Odontogenic cysts and tumors: what radiologists need to

know?

Poster No.: C-0872

Congress: ECR 2019
Type: Educational Exhibit
Authors: 1 2 1 2
J. de Grazia , C. A. Robles , G. A. Miranda , A. Salas , R. Núñez
2 2 2 2 2
Flores , C. Matus Yañez , P. Orellana , A. Pontoni , F. LAHSEN ;
1 2
Santiago, RM/CL, Santiago/CL
Keywords: Infection, Cysts, Cancer, Diagnostic procedure, MR, CT, Cone
beam CT, Head and neck, Bones
DOI: 10.26044/ecr2019/C-0872

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Page 1 of 22
Learning objectives

• To know the 4 basic questions in radiological evaluation of mandibular /

maxillary lesions.
• To review the characteristics of the main cystic and tumoral odontogenic
lesions, emphasizing the answer of the 4 basic questions.

Page 2 of 22
Background

Radiologists who report head and neck exams often face mandibular / maxillary lesions,
either as the main finding of the examination or as an incidental finding. Many of these
lesions are of dental origin, and their nature is varied: cysts of the odontogenic apparatus,
neoplasms (benign or malignant), among others.

The imaging findings of many of these diseases may be indistinguishable, despite

considerable differences in the underlying pathological process, reason why the
histological study most of times is required to confirm the diagnosis. In this scenario, the
role of the radiologist is to narrow the differential diagnosis, characterizing the extent and
complexity of the lesion.

The main imaging studies used to characterize the details of an odontogenic lesion
are multidetector computed tomography (MDCT), cone beam computed tomography
(CBCT) and magnetic resonance imaging (MRI). Differences between MDCT and CBCT,
emphasizing their respective advantages, are summarized in Fig. 1 on page 4. The
main advantages of MRI are its lack of ionizing radiation and its high contrast resolution.

On this educational exhibit we propose 4 basic questions that should be answered

by the radiologist in order to address the diagnosis of odontogenic lesions. After that,
the radiological characteristics of the main cystic and tumoral odontogenic lesions
are reviewed, emphasizing the answer of the 4 basic questions. Non-odontogenic
mandibular / maxillary lesions are not included in this review.

Page 3 of 22
Images for this section:

Fig. 1: Characteristics of MDCT and CBCT. The advantages of each technic are
highlighted in red colour. MDCT has better contrast resolution, better signal-to-noise ratio,
possibillity of using intravenous contrast material and better visualization of soft tissues.
On the other hand, CBCT has lower radiation dose, better spatial resolution and lower
cost.

© Department of Radiology, Universidad de Chile

Page 4 of 22
Findings and procedure details

The basic radiological approach to mandibular / maxillary lesions should include 4

questions: 1) Is the lesion related to a tooth? (odontogenic v/s non-odontogenic); 2)
Where is the lesion located with respect to the tooth? (periapical v/s pericoronary v/s inter-
radicular); 3) How the lesion acts with respect to the neighboring teeth (displacement v/
s resorption of the roots); 4) What is the density of the lesion? (radiolucent v/s mixed v/s
radiodense). These questions are outlined in Fig. 2 on page 10, Fig. 3 on page 10,
Fig. 4 on page 11 and Fig. 5 on page 12.

To this 4 basic questions other features can be added to help in the differential diagnosis:
single v/s multiple, focal v/s diffuse, unilocular v/s multilocular, well v/s ill defined borders,
destruction v/s expansion of the bone cortex, presence of periosteal reaction, location
(mandibullary v/s maxillary, anterior v/s posterior).

The main odontogenic lesions may be grouped into the following categories:

• Radiolucent cystic: periapical or radicular cyst, dentigerous or follicular cyst,

odontogenic keratocystic tumor.
• Radiolucent solid: ameloblastoma, odontogenic myxoma.
• Radiodense: odontoma, cementoblastoma or true cementoma, cemento-
osseous dysplasia.

Radiolucent cystic lesions:

Endodontal disease:

• Infection from caries, with entrance to the pulp chamber and extension down
by the root canal to the apical foramen, leading to an apical periodontitis with
bone resorption.
• Formation of an abscess (acute form) or a granuloma (chronic form). After
that the disease evolves to a periapical or radicular cyst (latent form, the
most frequent odontogenic cyst).
• Imaging ⇒
• Radiolucent lesion surrounding the root apex, usually <1 cm.
• Small lesions may present just as radiolucent crescent shaped areas
surrounding the root apex.
• On axial images periapical cysts usually present a "target" appearance
(radiodense root apex in the center of the radiolucent lesion).
• Condensans osteitis surrounding the cyst is a common finding (sclerosis due
to bone reaction to the inflammatory process).

Page 5 of 22
 • The presence of sclerotic border and the density of the lesion are not useful
criteria to differentiate between periapical granuloma and cyst.

Periodontal disease:

• Initial infection as gingivitis, with extension through the periodontal ligament,

forming a periodontal sac.
• Imaging ⇒
• Radiolucent area extending down by the side of the root (periodontal
pocket), variable in extent (it may reach the root apex).
• It may present condensans osteitis surrounding the cyst (sclerosis due to
bone reaction to the inflammatory process).

Both diseases - endodontal and periodontal - may coexist in the same dental element
# endo-periodontal lesions.

Endodontal and periodontal disease are schematized in Fig. 6 on page 13 and

presented on a CT exam in Fig. 7 on page 14.

Dentigerous (follicular) cyst:

• The second most frequent odontogenic cyst.

• Pericoronary location (usually in relation to a third molar).
• Corresponds to fluid accumulated between the two sheets of enamel
epithelium (developmental cyst).
• Imaging ⇒
• Pericoronary radiolucent lesion with walls that converge at an acute angle in
the cemento-enamel junction.
• Variable size, it can expand the bone and displace teeth.

A dentigerous cyst presented on a CT exam is shown in Fig. 8 on page 15.

Keratocystic odontogenic tumor (odontogenic keratocyst):

• 5-15% of mandibular / maxillary cysts, with peak incidence between the 2nd
and 3rd decade.
• It develops from the dental lamina (odontogenic epithelium), so it grows in
the support areas of the teeth.
• Twice frequent in the mandible than in the maxillary bone.
• Locally aggressive lesion, it can present recurrence.
• The presence of multiple odontogenic keratocysts is characteristic of the
Basal Cell Nevus Syndrome (Gorlin-Goltz).
• Imaging ⇒
• Radiolucent lesion that can be loculated, smooth or lobed.
• Usually located in the mandibular ramus or body.

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 • It can expand and even erode the cortical bone.
• It can displace the dental roots, but it does not erode them.
• In CT the density is higher than that of water, due to the presence of
keratinized material.
• In MRI the signal is high on T1 (by proteinaceous content) and high on T2.

Radiolucent solid lesions:

Ameloblastoma:

• Primary odontogenic tumor, derived from enamel-forming embryonic cells,

whose regression fails during development.
• Peak of incidence in the 3rd and 4th decade.
• Is the second odontogenic tumor in frequency after the odontoma.
• More frequent in the mandible than in the maxillary bone.
• 5% of the cases originate from the epithelium of a dentigerous cyst.
• Is a benign tumor, but locally aggressive.
• There are multiple subtypes, most of them indistinguishable on imaging
studies.
• There are some ameloblastoma forms with malignant behavior: ameloblastic
carcinoma (with a frankly malignant histology) and malignant ameloblastoma
(with presence of metastases, despite a well-differentiated histology).
• Imaging ⇒
• Expansive radiolucent lesion.
• Located more frequently posterior in the mandible.
• Uni or multiloculated, with a "soap bubbles" appearance.
• The loss of the lamina dura (compact bone that lies adjacent to the
periodontal ligament in the tooth socket) and the erosion of the adjacent
dental roots are characteristic findings, which reflect an aggressive local
behavior.
• It has tendency to destruct the cortical bone and extent to the soft tissues.
• The presence of a large solid component with enhancement, intralesional
papillary projections and extra bony extension should lead to suspicion of
malignant behavior.
• MRI is the better examination for demonstrating intralesional solid
component with enhancement and the extra bony soft tissue extension.

An ameloblastoma presented on a CT exam and the radiographic examination of its

surgical specimen are shown in Fig. 9 on page 16.

Odontogenic myxoma:

• Uncommon tumor, which occurs in the 2nd - 3rd decade.

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 • Clinically and radiologically indistinguishable from an ameloblastoma.
• It presents as a multiloculated radiolucent lesion, with internal bony
trabeculae.
• Histologically benign, but locally aggressive.

Radiodense lesions:

Odontoma:

• Most frequent odontogenic tumor.

• Usually occurs in the 2nd - 3rd decade.
• It is a benign tumor, even considered as an odontogenic hamartoma.
• The presence of enamel inside the lesion can be considered virtually
pathognomonic of an odontoma.
• Half of the cases occur in relation to an unerupted tooth.
• It is encapsulated, and therefore easily enucleable.
• 3 types ⇒
• Simple odontoma: supernumerary teeth or denticles.
• Compound odontoma: most common type of odontoma, more frequent in
the mandible than in the maxillary bone. Organized structured tissue, being
able to distinguish the components of a tooth. Imaging: multiple small and
well-defined malformed or rudimentary teeth.
• Complex odontoma: 24% of the odontomas, more frequent in the posterior
mandible. Disorganized dental tissue, which does not mimic a normal
or rudimentary tooth. Imaging: circumscribed radiopaque mass, with
amorphous calcifications, often in relation to the crown of an unerupted
tooth.

A compound odontoma presented on a CT exam is shown in Fig. 10 on page 17.

Cementoblastoma (true cementoma):

• It is a rare benign tumor (<1% of odontogenic tumors), which occurs in the

2nd - 3rd decade.
• Typically located in the molar - premolar region of the mandible.
• Initially it is a radiolucent lesion, but it become radiopaque as cement is
deposited.
• Imaging ⇒
• Radiodense periapical lesion with a fine radiolucent halo.
• Attached to the root of a tooth.
• It can expand the cortical bone.

A cementoblastoma presented on a panoramic dental radiography and CT is shown in

Fig. 11 on page 18.

Page 8 of 22
Cemento-osseous dysplasia:

• Hamartomatous lesion located in relation to the radicular apex, due to

proliferation of connective tissue in the periodontal membrane.
• Also known as cemental or periapical bone dysplasia.
• More frequent in women, in the 4th - 5th decade.
• 3 types ⇒
• Periapical cemento-osseous dysplasia: more frequent in African
descendants. Localized mostly in the anterior mandible, affecting one or a
few teeth.
• Focal cement-osseous dysplasia: more frequent in Caucasians
descendants. Located in the posterior mandible, affecting molars.
• Florid cemento-osseous dysplasia: more frequent in African descendants.
Affects two or more dental quadrants.
• Imaging ⇒
• Periapical location.
• Initially it is a radiolucent lesion. It progressively calcifies, starting from its
central portion. Subsequently, it becomes a well-defined sclerotic lesion with
a radiolucent halo.
• It does not fuse with the dental root. The lamina dura and the periodontal
ligament are intact.

Page 9 of 22
Images for this section:

Fig. 2: First question: is the lesion related to a teeth? If the answer is no, the lesion is non
odontogenic (origin in the bone); if the answer is yes, the lesion is odontogenic (origin
in the tooth).

© Department of Radiology, Universidad de Chile

Page 10 of 22
Fig. 3: Second question: where is the lesion located with respect to the tooth? Periapical
(centered on the root of the tooth), pericoronary (around the crown of a non erupted
tooth), inter-radicular (between the roots of a edentulous area).

© Department of Radiology, Universidad de Chile

Page 11 of 22
Fig. 4: Third question: how the lesion acts with respect to the neighboring teeth?
Displacement and divergence of the roots in non aggressive lesions, resorption of the
roots (rhizolysis) in aggressive lesions.

© Department of Radiology, Universidad de Chile

Page 12 of 22
Fig. 5: Fourth question: what is the density of the lesion? Radiolucent (lytic), mixed,
radiodense (sclerotic).

© Department of Radiology, Universidad de Chile

Page 13 of 22
Fig. 6: Endodontal disease: infection from caries (curved black arrow), with entrance to
the pulp chamber (straight black arrow) and extension down by the root canal to the apical
foramen (black arrowhead), leading to an apical periodontitis with bone resorption (open
arrows). Periodontal disease: the normal periodontal ligament is depicted (thick arrows);
the portion affected by periodontal disease results in a periodontal pocket (thin arrow),
with resorption of adjacent bone (arrowheads), extending down by the side of the root.

© - Santiago/CL

Page 14 of 22
Fig. 7: 60 years-old man. CBCT of the mandible, panoramic view. Endodontal disease:
round radiolucent lesion surrounding the root apex, with sclerotic border (white arrows).
Periodontal disease: radiolucent area extending down the side of the root reaching the
apex (black arrowheads).

© - Santiago/CL

Page 15 of 22
Fig. 8: 20 years-old man. MDCT of the facial bones. Voluminous pericoronary radiolucent
lesion, located in relation to a non erupted right third molar, with walls that converge
at an acute angle in the cemento-enamel junction (white arrows). The lesion has fluid
attenuation and there is no evident soft tissue component with enhancement on it. There
is marked bone expansion (white arrowheads). This lesion turned out to be a dentigerous
cyst.

© Department of Radiology, Universidad de Chile

Page 16 of 22
Fig. 9: 58 years-old man. MDCT of the facial bones. Expansive radiolucent lesion situated
in an edentulous area of the left mandibular body, with destruction of the cortical bone
(white arrows). The lesion has a multiloculated configuration, with soft tissue component
that extends beyond its margings. The surgical specimen radiography confirms its
multiloculated configuration, with a "soap bubbles" appearance (black arrowheads). This
lesion turned out to be an ameloblastoma.

© Department of Radiology, Universidad de Chile

Page 17 of 22
Fig. 10: 10 years-old woman. MDCT of the mandible (incuding volume rendering). A small
radiodense pericoronary lesion is seen in relation to a non erupted right inferior incisive
tooth. The lesion has an organized structure, being able to distinguish the components
of a tooth on it (white arrows). This lesion turned out to be a compound odontoma.

© Department of Radiology, Universidad de Chile

Page 18 of 22
Fig. 11: 14 years-old woman. Panoramic dental radiography and MDCT of the mandible.
There is a radiodense periapical lesion attached to the root of the first inferior left molar
(white arrows). This lesion turned out to be a cementoblastoma.

© Department of Radiology, Universidad de Chile

Page 19 of 22
Conclusion

The role of the radiologist when facing an odontogenic lesion is to narrow the differential
diagnosis, characterizing the extent and complexity of the lesion.

The diagnostic approach of odontogenic lesions should include answering 4 questions:

1) Is the lesion related to a tooth? (odontogenic v/s non-odontogenic); 2) Where is the
lesion located with respect to the tooth? (periapical v/s pericoronary v/s inter-radicular);
3) How the lesion acts with respect to the neighboring teeth (displacement v/s resorption
of the roots); 4) What is the density of the lesion? (radiolucent v/s mixed v/s radiodense).

Page 20 of 22
Personal information

Department of Radiology, Universidad de Chile.

Page 21 of 22
References

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characteristics of benign and malignant lesions of the mandible.
RadioGraphics. 2006; 26:1751-68.
3. Curé J, Vattoth S, Shah R. Radiopaque jaw lesions: an approach to the
differential diagnosis. RadioGraphics. 2012; 32:1909-25.
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