Clinical Radiology xxx (2014) 1e16

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Clinical Radiology
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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
Primary mandibular lesions include neoplasms (benign or
malignant), tumour-like lesions and cysts arising from the
odontogenic apparatus. The classification was published by
the World Health Organization (WHO) in 2005 and sub-
divides lesions by the predominant odontogenic tissue
involved.1 Other lesions in the mandible include cystic le-
sions, solid benign and malignant lesions; infectious and in-
flammatory processes; and vascular and tumour-like lesions.2
Although some mandibular lesions will display typical
features on imaging studies, many lesions will demonstrate
similar, almost indistinguishable imaging findings despite
the considerable differences in the underlying disease that
they represent. Information regarding the age and gender of
the patient, along with pertinent imaging findings such as
the location within the mandible, relationship to the tooth,
margins of the lesion, size of the lesion and solid or cystic
nature of the lesion; all aid in narrowing the differential
diagnosis.2 Ultimately however, biopsy is required in many
instances to make the diagnosis. The role of imaging
therefore lies in narrowing the differential diagnosis,
assessing the extent and complexity of a lesion, and helping
to guide further patient management.
The purpose of this article is to review the most
commonly encountered cystic and solid lesions of the
mandible to help radiologists familiarise themselves with
commonly encountered jaw diseases. Rather than providing
an exhaustive review of all conditions affecting the mandible
by their tissue of origin, we will divide the lesions into the
broad and clinically useful categories: common radiolucent
lesions, common radio-opaque lesions, and conditions with
mixed radiolucenteradio-opaque appearances.
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;
fax: þ353 1 410 3455.
E-mail address: dr.markharmon@gmail.com (M. Harmon).
mandible manifest radiologically as radiolucent lesions.
These include cystic lesions, solid benign and malignant
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.

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 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)
Odontogenic keratocysts have been renamed keratocys-
tic odontogenic tumours because of their locally aggressive
behaviour.11 They account for 5e15% of all jaw cysts.12,13
These cysts occur in patients of all ages, but have a peak
in the second and third decades. The cysts develop from the
dental lamina, which is found throughout the jaw and
overlying alveolar mucosa; thus the cysts occur throughout
the tooth-bearing regions and occur twice as often in the
mandible as in the maxilla. These cysts may recur, possibly
related to the presence of small adjacent daughter cysts or
to the ability of the cyst epithelium to proliferate.
Radiographically, the cysts manifest as radiolucent le-
sions that may be loculated; they can have a smooth or a
scalloped border. They are typically located in the ramus or
body of the mandible and similar to dentigerous cysts may
be associated with an impacted tooth. The cysts grow along
the length of the mandible and may expand the cortical
bone and erode the cortex. They may displace the roots of
teeth, but should not cause significant root erosion (Fig 3).
CT and MRI can be helpful in characterizing the lesions. At
CT the cyst contents are higher attenuation than water
owing to the keratinized material; this accounts for the
“cheesy” appearance of the cyst contents. At MRI, the cyst
contents demonstrate variable T1 and mixed T2 signal
characteristics depending on the proteinaceous content of
the fluid. Ultimately, the diagnosis is independent of the
cyst’s location and radiographic appearance and is depen-
dent on the cyst’s microscopic features at histopathology.
Figure 3 (a) Radiograph demonstrating a large lucent mandibular
lesion with a scalloped border. (b) CTof the lesion demonstrates a lesion
expanding and thinning the cortex, but without extension into adja-
cent soft tissues (thin arrow). Histology confirmed the lesion as a ker-
atocystic odontogenic tumour. The lesion initially appears similar to the
ameloblastoma in Fig. 5(d), but note that the odontogenic cyst displaces
the roots of adjacent teeth and demonstrates only mild root erosion.
Multiple keratocystic odontogenic tumours are a feature
of basal cell naevus syndrome (GorlineGoltz syndrome). In
this autosomal dominant syndrome, multiple jaw cysts
develop in early childhood (Fig 4).14 Associated features
include: midface hypoplasia, frontal bossing, intellectual
disability, and calcification of the falx cerebri. Nevoid basal
cell carcinomas tend to appear later than the cysts, but
before 30 years of age.2
Primordial cyst
Primordial cysts are considered to arise from a degen-
erated enamel organ and are found in place of a missing
tooth. They are well-defined, non-expansile lucent lesions
without an associated tooth.15 Although the term is now
usually synonymous with keratocystic odontogenic lesions,
some believe they represent a separate entity.2
Residual cyst
A residual cyst is the term for a cyst that remains after the
removal of a carious tooth. They are therefore usually per-
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
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4 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16
Figure 4 (a) Radiograph demonstrates multiple radiolucent lesions
(thin arrows), many associated with carious teeth. (b) However, the
lesions are large and CT demonstrates expansion of the cortex and
displacement of adjacent teeth. Resection confirmed multiple kera-
tocystic odontogenic tumours in this patient with Gorlin’s syndrome.
Stafne cyst
A Stafne cyst, also known as a static bone cavity, is a
pseudocyst caused by inward bowing of the medial
mandibular cortex into the medullary cavity. Radiographi-
cally they manifest as a well-defined, ovoid or round radio-
lucent lesion within a cortical defect on the medial surface of
the posterior mandible; often near the angle of the mandible.
They typically contain fat or submandibular salivary gland.13
Traumatic bone cyst (solitary/simple/haemorrhagic bone
cyst)
Traumatic bone cysts, also known as solitary/simple or
haemorrhagic bone cysts, are not true cysts, as they do not
have an epithelial lining. The exact aetiology of these le-
sions is not clear; either trauma resulting in intramedullary
haematoma or degeneration of another benign tumour are
thought to be the most likely causes.2,16 The end result is a
haemorrhagic, unilocular cavity, which appears radiologi-
cally as an irregular, scalloped, and sometimes expansive
lucency, which extends between the roots of adjacent teeth.
CT and MRI can occasionally help in further diagnosis, but
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
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
the third and fourth decades and have no sex predilection. It is
estimated that they represent 10e18% of odontogenic tu-
mours and are the second most common odontogenic tumour
after odontome. They occur mainly in the mandible.2,17
Approximately 5% arise from the epithelial lining of dentig-
erous cysts.17 Ameloblastomas are usually benign but locally
aggressive lesions that typically present as a slow-growing,
painless mass. Malignant behaviour is rare, but occurs in
two forms: ameloblastic carcinoma, which demonstrates
frankly malignant histology; and malignant ameloblastoma,
which metastasizes despite well-differentiated histology,
usually following repeated surgery and is thought to repre-
sent tumour seeding rather than true metastases.
Radiographically, ameloblastomas appear as expansile,
radiolucent lesions, most commonly in the posterior
mandible. They can be unilocular or multilocular with a
“soap-bubble” appearance that is characteristic, but not
pathognomonic (Fig 5). Loss of the lamina dura and erosion
of the roots of adjacent teeth is a distinctive feature
reflecting the locally aggressive characteristics of the le-
sions.18 The tumour also has a tendency to break through
the cortex of the bone with tumour extension into the
adjacent soft tissues.17,19
Although multiple subtypes of ameloblastoma exist,
most cannot be distinguished on imaging. A histopatho-
logical diagnosis is required to provide definitive subtype
diagnosis and to determine any carcinomatous change. The
desmoplastic ameloblastoma subtype, however, has more
distinguishing features of coarse internal calcifications with
poorly defined borders due to surrounding cortical
 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
appearance and may be mistakenly diagnosed as a fibro-
osseous lesion.19
CT is useful in assessing the extent of lesions, sites of
cortical perforation, and involvement of the adjacent soft
tissues.17,19 Preoperative diagnosis of malignant disease is
difficult, but large, enhancing solid components, extra-
osseous extension, and papillary projections represent
more aggressive features and should raise concern for ma-
lignant behaviour (Fig 6).18 MRI is also useful in assessing
the extent of disease with solid components, septa, and any
papillary projections demonstrating vivid post-contrast

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6 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16
Figure 6 (a) Radiograph demonstrates a large radiolucent lesion with
a scalloped border expanding the left ramus of the mandible. This
could represent an ameloblastoma or a keratocystic odontogenic
tumour. (b) Contrast-enhanced CT was performed which shows
marked cortical expansion (thin arrows) and large solid enhancing
components (open arrow). Ameloblastic carcinoma was confirmed
histologically.
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(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
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
mistaken for periodontal disease. Tumour progression will
appear as an ill-defined radiolucent lesion within the
mandible, usually without periosteal reaction or bony
sclerosis. A “moth-eaten” pattern will be seen in some cases.
Advanced disease will demonstrate a “floating teeth”
appearance on panoramic radiography (Fig 8). Importantly,
the roots of adjacent teeth are not resorbed. CT, MRI, and
 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16
Figure 7 (a) Radiograph demonstrates a well-defined radiolucent
lesion with containing a bony septum within the left mandible (thin
arrows). (b) A CT demonstrates multiple bony septa traversing the
lesion, expansion of the bone, and thinning and remodelling of the
cortex. The lesion was excised and diagnosed as a giant cell granuloma.
PET/CT imaging are more sensitive for early mandibular
involvement and are used in treatment planning to assess
the extent of local disease and any metastatic spread.
Suppurative osteomyelitis
The imaging appearances of osteomyelitis vary depend-
ing on the chronicity of the infection and the grade of the
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(2014), http://dx.doi.org/10.1016/j.crad.2014.10.011
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-
times as the first clinical manifestation of an occult primary
tumour. Radiographically, metastases are usually ill-defined
radiolucent lesions, often in the posterior or angle of the
mandible.33 Common tumours metastasizing to the
mandible include breast, lung, renal, gastric, and thyroid.
Prostate cancer can also affect the mandible, but usually as a
blastic lesion.
Multiple myeloma can present a single lesion, although
usually it appears as multiple “punched out” lesions or
diffuse bony destruction. The “punched-out” lesions of
myeloma appear as regular, round or ovoid radiolucent le-
sions without a sclerotic rim. If the disease burden is large,
the entire bone may be destroyed.
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

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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-

Figure 9 Radiograph demonstrating a focal radio-opaque lesion
associated with the distal root of the left first molar tooth consistent
with an enostosis (idiopathic osteosclerosis).
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-
rounded by a radiolucent zone (the fibrous capsule).
Odontomas are usually well encapsulated, and therefore,
easily enucleated. Recurrences are rare.

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

Ameloblastic fibro-odontomas Cementoblastoma

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

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 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16
size, they may expand cortical bone. In themselves, they are
usually asymptomatic, but may present with dull pain that is
typically relieved by non-steroidal anti-inflammatory
drugs.38,39 It is important to be aware that extraction of the
involved tooth may be difficult or impossible.37
Osteoma
Osteomas are benign neoplasms formed of compact
(ivory osteomas) or cancellous bone. Common sites include
the paranasal sinuses, skull vault, and mandible. They most
commonly occur in an endosteal or periosteal location and
vary greatly in size. They are more common in women.40 In
general, osteomas occur most frequently in the sixth
Figure 12 (a) Radiograph and (b) axial CT image demonstrate a
dense, well-defined, exophytic lesion involving the left mandibular
ramus. CT demonstrates a wide base that extends into the bone. Bi-
opsy confirmed a mandibular osteoma.
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11
decade, but mandibular osteomas are more common in the
second decade. The need for intervention and management
is determined by clinical symptoms.
Radiographically, mandibular osteomas appear as well-
circumscribed, dense, sclerotic bony masses, which are
attached to the underlying bone by a broad base or pedicle
(Fig 12).2 At CT, compact (ivory) osteomas will appear as
dense mature bone with scant marrow and cancellous os-
teomas will demonstrate lamellar trabeculae with abun-
dant marrow.
The presence of multiple osteomas should prompt
screening for Gardner’s syndrome, as the development of
osteomas often precedes the onset of colonic polyps.2
Exostoses
Exostoses, or tori, are localized bony protuberances on
the surface of the mandible or maxilla. Compact exostoses
Figure 13 (a) Axial and (b) coronal CT images in the same patient
demonstrating bilateral maxillary exostoses (thin arrows) arising
from the lingual surface of the maxilla and a torus palatinus (open
arrow).
12 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16

are uniformly radiodense, whereas those that contain
marrow cavity will contain trabeculae. They resemble os-
teomas and are differentiated based on their typical loca-
tion. Three patterns occur: torus mandibularis is seen as an
outgrowth of bone along the lingual surface of the
mandible, just above the mylohyoid line and is bilateral in
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
the buccal or lingual surface of the maxilla, usually in the
molar region (Fig 13).2
Tori are removed if they are constantly traumatized, if
they interfere with function and swallowing or if required
for fitting a denture or prosthesis.
Malignancy
Blastic metastases, typically from breast or prostate
carcinoma, can present as a focal or diffuse radiodense
lesion of the mandible. Osteogenic sarcoma of
the mandible usually presents in the third decade of life (a
decade later than elsewhere). They typically present with
pain and swelling. Radiographically, they may appear
as lytic, destructive lesions (osteolytic type), sclerotic le-
sions (osteoblastic type) or with a mixed pattern. The
osteoblastic type is most common in the mandible.2 They
may be poorly assessed with radiographs and are better
evaluated with cross-sectional imaging techniques
(Fig 14).
Diffuse radio-opaque lesions
Sclerosing osteomyelitis
Chronic or sclerosing osteomyelitis of the mandible may
present as a focal or diffuse radiodensity. It is believed to be
due to a proliferative reaction of the bone to chronic low-
grade infection, which results in thickening of the cortex
and trabeculae. Diffuse periosteal reaction and sequestra-
tions of necrotic bone are commonly seen in chronic oste-
omyelitis. CT, MRI, and bone scintigraphy are useful in
assessing the disease, but differentiation of osteomyelitis
from other sclerosing lesions, osseous dysplasias, and a
number of malignant lesions can remain a challenge; thus
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
Osteonecrosis
Bisphosphonate-associated osteonecrosis of the jaw is a
relatively new entity encountered over the past decade.41,42
Clinically, it usually manifests as an area of exposed bone
that has been present for more than 8 weeks, commonly at a
site of a previous dental extraction. It may present with pain
and swelling, loosening of teeth or superimposed infection.
Occasionally, the changes may be present without bone
exposure.43,44 The diagnosis requires a history of bisphosph-
onate usage and the absence of a history of radiotherapy.
There is also increasing evidence of osteonecrosis associated
with RANKL (receptor activator of nuclear factor-kappa B
lignand) inhibitors such as denosumab.4547
The appearance of osteonecrosis of the jaw at radiog-
raphy and CT is variable and includes ill-defined areas of
lucency or low attenuation, a permeative appearance,
cortical destruction, bony sequestrum, periosteal reaction,
or sclerotic changes.48 The most commonly encountered
appearance is diffuse osseous sclerosis (Fig 15),49 but peri-
osteal reaction and bony sequestration may predominate
late in the disease process.50 The imaging differential in-
cludes chronic sclerosing osteomyelitis, osteoradionecrosis,
Figure 15 (a) Radiograph and (b) CT image demonstrate the diffuse
sclerotic appearance of bisphosphonate-induced osteonecrosis in this
patient who was receiving high-dose intravenous bisphosphonates.
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13
metastases, and Paget’s disease; biopsy can result in path-
ological fracture and should only be considered if there is a
strong suspicion of malignancy. The differentiation of
osteonecrosis from sclerosing osteomyelitis can be difficult
both clinically and histologically, and both will often co-
exist; therefore, management will often be dictated based
on clinical grounds.48,50
As the imaging findings at CT, MRI, and scintigraphy are
generally non-specific,48,49 the primary role of imaging is to
demonstrate the extent of disease prior to any surgical
intervention and to assess for any complications such as
pathological fracture.
Fibrous dysplasia
Fibrous dysplasia of the mandible will present with the
same clinical and radiographic appearances as elsewhere in
the body. Fibrous dysplasia will typically appear as homo-
geneously dense, expanded bone that results in the typical
“ground-glass appearance” (Fig 16). However, similar to
elsewhere in the body, it can also appear as a radiolucent
Figure 16 (a) Radiograph demonstrates subtle increased density in
the right body of the mandible (open arrows). (b) CT demonstrates
expansion of the bone and a “ground-glass” type matrix (open ar-
rows). The abnormality was confirmed as fibrous dysplasia.
14 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16
lesion. It seldom progresses beyond the third decade and
symptoms usually relate to deformity or mass effect.
Fibrous dysplasia may result in superior or inferior
displacement of the mandibular canal. Some authors have
suggested that upward displacement of the mandibular
canal is pathognomic of fibrous dysplasia.51,52 Cherubism
was previous thought to be a form of polyostotic fibrous
dysplasia of the mandible, but is now considered a distinct
entity.53e55
Paget’s disease
The radiographic appearances of Paget’s disease will
vary with the stage of disease activity. In the later stages of
disease, it will appear as thickened, expanded, and scle-
rotic bone. It is more common in the maxilla than the
mandible.2
Mixed radiolucenteradio-opaque lesions of
the mandible
Mixed density lesions of the mandible can occur for a
number of reasons including: the presence of two or more
tissues with differing radiographic densities, varying de-
grees of inflammatory soft tissue within a lesion, or local-
ised resorption of bone from within a lesion.
A number of the radiolucent and radio-opaque lesions
and processes already discussed can have variable appear-
ances and will often fall within this category (Table 4).
These include malignant/metastatic lesions, osteomyelitis,
osteonecrosis, osteoradionecrosis, Paget’s disease, and
fibrous dysplasia. Cementomas may also appear mixed in
their early stages. Other lesions that result in a mixed
appearance include the cemental dysplasias and immature
fibro-osseous lesions.
Table 4
Differential diagnosis of a mixed radiolucent-radio-opaque
lesion of the mandible.
FOCAL
Calcifying epithelial odontogenic tumour (Pindborg
tumour)
Cemento-ossifying fibroma
Adenomatoid odontogenic tumour
Calcifying cystic odontogenic tumour
Periapical cemental dysplasia
Desmoplastic ameloblastoma
Intermediate stage cementoblastoma
Haemangioma
DIFFUSE
Osteomyelitis
Osteonecrosis
Osteoradionecrosis
Florid cemental dysplasia
Fibrous dysplasia
Paget’s disease
Ewing’s sarcoma
Lymphoma
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Calcifying epithelial odontogenic tumour (Pindborg
tumour)
These are composed of islands of epithelial odontogenic
cells with small calcified bodies, within a fibrous stroma.
The mean age at diagnosis is 40 years. About half of the
lesions are associated with the crown of an impacted tooth.2
The tumour will appear as a radiolucent mass with scat-
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
behaviour of the lesion. The internal scattered calcifications
will often differentiate it from ameloblastomas.
Cemental dyplasias
Periapical cemental dysplasia always occurs at the root of
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
are often multifocal. Radiographic appearances depend on
the stage of disease: early lesions appear as well-
circumscribed radiolucencies at the root of a tooth. As
they progress, they appear as mixed radiolucent/radio-
opaque lesions and finally mature lesions will appear as a
mineralised radio-opaque mass surrounded by a narrow
radiolucent halo.2,3 A diffuse form of the condition is known
as florid cemental dysplasia. The diagnosis is usually ob-
tained with plain film and occasionally CT; other imaging
methods are usually not helpful.2
Cemento-ossifying fibromas
Cemento-ossifying fibromas are benign lesions
comprising of fibrous tissue and varying amounts of tra-
beculated bone. As the lesions mature, they become more
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
more aggressive form in children younger than 15 is known
as a juvenile ossifying fibroma. It is more commonly found
in the maxilla.2
Adenomatoid odontogenic tumour
A rare benign lesion that typically occurs in the second
decade. It is more common in girls, and approximately
twice as common in the maxilla as the mandible. Typically
the lesion involves the crown of an unerupted tooth; thus
mimicking a dentigerous cyst. The lesions appear as well-
circumscribed radiolucencies with varying amounts of
punctate calcifications. They are slow growing and can
either displace or prevent the eruption of teeth.
Calcifying cystic odontogenic tumour (Gorlin cyst)
This is a rare odontogenic tumour comprised of both
solid and cystic elements; it can occur at any age. Radio-
graphically, it will appear as a uni- or multilocular lucent
lesion with well-defined margins, containing scattered
 M. Harmon et al. / Clinical Radiology xxx (2014) 1e16
Table 5
Lesions that may be associated with the crown of a
tooth.
RADIOLUCENT
Dentigerous cysts
Odontogenic keratocysts
Ameloblastoma
RADIO-OPAQUE
Odontoma
Ameloblastic fibro-odontoma
MIXED RADIOLUCENT-RADIO-OPAQUE
Adenomatoid odontogenic tumour
Calcifying epithelial odontogenic tumour
Calcifying cystic odontogenic tumour
calcifications of varying irregular sizes; this may result in a
“salt and pepper” appearance to the lesion.2 Appearances
are similar to other focal mixed radiolucenteradio-opaque
lesions such as adenomatoid odontogenic tumours, ame-
loblastic fibro-odontomas, and calcifying epithelial odon-
togenic tumours (Pindborg).
Conclusion
Despite the broad spectrum of pathological processes
that affect the mandible, there is considerable overlap in
their imaging appearance and biopsy is often required to
make the final diagnosis. Thus, similar to bony disease
elsewhere in the body, the combination of clinical history,
patient demographics, location of the lesion within the
bone, relationship to a tooth (Table 5), and imaging ap-
pearances should enable the radiologist to provide a short,
reasonable differential diagnosis rather than definitively
making the diagnosis. CT and MRI are useful adjuncts for
some lesions, but overall the role of more complex imaging
investigations usually lies in assessing the extent of disease
when surgical planning is being considered.
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