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Cysts and Cystic Lesions of the Mandible: Clinical and Radiologic-Histopathologic Review¹

¹ From the Department of Diagnostic Imaging and Therapeutics, School of Medicine (R.J.S., H.M.K., D.P.N.), and the Department of Oral Diagnosis, Division of Oral and Maxillofacial Radiology, School of Dental Medicine (A.G.L.), University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT 06030. Presented as a scientific exhibit at the 1997 RSNA scientific assembly. Received April 13, 1998; revision requested May 22; final revision received February 17, 1999; accepted February 17. Address reprint requests to A.G.L.

View larger version (156K): [in a new window]   Figure 1a.   Ameloblastoma in a 67-year-old man. An abnormality was seen incidentally on a full-mouth radiographic series obtained for routine dental care; additional radiographic views and a computed tomographic (CT) scan were then obtained. (a) Panoramic radiograph shows a well-defined, noncorticated, lucent lesion between the roots of a canine and the first premolar (arrows). There is loss of the lamina dura with some minimal tooth displacement. (b) Axial CT scan shows a focal area of decreased attenuation in the right anterior aspect of the mandible with perforation of the buccal plate. Enucleation of the lesion (removal of contents and curettage of margins) was performed. (c) Photomicrograph (hematoxylin-eosin stain) shows islands of odontogenic epithelium in a fibrous connective-tissue stroma. This lesion was small and at an early stage; it is unusual to incidentally discover an ameloblastoma at radiography. The differential diagnosis for this case includes ameloblastoma, traumatic bone cyst, lateral periodontal cyst, radicular cyst, and other odontogenic tumors.

View larger version (133K): [in a new window]   Figure 1b.   Ameloblastoma in a 67-year-old man. An abnormality was seen incidentally on a full-mouth radiographic series obtained for routine dental care; additional radiographic views and a computed tomographic (CT) scan were then obtained. (a) Panoramic radiograph shows a well-defined, noncorticated, lucent lesion between the roots of a canine and the first premolar (arrows). There is loss of the lamina dura with some minimal tooth displacement. (b) Axial CT scan shows a focal area of decreased attenuation in the right anterior aspect of the mandible with perforation of the buccal plate. Enucleation of the lesion (removal of contents and curettage of margins) was performed. (c) Photomicrograph (hematoxylin-eosin stain) shows islands of odontogenic epithelium in a fibrous connective-tissue stroma. This lesion was small and at an early stage; it is unusual to incidentally discover an ameloblastoma at radiography. The differential diagnosis for this case includes ameloblastoma, traumatic bone cyst, lateral periodontal cyst, radicular cyst, and other odontogenic tumors.

View larger version (194K): [in a new window]   Figure 1c.   Ameloblastoma in a 67-year-old man. An abnormality was seen incidentally on a full-mouth radiographic series obtained for routine dental care; additional radiographic views and a computed tomographic (CT) scan were then obtained. (a) Panoramic radiograph shows a well-defined, noncorticated, lucent lesion between the roots of a canine and the first premolar (arrows). There is loss of the lamina dura with some minimal tooth displacement. (b) Axial CT scan shows a focal area of decreased attenuation in the right anterior aspect of the mandible with perforation of the buccal plate. Enucleation of the lesion (removal of contents and curettage of margins) was performed. (c) Photomicrograph (hematoxylin-eosin stain) shows islands of odontogenic epithelium in a fibrous connective-tissue stroma. This lesion was small and at an early stage; it is unusual to incidentally discover an ameloblastoma at radiography. The differential diagnosis for this case includes ameloblastoma, traumatic bone cyst, lateral periodontal cyst, radicular cyst, and other odontogenic tumors.

View larger version (136K): [in a new window]   Figures 2-4.   (2) Ameloblastoma. Lateral oblique radiograph of the mandible shows an expansile, multilocular, lucent lesion with coarse internal trabeculae and displacement of teeth and adjacent structures. The differential diagnosis includes ameloblastoma and odontogenic keratocyst. (3) Ameloblastoma. Axial CT scan shows an expansile, locular, hypoattenuating lesion in the left aspect of the mandible with well-corticated buccal expansion. (4) Mural ameloblastoma. Low-power photomicrograph (hematoxylin-eosin stain) shows an ameloblastoma (T) arising from the epithelial lining (arrow) of a dentigerous cyst surrounded by a fibrous capsule (F).

View larger version (130K): [in a new window]   Figures 2-4.   (2) Ameloblastoma. Lateral oblique radiograph of the mandible shows an expansile, multilocular, lucent lesion with coarse internal trabeculae and displacement of teeth and adjacent structures. The differential diagnosis includes ameloblastoma and odontogenic keratocyst. (3) Ameloblastoma. Axial CT scan shows an expansile, locular, hypoattenuating lesion in the left aspect of the mandible with well-corticated buccal expansion. (4) Mural ameloblastoma. Low-power photomicrograph (hematoxylin-eosin stain) shows an ameloblastoma (T) arising from the epithelial lining (arrow) of a dentigerous cyst surrounded by a fibrous capsule (F).

View larger version (128K): [in a new window]   Figures 2-4.   (2) Ameloblastoma. Lateral oblique radiograph of the mandible shows an expansile, multilocular, lucent lesion with coarse internal trabeculae and displacement of teeth and adjacent structures. The differential diagnosis includes ameloblastoma and odontogenic keratocyst. (3) Ameloblastoma. Axial CT scan shows an expansile, locular, hypoattenuating lesion in the left aspect of the mandible with well-corticated buccal expansion. (4) Mural ameloblastoma. Low-power photomicrograph (hematoxylin-eosin stain) shows an ameloblastoma (T) arising from the epithelial lining (arrow) of a dentigerous cyst surrounded by a fibrous capsule (F).

View larger version (120K): [in a new window]   Figure 5a.   Odontogenic keratocyst in a 13-year-old boy. An abnormality was seen incidentally on conventional radiographs obtained for planning of orthodontic treatment. (a) Lateral oblique radiograph shows an ellipsoid, expansile, multilocular, corticated, lucent lesion occupying the anterior two-thirds of the left ramus with an impacted third molar crown displaced inferiorly within the lesion. The mandibular canal appears to be displaced inferiorly as well. (b) Posteroanterior radiograph shows buccal (lateral) displacement of the third molar by the lesion. The patient underwent en bloc resection. The differential diagnosis includes dentigerous cyst, odontogenic keratocyst, and ameloblastoma.

View larger version (149K): [in a new window]   Figure 5b.   Odontogenic keratocyst in a 13-year-old boy. An abnormality was seen incidentally on conventional radiographs obtained for planning of orthodontic treatment. (a) Lateral oblique radiograph shows an ellipsoid, expansile, multilocular, corticated, lucent lesion occupying the anterior two-thirds of the left ramus with an impacted third molar crown displaced inferiorly within the lesion. The mandibular canal appears to be displaced inferiorly as well. (b) Posteroanterior radiograph shows buccal (lateral) displacement of the third molar by the lesion. The patient underwent en bloc resection. The differential diagnosis includes dentigerous cyst, odontogenic keratocyst, and ameloblastoma.

View larger version (136K): [in a new window]   Figure 6a.   Primordial odontogenic keratocyst in a 40-year-old woman. An abnormality was discovered incidentally on a full-mouth radiographic series obtained for routine dental care; additional radiographic views were then obtained. There was no history of a third molar ever being present in the area. (a) Lateral oblique radiograph shows an ellipsoid, well-defined, corticated, lucent lesion with no internal structure at the junction of the alveolar crest and left ascending ramus. (b) Frontal radiograph shows lingual expansion. The patient underwent marsupialization of the lesion (opening and curettage of the lesion with the mucosal margins placed into the lesion; mucosa grows over the inferior surface with the defect left open, and the defect heals by second intention). The differential diagnosis includes residual cyst, odontogenic keratocyst, and ameloblastoma.

View larger version (134K): [in a new window]   Figure 6b.   Primordial odontogenic keratocyst in a 40-year-old woman. An abnormality was discovered incidentally on a full-mouth radiographic series obtained for routine dental care; additional radiographic views were then obtained. There was no history of a third molar ever being present in the area. (a) Lateral oblique radiograph shows an ellipsoid, well-defined, corticated, lucent lesion with no internal structure at the junction of the alveolar crest and left ascending ramus. (b) Frontal radiograph shows lingual expansion. The patient underwent marsupialization of the lesion (opening and curettage of the lesion with the mucosal margins placed into the lesion; mucosa grows over the inferior surface with the defect left open, and the defect heals by second intention). The differential diagnosis includes residual cyst, odontogenic keratocyst, and ameloblastoma.

View larger version (153K): [in a new window]   Figure 7a.   Dentigerous cyst in a 42-year-old man with painful third molars. A full-mouth radiographic series showed an abnormality; additional radiographic views were then obtained. (a) Panoramic radiograph shows an ellipsoid, expansile, well-defined, corticated, lucent lesion with undulating margins in the right mandible. An associated tooth is seen within the lesion. (b) Posteroanterior radiograph shows lingual expansion (arrow). The patient underwent tooth extraction and enucleation. The differential diagnosis includes dentigerous cyst, odontogenic keratocyst, and ameloblastoma.

View larger version (139K): [in a new window]   Figure 7b.   Dentigerous cyst in a 42-year-old man with painful third molars. A full-mouth radiographic series showed an abnormality; additional radiographic views were then obtained. (a) Panoramic radiograph shows an ellipsoid, expansile, well-defined, corticated, lucent lesion with undulating margins in the right mandible. An associated tooth is seen within the lesion. (b) Posteroanterior radiograph shows lingual expansion (arrow). The patient underwent tooth extraction and enucleation. The differential diagnosis includes dentigerous cyst, odontogenic keratocyst, and ameloblastoma.

View larger version (141K): [in a new window]   Figure 8.   Radicular cyst in a 40-year-old man. An abnormality was seen incidentally on a panoramic radiograph obtained for planning of denture treatment. Panoramic radiograph shows a retained tooth fragment with an absent lamina dura. Extending from the root apex is an ellipsoid, corticated, lucent lesion with no internal calcification (arrows), an appearance consistent with a root fragment and associated radicular cyst. The root fragment was removed, and the cyst was curetted. Microscopic features were consistent with a radicular cyst. The radiographic appearance of this lesion is typical of a radicular cyst or periapical granuloma because of the association with a severely carious tooth.

View larger version (140K): [in a new window]   Figure 9.   Complex odontoma in a 30-year-old man with painful third molars. Panoramic radiograph shows an ellipsoid lesion of mixed opacity in the posterior body of the mandible (arrows); the lesion is surrounded by a lucent follicular space. The third molar is displaced into the ramus. Tooth extraction with enucleation of the lesion was performed. The differential diagnosis includes odontoma, focal cemento-osseous dysplasia, and calcifying epithelial odontogenic tumor (Pindborg tumor).

View larger version (142K): [in a new window]   Figure 10a.   Cystic odontoma in a 17-year-old boy with painful third molars. An abnormality was discovered incidentally on a panoramic radiograph obtained for planning of tooth extraction; a CT scan was then obtained. (a) Panoramic radiograph shows a large, focal area of heterogeneous calcification with displaced second and third molars. The opaque portions are surrounded by a lucent follicular space (arrowhead). There is marked cystic expansion of all bone margins (arrows). (b) Coronal CT scan shows a heterogeneously calcified mass with expansion and cyst formation superiorly. A toothlike structure is seen internally (arrow). (c) Axial CT scan also shows the lesion. (d) Photomicrograph (hematoxylin-eosin stain) shows cyst formation in bone (B) with an epithelial lining (arrow) and an internal mass of mature dental hard tissue (D). The patient underwent enucleation and curettage. The differential diagnosis is limited and includes cystic odontoma and ameloblastic fibro-odontoma. An odontogenic keratocyst or mural ameloblastoma could develop in the cystic portion of this lesion.

View larger version (143K): [in a new window]   Figure 10b.   Cystic odontoma in a 17-year-old boy with painful third molars. An abnormality was discovered incidentally on a panoramic radiograph obtained for planning of tooth extraction; a CT scan was then obtained. (a) Panoramic radiograph shows a large, focal area of heterogeneous calcification with displaced second and third molars. The opaque portions are surrounded by a lucent follicular space (arrowhead). There is marked cystic expansion of all bone margins (arrows). (b) Coronal CT scan shows a heterogeneously calcified mass with expansion and cyst formation superiorly. A toothlike structure is seen internally (arrow). (c) Axial CT scan also shows the lesion. (d) Photomicrograph (hematoxylin-eosin stain) shows cyst formation in bone (B) with an epithelial lining (arrow) and an internal mass of mature dental hard tissue (D). The patient underwent enucleation and curettage. The differential diagnosis is limited and includes cystic odontoma and ameloblastic fibro-odontoma. An odontogenic keratocyst or mural ameloblastoma could develop in the cystic portion of this lesion.

View larger version (143K): [in a new window]   Figure 10c.   Cystic odontoma in a 17-year-old boy with painful third molars. An abnormality was discovered incidentally on a panoramic radiograph obtained for planning of tooth extraction; a CT scan was then obtained. (a) Panoramic radiograph shows a large, focal area of heterogeneous calcification with displaced second and third molars. The opaque portions are surrounded by a lucent follicular space (arrowhead). There is marked cystic expansion of all bone margins (arrows). (b) Coronal CT scan shows a heterogeneously calcified mass with expansion and cyst formation superiorly. A toothlike structure is seen internally (arrow). (c) Axial CT scan also shows the lesion. (d) Photomicrograph (hematoxylin-eosin stain) shows cyst formation in bone (B) with an epithelial lining (arrow) and an internal mass of mature dental hard tissue (D). The patient underwent enucleation and curettage. The differential diagnosis is limited and includes cystic odontoma and ameloblastic fibro-odontoma. An odontogenic keratocyst or mural ameloblastoma could develop in the cystic portion of this lesion.

View larger version (145K): [in a new window]   Figure 10d.   Cystic odontoma in a 17-year-old boy with painful third molars. An abnormality was discovered incidentally on a panoramic radiograph obtained for planning of tooth extraction; a CT scan was then obtained. (a) Panoramic radiograph shows a large, focal area of heterogeneous calcification with displaced second and third molars. The opaque portions are surrounded by a lucent follicular space (arrowhead). There is marked cystic expansion of all bone margins (arrows). (b) Coronal CT scan shows a heterogeneously calcified mass with expansion and cyst formation superiorly. A toothlike structure is seen internally (arrow). (c) Axial CT scan also shows the lesion. (d) Photomicrograph (hematoxylin-eosin stain) shows cyst formation in bone (B) with an epithelial lining (arrow) and an internal mass of mature dental hard tissue (D). The patient underwent enucleation and curettage. The differential diagnosis is limited and includes cystic odontoma and ameloblastic fibro-odontoma. An odontogenic keratocyst or mural ameloblastoma could develop in the cystic portion of this lesion.

View larger version (136K): [in a new window]   Figure 11a.   Odontogenic myxoma in a 75-year-old man. An abnormality was seen incidentally on a full-mouth radiographic series obtained for routine dental care; additional radiographic views were then obtained. Mild fullness was felt at palpation of the inferior border of the mandible. (a) Panoramic radiograph shows an expan-sile, ellipsoid, partially corticated, lucent lesion with heterogeneous internal mineralization in the right posterior aspect of the mandibular body and extending into the lower ascending ramus (arrows). (b) Posteroanterior radiograph shows extension of the lesion (arrows) well up into the ramus. En bloc resection was performed. The radiographic appearance of this lesion is more typical of a calcifying epithelial odontogenic tumor, which should be first in the differential diagnosis. Other considerations include odontogenic myxoma and cystic odontoma.

View larger version (126K): [in a new window]   Figure 11b.   Odontogenic myxoma in a 75-year-old man. An abnormality was seen incidentally on a full-mouth radiographic series obtained for routine dental care; additional radiographic views were then obtained. Mild fullness was felt at palpation of the inferior border of the mandible. (a) Panoramic radiograph shows an expan-sile, ellipsoid, partially corticated, lucent lesion with heterogeneous internal mineralization in the right posterior aspect of the mandibular body and extending into the lower ascending ramus (arrows). (b) Posteroanterior radiograph shows extension of the lesion (arrows) well up into the ramus. En bloc resection was performed. The radiographic appearance of this lesion is more typical of a calcifying epithelial odontogenic tumor, which should be first in the differential diagnosis. Other considerations include odontogenic myxoma and cystic odontoma.

View larger version (134K): [in a new window]   Figure 12a.   Juvenile ossifying fibroma in a 13-year-old boy with painless swelling over the posterior body and angle of the mandible, which was evaluated with radiographs and a bone scan. (a) Lateral oblique radiograph shows an expansile, ellipsoid, lucent lesion in the posterior mandibular body with no internal structure (arrows). There is thinning of the inferior mandibular border. Tooth displacement is present. (b) Frontal radiograph shows buccal plate expansion and thinning. (c) Technetium-99m methylene diphosphonate bone scan shows focal, expansile, intense uptake in the right aspect of the mandible. The lesion was surgically explored and enucleated. The differential diagnosis includes traumatic bone cyst, central giant cell lesion, odontogenic tumor or cyst, and a vascular lesion.

View larger version (103K): [in a new window]   Figure 12b.   Juvenile ossifying fibroma in a 13-year-old boy with painless swelling over the posterior body and angle of the mandible, which was evaluated with radiographs and a bone scan. (a) Lateral oblique radiograph shows an expansile, ellipsoid, lucent lesion in the posterior mandibular body with no internal structure (arrows). There is thinning of the inferior mandibular border. Tooth displacement is present. (b) Frontal radiograph shows buccal plate expansion and thinning. (c) Technetium-99m methylene diphosphonate bone scan shows focal, expansile, intense uptake in the right aspect of the mandible. The lesion was surgically explored and enucleated. The differential diagnosis includes traumatic bone cyst, central giant cell lesion, odontogenic tumor or cyst, and a vascular lesion.

View larger version (123K): [in a new window]   Figure 12c.   Juvenile ossifying fibroma in a 13-year-old boy with painless swelling over the posterior body and angle of the mandible, which was evaluated with radiographs and a bone scan. (a) Lateral oblique radiograph shows an expansile, ellipsoid, lucent lesion in the posterior mandibular body with no internal structure (arrows). There is thinning of the inferior mandibular border. Tooth displacement is present. (b) Frontal radiograph shows buccal plate expansion and thinning. (c) Technetium-99m methylene diphosphonate bone scan shows focal, expansile, intense uptake in the right aspect of the mandible. The lesion was surgically explored and enucleated. The differential diagnosis includes traumatic bone cyst, central giant cell lesion, odontogenic tumor or cyst, and a vascular lesion.

View larger version (144K): [in a new window]   Figure 13.   Focal cemento-osseous dysplasia in an asymptomatic 25-year-old man. An abnormality was seen incidentally on a full-mouth radiographic series obtained for routine dental care; additional radiographic views were then obtained. There were no associated clinical abnormalities. Lateral oblique radiograph shows an ellipsoid, lucent lesion with hyperostotic borders (arrows). Amorphous mineralization is seen above and below the superior border of the lesion (arrowheads). There is depression of the inferior border of the mandible with erosion of the cortex. No tooth displacement is present. The patient underwent curettage of the lesion. The differential diagnosis includes focal cemento-osseous dysplasia, periapical cemento-osseous dysplasia, and ossifying fibroma.

View larger version (101K): [in a new window]   Figure 14.   Periapical cemento-osseous dysplasia in an asymptomatic 47-year-old woman. Periapical radiographs show multiple lesions of mixed opacity (arrows) clustered at and inferior to the root apices of the canine and incisor teeth. Periodontal ligament spaces (arrowheads) are intact around all tooth roots.

View larger version (80K): [in a new window]   Figure 15.   Florid osseous dysplasia in a 65-year-old man. Panoramic radiograph shows primarily opaque masses in the right posterior aspects of the maxilla and mandible and a lesion of mixed opacity in the left aspect of the mandibular body.

View larger version (141K): [in a new window]   Figure 16a.   Traumatic bone cyst in a 12-year-old boy. A lesion was discovered on a routine panoramic radiograph obtained for planning of orthodontic treatment. (a) Panoramic radiograph shows a large, ellipsoid, well-defined, corticated, lucent lesion undulating between the premolar and molar teeth on the right side of the mandible (arrows). Minimal tooth displacement is present along with loss of the lamina dura of roots within the lesion. All teeth were vital. (b) Axial CT scan shows an area of low attenuation in the right aspect of the mandible with expansion and thinning of the lingual cortex (arrows) and displacement of the first premolar. Large marrow spaces, typical in a child's mandible, are seen on the contralateral side (arrowheads). (c) Photomicrograph (hematoxylin-eosin stain) shows a portion of an osseous cyst wall (B) that lacks an epithelial lining with a fibrovascular stroma (S) at the periphery. The patient underwent enucleation of the lesion. The differential diagnosis includes central giant cell granuloma, traumatic bone cyst, ameloblastic fibroma, hemangioma, and ossifying fibroma.

View larger version (122K): [in a new window]   Figure 16b.   Traumatic bone cyst in a 12-year-old boy. A lesion was discovered on a routine panoramic radiograph obtained for planning of orthodontic treatment. (a) Panoramic radiograph shows a large, ellipsoid, well-defined, corticated, lucent lesion undulating between the premolar and molar teeth on the right side of the mandible (arrows). Minimal tooth displacement is present along with loss of the lamina dura of roots within the lesion. All teeth were vital. (b) Axial CT scan shows an area of low attenuation in the right aspect of the mandible with expansion and thinning of the lingual cortex (arrows) and displacement of the first premolar. Large marrow spaces, typical in a child's mandible, are seen on the contralateral side (arrowheads). (c) Photomicrograph (hematoxylin-eosin stain) shows a portion of an osseous cyst wall (B) that lacks an epithelial lining with a fibrovascular stroma (S) at the periphery. The patient underwent enucleation of the lesion. The differential diagnosis includes central giant cell granuloma, traumatic bone cyst, ameloblastic fibroma, hemangioma, and ossifying fibroma.

View larger version (158K): [in a new window]   Figure 16c.   Traumatic bone cyst in a 12-year-old boy. A lesion was discovered on a routine panoramic radiograph obtained for planning of orthodontic treatment. (a) Panoramic radiograph shows a large, ellipsoid, well-defined, corticated, lucent lesion undulating between the premolar and molar teeth on the right side of the mandible (arrows). Minimal tooth displacement is present along with loss of the lamina dura of roots within the lesion. All teeth were vital. (b) Axial CT scan shows an area of low attenuation in the right aspect of the mandible with expansion and thinning of the lingual cortex (arrows) and displacement of the first premolar. Large marrow spaces, typical in a child's mandible, are seen on the contralateral side (arrowheads). (c) Photomicrograph (hematoxylin-eosin stain) shows a portion of an osseous cyst wall (B) that lacks an epithelial lining with a fibrovascular stroma (S) at the periphery. The patient underwent enucleation of the lesion. The differential diagnosis includes central giant cell granuloma, traumatic bone cyst, ameloblastic fibroma, hemangioma, and ossifying fibroma.

View larger version (109K): [in a new window]   Figure 17.   Lingual salivary gland inclusion defect in a 67-year-old man. An abnormality was seen incidentally on a full-mouth radiographic series obtained for routine dental care; additional radiographic views were then obtained. Lateral oblique radiograph shows a well-defined, ellipsoid to rectangular, corticated, lucent lesion (arrowheads) anterior to the mandibular angle and inferior to the mandibular canal (arrows). Because this radiographic finding is virtually pathognomonic of a lingual salivary gland inclusion defect, no treatment was given. The differential diagnosis for larger, less characteristic variants includes arteriovenous malformation and hemangioma.

View larger version (117K): [in a new window]   Figure 18.   Central giant cell granuloma in a 14-year-old girl with progressive swelling over the anterior mandible. Cross-sectional occlusal radiograph shows an expansile, corticated, lucent lesion in the anterior mandible with undulating margins and wispy internal septa. Displacement of teeth is present, and the lesion crosses the midline. Enucleation of the lesion was performed. The differential diagnosis includes central giant cell granuloma, ameloblastoma, cherubism in a child, and brown tumor of hyperparathyroidism in an older patient.

View larger version (139K): [in a new window]   Figure 19.   Brown tumor of hyperparathyroidism in a 56-year-old woman with an unremarkable medical history and an ill-fitting, painful mandibular denture. Radiographs were obtained for routine dental care. Lateral oblique radiograph shows a large, lucent lesion in the mandibular body with expansion of the alveolar crest (arrows) and wispy internal septa. "Windowing" of bone is seen (arrowheads) and is explained by lingual expansion. An occlusal view obtained in the mediolateral plane demonstrated comparable findings. Because of the radiographic findings, mainly generalized demineralization of the jaws and resorption of the lamina dura of the visualized teeth, a diagnosis of hyperparathyroidism was suggested and was confirmed with serum assays. Subsequently, the patient underwent treatment for hyperparathyroidism.

View larger version (110K): [in a new window]   Figure 20a.   Arteriovenous malformation in a 23-year-old woman with painless, progressive swelling in the right mandibular angle and submandibular region. The mass was faintly pulsatile. (a) Posteroanterior radiograph shows a laterally expansile, lucent lesion in the right aspect of the mandible with smooth, thin, corticated borders and no internal structure. (b) Lateral oblique radiograph shows the lesion to be at the mandibular angle. The margins within the mandible are poorly defined (arrows), whereas the external margins are well defined (arrowheads). Aspiration produced bright red blood, and angiography was performed. (c) External carotid arteriogram shows a vascular mass supplied by the lingual artery overlying the posterior body and angle of the mandible. The lesion was resected. The differential diagnosis before angiography included arteriovenous malformation, hemangioma, and soft-tissue malignancy invading the mandible.

View larger version (103K): [in a new window]   Figure 20b.   Arteriovenous malformation in a 23-year-old woman with painless, progressive swelling in the right mandibular angle and submandibular region. The mass was faintly pulsatile. (a) Posteroanterior radiograph shows a laterally expansile, lucent lesion in the right aspect of the mandible with smooth, thin, corticated borders and no internal structure. (b) Lateral oblique radiograph shows the lesion to be at the mandibular angle. The margins within the mandible are poorly defined (arrows), whereas the external margins are well defined (arrowheads). Aspiration produced bright red blood, and angiography was performed. (c) External carotid arteriogram shows a vascular mass supplied by the lingual artery overlying the posterior body and angle of the mandible. The lesion was resected. The differential diagnosis before angiography included arteriovenous malformation, hemangioma, and soft-tissue malignancy invading the mandible.

View larger version (140K): [in a new window]   Figure 20c.   Arteriovenous malformation in a 23-year-old woman with painless, progressive swelling in the right mandibular angle and submandibular region. The mass was faintly pulsatile. (a) Posteroanterior radiograph shows a laterally expansile, lucent lesion in the right aspect of the mandible with smooth, thin, corticated borders and no internal structure. (b) Lateral oblique radiograph shows the lesion to be at the mandibular angle. The margins within the mandible are poorly defined (arrows), whereas the external margins are well defined (arrowheads). Aspiration produced bright red blood, and angiography was performed. (c) External carotid arteriogram shows a vascular mass supplied by the lingual artery overlying the posterior body and angle of the mandible. The lesion was resected. The differential diagnosis before angiography included arteriovenous malformation, hemangioma, and soft-tissue malignancy invading the mandible.

View larger version (111K): [in a new window]   Figure 21a.   Mucoepidermoid carcinoma in a 67-year-old man. A lesion was partially seen on intraoral radiographs obtained for routine dental care; additional views were obtained. (a) Lateral oblique radiograph shows a multilocular area of lucency with undulating borders and no internal structure. The lesion is eroding through the alveolar crest (arrows). (b) Posteroanterior radiograph shows lingual expansion on the right side with erosion through the lingual cortex (arrows). This lesion has the classic appearance of an ameloblastoma given its location, size, undulating borders, and absence of internal structure. The borders are relatively well defined except for erosion of the alveolar crest and lingual cortex, which can occur with ameloblastomas. A biopsy specimen showed features consistent with mucoepidermoid carcinoma, but the patient refused treatment and was lost to follow-up. The differential diagnosis includes ameloblastoma, odontogenic keratocyst, and residual dentigerous cyst.

View larger version (119K): [in a new window]   Figure 21b.   Mucoepidermoid carcinoma in a 67-year-old man. A lesion was partially seen on intraoral radiographs obtained for routine dental care; additional views were obtained. (a) Lateral oblique radiograph shows a multilocular area of lucency with undulating borders and no internal structure. The lesion is eroding through the alveolar crest (arrows). (b) Posteroanterior radiograph shows lingual expansion on the right side with erosion through the lingual cortex (arrows). This lesion has the classic appearance of an ameloblastoma given its location, size, undulating borders, and absence of internal structure. The borders are relatively well defined except for erosion of the alveolar crest and lingual cortex, which can occur with ameloblastomas. A biopsy specimen showed features consistent with mucoepidermoid carcinoma, but the patient refused treatment and was lost to follow-up. The differential diagnosis includes ameloblastoma, odontogenic keratocyst, and residual dentigerous cyst.