Clinical PresentationA 36 year old Caucasian male visited his family dentist fora routine annual examination. Periapical radiographs oflong-impacted mandibular third molars showed radiolu-cencies associated with the crowns of each. An orthopan-tomograph taken at the time confirmed bilateral pericoronalradiolucencies, with the right lesion larger than the left(Fig. 1). There was no obvious cortical expansion, nooverlying mucosal changes and no symptoms or history ofposterior mandibular pain. The patient was not aware ofany systemic diseases, nor was he aware of any otherfamily members with similar jaw radiolucencies.Differential DiagnosisVery few radiographic disorders can be definitively diag-nosed without microscopic evaluation; nevertheless, a greatdeal of information can be gleaned from a thorough reviewof the radiographic features of a particular case. In truth,the more changes one can describe, the better the differ-ential diagnosis becomes and, of course, the more logicalthe management plan. The present case is especiallyinteresting because of the wealth of features visible withinone cone beam CT scan (CBCT). It also points out agrowing problem with CBCT images, namely, that we lackthe extensive experience needed to properly interpret them[1]. With routine dental radiographs, despite the tremen-dous imaging artifacts associated with them, health pro-fessionals long ago developed confidence in theirinterpretation of images. Someday, undoubtedly, we willhave the same confidence in our interpretation of CBCT—but we are not there yet.At first glance (Fig. 1), this case is a simple one ofbilateral, pericoronal, unilocular radiolucencies withoutcalcifications and with well demarcated borders. The sharpborders and mild sclerotic rimming around the lesionsprovide strong assurance that their biological behavior isthat of benign, slowly enlarging entities. These signs alsopoint out a lack of salient infection or inflammation in thearea, as does the asymptomatic nature of the lesion and thefact that overlying soft tissues show no clinical signs ofinflammation. Moreover, in the pantographic view (Fig. 1)there is no evidence of cortical or inferior border expan-sion, cortical perforation or root resorption, although theright lesion seems to demonstrate destruction of at least aportion of the lamina dura on the adjacent erupted molar.The left side lesion is small enough to strongly suggesteither a hyperplastic follicle or early dentigerous cyst [1–3]. Much less likely, and based primarily on the pericoronallocation and unilocular appearance, would be odontogenicfibroma, odontogenic keratocyst (keratinizing odontogenictumor), orthokeratinized odontogenic cyst, unicystic ame-loblastoma or adenomatoid odontogenic tumor (AOT) [2].Age, alone, would tend to rule out unicystic ameloblas-toma, and the posterior mandibular location speaks againstthe AOT. Of course, the dentigerous cyst is the mostcommon bilateral pericoronal lesion and it must be kept inmind that all bilateral cystic odontogenic lesions suggestinvolvement with the nevoid basal cell carcinoma
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