (1, 4, 8, 17).
between the embryonic median
MR imaging can be useful in
nasal process and the maxillary
differentiating ameloblastomas
process. Cysts would then develop
from various other cysts by demon-
after the teenage years and in later
strating a mixed pattern of solid and
adult life between the permanent
cystic components, irregularly thick
maxillary canine and lateral incisor
wall, papillary projections, homo-
teeth, ostensibly due to sponta-
geneous fluid of low T1-weighted
neous activation of these entrapped
and high T2-weighted signal intensi-
epithelial cells. Today, it is recog-
ty, and marked enhancement of
nized that epithelial entrapment
solid portions (Fig. 6B) (Table I).
does not occur in location, render-
Furthermore, MRI provides addition-
ing the term “globulomaxillary
al preoperative information by
cyst” as a misnomer. Cysts in this
providing an excellent delineation
location should be regarded rather
of tumor versus normal tissue
as odontogenic cysts (e.g. radicular
and the differentiation between
cyst, odontogenic keratocyst, lateral
solid and cystic elements. Further-
periodontal cyst) (7).
more, MR imaging is more
accurate in detecting recurrence at
Lateral periodontal cyst
an earlier stage since it has the
potential to allow distinction of The lateral periodontal cyst is a
recurrent lesions from postopera- developmental cyst that arises from
tive fibrosis by means of the differ- dental lamina rests that lie within
ence in signal intensity on T2- interradicular crestal or midroot-
weighted images. The latter will level bone. Therefore it develops
show low to intermediate signal between the teeth. It occurs mostly
intensity in most cases, while the in adults older than 21 years and
former will show high signal intensi- primarily around the premolars and
ty (1, 11, 21). the canine areas. The cyst will
 MKA BEELDVORMING — DECEMBER 10-11, 2004, ANTWERP 85

B
A
Fig. 7. — Multilocular ameloblastoma. Axial CT images (A soft
tissue window B bone window) and 3D image (C) demonstrate
a radiolucency involving the left body and ramus of the
mandible with marked buccal-lingual cortical expansion.
Cortical pressure resorption and internal septation are noted.
The 3D image shows a soap-bubble appearance.

usually present as a round or

teardrop-shaped unilocular radio
lucency between teeth. The teeth
will be vital and may show root
divergence (7).

Odontogenic fibroma
Odontogenic fibroma is a fibro-
blastic neoplasm containing vari-
able amounts of apparently inactive
odontogenic epithelium. This is a
rare disease, found in individuals
aged 20 years and younger, with the
major site being the mandibular
molar portion.
Radiographically, odontogenic
fibroma shows a well-defined,
unilocular, radiolucent lesion
(Fig. 8). It is frequently characterized
by severe bone swelling and sharp
resorption of the roots of adjacent
teeth (16).
Odontogenic myxoma (myxofibro-
ma)
Odontogenic myxoma is a rare,
benign tumor (3%-6% of odonto-
genic tumors) which originates in
the mesenchymal portion of the
tooth germ with growth characteris-
tics and a clinical and radiographic
presentation similar to those of
ameloblastoma. It shows infiltrative
growth but does not metastasize. Its
C
peak age (between 15 to 30 years) is
slightly younger than that for the
ameloblastoma. The myxoma differs
from the ameloblastoma in site pref-
erence as well. While the ameloblas-
toma is much more commonly seen
in the third molar areas, particularly
in the mandible, the odontogenic
myxoma is evenly distributed
throughout the jaws (7, 17, 22, 23).
Some authors describe the lesion
typically multilocular with a ‘soap-
bubble’ or “honeycomb” appear-
ance, while others claim it appears
most frequently as a unilocular radi-
olucency with well- or poorly-
defined borders. Expansion of the
cortex and displacement of teeth are
common findings with larger
lesions. The multilocular lesions
may simulate ameloblastoma,
odontogenic fibroma, central giant
cell granuloma (increasing likely in
individuals between 5 and 15 years
of age) or hemangioma (6, 8, 16, 17,
22-24). MR imaging shows low sig-
nal intensities on T1-weighted
images and high signal intensities
on T2-weighted images, reflecting
the rich myxoid stroma. A gradual
enhancement pattern may be seen
(12, 16).
Nasopalatine duct (incisive canal)
cyst
The nasopalatine canals are small
paired openings in the midline of
the anterior palate that transmit the
nasopalatine artery and nerve as
well as remnants of the embryonic
nasopalatine duct. Cysts that occa-
sionally form from remnants of the
nasopalatine duct constitute the
86 JBR–BTR, 2006, 89 (2)

A B
Fig. 8. — Odontogenic fibroma. Axial CT images through the mandible filmed with bone window demonstrate a unilocular expan-
sile lesion with anterior displacement of a tooth.

A B
Fig. 9. — Nasopalatine duct (incisive canal) cyst.Axial (A) and coronal (B) CT sections (bone window settings) reveal an oval
shaped cyst with bony expansion in the nasopalatine duct (arrowheads).

common nonodontogenic cyst (5,
7). Men are slightly more affected
than women, and most individuals
are in the 40- to 60-year age range
(25).
Radiographically, a nasopalatine
duct cysts appears as a round or
ovoid radiolucency between the
roots of the maxillary central
incisors (Fig. 9). The term “heart-
shaped” radiolucency is sometimes
used but this appearance is actually
an artefact caused by superimposi-
tion of the overlying anterior nasal
spine on the radiolucency. If suffi-
ciently large, they may diverge the
central incisors or cause a smooth,
regular resorption of the roots.
Differentiation with radicular cysts
occurring at this location may be dif-
ficult on panoramic radiographs and
reformatted CT images may be use-
ful in these cases (1, 2, 4).
Idiopathic bone cavity (traumatic
bone cyst)
Idiopathic bone cavities are
empty cavities in bone that have an
unknown cause. They have erro-
neously been called “traumatic
bone cysts” for many years.
However, they lack an epithelial lin-
ing required of a cyst and are not
specifically related to trauma. These
lesions are usually discovered in the
2nd decade of life and located in the
body of the mandible (7).
The classic description of an idio-
pathic bone cavity in the jaws is a
radiolucent lesion that scallops
between the roots of teeth with
preservation of the lamina dura. The
cysts may be slightly irregular in
shape and have poorly defined bor-
ders often referred as an “prelimi-
nary pencil-sketch appearance” (26).
Since the cyst can contain serosan-
guinous fluid, CT and MR imaging
may be helpful to evaluate the con-
tents of the cyst. A relatively high
density on CT is consistent with
 MKA BEELDVORMING — DECEMBER 10-11, 2004, ANTWERP 87

B
Fig. 10. — Idiopathic bone cavity. A, Coronal noncontrast spin-
echo T1-weighted MR image reveals a cystic, expansile lesion in
the left mandibular ramus with intrinsic T1 shortening. B, Axial fat
suppressed TSE T2-weighted MR image shows a fluid-fluid level
within the lesion. MR findings are consistent with a hemorrhag-
ic content. Therefore the presumptive diagnosis of an idiopathic
bone cavity was made. The differential diagnosis with aneurys-
A mal bone cyst is -however- very difficult on imaging.

blood products, but the density can
be variable. On MRI, T1-weighted
images, the cyst may show variable
signal intensities ranging from low
to high according to the age of the
haematoma (Fig. 10) (1, 3, 5, 8, 27).
Aneurysmal bone cyst
Aneurysmal bone cysts are
blood-filled cavities that lack an
endothelial lining. They may devel-
op after trauma or secondarily with-
in a pre-existing bone lesion. These
rare lesions frequently occur in
patients under 20 years of age and
in the posterior mandible (8, 17).
On imaging, they may present as
an expansile, unilocular or multiloc-
ular radiolucency. CT and MR imag-
ing can demonstrate characteristic
fluid-fluid levels in aneurysmal bone
cysts (17, 28).
Central giant cell granuloma
The central giant cell granuloma,
formerly known as giant cell (repar-
ative) granuloma, is a relatively
common giant cell-containing lesion
and occurs predominantly in chil-
dren and young adults. The lesion is
considered a reactive process, prob-
ably in response to intraosseous
hemorrhage . The radiographic fea-
tures of central giant cell granuloma
vary. The lesions have variably well-
or ill-defined margins and may
cause cortical expansion. Larger
lesions assume a multilocular
appearance with whispy internal
septa. Central giant cell granuloma
has a predilection for the anterior
mandible and often cross the mid-
line. Divergence of tooth roots,
resorption of the lamina dura and

A
Fig. 11. — Central giant cell granuloma. A, A panoramic radi-
ograph shows a unilocular, ellipsoid, well-defined but non-cor-
ticated radiolucent lesion located in the premolar area of the
mandible (arrowheads) causing divergence of tooth roots and
resorption of the lamina dura. The first molar is missing.
B, Coronal CT section (bone window setting). Resorption of the
roots of erupted teeth is a characteristic feature of this lesion.
B
88 JBR–BTR, 2006, 89 (2)

A
Fig. 12. — Giant cell lesion of hyperparathyroidism. A, A
panoramic radiograph shows a multilocular, noncorticated radi-
olucent lesion in the left mandible with a fractured tooth which
appears to float in the osteolytic space. Note also the general-
ized demineralisation of the medullary bones of the jaws and
the loss of the lamina dura around the dentition. B, Axial CT
section (bone window setting) demonstrates a radiolucent,
multilocular lesion with whispy internal septa and osseous
expansion. The various loculi are irregular in shape and vary in B
size.

roots, and more aggressive bone
destruction may occur (Fig. 11) (1, 3,
5, 6, 17).
Giant cell lesion of hyperparathy-
roidism
Brown tumors of hyperparathy-
roidism appear identical to central
giant cell granulomas at radiogra-
phy and are similar histologically,
but the age of the patient and the
serum parathyroid hormone and
calcium levels should help distin-
guish these entities. Concurrent
bone changes associated with
hyperparathyroidism, such as gen-
eralized demineralisation of the
medullary bones of the jaw and loss
of lamina dura around the teeth can
help differentiate brown tumors
(Fig. 12) (6, 17).
Static bone cyst (Stafne’s cyst, sub-
mandibular salivary gland depres-
sion)
The static bone cyst is not a true
cyst but rather a innocuous convex-
ity in the lingual cortex of the
mandible that would be of no con-
sequence if they did not produce a
radiolucency in jaw radiographs
that may difficult to distinguish from
more serious conditions. It occurs in
0.1% to 1.3% of the population and
results from aberrantly located or
entrapped salivary gland parenchy-
ma (5).
A static bone cavity is usually an
incidental radiologic finding, most
often appearing as a unilateral,
ovoid, radiolucent, corticated defect
near the angle of the mandible
below the inferior alveolar canal (4,
29). The cortical demarcation is usu-
ally thicker than those seen in other
jaw cysts (2). Sialography, CT, CT-
sialography and MRI have all been
proposed as useful additional stud-
ies by showing the submandibular
gland within the bone cavity. Other
reported contents include muscle,
lymphatic tissue, fat and/or blood
vessels which may be explained by
intermittent gland herniation or
regression of the herniated gland
(29-31).
Poorly circumscribed radiolucent
lesions
Poorly circumscribed lesions
invariably represent aggressive
inflammatory or neoplastic process-
es (See article Imaging Approach for
Differential Diagnosis of Jaw
Lesions: a Quick Reference Guide,
also featuring this issue).
Acute osteomyelitis
Acute osteomyelitis results from
either the direct extension of an
acute pulpal infection without the
formation of a granuloma or from
the acute exacerbation of a chronic
periapical lesion. It may also occur
following penetrating trauma or var-
ious surgical procedures (1, 5).
Plain films are often unremark-
able for the first 7 to 14 days except
for a possible widening of the peri-
odontal space around the root apex
or generalized osteoporosis. After
this period, plain film findings
include ill definition of trabeculae,
single or multiple ill-defined radiolu-
cent areas, and loss of the lamina
dura. Ill definition of the wall of a
periapical lesion may occur. CT find-
ings that may be seen comprise
sinus tracts, periosteal reactions,
abscess formation, myositis, fasci-
itis and cellulitis. Intravenous con-
trast and bone window settings are
complementary as they may
demonstrate the presence of a soft
tissue abscess or periapical abscess
not seen on plain films. On MR
imaging inflammatory changes
involving both bone marrow and
soft tissue can be observed (1, 5).
Direct neoplastic extension
Neoplasms arising in the soft tis-
sue bordering the jaws (e.g. squa-
mous cell carcinoma, salivary
tumors and lymphomas) may
directly invade the bone causing
osseous destruction. The radio-
graphic appearance of direct inva-
sion typically is one of ill-defined
geographic (Fig. 13), moth-eaten or
permeative bone destruction adja-
cent to soft tissue abnormalities
including soft tissue masses, loss of
fascial planes, and ulcerations (1, 5).
The pattern of periosteal reaction
(PR) on CT in combination with the
pattern of the cortical destruction
can be useful in differentiating
osteomyelitis from malignant
tumors. Lamellated PR is mainly
found in patients with osteomyelitis
with no, or only small areas of corti-
cal destruction. On the other hand,
no or spiculated PR associated with
gross destruction or permeative cor-
tical destruction is mostly seen in
malignant tumors (32, 33). MR
imaging is a sensitive method for
detecting mandibular invasion but
 MKA BEELDVORMING — DECEMBER 10-11, 2004, ANTWERP 89

A
Fig. 13. — Adenoid cystic carcinoma of the minor salivary
glands with direct extension into the mandible. B
A, Coronal CT section (soft tissue window setting) reveals an
enhancing lesion in the buccal mucosa of the right mandible (arrowheads). B, Coronal CT section (bone window setting) demon-
strates a destructive radiolucent lesion secondary to direct extension from the adenoid cystic carcinoma. The lesion is eroding
through the buccal cortex (arrowheads).

Fig. 14. — Non-Hodgkin’s lymphoma of the mandible.

Panoramic dental CT scan (A) shows a poorly defined, lytic
lesion in the right mandible (black arrowheads). The lesion is
hypointense on T1-weighted (B) and slightly hyperintense on T2-
weighted (C) MR images and enhances on post Gd-DTPA MR
scan (D). Note the cortex perforation (arrow) and soft tissue
thickening adjacent to the lateral mandibular cortex (white
arrowheads), consistent with extraosseous spread of lym-
A phoma.

B C D
90
has a low positive predictive value.
A negative study virtually excludes
cortical/periosteal or bone marrow
invasion (34).
Primary lymphoma (non-Hodgkin’s
lymphoma)
Primary lymphoma involving the
jawbones is uncommon. The tumor
has a predilection for the mandible.
On radiographs and CT, it appears
as a poorly defined irregular area of
radiolucency. As it progresses, the
lesion expands bone, disrupts the
cortical plate, and produces a soft
tissue mass. CT may identify minor
alterations in radiodensity reflecting
the presence of intramedullary lym-
phomatous infiltration. MR imaging
is very sensitive for early detection
of bone marrow involvement
(Fig. 14) (3, 8, 35).
Conclusion
Although the combination of dif-
ferent imaging techniques may sug-
gest a diagnosis in most radiolucent
lesions, histological confirmation is
often mandatory, especially in
symptomatic well circumscribed
lesions or poorly circumscribed
radiolucent lesions.
References
1. DelBalso A.M.: An approach to the
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 MKA BEELDVORMING — DECEMBER 10-11, 2004, ANTWERP 91

TUMORS AND TUMOR-LIKE LESIONS OF THE JAW

MIXED AND RADIOPAQUE LESIONS
A. Bernaerts1, F.M. Vanhoenacker1, 2, J. Hintjens3, K. Chapelle3, R. Salgado1, B. De Foer4, A.M. De Schepper1

Radiopaque lesions and lesions of mixed radioopacity are far less frequent than their radiolucent counterparts.
Included in this spectrum are infectious and metastatic disease, inherited and developmental disorders and rare
tumoral lesions.
This article deals with the imaging features that may assist in the (differential) diagnosis of these lesions. In many
instances, the radiological characterization is typical (osteoma, enostoma, fibrous dysplasia, Paget disease…),
obviating the need for further invasive histological confirmation. Other lesions may share overlapping clinical, radio-
logical and pathological features. In these cases, correlation of histopathological diagnosis with clinical findings and
imaging features is of utmost importance for a correct diagnosis.

Key-words: Jaws, neoplasms – Jaws, CT – Jaws, MR.

Jaw lesions with a radiopaque or
mixed appearance are generally
less frequent than radiolucent or
cyst-like lesions.
The radiological pattern of some
lesions is so characteristic that fur-
ther invasive diagnostic procedures
(biopsy) are not required. However,
other lesions share overlapping clin-
ical, radiological and pathological
features, rendering difficulties in the
diagnosis.
The purpose of this article is to
give an overview of the imaging fea-
tures, assisting in the differential
diagnosis of radiopaque or mixed
radiolucent-radiopaque lesions.
Lesions with mixed or variable
appearances
A mixed radiolucent-radiopaque
appearance can result from the
presence of two or more tissues
with different radiographic densi-
ties, varying degrees of maturation
of the inflammatory soft tissue with-
in the lesion, and localized resorp-
tion and apposition of new bone
within or around the lesion. This
appearance may indicate osteo-
myelitis, an immature fibro-osseous
lesion, or tumor (See article Imaging
Approach for Differential Diagnosis
of Jaw Lesions: a Quick Reference
Guide, also featuring this issue) (1-
3). The group of fibro-osseous
lesions are characterized by the
replacement of the bone with a
benign fibrous tissue containing
various amounts of mineralized (cal-
From: 1. Department of Radiology, Universitair Ziekenhuis Antwerpen (University of
Antwerp), Edegem, 2. Department of Radiology, 3.Department of Oral and Maxillo-
facial Surgery, AZ St-Maarten, Campus Duffel, Duffel, 4. Department of Radiology, AZ
Sint-Augustinus, Wilrijk, Belgium.
Address for correspondence: Dr F.M. Vanhoenacker, M.D., Department of Radiology,
Universitair Ziekenhuis Antwerpen (University of Antwerp), Wilrijkstraat 10, B-2650
Edegem, Belgium.
cified) structures (4). It includes con-
ditions that can be developmental
(fibrous dysplasia), neoplastic (ossi-
fying fibroma), or dysplastic (reac-
tive) (cemento-osseous dysplasia)
in origin (2).
Chronic osteomyelitis
Chronic osteomyelitis is a persis-
tent inflammation of bone and bone
marrow, resulting from either an
untreated or inadequately treated
acute infection or a long-term low-
grade reaction to a subclinical infec-
tion. The three major forms of chron-
ic osteomyelitis occurring in the
jaws are (1) chronic suppurative
osteomyelitis; (2) chronic sclerosing
osteomyelitis; and (3) osteomyelitis
with proliferative periostitis (1, 3).
Chronic suppurative osteomyelitis
In suppurative osteomyelitis, the
infection starts in the medullary
portion of bone with pus accumula-
tion (5). Radiographs show mixed
ill-defined radiolucent and radio-
paque zones representing areas of
bone destruction or abscess forma-
tion and bone proliferation respec-
tively. Other distinctive radiologic
findings are the presence of foci of
increased density representing dead
bone or “sequestra” or extensive
periosteal reactions which can result
in the formation of an osseous shell
around involved areas called the
“involucrum” (Fig. 1). Extension of
the inflammatory process into adja-
cent soft tissues and fascial spaces
can result in myositis or abscess for-
mation with acutely or chronically
draining sinus tracts. (1, 3)
Chronic sclerosing osteomyelitis
Sclerosing osteomyelitis is a pre-
dominant proliferative reaction of
bone resulting in a thickened trabec-
ular bone network originating from
the endosteum. (5). It can be either
focal or diffuse in extent. The focal
type, also known as periapical
osteitis or condensing osteitis, is a
common condition. Radiographi-
cally, a circumscribed periapical
radiopaque area is seen. The diffuse
form is an uncommon disease
which presents as a diffuse
endosteal sclerosis on radiographs
and CT (Fig. 2) (1, 3).
Osteomyelitis with proliferative
periostitis (Garré osteomyelitis)
Osteomyelitis with proliferative
periostitis, formerly described as
Garré osteomyelitis or periostitis
ossificans, is a clinical-radiographic
variant of a chronic osteomyelitis in
which periosteal reaction predomi-
nates. The disease is seen almost
exclusively in children (5). Radio-
graphs of this disease show laminar
periosteal new bone (the so-called
onion peel appearance), which is
most evident on the inferior, buccal
or lingual aspect of the mandible
(Fig. 3) (1, 3).
Fibrous dysplasia
Fibrous dysplasia is a disease of
bone maturation and remodelling in
which the normal medullary bone
and cortices are replaced by a disor-
ganized fibrous woven bone. The
condition develops primarily in chil-
dren and teenagers. Fibrous dyspla-
sia can occur in a monostotic or
polyostotic form with the former
92 JBR–BTR, 2006, 89 (2)

A
Fig. 1. — Chronic suppurative osteomyelitis. Axial CT section
(A) through the mandible shows a large sequestrum (arrow-
head) surrounded by a radiolucent abscess cavity and B
periosteal new bone called the involucrum. A spotview (B)
reveals an opening within the involucrum, better known as the
cloaca (arrowhead).

B
Fig. 2. — Diffuse chronic sclerosing osteomyelitis. CT
(DentaScan) scan of the mandible. Axial view (A) reveals
endosteal sclerosis with some internal radiolucent foci in the
left body of the mandible. There is no or little extracortical bone
formation or cortical destruction. Panoramic view (B) illustrates
A the disappearance of the inferior border cortex.

most common. Craniofacial fibrous
dysplasia involves the maxilla and
adjacent bones and is still consid-
ered a form of monostotic fibrous
dysplasia (1, 5).
Fibrous dysplasia of the facial
bone can demonstrate varying
degrees of osseous expansion and
cortical thinning resulting in gross
osseous deformities, as well as
variations in radiopacities on plain
film and densities on CT studies.
Lucent lesions represent early, pre-
dominantly fibrous lesions, whereas
more mature lesions containing a
greater amount of mineralized tis-
sues have a ground glass or sclerot-
ic appearance (Fig. 4). Other key
radiographic features are the lack of
a sharp marginal definition, the
effacement of the lamina dura of the
teeth in the affected area and supe-
rior displacement of the mandibular
canal. The latter is a noteworthy dif-
ferential diagnostic feature since
many other fibro-osseous lesions
develop above the canal being den-
tal related lesions. MR imaging also
depends on the variety of compo-
nents of the disease, especially on
T2-weighted images. The fibrous
components often shows enhance-
ment after contrast administration.
If the lesion has rich cartilaginous
components or cystic changes, its
signal intensities can be brighter:
the former show gradual enhance-
ment, while the latter show no
enhancement (1, 3, 4).
 MKA BEELDVORMING — DECEMBER 10-11, 2004, ANTWERP
Fig. 3. — Osteomyelitis with proliferative periostitis. Axial CT
section through the mandible shows laminar periosteal new
bone on the buccal and lingual aspect of the left side of the
mandible.
Ossifying fibroma (cemento-ossify-
ing fibroma)
Ossifying fibroma is an encapsu-
lated, benign neoplasm arising from
multipotential mesenchymal cells
(capable of differentiation into
cementum, osteoid, or fibrous tis-
sue) in the periodontal ligament
(connective tissue that anchors the
tooth to the alveolar ridge). Except
for the juvenile variety, ossifying
fibromas seem to occur mostly in
the third and fourth decade of life,
with women more often affected
than men. The lesion develops pre-
dominantly in the mandibular pre-
molar-molar region and is usually
located in close proximity to the
roots of the teeth (4, 6).
Radiographically, the tumor pre-
sents as a well circumscribed, often
expansile lesion. Their degree of
opacity depends either on its matu-
ration grade or on its tissue compo-
sition (bone or cement). Early stage
lesions are radiolucent, whereas
progressive matrix mineralization
results in radiopacity at a later
stage. Lesions containing large
amounts of cementum or bone
exhibit markedly increased densi-
ties. Adjacent dental roots may be
displaced and unlike the cemento-
blastoma, it is infrequently associat-
ed with root resorption. When
lesions become large, the inferior
margin of the mandible typically
bows downward. On CT-scan, ossi-
fying fibromas appear as an expan-
sile mass surrounded by a thick or
thin radiodense rimming. MR shows
a mass with diffuse intermediate to
low signal on both pulse sequences
consistent with the low free-water
content of the calcific and fibrous
tissue. There is a moderate contrast
enhancement (1, 4, 7-10).
Periapical cemental dysplasia and
florid cemental dysplasia
Periapical cemental dysplasia is
believed to be a reactive process.
The initial lesion is the result of
proliferation of connective tissue
from the periodontal membrane (3,
4, 11). Periapical cemental dysplasia
typically presents as an asympto-
matic lesion in the bone around the
root apices of mandibular incisors
of middle-aged black women (1, 4,
7).
These lesions can be divided
radiographically into three stages: a
rather well-defined radiolucency at
the apex of a tooth (osteolytic
stage), a lesion that is partly radiolu-
cent and partly radiopaque, with a
dense central core (cementoblastic
stage), and transformation into a
mineralized radiopaque mass sur-
rounded by a radiolucent zone
(mature inactive stage).
93
Fig. 4. — Fibrous dysplasia. A portion
of panoramic radiograph of fibrous dys-
plasia, showing diffuse, ill-defined,
ground glass radiopaque lesion, involv-
ing right body and ramus of mandible
(Courtesy of G. Siegal, Birmingham,
USA).
The size does not exceed 1 cm.
The teeth associated with periapical
cemental dysplasia are vital as
opposed to the devitalized tooth
seen with periapical granuloma (1,
3, 7, 11).
Florid cemental dysplasia (florid
cementoosseous dysplasia), an exu-
berant form of periapical cemental
dysplasia, manifests as diffuse, mul-
tiquadrant distribution of mixed
lucent-opaque osseous changes in
both the mandible and maxilla (3, 4,
12).
Metastatic lesions
The bones of the mandible in par-
ticular and to a lesser extent of the
maxilla are frequent sites for
metastatic deposits from carcino-
mas elsewhere in the body. The
most common primary tumors are
in order of frequency in the breast,
lung, kidney, prostate, thyroid and
stomach (5). Metastases are usually
lytic in nature. On occasion a mixed
lesion of lytic and blastic areas may
be encountered, usually from a car-
cinoma of the breast. Prostate carci-
noma, as elsewhere in the skeleton,
can present with purely blastic
lesions. Most CT scans will show a
soft tissue mass expanding bone,
causing cortical destruction (1, 3, 5).
Osteosarcoma
Osteosarcomas are malignant
tumors of the bone. Osteosarcomas
of the mandible or maxilla, also
referred to as gnathic osteosarco-
mas, account for approximately 5%
of all osteosarcomas and are con-
94 JBR–BTR, 2006, 89 (2)

A B
Fig. 5. — Osteogenic sarcoma. A, Axial CT section with soft tissue window setting
shows an extensive mandibular lesion extending throughout the masticator space and
compressing the parapharyngeal space. B, Axial CT section with bone window setting
at the same level demonstrates a perpendicular, spiculated periosteal reaction. C, Axial
SE T1-weighted MR image demonstrating a low intensity, irregular delineated lesion.
D, Axial Gd-enhanced SE T1-weighted MR image showing strong enhancement of the
lesion. The irregular borders of the lesion, the infiltrative intramedullary extension and
the spiculated pattern of new bone formation are particularly well demonstrated
(Courtesy of Dr. D. Vanel / Reprinted with permission (23)).

sidered different from conventional the jaw may be better evaluated on

osteosarcomas owing to an older
age of onset, usually between 30
and 39 years old, and better progno-
sis (13). Several predisposing fac-
tors, such as prior irradiation, genet-
ic factors, fibrous dysplasia and
Paget disease have been suggested
(7). Radiographically, early gnathic
osteosarcomas may present with
symmetrical widening of the peri-
odontal ligament (best illustrated by
periapical radiographs) and irregu-
lar and indistinct borders of the
mandibular canal (best demonstrat-
ed by panoramic radiographs).
Advanced cases of osteosarcomas
may demonstrate a poorly defined
osteolytic, osteoblastic or mixed
pattern of involvement; lytic lesions,
however, are far the most common.
Additional radiographic findings
may include localized supereruption
of a tooth, a “floating tooth” or a
“hanging tooth” caused by resorp-
tion of bone around the root and
bone formation above the alveolar
crest. The classic “hair on end”
appearance of periosteal reaction is
seen in about 25% of cases (Fig. 5).
CT reveals tumoral calcifications,
cortical destruction, periosteal reac-
tion and soft tissue involvement,
indicating an aggressive neoplastic
process. The extent of tumor spread
within the marrow space or outside
MR imaging (1, 3, 7, 13-15).
Chondroma
Chondromas are uncommon jaw
lesions that presumably arise from
cartilaginous remnants in bone.
They appear as an irregular, well- or
poorly-defined osteolytic area in the
body of the mandible and occasion-
ally in the condyle. Mottled calcifica-
tions in the tumor may be present.
Since chondromas are neoplasms of
hyaline cartilage, these lesions have
high signal intensities on T2-weight-
ed MR images, while T1-weighted
MR images often show low signal
intensities similar to those of water
(3, 13).
Adenomatoid odontogenic tumor
The adenomatoid odontogenic
cyst (AOC) is a cystic hamartoma
arising from odontogenic epitheli-
um with duct-like structures in the
epithelial lining which have led to
the tumor being called “adenoma-
toid”. AOCs account for approxi-
mately 3% of all odontogenic
tumors. It has sometimes been
referred to as the “two-thirds
tumor” because about two thirds
occur in the maxilla, two thirds
occur in young women (preteen and
teenage years), two thirds are asso-
D
ciated with an unerupted tooth, and
two thirds of those tooth are canine
teeth (3, 5, 16).
The cyst’s radiographic appear-
ance will be that of a well-demarcat-
ed, unilocular radiolucency frequent-
ly associated with an impacted tooth
and punctate calcifications either
sprinkled throughout or in clusters.
The impacted tooth is completely
contained in the lesion as opposed
to a dentigerous cyst which attaches
at the cementoenamel junction area
(3, 5, 17, 18).
Calcifying epithelial odontogenic
tumor (Pindborg tumor)
The calcifying epithelial odonto-
genic tumor (CEOT), first described
by Pindborg, is an uncommon
odontogenic neoplasm with a vari-
able biologic behaviour ranging
from very mild to moderate inva-
siveness. Odontogenic epithelium is
evidently the origin of this tumor
but the exact cell differentiation
remains unknown. The tumor occurs
in individuals over a wide age
range, but peaks in incidence in the
40s. The molar region of the
mandible is the preferred site (5).
 MKA BEELDVORMING — DECEMBER 10-11, 2004, ANTWERP
A
Fig. 6. — Calcifying odontogenic cyst. Axial CT images filmed
with soft tissue window (A) and bone window (B) show a
unilocular radiolucency with a well corticated buccal expansion
located in the incisor-canine area of the maxilla. Note the
peripheral calcifications of varying opacity.
CEOT has been described in the
literature with various radiological
features, such as pericoronal or non-
tooth related radiolucency, mixed
radiolucent-radiopaque or dense
radiopacity, unilocular or multilocu-
lar and with well or diffuse borders.
The presence of internal calcifica-
tions is an important clue to the dif-
ferential diagnosis with other
expansile radiolucent lesions of the
jaw. The high association with
impacted teeth (in approximately
50%) helps differentiate it from the
ossifying fibroma. In contrast with
the dentigerous cysts which are
more frequently associated with
third molars, CEOT are mostly
found around first and second
molars (3, 9, 11, 18, 19).
Calcifying odontogenic cyst (Gorlin
cyst)
A calcifying odontogenic cyst
(COC), first described by Gorlin et
al., is a rare developmental odonto-
genic lesion originating from dental
lamina rest. They can occur at any
age but are more common in the
teenage years. Most COC are locat-
ed in the maxilla with a predilection
for the incisor-canine area (5, 20).
COC is also known to display a
variable radiological pattern, but
mostly presents as a unilocular radi-
olucency with internal irregular cal-
cified bodies of varying size and
opacity (Fig. 6). In 33´% of cases
COCs are associated with unerupted
teeth. CT and MR are complemen-
tary to conventional radiographs by
characterising the lesion as cystic or
solid and detecting more subtle cal-
cifications (owing to high resolution
B
CT and gradient echo recalled
sequences). Detection of such calci-
fications is crucial in the differential
diagnosis of these odontogenic
tumors (3, 20-22).
Paget’s disease
Paget’s disease is a condition of
excessive bone resorption followed
by disorganized repair. Its etiology is
unknown, but several theories have
been advanced, of which a slow
virus theory has received the great-
est support (5). Paget’s disease pri-
marily occurs in patients older than
50 years and usually results in
enlargement of the involved bones.
Jaw involvement is typically sym-
metrical with the maxilla affected
twice as frequently as the mandible
(2, 5).
On imaging, the jaw lesions have
a variable appearance, depending on
the stage of the disease progression.
Different patterns include “geograph-
ic demarcated” radiolucency, mixed
areas with a “cotton wool-like”
appearance, and more dense sclerot-
ic areas (Fig. 7A). Loss of the lamina
dura and hypercementosis may be
noted around root apices in long-
standing cases (2, 3). Radionuclide
studies demonstrate areas of marked
uptake in involved areas (Fig. 7B).
Laboratory findings typically include
elevations in serum alkaline phos-
phatase and urinary hydroxyproline.
Radiopaque lesions
Discrete radiopaque lesions are
nearly always benign, often repre-
senting an overgrowth of bone or
cementum (See article Imaging
95
Approach for Differential Diagnosis
of Jaw Lesions: a Quick Reference
Guide, also featuring this issue) (1,
2). A combination of plain radiogra-
phy and high-resolution CT yields
the best results in differentiating
these lesions (3).
Odontoma
Odontomas are hamartomas of
aborted tooth formation, of which
there are two general types. One
type which forms multiple small
tooth-like structures is called the
“compound odontoma”. The other
type forms an amorphous calcified
mass and is called the “complex
odontoma”. Odontomas are the
most common odontogenic neo-
plasms and occur primarily in chil-
dren and young adults (1, 5).
Radiographically, the compound
type will present with a gravel-like
appearance in which the outline of
miniature teeth may be noticed
(Fig. 8). The complex odontoma will
present as a dense amorphous and
irregularly shaped mass (Fig. 9).
Odontomas may be surrounded by
a lucent follicle that is caused by a
fibrous capsule. Most are 1-3 cm in
diameter and can cause impaction,
malpositioning, or resorption of
adjacent teeth (1, 3, 7, 11, 12).
Cementoblastoma
The cementoblastoma is a
hamartomatous proliferation of
cementoblasts forming disorgan-
ized cementum around the apex of a
tooth root. Most lesions occur in the
mandible rather than in the maxilla
with the mandibular first molar
96
A the skull, increased sclerosis is seen both
most frequently involved. They are
usually found in teenagers or adults
younger than 30 years (5).
Radiographically, the lesion char-
acteristically shows a spherical
radiopaque mass encompassing
and essentially replacing the root
apex. A radiolucent halo is charac-
teristic, which represents the periph-
eral unmineralized tissues of the
germinative cellular layers (1, 3, 5,
7, 11).
A B
Fig. 8. — Compound odontoma. Axial CT image (A) and 3D image (B) show an expansile lesion containing multiple malformed
teeth.
JBR–BTR, 2006, 89 (2)
B An osteochondroma is a benign
Fig. 7. — Juvenile Paget’s Disease.
Scintigraphy (A) reveals a widespread
increased tracer uptake throughout the
entire skeleton, predominantly at the
skull and facial bones. Note also the
characteristic deformity of the long
bones. On a standard radiography (B) of
in the calvaria as in the facial bones.
Some lytic areas are present within the
calvaria as well.
Osteoma
Osteoma is a benign bone tumor
composed of compact or cancellous
bone and is considered as the most
common osseous neoplasm of the
jaw bones (1, 7, 13). Such lesions
may develop as pedunculated or
sessile superficial bony masses
(periosteal osteoma) or arise within
the medullary cavity (endosteal
osteoma or enostoma) (2). The
tumor shows a predilection for the
mandible, especially the ramus and
the inferior border below the molars
(13). Osteomas usually occur as a
single lesion but may be associated
with Gardner syndrome, an inherit-
ed autosomal-dominant trait charac-
terized by intestinal (colorectal)
polyposis, soft tissue lesions (fibro-
matosis, cutaneous epidermoid
cysts, lipomas, or leiomyomas), and
multiple craniofacial osteomas (10).
Radiographically osteomas appear
as small, well-circumscribed sclerot-
ic lesions, but some may show a
sclerotic periphery with central
lucency (Fig. 10) (7, 13).
Osteochondroma
lesion thought to arise from over-
growth of cartilage at a growth site.
These tumors show a predilection
for the coronoid and condylar
processes. On radiographs and CT,
they usually appear as radiopaque
extraosseous projections. Lesions
involving the coronoid process can
result in a mushroom-shaped
enlargement. CT is used most com-
monly to demonstrate its relation-
ship of the lesion to the parent bone.
The tip of the osteochondroma is
typically covered by a cartilaginous
cap that shows variable degree of
calcifications. After intravenous
administration of contrast material,
enhancement is usually limited to
the fibrovascular tissue that covers
the nonenhancing cartilage cap (1,
3, 13).
Torus
A torus is a localized outgrowth
of bone, in other words, an exosto-
 MKA BEELDVORMING — DECEMBER 10-11, 2004, ANTWERP 97

Fig. 10. — Endosteal osteoma or enostoma. Small osteoscle-

rotic round lesion below the second left mandibular molar on a
panoramic view (arrowhead).

Fig. 9. — Complex odontoma. Axial CT image shows a focus

of high density in the mandible surrounded by a lucent rim A
(arrowheads). There is disordered organization of dental tissue
but no obvious true tooth element.

B
Fig. 12. — Coronal (A) and axial (B) CT scans through the
palate show a torus palatinus extending from the midline of the
palate (arrow).
Fig. 11. — Torus palatinus. A lateral pro-
jection of the skull demonstrating a
small torus palatinus in the palatal mid-
line (arrow).

sis arising on the surface of the occurring in the midline of the hard They are usually bilateral. Although
maxilla or mandible. Tori are named palate (Figs. 11 and 12). “Tori the literature states a high preva-
according to location. The most mandibulari” occur on the lingual lence of tori (approximately 20% for
common is the “torus palatinus”, surface of the mandible (Fig. 13). torus palatinus and approximately
98
Fig. 13. — Torus mandibularis. Axial CT through the mandible
demonstrates bilateral bony exostosis of the lingual surface of
the mandible (arrows).
8% for torus mandibularis), this high
frequency is overestimated accord-
ing to our personal experience.
Radiographically, tori are recog-
nized as exophytic lesions that
vary in size and can be flat,
nodular or slightly pedunculated.
Tori composed of compact bone are
of uniform radiopacity, whereas
those that contain a marrow space
have trabeculations (1, 2, 3, 13).
They should not be confused with
genial tubercles, which are promi-
nent insertional spines at the
mandibular insertion of the genio-
hyoid and genioglossus muscles
(Fig. 14) (3).
Conclusion
A number of mixed and
radiopaque lesions can be charac-
terized solely by imaging. Radiolo-
gical features – however – are not
always specific for a definite diagno-
sis and histological confirmation is
mandatory in many instances. On
the other hand, interpretation of his-
tological findings of those lesions
requiring biopsy should never been
done without knowledge of clinical
and radiological data. Indeed, like
with other bone tumors elsewhere
in the body, correlation of
histopathological, clinical and radio-
logical information is of utmost
JBR–BTR, 2006, 89 (2)
Fig. 14. — Genial tubercles. Axial CT image of mandible illus-
trates two genial tubercles at the insertion of the geniohyoid
muscle (arrows).
importance to obtain a correct diag-
nosis.
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