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Radiographic characteristics of the calcifying odontogenic cyst
Radiographic characteristics of the calcifying odontogenic cyst
KelJi Tanimoto, Shinlchl Tomita, Maaayukl Aoyama, Yoshlhlko Furukl, Minoru FuJlta and Takuro Wada Department of Oral Radiology, Hiroshlma University, School of Dentistry, Japan
K. Taniraoto, S. Tomita, M. Aoyama, E Furuki, M. Fujita and T. Wada: Radiographic characteristics of the calcifying odontogenic cyst. Int. J. Oral Maxillofac. Surg. 1988; 17: 29-32. Abstract. 4 additional cases of calcifying odontogenic cysts (COC) were reported, together with the radiographic interpretation of 138 cases from the literature. From the review of the literature and of our own cases, the root resorption is one of the most common diagnostic findings as is cystic radiolucency accompanied by radiopacities. Other radiographic characteristics, such as loculation, tooth divergency and bone resorption were emphasized.
Calcifying odontogenic cyst (COC) is one of the rarest and most disputable cysts in the oral region, Many reports have been presented since G o ~ et aL 17 proposed this term in 1962. Recently ~.hLrrORPdS et al. ~ reported 16 cases and have suggested that COC consists of 2 entities, a unicystic and a neoplastic. Radiographic appearance of COC has also been reported by many authors, but there are few papers which describe detailed radiographic features. The purpose of this article is to obtain the radiographic characteristics in detail from a review of 138 cases from the literature and from 4 additional cases.
Histological diagnosis. Calcifying odontogenie cyst with complex odontoma. Case 2 A 14-year-old female was referred with right buccal swelling and gingival swelling of the right molar region. Radiographicfeatures (Fig. 2). A large radiolucent lesion circumscribed by cystic margin was observed. This lesion had radiopaque materials which were composed of 2 different patterns. The lower localized masses were composed of the mixture of many tooth-like and amorphous radiopaeities. These were considered to be compound and complex odontomas. The other was composed of small islands of radiopacities in a row which were located from the distal side of the crown of the impacted canine to the odontomas,
Key words: odontogenic tumor; calcifying odontogenic cyst; radiology.
Accepted for publication 10 August 1987
like the Chishima islands (Fig. 2, arrows). The buccal roots of the first and second molars were markedly resorbed, and the roots of the lateral incisor and the premolars were eroded. Tooth divergency between the lateral incisor and the first premolar was noticed. The cystic margin of this lesion partly disappeared at the lateral expanded site. OperativeJ'mdings. Enucleation of the cyst with the canine was performed. The cyst was unilocular and easily removed from the bone. Histological diagnosis. Calcifying odontogenie cyst with complex and compound odontoma.
Case 3 A 17-year-oldfemale was referred because of an impacted tooth or supernumerary tooth. Radiographic features (Figs. 3, 4). Fig. 3
Case reports Case 1 A 17-year-old male was referred because of delayed eruption of the right maxillary canine. Radiographicfeatures (Fig. I). A large radiolucent lesion was observed accompanying the impacted canine. Its pedeoronal space continued to the radiolucent lesion in which many localized amorphous radiopaque masses were scattered. Some of them were considered to be odontomas. Root resorptions of the premolars and the first molar were remarkable. Tooth divergency between the lateral incisor and the first premolar was noticed. Operativefindings. The cyst was enueleated with the canine. It was unilocular and the cyst wall was easily stripped from the bone. The crown of the canine and the apex of • the first premolar were denuded to the cystic lumen. Several calcified masses were ricegrain sized and others were smaller. Most of them were adherent to the cyst wall.
Fig. 1. Case I. Periapical radiographs of the large radiolucent lesion with impacted canine and many radiopaque masses. Root resorptions of the premolars and the first molar are notable.
Tanimoto, Tomita, Aoyama, Furuki, Fujita and Wada
30
lesion (Fig. 5). Both buccal and lingual expansions were indicated, but the cystic margin could not be seen at the buccal, lingual and occlusal surfaces of the lesion. The resorption of cortical bone was also noticeable (Fig. 6). Operativefindings. The cyst was enucleated and the second molar was extracted. Bone defect was confirmed at the buccal and a part of the lingual surface of the cyst. The root of the first molar was not exposed in the lumen of this cyst. Histological diagnosis. Calcifying odontogenie cyst.
Fig. 2. Case 2. Panoramic radiograph of a large radiolucent lesion which involves the right maxillary canine with compound and complex odontomas. The other radiopaque masses mimics the chain of the Chishima Islands (white arrows).
Discussion
showed an impacted left maxillary canine with an enlarging pericoronal space. Just below the pericoronal space, small radiopacities were observed. They were circumscribed by the radiolucent zone with radiopaque margin. The radiolucent zone continued to the pericoronal space of the canine and the radiopaque margin disappeared at the region superimposed on the follicular space. None of the roots were involved by this lesion. The continuity between the pericoronal margin and the radiopaque margin was markedly shown in the panoramic radiograph (Fig. 4). The perieoronal lesion and the radiopacities seemed to be strongly related. Operative findings. Enueleation of the calcified masses with extraction of the canine was performed. Small tooth-like calcifications were found under the bone. Histological diagnosis. Calcifying odontogenie cyst.
Fig. 4. Case 3. Panoramic radiograph of the lesion. Note the continuity between pericoronal margin and circumscribed radiopaque line.
Case 4
A 36-year-old female complaining of gingival swelling of the right mandible. Radiographic features (Figs. 5, 6). The impacted second molar was pressed down to the inferior border of the mandible and its pericoronal space was enlarged with a partly disrupted cystic margin. The mesial side of the lesion was loculated. Many small radiopacities were flecked at the peripheries of the cystic space. The distal root of the first molar was eroded by this cystic lesion. The mandibular canal was forced down by this"
Since GORLIN et alJ ~ proposed the term calcifying odontogenic cyst in 1962, m a n y cases o f this lesion have been reported 1-34.37-39,41qs. However, as the number o f cases is limited in most reports, consistent information has been difficult to obtain to date. Thus, with the aid o f the literature, 142 cases including our own 4 cases have been reviewed. There appeared to be no predilection regarding age or sex (Fig. 7). A c c o r d i n g to SrIEAR35, the age distribution has a bimodal peak and the second peak appears between 60 and 69 years o f age. F r o m our analysis, the bimodal peak was not noticeable, but the second decade was shown as the predisposing age. In our report, 9 patients were in the 7th decade. There was also no prevalence in the
..,
Fig. 3. Case 3. Periapical radiograph of the lesion. The ring-like radiopacities are seen just below the pericoronal space of the left maxillary canine. The circumscribed radiolucent zone continues to pericoronal space.
Fig. 5. Case 4. Periapical radiograph of the radiolucent lesion with small dispersed radiopacities. Note that the alveolar surface of the cystic margin is disrupted.
Fig. 6. Case 4. Occlusal radiograph of the lesion. The small radiopacities are dispersed in the whole radiolucent area and the cystic margin disappears in the buccal and lingual surfaces with marked resorption of cortical bone.
Radiography o f COC 51 male ~
40
emale
t
30
total
23
T
20
15
"-~T, 1
3
4
15
9 ,2_1 9 .~ 5
6
7
8
9 Decade
Age
Fig. 7. Age and sex distribution of COC (142 caSeS).
sites (Table 1). Excluding 3 cases o f unknown location, 73 cases (52.5%) were in the maxilla, and 66 (47.5%) were in the mandible. The intraosseous lesion was found in 117 cases (82.4%), while the extraosseous was seen in 23 cases (16.2%), leaving 2 cases unknown. Most papers or textbooks reported that the extraosseous type occurred in about 1/3 of cases but from the analysis here, it was only about I/6. A m o n g the 117 published intraosseous cases and our own cases, the multilocular cases occurred in only 10 (8.5%) cases, the unilocular in 47 (40.2%), and others were non-descriptive or unknown. Some authors 3,~4,t8described that root resorption of the adjacent tooth occurred occasionally, but ALTrm & FARMAN~ reported that 6 out o f 8 cases showed the resorption of the adjacent roots. We found that many o f the cases in the literature (69 cases) did not describe the root resorption, and some authors described "no root resorption" even though it was seen radiographicaUy. So, according to the description in the reports, the cases could be divided into 3 groups; root resorption positive, negative, and undescribed or unknown. In the 50 intraosseous cases described, 27 (54%) were positive and 23 (46%) were negative. Out o f the 23 negative cases, 15 (30%) did not have adjacent roots (edentulous). Thus, only 8 cases belonged to the negative group. Hence, 27 cases out of 35 which actually had adjacent roots, were positive (77.1%). This % was rather high as compared to
the root resorption (82%) o f the amelobalstoma in the article o f STRUTHERS & S ~ 4°. We thus concluded that root resorption was one o f the most important radiographic findings in COC, if the adjacent teeth were involved. In the extraosseous cases, 2 were reported to have root resorption:*. 9 out of 23 extraosseous cases (39.1%) had bone resorption. These findings were also suggestive o f a highly resorbing potentiality o f COC. The tooth divergence was also a very important finding, but most o f the cases lacked this information. Other important findings were impacted tooth (32.5%) and odontomas and/or some other accompanying calcifications (45.3%). Though the features ofexpansion were not described in most cases, 17 cases had local expansion and perforation o f the cortex was observed in 10 cases. SHEAR" said "Perforation o f the cortical plate, when present, may be radiologically demonstrable." We concur with this opinion; its features were shown in cases 2, 4. This might suggest the relationship to the disruption of the expanded cystic margin. Conclusion
4 cases o f calcifying odontogenic cyst were reported. Cases 1 and 2 were large radiolucent lesions in the maxilla combined with odontomas. Other small radiopaque masses were also noted. Tooth divergence and root resorption were remarkable. Case 3 was a small radiolucent lesion in the maxilla with ringlike radiopaque masses. Case 4 was a moderate radiolucent lesion and many small radiopaque masses were scattered in it. Perforation o f the cystic margin was evident. All o f the cases were associated radiographically with the impacted tooth crowns. 138 cases of reported COC were reviewed from the literature. The nature o f this lesion was studied with regard to the age, sex, location and tooth behavior. F r o m this study, we suggested that root resorption is one o f the most diag-
Table 1. Location of COC Anterior to 1st molar • maxilla mandible unknown
63 (I0) 48 (10) 0
Posterior to 1st molar 6 17 (2) 0
* 1 case was on the right side of the neck, blacket extraosseous.
Undetermined 4 I 3* (1)
31
nestle findings, as is cystic radiolucency accompanied by radiopacities. Loculation, tooth divergence, and bone resorption were also characteristics o f radiographic manifestations. References
1. Abrams, A. M. & Howell, F. V.: The calcifying odontogenic cyst. Report of 4 cases. Oral Surg. 1968: 25: 594--606. 2. Altini, M. & Farman, A. G.: The calcifying odontogenic cyst. 8 cases and a review of the literature. Oral Surg. 1975: 40: 751-759. 3. Anneroth, G. & Nordenram, A.: Calcifying odontogenic cyst. Oral Surg. 1975: 39: 794-801. 4. Bhaskar, S. N.: Gingival cyst and keratinizing amdoblastoma. Oral Surg. 1965: 19: 796-807. 5. Chandi, S. M. & Simon, G. T.: Calcifying odontogenic cyst. Report of 2 cases. Oral Surg. 1970: 30: 99-104. 6. Chaves, E. & Pessoa, J.: The calcifying odontogenic cyst. Report of 2 cases. Oral Surg. 1968: 25: 849-855. 7. Chaves, E., Arnaud, A. C. & Oliveira, A. M.: Abbreviated case report. Calcifying epithelial odontogenic cyst. Oral Surg. 1972: 34: 434-436. 8. Chen, S. Y. & Miller, A. S.: Ultrastructure of the keratinizing and calcifying odontogenic cyst. Oral Surg. 1975: 39: 769-780. 9. Clark, M. J., Alley, R. S., Steed, D. L. & Tilson, H. B.: The keratinizing and calcifying odontogenic cyst (Goflin cyst). J. Am. Dent. Assoc. 1980: 100: 563-564. 10. Cran, J. A., Herd, J. R., Lindsay, T. B. & Locke, J. I-k: The calcifying odontogenic cyst. Aust. Dent. d. 1973: Ig: 10-I 1. 1I. Ebling, H. & Wagner, J. E.: Calcifying odontogenic cyst. Oral Surg. 1967: 24: 537-539. 12. Eda, S., Kawahara, H., Yamamura, T., Imaizumi, I., Ohi, M. & Ichikawa, T.: A case of calcifying odontogenie cyst associated with odontoma. Bull. Tokyo Dent. Coll. 1971: 12: 1-7. 13. Farman, A. G., Smith, S. N., Nortje', C. J. & Grotepass, E W.: Calcifying odontogenie cyst with ameloblastic fibre-edentome: one lesion or two? £ Oral PathoL 1978: 7: 19-27. 14. Fejerskov, O. & Krogh, J.: The calcifying ghost cell odontogenic tumor - or the calcifying odontogenic cyst. d. Oral Pathol. t972: 1: 273--287. 15. Freedman, P. D., Lumerman, H. & Gee, J. K.: Calcifying odontogenic cyst. A review of 70 cases. Oral Surg. 1975: 40: 93-106. 16. Gold, L.: The keratinizing and calcifying odontogenie cyst. Oral Surg. 1963: 16: 1414-1424. 17. Gorlin, R. J., Pindborg, J. J., Clausen, F, P. & Vickers, R. A.: The calcifying odontogenic cyst - a possible analogue of
32
Tanimoto, Tomita, Aoyama, Furuki, Fujita and Wada
the cutaneous calcifying epithelioma of Malherbe. An analysis of 15 cases. Oral Surg. 1962: 15: 1235-1243. 18. Gorlin, R. J., Pindborg, J. J., Redman, R. S., Williamson, J. J. & Hansen, L. S.: The calcifying odontogenic cyst. A new entity and possible analogue of cutaneous calcifying epithelioma of Malherbe. Cancer 1964: 17: 723-729. 19. Herd, J. R.: The calcifying odontogenic cyst. Aust. Dent. J. 1972: 17: 421-428. 20. Ikemura, K., Horie, A., Tashiro, H. & Nandate, M.: Simultaneous occurrence of a calcifying odontogenic cyst and its malignant transformation. Cancer 1985: 56: 2861-2864. 21. Johnson, R. H. & Topazian, R. G.: Calcifying odontogenic cyst: report of case. J. Oral Surgery. 1968: 26: 394--400. 22. Komiya, Y., Susa, A., Kawachi, H., Yamamura, T., Eda, S. & Kawachi, I".: Calcifying odontogenic cyst. Report of a case. Oral Surg. 1969: 27: 90-94. 23. McGowan, R. H. & Browne, R. M.: The calcifying odontogenic cyst: a problem of preoperative diagnosis. Br. J. Oral Surg. 1982: 20: 203-212. 24. Nagao, T., Nakajima, T., Fukushima, M. & Ishiki, T.: Calcifying odontogenic cyst: a survey of 23 cases in the Japanese literature. J. Maxillofac. Surg. 1983: II, 174-179. 25. big, K. H. & Slat, C. H.: Clear cell change in a calcifying odontogenic cyst. Oral Surg. 1985: 60: 417-419. 26. O'Brien, IF. V. & Gorman, J. M.: Calcifying odontogenic cyst. A case report. Br. Dent. J. 1972: 133: 151-152.
27. Overgaard, R. H. & Holland, E S.: The calcifying odontogenic cyst. A case report. Br. J. Oral Surg. 1967: 5: 169-172. 28. Petri, III W. H. & Stump, T. E.: Calcifying odontogenic cyst: report of 3 cases. J. Oral Surg. 1976: 34: 1105-1108. 29. Praetorius, E, Hjzrting-Hansen, E., Gorlin, R. J. & Vickers, R. A.: Calcifying odontogenic cyst. Range, variations and neoplastic potential. Acta Odontol. Scand. 1981: 39: 227-240. 30. Pullman, S. E & Seldin, R.: The calcifying odontogenic cyst: report of case. J. Oral Surg. 1971: 29: 367-370. 31. Russell, J. G. & Corkery, P. F.: Abbreviated case reports. Calcifying odontogenic cyst. Oral Surg. 1970: 29: 877-878. 32. Saito, I., Suzuki, T., Yamamura, J., Miyake, M., Suto, K. & Kusuhara, H.: Calcifying odontogenic cyst. Case reports, variations, and tumorous potential. J. Nihon Univ. Sch. Dent. 1982: 24: 69-78. 33. Sank, J. J.: Calcifying and keratinizing odontogenic cyst. J. Oral Surgery 1972: 30: 893-897. 34. Seeliger, J. E. & Reyneke, J. P.: The calcifying odontogenic cyst: report of case. J. Oral Surg. 1978: 36: 469--472. 35. Shear, M.: Cysts of the oral regions, 2nd edition. Bristol, Wright.PSG, 1983, pp, 73-86. 36. Shear, M.: Cysts of the jaws: recent advances. J. Oral PathoL 1985: 14: 43-59. 37. Slootweg, P. J. & Koole, R.: Recurrent calcifying odontogenic cyst (case report). J. Maxillofae. Surg. 1980: 8: 143-145. 38. Smith, J. F. & Blankenship, J.: The calci-
lying odontogenic cyst. Oral Surg. 1965: 20:624--63 I. 39. Soames, J. V.: A pigmented calcifying odontogenic cyst. Oral Surg. 1982: 53: 395-400. 40. Struthers, P. & Shear, M.: Root resorption by ameloblastomas and cysts of the jaws. Int. J. Oral Surg. 1976: 5: 128-132. 41. Swan, R. H., Houston, G. D. & Moore, S. P.: Peripheral calcifying odontogenic cyst (Gorlin cyst). J. Periodontal. 1985: 56: 340-343. 42. Sycamore, E, M.: Calcifying odontogenic cyst. Report of a case. Br. Dent. J. 1964: 116: 164-166. 43. Takeda, Y., Kuroda, M., Suzuki, A. & Fujioka, Y.: Pigmented variant of calcifying odontogenic cyst. Report of an additional case and a review of literature. Acta Pathol. Jpn. 1985: 35: 1023-1027. 44. Uhnansky, M., Azaz, B. & Sela, J.: Calcifying odontogenic cyst: report of cases. J. Oral Surg. 1969: 27: 415-419. 45. Wright, B. A., Bhardwaj, A. K. & Murphy, D.: Recurrent calcifying odontogenic cyst. Oral Surg. 1984: 58: 579--583. Address: K. Tanimoto Department of Oral Radiology Hiroshima University School of Dentistry 1-2-3, Kasumi. Minami-Ku Hiroshima 734 Japan
KelJi Tanimoto, Shinlchl Tomita, Maaayukl Aoyama, Yoshlhlko Furukl, Minoru FuJlta and Takuro Wada Department of Oral Radiology, Hiroshlma University, School of Dentistry, Japan
K. Taniraoto, S. Tomita, M. Aoyama, E Furuki, M. Fujita and T. Wada: Radiographic characteristics of the calcifying odontogenic cyst. Int. J. Oral Maxillofac. Surg. 1988; 17: 29-32. Abstract. 4 additional cases of calcifying odontogenic cysts (COC) were reported, together with the radiographic interpretation of 138 cases from the literature. From the review of the literature and of our own cases, the root resorption is one of the most common diagnostic findings as is cystic radiolucency accompanied by radiopacities. Other radiographic characteristics, such as loculation, tooth divergency and bone resorption were emphasized.
Calcifying odontogenic cyst (COC) is one of the rarest and most disputable cysts in the oral region, Many reports have been presented since G o ~ et aL 17 proposed this term in 1962. Recently ~.hLrrORPdS et al. ~ reported 16 cases and have suggested that COC consists of 2 entities, a unicystic and a neoplastic. Radiographic appearance of COC has also been reported by many authors, but there are few papers which describe detailed radiographic features. The purpose of this article is to obtain the radiographic characteristics in detail from a review of 138 cases from the literature and from 4 additional cases.
Histological diagnosis. Calcifying odontogenie cyst with complex odontoma. Case 2 A 14-year-old female was referred with right buccal swelling and gingival swelling of the right molar region. Radiographicfeatures (Fig. 2). A large radiolucent lesion circumscribed by cystic margin was observed. This lesion had radiopaque materials which were composed of 2 different patterns. The lower localized masses were composed of the mixture of many tooth-like and amorphous radiopaeities. These were considered to be compound and complex odontomas. The other was composed of small islands of radiopacities in a row which were located from the distal side of the crown of the impacted canine to the odontomas,
Key words: odontogenic tumor; calcifying odontogenic cyst; radiology.
Accepted for publication 10 August 1987
like the Chishima islands (Fig. 2, arrows). The buccal roots of the first and second molars were markedly resorbed, and the roots of the lateral incisor and the premolars were eroded. Tooth divergency between the lateral incisor and the first premolar was noticed. The cystic margin of this lesion partly disappeared at the lateral expanded site. OperativeJ'mdings. Enucleation of the cyst with the canine was performed. The cyst was unilocular and easily removed from the bone. Histological diagnosis. Calcifying odontogenie cyst with complex and compound odontoma.
Case 3 A 17-year-oldfemale was referred because of an impacted tooth or supernumerary tooth. Radiographic features (Figs. 3, 4). Fig. 3
Case reports Case 1 A 17-year-old male was referred because of delayed eruption of the right maxillary canine. Radiographicfeatures (Fig. I). A large radiolucent lesion was observed accompanying the impacted canine. Its pedeoronal space continued to the radiolucent lesion in which many localized amorphous radiopaque masses were scattered. Some of them were considered to be odontomas. Root resorptions of the premolars and the first molar were remarkable. Tooth divergency between the lateral incisor and the first premolar was noticed. Operativefindings. The cyst was enueleated with the canine. It was unilocular and the cyst wall was easily stripped from the bone. The crown of the canine and the apex of • the first premolar were denuded to the cystic lumen. Several calcified masses were ricegrain sized and others were smaller. Most of them were adherent to the cyst wall.
Fig. 1. Case I. Periapical radiographs of the large radiolucent lesion with impacted canine and many radiopaque masses. Root resorptions of the premolars and the first molar are notable.
Tanimoto, Tomita, Aoyama, Furuki, Fujita and Wada
30
lesion (Fig. 5). Both buccal and lingual expansions were indicated, but the cystic margin could not be seen at the buccal, lingual and occlusal surfaces of the lesion. The resorption of cortical bone was also noticeable (Fig. 6). Operativefindings. The cyst was enucleated and the second molar was extracted. Bone defect was confirmed at the buccal and a part of the lingual surface of the cyst. The root of the first molar was not exposed in the lumen of this cyst. Histological diagnosis. Calcifying odontogenie cyst.
Fig. 2. Case 2. Panoramic radiograph of a large radiolucent lesion which involves the right maxillary canine with compound and complex odontomas. The other radiopaque masses mimics the chain of the Chishima Islands (white arrows).
Discussion
showed an impacted left maxillary canine with an enlarging pericoronal space. Just below the pericoronal space, small radiopacities were observed. They were circumscribed by the radiolucent zone with radiopaque margin. The radiolucent zone continued to the pericoronal space of the canine and the radiopaque margin disappeared at the region superimposed on the follicular space. None of the roots were involved by this lesion. The continuity between the pericoronal margin and the radiopaque margin was markedly shown in the panoramic radiograph (Fig. 4). The perieoronal lesion and the radiopacities seemed to be strongly related. Operative findings. Enueleation of the calcified masses with extraction of the canine was performed. Small tooth-like calcifications were found under the bone. Histological diagnosis. Calcifying odontogenie cyst.
Fig. 4. Case 3. Panoramic radiograph of the lesion. Note the continuity between pericoronal margin and circumscribed radiopaque line.
Case 4
A 36-year-old female complaining of gingival swelling of the right mandible. Radiographic features (Figs. 5, 6). The impacted second molar was pressed down to the inferior border of the mandible and its pericoronal space was enlarged with a partly disrupted cystic margin. The mesial side of the lesion was loculated. Many small radiopacities were flecked at the peripheries of the cystic space. The distal root of the first molar was eroded by this cystic lesion. The mandibular canal was forced down by this"
Since GORLIN et alJ ~ proposed the term calcifying odontogenic cyst in 1962, m a n y cases o f this lesion have been reported 1-34.37-39,41qs. However, as the number o f cases is limited in most reports, consistent information has been difficult to obtain to date. Thus, with the aid o f the literature, 142 cases including our own 4 cases have been reviewed. There appeared to be no predilection regarding age or sex (Fig. 7). A c c o r d i n g to SrIEAR35, the age distribution has a bimodal peak and the second peak appears between 60 and 69 years o f age. F r o m our analysis, the bimodal peak was not noticeable, but the second decade was shown as the predisposing age. In our report, 9 patients were in the 7th decade. There was also no prevalence in the
..,
Fig. 3. Case 3. Periapical radiograph of the lesion. The ring-like radiopacities are seen just below the pericoronal space of the left maxillary canine. The circumscribed radiolucent zone continues to pericoronal space.
Fig. 5. Case 4. Periapical radiograph of the radiolucent lesion with small dispersed radiopacities. Note that the alveolar surface of the cystic margin is disrupted.
Fig. 6. Case 4. Occlusal radiograph of the lesion. The small radiopacities are dispersed in the whole radiolucent area and the cystic margin disappears in the buccal and lingual surfaces with marked resorption of cortical bone.
Radiography o f COC 51 male ~
40
emale
t
30
total
23
T
20
15
"-~T, 1
3
4
15
9 ,2_1 9 .~ 5
6
7
8
9 Decade
Age
Fig. 7. Age and sex distribution of COC (142 caSeS).
sites (Table 1). Excluding 3 cases o f unknown location, 73 cases (52.5%) were in the maxilla, and 66 (47.5%) were in the mandible. The intraosseous lesion was found in 117 cases (82.4%), while the extraosseous was seen in 23 cases (16.2%), leaving 2 cases unknown. Most papers or textbooks reported that the extraosseous type occurred in about 1/3 of cases but from the analysis here, it was only about I/6. A m o n g the 117 published intraosseous cases and our own cases, the multilocular cases occurred in only 10 (8.5%) cases, the unilocular in 47 (40.2%), and others were non-descriptive or unknown. Some authors 3,~4,t8described that root resorption of the adjacent tooth occurred occasionally, but ALTrm & FARMAN~ reported that 6 out o f 8 cases showed the resorption of the adjacent roots. We found that many o f the cases in the literature (69 cases) did not describe the root resorption, and some authors described "no root resorption" even though it was seen radiographicaUy. So, according to the description in the reports, the cases could be divided into 3 groups; root resorption positive, negative, and undescribed or unknown. In the 50 intraosseous cases described, 27 (54%) were positive and 23 (46%) were negative. Out o f the 23 negative cases, 15 (30%) did not have adjacent roots (edentulous). Thus, only 8 cases belonged to the negative group. Hence, 27 cases out of 35 which actually had adjacent roots, were positive (77.1%). This % was rather high as compared to
the root resorption (82%) o f the amelobalstoma in the article o f STRUTHERS & S ~ 4°. We thus concluded that root resorption was one o f the most important radiographic findings in COC, if the adjacent teeth were involved. In the extraosseous cases, 2 were reported to have root resorption:*. 9 out of 23 extraosseous cases (39.1%) had bone resorption. These findings were also suggestive o f a highly resorbing potentiality o f COC. The tooth divergence was also a very important finding, but most o f the cases lacked this information. Other important findings were impacted tooth (32.5%) and odontomas and/or some other accompanying calcifications (45.3%). Though the features ofexpansion were not described in most cases, 17 cases had local expansion and perforation o f the cortex was observed in 10 cases. SHEAR" said "Perforation o f the cortical plate, when present, may be radiologically demonstrable." We concur with this opinion; its features were shown in cases 2, 4. This might suggest the relationship to the disruption of the expanded cystic margin. Conclusion
4 cases o f calcifying odontogenic cyst were reported. Cases 1 and 2 were large radiolucent lesions in the maxilla combined with odontomas. Other small radiopaque masses were also noted. Tooth divergence and root resorption were remarkable. Case 3 was a small radiolucent lesion in the maxilla with ringlike radiopaque masses. Case 4 was a moderate radiolucent lesion and many small radiopaque masses were scattered in it. Perforation o f the cystic margin was evident. All o f the cases were associated radiographically with the impacted tooth crowns. 138 cases of reported COC were reviewed from the literature. The nature o f this lesion was studied with regard to the age, sex, location and tooth behavior. F r o m this study, we suggested that root resorption is one o f the most diag-
Table 1. Location of COC Anterior to 1st molar • maxilla mandible unknown
63 (I0) 48 (10) 0
Posterior to 1st molar 6 17 (2) 0
* 1 case was on the right side of the neck, blacket extraosseous.
Undetermined 4 I 3* (1)
31
nestle findings, as is cystic radiolucency accompanied by radiopacities. Loculation, tooth divergence, and bone resorption were also characteristics o f radiographic manifestations. References
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