DENTAL ANOMALIES

Number of Teeth
Supernumerary Teeth
o Develop in addition to the normal complement as a result of excess dental lamina
in the jaws
o Single: anterior maxilla and maxillary molar region
o Multiple: premolar regions
Missing Teeth
o Hypodontia
o Oligodontia
o Anodontia
o Most commonly missing teeth: third molars -> second premolars -> maxillary
lateral -> mandibular central incisors
Size of Teeth
Macrodontia
o Teeth are larger than normal
o Hemangioma - can result in increase in the size and accelerate the development
of adjacent teeth
Microdontia
o Teeth are smaller than normal
o Often the lateral incisors and third molars may be small
o Supernumerary teeth may also be microdonts
Eruption of Teeth
Transposition
o Two typically adjacent teeth have exchanged positions in the dental arch
o Most frequently: permanent canine and first premolar
Altered Morphology of Teeth
Fusion
o Union of adjacent tooth germs of developing teeth
o The crowns of the fused teeth appear to be large and single
Gemination
o “Twinning”
o Rare anomaly that arises when a single tooth bud attempts to divide
o Cause is unknown
o Frequently affects the primary teeth (usually incisor region)
Concrescence
o Roots of two or more primary or permanent teeth are fused by cementum
o result of traumatic injury or crowding of teeth with resorption of interdental bone
o Frequently involved: maxillary molars (third molar and supernumerary tooth)
o True concrescence – during the development
o Acquired concrescence – occurs later
Taurodontism
o Appears elongated and the roots short
o May occur in any tooth in either the permanent or primary dentition
Dilaceration
 o Disturbance in tooth formation that produces a sharp bend or curve in the tooth
anywhere in the crown or the root
Dens Invaginatus, Dens in Dente & Dilated Odontome
o “Tooth within a tooth ”
o Result from varying degrees of invagination or infolding of the enamel surface
into the interior of a tooth
o Less severe: dens invaginatus
o Most severe: dilated odontome
o Can occur in either the cingulum area (dens invaginatus) or incisal edge (dens in
dente) of the crown or in the root during tooth development
Dense Evaginatus
o “Leong’s premolar”
o Result of an outpouching of the enamel organ
o Appears as a tubercle of enamel on the occlusal surface of the affected tooth
AMELOGENESIS IMPERFECTA
• Genetic anomaly arising from mutations
• Leads to marked changes in enamel
- Lack of normal prismatic structure
- Laminated thickness or at periphery
• Dentin and root form: normal
• Eruption of affected teeth: delayed, tendency for tooth impaction

Four General types:

1. Hypoplastic type
• Enamel of affected teeth:
- Fails to develop normal thickness
- Maybe abnormal: rough, pitted, smooth, or glossy
• Dentin
- Imparts a yellowish-brown color to tooth
• Crown
- Undersized
- Roughly square shape
• Posterior tooth (occlusal surface)
- Flat with low cusps

2. Hypomaturation type
• Enamel:
- Mottled appearance
- Normal thickness
- Softer than normal
- Color: clear to cloudy white,yellow, or brown
• “snow-capped” teeth
- Teeth capped with white, opaque enamel

3. Hypocalcified type
 • More common than hypoplastic
• Enamel
- Poorly mineralized (less dense than dentin)
- Stained and darkened
• Crown
- Normal size and shape
- Soft enamel :abrades rapidly
- Softer dentin: wears down rapidly
• Young person: dark brown from food strain

4. Hypomaturation/hypocalcification type associated with taurodontism

• Combinations of hypomaturation and hypocalcification
• Involves both permanent and deciduous dentition
• HYPOMATURATION-HYPOCACIFICATION
– If the dominant defect is hypomaturation
– Enamel
• mottled and discolored( yellow to brown)
• Same radiopacity as dentin
• HYPOCALCIFICATION-HYPOMATURATION
– If the dominant defect is hypocalcification
– Enamel
• thin

RADIOGRAPHIC FEATURES
• Hypoplastic form
– Square crown
– Thin radiopaque layer of enamel
– Low or absent cusp
– Multiple contacts between teeth
– Anterior teeth:
 “picket fence” type of appearance
– Normal enamel density
• Hypomaturation form
– Normal thickness of enamel but of same density with dentin
• Hypocalcified form
– Normal thickness of enamel but the density is more radiolucent than dentin

DIFFERENTIAL DIAGNOSIS
• Presence of:
– Advance abrasion
– If the secondary dentin obliterates the pulp chambers appears similar
dentinogenesis imperfacta

MANAGEMENT
• Restoration of esthetics and function
DENTINOGENESIS IMPERFECTA
• Synonym: Hereditary opalescent dentin
• Definition
– genetic anomaly involving primarily the dentin
– Enamel thinner than normal
• Three types:
– Type I
 Associated with osteogenesis imperfecta
 Caused by mutations of one of two genes involved in synthesis of
collagen type I
 Roots and pulp chambers
 Small and underdeveloped
 Primary dentition more severely affected that permanent dentition

– Type II
 Similar to type I but only affects dentin without any skeletal defects
 Enlarged pulp chambers in primary teeth

– Type III
 So-called Brandywine isolate
 Exhibit enlarged pulp chambers
 More susceptible to pulp exposure
 Type II & III
 Associated with mutations of dentin dialophosphoprotein
(DSPP) gene
 Occurs with equal frequency in both sexes
 Both in deciduous and permanent dentition

CLINICAL FEATURES
• High degree of amber-like translucency
• variety of colors: yellow to blue-gray
• Enamel easily fractures
• Crown wear readily
• In adults,
– Teeth frequently wear down to gingiva
– Exposed dentin becomes stained
– Abraded teeth: dark brown to black
• Some patient demonstrate an anterior open bite

RADIOGRAPHIC FEATURES
• Crown
– Normal size
– Constriction of cervical portion
– Slight to marked attrition at occlusal surface
 • Roots
– Short and slender
• Partial or complete obliteration of pulp chambers
• Root canals: absent or threadlike

DIFFERENTIAL DIAGNOSIS
• Dentin dysplasia

MANAGEMENT
• Teeth should not be extracted from patients 5 to 15 years of age
• Place full overdentures on teeth
– Prevent alveolar resorption
• In adults
– Extraction of teeth and replacement can be recommended

OSTEOGENESIS IMPERFECTA
• Hereditary disorder characterized by osseus fractures
• Pathogenesis:
– Inborn error in synthesis of type 1 collagen which results in brittle bones
• Transmitted as autosomal dominant trait
• Patient may have:
– Blue sclera
– Wormian bones
– Skeletal deformities
– Progressive osteopenia
• May include:
– class III malocclusions
– Increased incidence of impacted first and second molar

DENTIN DYSPLASIA
 Genetically inherited autosomal-dominant abnormality
 Resembles dentinogenesis imperfect
 Two types:
1. TYPE 1 (RADICULAR)
- Most changes found in roots
2. TYPE 2 (CORONAL)
- Most changes found in crown
- DSPP gene
 Rarer than dentinogenesis imperfect

CLINICAL FEATURES
• Type 1
- Normal color and shape
- Slight bluish-brown is apparent
- Often misaligned in the arch
 - Drifting and spontaneous exfoliation with little or no trauma
• Type 2
- Crowns
 Primary teeth
 Same color,size, and contour with dentinogenesis imperfect
 Permanent teeth
 Normal

RADIOGRAPHIC FEATURES
• Type 1
- Roots
 Both (primary and permanent teeth)
 Short or abnormally shaped
 Molar roots have a shallow “W” shape
 Primary teeth
 Thin spicules
- Pulp chambers & root canals
 Completely fill in before eruption
- 20% associated with osteitis
• Type 2
- Obliteration of pulp chamber and reduction in caliber of root canals occur
after eruption
- Pulp chambers
 Flamed or thistle shaped
 Multiple stones
 Anterior teeth and premolars = thistle shaped
- Roots
 Normal in shape and proportions

DIFFERENTIAL DIAGNOSIS
• Dentinogenesis imperfect

MANAGEMENT
• Type 1
- Prosthetic replacement
• Type 2
- Crowned
- Prosthetic treatment

REGIONAL ODONTODYSPLASIA
• Synonym: ODONTOGENESIS IMPERFECTA & GHOST TEETH
• Rare condition
• Both enamel and dentin are hypoplastic and hypocalcified
• Affects few adjacent teeth in a quadrant
• Primary teeth affected= successors involved
CLINICAL FEATURES
• Small and mottled brown
• Susceptible to caries
• Brittle
• Subject to fracture and pulpal infection
• Central incisors
- Most often affected
• Lateral incisors and canine
- Occasionally shows defect (maxilla)
• Eruption
- Delayed or may not erupt

RADIOGRAPHIC FEATURES
• “ghostlike” appearance
• Pulp chambers
- Large
• Root canals
- Wide
• Root
- Short
• Enamel
- Thin and less dense

DIFFERENTIAL DIAGNOSIS
• Dentinogenesis imperfect

MANAGEMENT
• Retain and restore
• Unerupted teeth
- Retained
• Severely damaged permanent teeth
- Removal and replacement
ENAMEL PEARL
• Synonyms: ENAMEL DROP. ENAMEL NODULE, & ENAMELOMA
• Small globule of enamel (1 to 3mm in diameter)
• Occurs on roots of molars
• Found in 3% of population
• Formed by Hertwig’s epithelial root sheath
• Pulp horn extending from chamber of host tooth

CLINICAL FEATURES
• Formed below crest of gingiva
• Not detected during clinical examination
• Develop in furcal areas of molar teeth
• Maxillary molars
- In mesial or distal furca
 • Mandibular molars
- Buccal or lingual furca
• May predispose to:
- Periodontal pocket formation
- Subsequent periodontal disease
RADIOGRAPHIC FEATURES
• Smooth and round
• Small, round, radiolucent shadow

DIFFERENTIAL DIAGNOSIS
• Calculus or pulp stone

MANAGEMENT
• Removal of mass

TALON CUSP
• Anomalous hyperplasia of cingulum of maxillary or mandibular incisor
• Results in formation of supernumerary cusp

CLINICAL FEATURES
• Found in either sex
• Both primary and permanent incisors
• Varies in size
- Prominent cingulum
- Cusp-like structure
• Incisors bearing T-shaped
• Increased in teeth related to cleft palate syndromes

RADIOGRAPHIC FEATURES
• Radiopaque superimposed on crown
• Outline: smooth
• Enamel : normal
• Doesn’t reveal pulp horn
• Cusp: apparent
• Presence of supernumerary tooth

DIFFERENTIAL DIAGNOSIS
• Distinctive

MANAGEMENT
• Treatment

TURNER’S HYPOPLASIA
 • Synonym: Turner’s tooth
• Permanent tooth with local hypoplastic defect in its crown
• Caused by extension of periapical infections

CLINICAL FEATURES
• most often affects mandibular premolars
• hypomineralized area: stained
• hypoplasia: crown shows pitting or more pronounced defect

DIFFERENTIAL DIAGNOSIS
• deformation of tooth crown
MANAGEMENT
• restoration
INFLAMMATORY LESIONS OF THE JAWS
 Necrotic pulp and bony lesion is restricted to region of tooth- PERIAPICAL
INFLAMMATORY LESION
 Bone marrow and no longer contained to vicinity of tooth root apex-
OSTEOMYELITIS
 Extension of inflammation into bone from overlying soft tissue- PERIODONTAL
LESION
 Arises in tissues surrounding the crown of partially erupted tooth-
PERICORONITIS

GENERAL CLINICAL FEATURES

ACUTE LESIONS
 Recent onset
 Rapid onset
 Pronounced pan
 Fever and swelling
CHRONIC LESIONS
 Prolonged course
 Longer insidious onset
 Pain, less intense
 Fever
 Swelling
GENERAL PATHOLOGIC FEATURES
• LOCATION
 PERIAPICAL INFLAMMATORY LESIONS
 Epicenter- apex of a tooth
 Lesions of pulpal origin- Anywhere along root surface
 PERIODONTAL LESIONS
 Epicenter- alveolar crest
 If severe- bone inflammatory changes may extend to root furcation level or root
apex
 OSTEOMYELITIS
 Uncontained inflammation of bone
  Posterior mandible
 Maxilla- rarely

• PERIPHERY
 Well defined
 Gradual blending of normal trabecular pattern into sclerotic pattern
 Normal trabecular pattern- radiolucent region
• INTERNAL STRUCTURES
 CANCELLOUS BONE
 tipping the bone metabolic balance:
- Favor of resorption (radiolucent appearance)
- Toward bone formation (radiopaque or sclerotic appearance)
 Radiolucent region- no evidence of previous trabeculation
 ↑Radiopacity- ↑ bone formation on existing trabeculae
• EFFECTS ON SURROUNDING STRUCTURES
- Stimulation of bone formation
- Sclerotic pattern
- Bone resorption
- Radiolucency
- Periodontal ligament space: widened
• Chronic infection- root resorption may occur & cortical boundaries, resorbed
• PERIOSTEUM: layer potential lining cells
- differentiate into osteoblasts and lay down new bone
PERIAPICAL INFLAMMATORY LESIONS
• SYNONYMS:
- ACUTE APICAL PERIODONTITIS
- CHRONIC APICAL PERIODONTITIS
- PERIAPICAL ABSCESS
- PERIAPICAL GRANULOMA
• Radiolucent presentation- RAREFYING OSTEITIS
• Radiopaque presentation- SCLEROSING OSTEITIS, CONDESING OSTEITIS,
FOCAL SCLEROSING OSTEITIS
• Local response of bone around apex of tooth: - necrosis of pulp
- destruction of periapical tissues by extensive periodontal disease
• Pulpal necrosis- pulpal invasion of bacteria through caries or trauma
• CLINICAL FEATURES:
- Asymptomatic
- occasional toothache
- Severe pain
- w/ or w/o facial swelling
- Fever and lymphadenopathy

 Periapical abscess:
- Severe pain
- Mobility
 - Elevation of involved tooth
- Swelling
- Tenderness to percussion
 Dental abscess-Systemic
- Fever
- Facial swelling
- Lymphadenopathy
- Pain

• RADIOGRAPHIC FEATURES
 More chronic lesions:
- lytic(radiolucent)
- Sclerotic ( radiopaque) changes
- Both
• LOCATION
- epicenter: apex of involved tooth
- Lesion: within apical portion of PDLS

• PERIPHERY
- Ill defined
- Gradual transition from surrounding normal trabecular pattern into abnormal
bone pattern of lesion
• INTERNAL STRUCTURE
- Loss of bone density: widening of PDLS at apex of tooth
- At this early stage: no evidence of sclerotic bone reaction
- Later in evolution of disease: mixture of sclerosis and rarefaction of normal bone
occurs.
- ↑bone formation: PERIAPICAL SCLEROSIS OSTEITIS
- Bone resorption: PERIAPICAL RAREFYING OSTEITIS
DIFFERENTIAL DIAGNOSIS
• Two types of lesion:
- PERIAPICAL CEMENTAL DYSPLASIA (PCD)
- ENOSTOSIS ( dense bone island, osteosclerosis) at apex of tooth
• Early radiolucent phase of PCD, radiographic characteristics may not reliably
differentiate this lesion from a periapical inflammatory lesion
PERIAPICAL INFLAMMATORY LESIONS
• Management
- Root canal therapy
- Extraction with intention of eliminating the necrotic material in root canal & hence
the source of inflammation.
• Untreated
- Asymptomatic : drainage established through carious lesion or parulis.
- Lesion will spread: OSTEOMYELITIS> CELLULITIS
PERICORONITIS
• SYNONYM:
 OPERCULITIS
 - pericoronitis- inflammation of the tissues surrounding the crown of a partially
erupted tooth.
- Mand. 3rd molars in young adults
- Gingiva erupted portion of crown: inflamed
- Gingiva: swollen and secondary traumatized by opposing occlusion
- Inflammation may extend: bone, sorrounding crown of tooth
• Clinical features:
- Pain
- Swelling
- Trismus: common in lower 3rd molar
- Pain is felt on occlusion
- Ulcerated operculum: pain
- Eruption of 3rd molars in young adult: commonly seen
• Radiographic features:
- No changes when inflammatory lesion is confined to soft tissues to localized
rarefaction and sclerosis to osteomyeilitis in severe cases.
• Location:
- Centered on follicular space or portion of crown
- Mand 3rd molar : most common
• Periphery:
- Ill defined
- Gradual transition of normal trabeculae pattern> sclerotic region
• Internal structure:
- sclerotic with thick trabeculae
- Area of bone loss or radiolucency adjacent to crown(enlarges follicular space)
may be seen
- If lesion spreads> osteomyeilitis
• Effects on surrounding structures:
- Typical changes of sclerosis
- Rarefaction of surrounding bone
- Extensive cases: periosteal new bone formation> inferior cortex, post. Border of
ramus, coronoid notch of mand.
• Differential diagnosis:
- Mixed density or sclerotic lesions of partially erupted 3rd molar
- Enostosis and fibrous dysplasia
- Neoplasm
- Sclerotic form of osteosarcoma
- Squamous cell carcinoma
• Management:
- Antibiotic therapy
- Reduction in occlusion of opposing tooth
OSTEOMYEILITIS
• Inflammation of bone
• Inflammatory process:
- Bone: bone marrow
- Cortex: cancellous portion
 - Periosteum
• Bacteria and their products: inflammatory reaction in bone> destruction of
endosteal surface of cortical bone.
Other forms:
• Garre’s osteomyeilitis
- Exuberant periosteal response to inflammation
• Diffuse sclerosing osteomyeilitis
- Chronic form of osteomyeilitis with pronounced sclerotic response
• ACUTE PHASE
(SYNONYM:)
- ACUTE SUPPURATIVE OSTEOMYEILITIS
- PYOGENIC OSTEOMYEILITIS
- SUBACUTE SUPPURATIVE OSTEOMYEILITIS
- GARRES OSTEOMYEILITIS
- PROLIFERATIVE PERIOSTITIS
- PERIOSTITIS OSSIFICANS
- Caused by Infection that has spread to the bone marrow
- Jaws: Periapical lesion- common source of infection
• Clinical features:
- Strong male predilection
- mandible
• Signs and symptoms:
- Rapid onset
- Pain
- Swelling of adjacent soft tissues
- Fever
- Lymphadenopathy
- Leukocytosis
- Associated teeth: mobile and sensitive to percussion
- Purulent drainage
- Paresthesia of lower lip: 3rd division of 5th CN distribution: not uncommon
• Radiographic examination:
- A two phase nuclear medicine study composed of a technetium bone scan
followed by a gallium citrate scan may help to confirm diagnosis.
• Radiographic Features
- Early in disease: no radiographic changes
- Bone: inflammatory exudate & inflammatory cells> no radiographic change
• Location:
- Posterior body of mandible
- Maxilla: rare site
• Periphery:
- Ill defined periphery with gradual transition to normal trabeculae
• Internal structure:
- Slight ↓in density of involved bone
- Loss of sharpness of existing trabeculae
• Effects on surrounding structures:
 - Bone resorption or bone formation
- Crotical bone: resorbed
- Inflammatory exudate: lift periosteum & stimulate bone formation
- Radiographically: thin, faint, radiopaque line
- Effects on teeth and lamina dura: the same in periapical inflammatory lesions
• Differential diagnosis:
- fibrous dysplasia: children
- enlargement of bone
• Management:
- Antimicrobial treatment
CHRONIC PHASE
(SYNONYM)
• CHRONIC DIFFUSE SCLEROSING OSTEOMYEILITIS
• CHRONIC NONSUPPURATIVE OSTEOMYEILITIS
• CHRONIC OSTEOMYEILITIS WITH PROLIFERATIVE PERIOSTITIS
• GARRE’S CHRONIC NONSUPPURATIVE SCLEROSING OSTEITIS
- A sequela of inadequately treated acute osteomyeilitis
- Diffuse sclerosing osteomyeilitis refers to chronic osteomyeilitis: balance in bone
metabolism is tipped toward ↑bone formation
• Symptoms:
- Less severe
- Swelling
- Pain
- Fever
- Lymphadenopathy
• Chronic osteomyeilitis is similar to bone lesion in chronic recurrent multifocal
osteomyeilitis (CRMO) and syndrome acne hyperostosis and osteitis
• CRMO- condition often occurs symmetrically in long bones in children
• Radiographic examination:
- CT
- Bone scan: ↑bone formation
• Radiographic features:
 Location: posterior mandible
 Periphery: grudual transiton is seen between normal surrounding trabecular
pattern
- Disease active: radiolucent and poorly defined borders
• Internal structures:
- Greater and lesser radiopacity compared with surrounding normal bone
- Lesions: more radiopaque / sclerotic bone pattern.
• Differential diagnosis:
- presence of sequestra indicates osteomyeilitis
- Paget’s disease affects the entire mandible: rare in osteomyeilitis
• Management:
- hyperbaric oxygen therapy
- Long-term antibiotic therapy
- Bisphosphonate therapy
Diagnostic Imaging of Soft Tissue Infections
• MRI and CT may be used to differentiate soft tissue neoplasia from inflammatory
lesions.
• MRI – used in T1 and T2 with gadolinium and fat suppression modes
• CT- usually used with intravenous contrast.
Presence of soft tissue inflammation:
 Abnormal facial planes
 Thickening of the overlying skin and adjacent muscles
 Streaking of the fat planes
 Abnormal collections of gas in soft tissue

 Radiation induced changes to bone

• Therapeutic radiation damages the cellular elements of bone tissue by immediate
or delayed cell death, cellular injury with recovery, arrested cellular division, or
abnormal repair with neoplasia.
• Maturity and type of bone & dose of radiation – factors that affect how the bone
responds to this injury
• When immature is irradiated, growth retardation occurs
• As with osteomyelitis, there is a spectrum of radiographic appearances of
radiation damage to bone.
• From sclerosis with patchy radiolucency to osteoradionecrosis.
• Diagnosed as exposed bone sequestrum in the oral cavity
OSTEORADIONECROSIS
Definition
• Refers to an inflammatory condition of bone (osteomyelitis) that occurs after the
bone has been exposed to therapeutic doses of radiation usually given for a
malignancy of the head and neck region.
• It is characterized by the presence of exposed bone for a period of at least
3months occurring at any time after the delivery of the radiation therapy.
Clinical feature:
• The mandible is much more commonly affected than the maxilla is.
• Loss of mucosal covering and exposure of bone is the hallmark of
osteoradionecrosis.
• The exposed bones become necrotic as a result of loss of vascularity from the
periosteum and subsequently sequestrates, often leading to exposure of more
bone.
Radiographic features:
Often have similarities to chronic osteomyelitis
• Location: The mandible, especially the posterior mandible
• Periphery: ill-defined and similar to that in osteomyelitis.
• Internal structure: A range of bone formation to bone destruction occurs, often
with the balance heavily toward more bone formation, giving the affected bone an
overall sclerotic or radiopaque appearance.
• Effects on Surrounding Structures:
- Most common effect is the stimulation of sclerosis.
- In the alveolar process of the maxilla and mandible, there may be irregular widening
of the periodontal membrance space
- Bone resorption
Differential Diagnosis:
• Bone resorption, stimulated by high levels of irradiation, may stimulate bone
destruction from a malignant neoplasm, especially the maxilla.
MANAGEMENT:
Decortication with sequestrectomy and hyperbaric oxygen with antibiotics have been
used

BISPHOSPHATE-RELATED OSTEONECROSIS OF THE JAWS

Definition:
• Bisphosphates are potent synthetic analogs of pyrophosphates that act to inhibit
osteoclasts and reduce bone metabolism.
• Important in the treatment of bone lesions of multiple myeloma, hypercalcemia of
malignancy, metastatic bone tumors and osteoporosis.
Clinical feature:
• Denture trauma and spontaneous cases have been known and occur.
• The most common areas affected are the posterior mandible (60%) and maxilla
(40%) and both (90%)
• The areas may be asymptomatic or present with pain and swelling.
Radiographic features:
• More often than not, there are no specific radiographic findings with the clinically
exposed bone.
• Other reported findings: bone, widening if the periodontal membrane space, and
thickening of the lamina dura.
MANAGEMENT:
• Treatment is not satisfactory
• Surgical intervention and hyperbaric oxygen therapy have not been consistently
successful.

CHAPTER 21: CYSTS, AND CYSTLIKE LESIONS OF THE JAWS

 Introduction
A cyst is a pathologic cavity filled with fluid, lined by epithelium, and surrounded by a
definitive connective tissue wall. The cystic fluid either is secreted by the cells lining the
cavity or derives from the surrounding tissue fluid.
 CLINICAL FEATURES:
-Occurs more often in the jaws than in any other bon
- Radiolucent, swelling, lacking of pain, in association with unerupted teeth.

 Radiographic features
 Location:
May occur centrally in any location in the maxilla or mandible but rare in the condyle
and coronoid process; found most often in the tooth bearing region
• Periphery:
 - Those that originate in the bone usually have a periphery that is well defined and
corticated.
- However, a secondary infection or a chronic state can change this appearance ->
thicker, more sclerotic boundary or less apparent cortex
• Shape:
- Round or oval, resembling a fluid-filled balloon
• Internal Structures:
- Totally radiolucent
- However, long standing cysts may have a dystrophic calcification, which can give
the internal aspect a sparse, particulate appearance.
• Effects on Surrounding Structure:
-Cysts can grow slowly, sometimes causing displacement and resorption of teeth.
-Can expand the mandible, in a smooth, curved manner

 ODONTOGENIC CYSTS
RADICULAR CYST
• Synonyms: Periapical cyst
• Definition:
- Is a cyst that most likely results when rests of epithelial cells in the periodontal
ligament are stimulated to proliferate and undergo cystic degeneration by
inflammatory products from a nonvital tooth.
• Clinical features:
- Most common type of cyst in the jaws
- Arises from nonvital teeth
- Often produces no symptoms
- Large -> swelling
• Radiographic features
Location:
Epicenter is located approximately at the apex of a nonvital tooth.
- At the mesial or distal surface of a tooth root, opening of an accessory canal, or
infrequently in a deep periodontal pocket.
- 60% are found in the maxilla
Periphery and Shape: Usually has a well-defined cortical border
- If it becomes secondarily infected, inflammatory reaction may result in the loss of
this cortex
Internal structure: Radiolucent
Effects on surrounding tooth structures: If cyst is large, displacement and
resorption of the roots of adjacent teeth may occur.
• Differential Diagnosis:
- Differentiation of a small radicular cyst from an apical granuloma may be difficult
and in some cases impossible.
• Management:
- Extraction, endodontic therapy, and apical surgery
- Large radicular cyst -> surgical removal or marsupialization

RESIDUAL CYST
• Definition: Is a cyst that remains after incomplete removal of the original cyst.
• Clinical features: Is asymptomatic and often is discovered on radiographic
examination of an edentulous area. However, there may be some expansion of the
jaw or pain in the case of secondary infection.
• Radiographic Features:
Location: Occurs in both jaws, although they are found slightly more often in the
mandible.
Periphery and Shape: Has a cortical margin unless it becomes secondarily infected.
Oval or circular in shape.
Internal Structure: Radiolucent
Effect on surrounding Structures: Can cause tooth displacement or resorption
• Differential Diagnosis:
- Difficulty in determining whether a solitary cyst (odontogenic keratocyst) in the jaws
is a residual cyst.
• Management:
- Surgical removal or marsupialization or both if the cyst is large

DENTIGEROUS CYST
• Synonym: Follicular Cyst
• Definition: Is a cyst that forms around the crown of an unerupted tooth. It begins
when fluid accumulates in the layers of reduced enamel epithelium or between the
epithelium and the crown of the unerupted tooth.
• Clinical features: Second most common type of cyst in the jaws
- Missing tooth or teeth and possibly a hard swelling, occasionnaly resulting in facial
asymmetry.
- Patient has no pain or discomfort.
- 5% of this cyst is around supernumerary teeth
• Radiographic features:
Location: Epicenter is found just above the crown of the involved tooth. Most
commonly the mandibular or maxillary third molar or the maxillary canine.
- Attaches at the CEJ
Periphery and Shape: Well-defined cortex with a curved or circular outline. Cortex is
missing if infection is present.
Internal structure: Completely radiolucent except for the crown of the involved teeth.
Effects on Surrounding Structures: Has a propensity to distort and resorb adjacent
teeth.
- Commonly displaces the associated tooth in an apical direction.
• Differential Diagnosis:
- Because the histopathologic appearance of the lining epithelium is not specific, the
diagnosis relies on the radiographic and surgical observation of the attachment of
the cyst to the CEJ.
• Management:
- Surgical removal
- Marsupialization before removal

BUCCAL BIFURCATION CYST

• Synonym: Mandibular infected buccal cyst, paradental cyst, inflammatory
paradental cyst
• Definition: The source of epithelium probably is the epithelial cell rests in the
periodontal membrane of the buccal bifurcation of mandibular molars.
• Clinical features: Lack of or delay in eruption of a mandibular first or second molar
- The first molar is involved more frequently
• Radiographic Features:
Location: Most common location is the mandibular first molar, followed by the second
molar; bilateral cyst.
- In the buccal bifurcation of the affected molar
Periphery and shape: Periphery is not readily apparent, and the lesion may be a very
subtle radiolucent region superimposed over the image of the roots of the molar.
Internal structures: Radiolucent
Effects on Surrounding Structures: Tipping of the involved molar so that the root tips
are pushed into the lingual cortical plate of the mandible.
• Differential diagnosis:
Lesions that could elicit an inflammatory periosteal response on the buccal aspect of
mandibular molars, such as a periodontal abscess or Langerhan’s cell histiocytosis.
• Management:
- Conservative cutterage, although some cases have resolved without intervention.
BBCs do not recur.
Odontogenic Keratocyst (Keratocyst, Keratinizing Cyst)
 This is a non- inflammatory odontogenic cyst that arises from the dental lamina.
 It is lined by keratinizing epithelium
 it is usually located in the mandible (posterior body and ramus region).
 most develop during the second and third decade.
 It can become very large. It extends along the body of the mandible causing
minimal mediolateral expansion.
 Unilocular (often with scalloped margins) or multilocular. (more often in larger
lesions)
 Smooth margins, well-defined, often well-corticated.
 Tendency for recurrence after inadequate surgery. Adjacent teeth: vital, rarely
resorbed.
Lateral Periodontal Cyst
 Lateral Periodontal Cyst are thought to arise from Epithelial rests in
periodontum lateral to the tooth root.
 —It is a developmental odontogenic cyst.
 It arises from remnants of the dental lamina or from the reduced enamel
epithelium.
 —Common site: Along the lateral surface of the root of vital tooth. Usually in
mandibular premolar/canine region.
 —Usually asymptomatic.

—
 Small size (less than 1 cm in diameter).
—
 Unilocular, round or oval, well-defined, usually well corticated radiolucency.
 —
 Clinical features:
—
 Age: 9-90 years.
—
 Sex: M=F
—
 Site: Anterior part of jaws.
—
 On inspection: Solitary swelling, anterior to molars with the color same as
adjacent gingiva, shape is roughly oval of variable size, surface over the
swelling may be smooth.
 —On palpation: Non-tender, hard on palpation (eggshell crackling or soft) buccal
and lingual expansion, perforate the cortical plate and extend into the soft
tissues.
 —Displacement of the teeth has been described.

Radiographic features:
 —Nature: Radiolucent and radiopaque.
 —Site: Anterior part of jaws.
 —Shape: Oval or round.
 —Number: Solitary.
 —Outline: May be regular in few and in few other
irregular.
 —Border: Well defined.
 —Contents: radiopacities within radiolucency.
—
TREATMENT
 —Surgical enucleation

Nasopalatine duct cyst

 —Synonyms: Median anterior maxillary cyst, incisive canal cyst.
 —Most common type of maxillary developmental cyst.
 —Develop from remnant of the Nasopalatine duct
* Palpation: Tender or non-tender fluctuant swelling and in some cases through and
through fluctuation may be elicited between labial and palatal swellings.
Clinical features:
—
Age: 4th to 6th decades of life.
—
Sex: Male to female ratio 3:1.
—
Site: Maxillary anterior region. Posterior to palatine papilla.
—
Symptoms:
 Asymptomatic swelling (dull intermittent pain).
 Burning sensation or numbness over the palatal mucosa.
 Fluid discharge form oral cavity with a salty taste (due to mucoid secretion).
 Foul taste.
—
Radiographic features:
—
Nature: radiolucent
 site-between the central incisor,
 size varies from 17 to 22 mm,
—
shape is heart shape because anterior nasal spine is seen over the superior portion
of the cyst as a radiopaque shadow
  single in number
 well defined border and regular outline.
—
Additional features: Divergence of roots of central incisors, occasionally root
resorption seen from lateral respective, the cyst may expand the labial cortex as well
as palatal cortex. Floor of the nasal fossa may be displaced in a superior direction.

Nasolabial cyst
—
Now it has been suggested that the cyst arises from the remnants of nasolacrimal
duct, or from epithelial rest in fusion line of medial nasal, lateral nasal and maxillary
processes.
—
Clinical features:
—
Age: Wide age distribution for 12-75 years with a peak frequency in the 4th and 7th
decades.
—
Sex: Female preponderance F: M=3.7:1.
—
Symptom:
 Most frequent symptom is swelling.
 Pain.
 Difficulty in nasal breathing.
 Difficulty in wearing upper denture.
 Infected cyst discharge from nose.
—
Signs: Cysts grow slowly producing a swelling of lip. They fill out the nasolabial fold,
flaring of the alae, distort the nostril and produce a swelling of the floor of the nose.
Anteriorly they form a bulge in the labial sulcus. The cysts are fluctuant on bimanual
palpation.

Dermoid Cyst
Dermoid cysts are a cystic form of a teratoma thought to be derived from trapped
embryonic cells.
—
The resulting cysts are lined with epidermis and filled with keratin or sebaceous
material (and in rare cases with bone, teeth, muscle, or hair, in which case they are
properly called teratomas.

—
Clinical features:
—
1) Age: Any age Mostly 15 and 35 years
—
2) Sex: No predilection.
—
Site: floor of the mouth and sub-mental areas.
 —Slow growing or sudden in onset.
 —Lie above (tongue is displaced superiorly ) or below the mylohyoid muscle (soft
tissue in the sub-mental region is distended).
 —Non-tender
 —Size : can grow to several centimeters in diameter,
 —Color superficial- yellow to white, its surface is smooth,
and non ulcerated unless traumatized.
 —Consistency: soft to firm; it may be fluctuant and frequently is
rubbery or cheesy
 —
 Because dermoid cysts are soft tissue cysts, diagnostic imaging is best
accomplished by CT or MRI.
 —The periphery of the lesion usually is well defined by more radiopaque soft
tissue of this cyst compared with surrounding soft tissue, as seen in CT scan.
 —Dermoid cysts seldom have any internal mineralized structures when they
occur in the oral cavity
 —If teeth or bone form in the cyst, their radiopaque images, with characteristic
shapes and densities, are apparent on the radiograph

CYSTLIKE LESION
Simple bone cyst
—
Syn: Traumatic bone cyst/ extravasation cyst, progressive bone cavities/solitary bone
cyst.
—
Definition; SBC is a cavity within bone that is lined by connective tissue. It may be
empty or it may be filled with fluid.
—
Since this cyst has no epithelial lining it is called as false cyst.
—
Pathogenesis: aberration in bone remodeling or metabolism. No evidence exist to
support a traumatic cause

Chapter 22: Benign Tumors of the Jaws

What is a Benign Tumor?
• New uncoordinated growth
• Slowly growing and spread by direct extension
• NOT by metastases
• Resemble tissue origin
– Example: ameloblastoma
• Hamartoma also included in benign tumors
– Odontoma
• Hamartoma of dental tissue
• Derived from dental follicle
Clinical Features
• Insidious onset and grow slowly
• Painless
• Do not metastasize
• Can be detected by enlargement of jaws or found during radiographic
examination
Radiologic Features
LOCATION:
Radiologic Features
PERIPHERY AND SHAPE:
• Enlarge slowly
• Borders of benign tumor appear smooth, well defined, and corticated
• If tumor produces calcified product
– Central region with the most immature part of tumor
Radiologic Features
INTERNAL STRUCTURE:
• Radiolucent or radiopaque or mixture of both
If lesion contains radiopaque elements, it represents residual bone or calcified
material that is produced by tumor
Hyperplasia
• Growth formed by an increase in the number of cells of a tissue
• Reaction to a stimulus such as inflammation
• Limited growth potential
• Regress when stimuli is removed
• Have insidious onset
• Grow slowly
• Painless
• Do not metastasize
• Not life threatening
Detected by:
-enlargement of jaws
Hyperplasia
• Bony hyperplasia
– Growths of normal new bone
– Occur in characteristic locations
– Exostosis and hyperostosis
– Bony growth that occurs on the surface of normal bone
– Exostosis: a benign outgrowth of cartilaginous tissue on a bone
– Hyperostosis: an excessive growth of bone
Torus Palatinus (Palatine torus)
• Definition
– Bony protuberance (hyperostosis) that occurs in the middle third of the
midline of the hard palate
• Clinical Features
– 20% of the population
– Twice as often in women as in men
– More often in Native Americans, Eskimos, Norwegians
– Rare in children
– Base is along the central portion of hard palate
– Bulk reaches downward into oral cavity
– Size and shape can vary
– Lesions are flat, lobulated, nodular or mushroomlike
• Location
 – On maxillary periapical or panoramic
• Radiopaque shadow below and attached to hard palate
• Periphery and Shape
– Border of radiopaque shadow is well defined
– Have convex or lobulated outline
• Internal Sturcture
– Homogenously radiopaque
• Treatment
– Doesn’t usually acquire
– Maxillary denture
Torus Mandibularis (Mandibular torus)
• Definition
– Hyperostosis that protrudes from the lingual aspect of the mandibular
process
– Near premolars
• Clinical Features
– Less often on lingual surface of mandibular than on palate
– Single or multiple, unilaterally or bilaterally
– Premolar region
– Size varies
– Same sex predilection as torus palatinus
• Location
– On periapical radiographs, it appers radiopaqe shadow, superimposed on
the roots of premolars and molars
– Superimposed over about three teeth
• Periphery
– Sharply demarcated anteriorly on periapical film
• Internal Structure
– Radiopaque and homogenous
• Treatment
– Doesn’t usually acquire
– Mandibular denture
Dense Bone Island (Enostosis and Periapical idiopathic osteosclerosis)
• Internal counterparts of exostoses
• Localized growths of compact bone that develop within cancellous bone
• Clinical Features
• Asymptomatic
• Location
• More common in mandible
• Premolar-molar area
• Periphery
• well defined
• No trace of radiolucent margin
• Internal Structures
• radiopaque
• Effects on surrounding tissue
 • Mandibular first molar
• Vital
• Root resorption appears self-limiting
• Differential Diagnosis
• DBI located at root apex=periapical sclerosing osteitis
• Treatment
• Not required
Benign Tumors are separated in 2 groups:
1. Odontogenic tumors
2. Nonodontogenic tumors
Odontogenic Tumors
3 Categories:
1. Odontogenic Epithelial Tumors
2. Mixed Tumors
3. Odontogenic Ectomesenchyme
Ameloblastoma
Synonym
– Adamantinoma
– Adamantoblastoma
– Adontomes
– Embryoelastiques
– Epithelial odontoma
– Definition
– Locally invasive tumor
– Aggressive neoplasm that arises from the remnants of the dental lamina
and dental organ
– Clinical Features
– Occur in men and in blacks
– Young age (3 years old) and older than 80 years
– 20-50 years
– Swelling of the cheek, gingiva, hard palate
– Displaced and mobile
– No pain
– Location
– Molar-ramus region of mandible
– Third molar in maxilla, extend to maxillary sinus and nasal floor
– Periphery
– Well define
– Delineated with cortical border
– Internal Structure
– Totally radiolucent
– Honeycomb or soap bubble
– Loculations are larger posteriorly and smaller anteriorly

Recurrent Ameloblastoma
 • Multiple small cystlike structures with very coarse sclerotic cortical margins
• CT imaging – highly recommended
Treatment:
- Surgical resection
- Radiation theraphy

Calcifying Epithelial Odontogenic Tumor

Syn: Pinborg tumor and ameloblastoma of unusual type with calcification
• Rare neoplasm, less aggressive
• 1% of odontogenic tumors
Clinical Features:
- More common in men
- Age 8 to 92 yrs. old
- Jaw expansion
Radiographic features
• Loc: mandible, premolar-molar area with (52%) association with an unerupted or
impacted tooth
• P: well-defined cystlike cortex; some irregular or ill-defined
• IS: unilocular or multilocular, radiopaque
Treatment
-Local resection

MIXED TUMORS (OF ODONTOGENIC EPITHELIUM AND ODONTOGENIC

ECTOMESENCHYME

Odontoma
Syn: compound odontoma, compound composite odontoma, complex odontoma,
complex composite odontoma, odontogenic hamartoma, calcified, mixed odontoma
and cystic odontoma
• Most common odontogenic tumor
• Radiographically and histologically characterized by the production of mature
enamel, dentin, cementum and pulp tissue
• Probably a hamartoma
Clinical Features
- Compound odontoma – occur both in men and women
- Complex odontoma – 60% occur in women
- Age 10 to 20 yrs. Old
Radiographic Features
COMPOUND ODONTOMA
• Loc: Compound type – (62%) anterior maxilla associated with the crown of
unerupted canine
• P: well defined, smooth or irregular
• IS: largely radio opaque
Compound – toothlike structures or denticles

COMPLEX ODONTOMA
 • Loc: Complex type – mandibular 1st and 2nd molar
• P: well defined, smooth or irregular
• IS: largely radio opaque
Complex – irregular mass of calcified tissue
Treatment
- Simple excision

Ameloblastic Fibroma
Syn: soft odontoma, soft mixed odontoma, mixed odontogenic tumor,
fibroadamantoblastoma, and granular cell ameloblastic fibroma
• Benign, mixed odotogenic tumors
• Characterized by neoplastic proliferation of epithelium
Clinical features
- Completely benign, painless, slow-growing expansion and displacement of
the involved teeth
- No sex predilection
- Age 5 to 20 yrs. Old
- Swelling and occlusal pain
Radiographic features
• Loc: premolar-molar area of mandible
• P: well-defined, often corticated
• IS: unilocular, radiolucent
Treatment
- Enucleation
- Mechanical curettage of the surrounding bone

Ameloblastic Fibro-odontoma
• A mixed tumor with all the elements of ameloblastic fibroma but with scattered
collections of enamel and dentin
Clinical features
- Often associated with a missing tooth
- No sex predilection
Radiographic features
• Loc: posterior aspect (mandible)
• P: well-defined, sometimes corticated
• IS: mixed, radiolucent
Treatment
- Enucleation

Adenomatoid Odontogenic Tumor

Syn: Adenoameloblastoma and ameloblastic adenomatoid tumor
• Uncommon, nonaggressive tumors of odontogenic epithelium
• 3% of all oral tumors
Clinical features
- Age 5 to 50 yrs. Old
 - Sex – female
- Slow growing, enlarging, painless swelling or asymmetry
- Both central and peripheral tumor occur
Radiographic features
• Loc: 75% occur in maxilla, incisor-canine-premolar region
• P: well-defined corticated or sclerotic border
• IS: may be completely radiolucent or may contain faint radiopaque foci
Treatment
- Surgical excision