From radiology to microscopy: Unveiling the mandibular – Molar angle ramus pathologies: A retrospective study

Dentigerous cysts represent the most frequent type of benign odontogenic cysts that develop around the crown of an unerupted or impacted tooth. They are considered the second most common cystic lesion of the jaws, following radicular cysts. When associated with impacted teeth, dentigerous cysts can cause displacement of these teeth into abnormal or ectopic locations. Although ectopic eruption of teeth outside the oral cavity is not unusual, the occurrence of dentigerous cysts linked to ectopic teeth within the maxillary sinus is relatively uncommon. Diagnosis is primarily established using panoramic radiography; however, cone beam computed tomography (CBCT) is recommended when an ectopic tooth is associated with a mass in the maxillary sinus or before surgical intervention. The preferred treatment approach is surgical enucleation of the cyst along with removal of the associated impacted or unerupted tooth. This article presents CBCT findings from case of dentigerous cyst involving ectopic/supernumerary tooth in the maxillary sinus and reviews relevant literature published over the past 34 years.

The aim of this retrospective study is to determine the radiological features of keratocystic odontogenic tumors (KCOT) using cone-beam computed tomography (CBCT). CBCT images of 28 patients who had histopathologically-confirmed KCOT were retrospectively reviewed from the archives of the Department of Dentomaxillofacial Radiology, Gazi University Faculty of Dentistry. The location and size of KCOT, cortical expansion, cortical perforation, relation with the impacted teeth, and the impact on the mandibular canal were evaluated. The mean age of patients at initial diagnosis was 34.5 years. Patients with an impacted tooth were significantly younger than those without an impacted tooth (p<0.05). Among KCOTs, 21% were localized in the maxilla whereas 79% were found in the mandible. The lesions localized in the mandible were mostly found in the retromolar-ramus region. Of these patients, 93% had cortical expansion and 75% had bone perforation. Of the 22 mandibular lesions, 20 were in close proximity of the mandibular canal and 18 (90%) of these lesions had caused destruction in the mandibular canal. KCOTs exhibit their aggressive nature in the jaw bone. CBCT is a useful radiological imaging method to examine the radiologic characteristics of KCOTs such as bone destruction and their spatial relations with the neighboring anatomic structures.

Background: Odontogenic keratocyst (OKC) poses diagnostic challenges due to its aggressive nature and varied clinical as well as radiographic presentations, often resembling other cysts and tumors. The buccolingual to mesiodistal width ratio has been proposed as a potential radiographic parameter for diagnosing OKC. Aim: This study aimed to characterize OKC radiographically using cone beam computed tomography (CBCT) as well as panoramic radiographs, exploring the utility of the buccolingual to mesiodistal width ratio for diagnosis. Materials and Methods: An OKC retrospective radiography investigation was conducted with CBCT and panoramic radiographs from an archival database of patients in our institution, reported from 2019 to 2022. A total of 28 cases that were histopathologically confirmed OKC were analyzed. Results: Analyzing 28 histopathologically confirmed OKC cases, the mean age was 29.3 years, with a 3:4 female-to-male ratio. Predominantly located in the posterior mandible (60%), only one case occurred in the maxilla. The buccolingual to mesiodistal width ratio was &lt;0.5 in 71% of cases, and over 80% exhibited unilocular radiolucency with scalloped borders. Conclusion: CBCT’s width-length ratio has emerged as a significant diagnostic factor, though histopathology remains the gold standard. The research emphasizes the significance of considering radiographic parameters, with potential implications for OKC diagnosis.

To characterize and compare the radiographic and tomographic features of odontogenic lesions associated with impacted teeth in a Brazilian population. This retrospective, cross-sectional study analyzed 31,378 cases diagnosed between 2001 and 2023 from the pathology database of a dental school. Of these, 454 cases of intraosseous odontogenic lesions associated with impacted teeth and with available plain radiographs or cone-beam computed tomography (CBCT) scans were included. Demographic, clinical, and imaging variables were recorded. Agreement between imaging modalities was assessed in cases where both images were available. The most frequent diagnoses/lesions were dentigerous cyst (57.5%), odontogenic keratocyst (25.1%) and ameloblastoma (10.8%). Lesion characteristics varied significantly by type, including internal structure, loculation, shape, and associated resorption or displacement. Comparative analysis between 2D radiographs and CBCT (n = 37) revealed high agreement (> 90%) for internal content, bone location, and resorption. However, cortical discontinuity (40.7%), cortical expansion (51.8%), and mandibular canal involvement (48.1%) showed low concordance. CBCT detected these features more reliably. CBCT provides superior diagnostic accuracy compared to 2D imaging, particularly for cortical and canal involvement, which may guide surgical planning and reduce the risk of complications. Its use is recommended for comprehensive evaluation of odontogenic lesions associated with impacted teeth.

Residents’ journal review

The odontogenic keratocyst (OKC) is a benign intraosseous lesion that derives from remnants of the dental lamina. General practitioners usually use panoramic radiograph and cone-beam computed tomography (CBCT) as radiography examination of a suspected OKC lesion in the mandible or maxilla. Evaluation of post marsupialization could be assessed by using fractal dimension (FD) analysis of trabecular bone in panoramic radiograph and CBCT. In the present case, we use panoramic radiograph and CBCT for the treatment evaluation of OKC. The aim of this case report is to describe a case of OKC and evaluation of treatment progress by using FD analysis on panoramic radiograph and CBCT. A 40-year-old female patient came with a complaint of slowly enlarged swelling on the left mandible for 10 years. Low-grade pain occasionally happened to that women. Panoramic radiographs revealed multi-locular radiolucency extending from anterior of the mandible body to ascending ramus. Coronoid and condyloid process, and inferior border of the mandible were intact. OKC was confirmed based on biopsy of the lesion from extraction site of left lower third molar tooth. We did marsupialization from tooth extraction socket and let it open as a window to apply obturator. The researchers did a serial panoramic radiograph to evaluate treatment, showing reduction of radiolucency size and increasing of FD in lesion peripheral, it means that there was an osseous healing process. One year after marsupialization, the researchers did CBCT examination to evaluate bone regeneration and density. The result of CBCT showed the size reduction of the lesion in sagittal, coronal, and axial planes. CBCT also revealed bone formation from the periphery of the lesion. CBCT assessment and FD analysis of trabecular bone on panoramic radiograph is a reliable imaging method for the treatment evaluation of OKC and determination of ossification as well.

Objectives: Review the clinical presentation, incidence, radiologic features, management, and outcomes of jaw cysts in children treated at a single tertiary care academic institution. Discuss the appropriate work-up and expected outcomes of children presenting with signs or symptoms suggestive of a jaw cyst. Methods: Retrospective case series of pediatric patients age 16 and under who presented with a cystic lesion of the jaw to a tertiary care academic medical center from 1997 to 2012. Charts were reviewed for presenting symptoms, signs, radiological findings, pathology, intervention, and outcomes. Results: The charts of 76 pediatric patients evaluated for a jaw mass were reviewed. Twenty-nine were diagnosed with a cystic jaw lesion. The most common cystic lesions were dentigerous cysts (45%) and odontogenic keratocysts (34%). Forty-one percent of all cystic lesions were asymptomatic at presentation. The most common presenting complaint was local swelling, followed by incidental findings on panorex and dental irregularities (tooth impaction, gum change, or lesion). All patients, excluding one with an eruption cyst, required surgical intervention. Odontogenic keratocysts tended to have the worst outcomes, with frequent recurrence and an average of 2.5 procedures required. Conclusions: Pediatric jaw cysts are unusual, and data are scarce regarding their presentation and management. Many are asymptomatic and identified by panorex imaging of the jaws. Dentigerous cysts were the most common lesion seen in our series, closely followed by odontogenic keratocysts. Surgical intervention is required in the majority of patients. Odontogenic keratocysts may require additional procedures for cure.

Authors' response.

Response to the critique of “Keratocystic odontogenic tumor: systematic review with analysis of 72 additional cases from Mumbai, India”

CLINICAL PATHOLOGIC CONFERENCE CASE 1: A MULTILOCULAR RADIOLUCENCY OF THE RIGHT MANDIBLE

Objective: To analyze the imaging features of cone-beam CT (CBCT) of ameloblastoma (AB), odontogenic keratocyst (OKC) and dentigerous cysts (DC) associated with the mandibular impacted third molars,so as to provide useful information for differential diagnosis of these lesions. Methods: The patients who were with complete clinical data, pathological diagnosis and CBCT images from AB, OKC and DC around the mandibular impacted third molars were collected in Peking University Hospital of Stomatology from August 2016 to December 2021. A total of 109 patients (14 were diagnosed as AB, 23 were diagnosed as OKC and the others were diagnosed as dental cysts) were collected, including 73 males and 36 females. The age ranged from 11 to 70. The analyzed imaging features included location and internal density of the lesions, bone expansion, root resorption of adjacent teeth and types of the impacted teeth. The Chi square test was used to compare the gender of different lesions, and the Fisher's exact test was used to compare imaging features of lesions. When P<0.05, there was a significant difference among the three. Logistic regression analysis was performed to determine the imaging features that significantly contribute to correct imaging diagnosis. Corresponding P-values were calculated for all factors from multivariate models. Results: In the 23 cases of OKC, no special location was observed for the center of the lesion, heterogeneous high-density were seen in 21.7% of the cases, 56.5% of the cases had no significant bone expansion and the impacted teeth were not specially oriented. Among the 14 AB, 7 cases (7/14) were mainly located in the ramus of the mandible, and all cases (14/14) had buccal/lingual expansion of the jaw, 8 cases (8/14) presented root resorption of the adjacent teeth, and mesial impacted mandibular third molar were seen in 6 cases (6/14). Among the 72 DC, 88.9% (64/72) of the cases were mainly limited to the crown of the impacted third molar, 72.2% (52/72) of the cases had no obvious bone expansion, inverted impacted teeth were shown in 56.9% (41/72) of the cases. There was a significant difference among the three groups (χ2=7.30, P=0.026) in gender. AB and odontogenic cyst were more common in men than in women, while the incidence of OKC was roughly equal between men and women.There were significant differences in the location (P<0.001), internal density (P=0.001) of the lesions, bone expansion (P<0.001) and types of the impacted teeth (P<0.001), while no statistical difference was found for root resorption of adjacent teeth (P=0.153). Logistics regression analysis showed that the location of the lesion, internal density, bone expansion, root resorption of adjacent teeth and the types of impacted teeth had significant effects on the accurate diagnosis of the three kinds of lesions. Conclusions: Location, internal density, bone expansion and types of the impacted teeth played an important role in the correct imaging diagnosis. Further analysis indicates that when the classification of impacted teeth and the location of lesions are considered synchronously, DC can be differentiated from AB and OKC.

The management of palatally displaced maxillary canines: Considerations and challenges

Dentigerous cysts are the most common type of benign odontogenic lesions that associated with the crown of an unerupted or impacted tooth. They constitute the second most common cystic lesion of the jaws, after radicular cysts. Dentigerous cyst surrounding impacted teeth often displace these teeth into ectopic positions. Ectopic eruption of teeth into regions other than the oral cavity is common but dentigerous cysts associated with ectopic teeth within the maxillary sinus are fairly rare. The diagnosis is usually made by panoramic radiography. Cone beam computed tomography (CBCT) is indicated when an ectopic tooth is associated with an antral mass and prior to surgery. The standard treatment for a dentigerous cyst is enucleation and extraction of the cyst-associated impacted or unerupted tooth. We report CBCT findings of two cases of dentigerous cyst associated with an ectopic tooth in the maxillary sinus and review the literature reports of this condition over the past 34 years.

Ameloblastomas are benign odontogenic tumors characterized by local aggressiveness and a high potential for recurrence. Unicystic ameloblastoma (UA) is an uncommon variant that often mimics odontogenic cysts, making preoperative diagnosis challenging. Early and accurate differentiation is essential for guiding appropriate treatment planning and minimizing the risk of recurrence. This study is aimed at reporting two cases highlighting the diagnostic dilemma posed by UA. The first case involves a 65‐year‐old male patient with a well‐defined unilocular radiolucency extending from Teeth 35 to 44. Clinical and radiographic findings initially suggested a benign odontogenic cyst. However, cone beam computed tomography (CBCT) revealed cortical perforation, and histopathological examination confirmed a diagnosis of a mural unicystic ameloblastoma. The second case concerns a 20‐year‐old female patient who consulted with the chief complain of incidental discovery of a radiolucent image associated with an impacted wisdom mandibular right tooth during follow‐up orthodontic treatment on panoramic radiography. CBCT showed cortical expansion and thinning, with mandibular canal displacement. The differential diagnosis included a dentigerous cyst, an odontogenic keratocyst, and UA. Histopathological analysis confirmed a follicular ameloblastoma. These cases emphasize the importance of correlating clinical, radiographic, and histopathological findings to differentiate UA from cystic odontogenic lesions. Advanced imaging modalities such as CBCT, combined with histological examination, remain essential for a precise diagnosis and suitable treatment plan.

Age as a limiting factor for panoramic imaging in patients with ectopic maxillary canines.