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Radiologic Considerations in Evaluation of Radiolucent Lesions of the Mandible
T h e im p o r ta n c e o f r a d io lo g ic ev a lu a tio n in th e d ia g n o sis a n d tr ea tm en t o f s erio u s ly tic le s io n s is d isc u sse d . T w o c a s e s a r e p r e s e n t e d th a t illu stra te th e v a lu e o f d iffe r e n t r a d io lo g ic p r o c e d u r e s in a s c er ta in in g th e ex ten t o f su ch le s io n s a n d using th e in fo r m a tio n in s electin g th e b e s t t h e r a p e u t ic a p p r o a c h .
Radiologic considerations in evaluation of radiolucent lesions of the mandible A llan B. Reiskin, DDS, D Phil R ichard W. V alachovic, DMD
j l n a re cen t issu e o f T h e J o u r n a l, w e rep o rted th e case o f a 14-year-o ld b la ck g irl w ho h ad a ly tic le sio n in the p o sterior reg io n o f th e m a n d ib le .1 T h e ca se illu strated th e value o f a co m p reh en siv e ra d io lo g ic ev alu atio n based on h isto ry and p h y sica l ex a m in a tio n and also sh o w ed th e risk asso cia te d w ith a failu re to give ad equ ate co n sid e ra tio n to a ll o f th e fin d in g s o f the data base. T h e ro le o f th e ra d io lo g ic ex a m in a tio n in th e ev alu atio n o f ly tic le sio n s w as d iscu ssed . Tw o a d d itio n al ca se s are cu rre n tly p resen ted in w h ich the treatm en t of serio u s ly tic le sio n s o f the m an d ib le w as clea rly in flu en ced by th e re su lts o f ra d io lo g ic fin d in g s. E ach ca se illu strated th e ad v an tag es of sp e c ific ty p es o f e x a m in a tio n s in th e ev a lu a tio n o f ly tic le sio n s an d th e fo rm u latio n o f treatm en t p lan s. A lth o u g h rad io g rap h s a lo n e rarely p rovide the c lin ic ia n w ith a d e fin itiv e d iag n o sis, th e co m b in ed v alu e o f d ifferen t ra d io lo g ic p ro ced u res ca n sig n ifi ca n tly ad v an ce a c lin ic ia n ’s u n d erstan d in g o f the b io lo g ica l ch a ra cte ristic s and bo u n d aries o f ly tic le sio n s of the m an d ib le. T h is in fo rm atio n is essen tia l in e s ta b lish in g th e m o st ap p ro p riate th e ra p e u tic a p proach.
Report of cases CASE l . T h e p a tien t, a 6 8 -y e a r-o ld w h ite m an , ca m e to th e U n iv e rs ity o f C o n n e c tic u t S c h o o l o f D e n ta l M e d icin e on Jan 1 4, 1 9 8 0 , for ro u tin e d en tal care. He w as in good h ealth at th at tim e; th e m e d ica l h isto ry w as n o n co n trib u to ry and did n ot co n tra in d ica te d e n ta l th e ra p y . P re v io u s d e n ta l ca r e a p p e a red to be e p iso d ic. E xtraoral e x a m in a tio n o f th e head and n eck d isc lo se d a fa cia l asy m m etry w ith en la rg em en t o f the rig h t m a n d ib u lar an g le. L y m p h a d en o p a th y , sw ellin g o f th e m ajo r salivary g lan d s, or p a re sth e sia o f an y area o f th e fa ce or n eck w as n o t ap p aren t. C lin ica l d en tal ex a m in a tio n d isclo se d m an y m issin g , fractu red , and ca rio u s teeth w ith m o d era tely in fla m ed gin g iv a. A n u lcera ted and in d u rated le sio n a p p ro x im a tely 1 m m in d iam eter w as p resen t d istal to th e m an d ib u la r righ t first m o lar on one ed en tu lo u s rid ge. R a d io g ra p h ic e x a m in a tio n d isclo sed a large, m u ltilo c u la r ra d io lu cen t area a p p rox im ately 2 .5 cm in d ia m e te r in th e re g io n o f th e righ t m an d ib u lar m o lar to th e ram us (Fig 1). T h e m ed ial p late o f m a n d ib u lar b o n e h ad b een d estroyed an d th ere w as no ra d io g ra p h ic e v id e n c e of re a ctiv e JADA, Vol. 101, November 1980 ■ 771
F ig 2 ■ Q u a lity o f p e rip h e ra l m a rg in s v a rie d fro m o n e p a rt o f le sio n to a n o th e r. No co rte x w as v isib le alo n g s u p e rio r a sp e c t o f le sion .
F ig 1 ■ T o p , p e ria p ic a l v iew o f re g io n o f m a n d ib u la r m o la r sh ow s m u ltilo c u la r ra d io lu c e n t d e fect in re g io n o f m issin g m o la rs. Bottom , p e ria p ic a l v iew o f m a n d ib le m ore c le a rly sh o w s m u ltilo c u la r an d d e s tru ctiv e n a tu r e o f lesio n .
fo rm a tio n o f b o n e at th e p erip h ery o f th e le sio n . A la t eral v iew (Fig 2) sh o w ed th at th e le sio n w as su r ro u n d ed by a th in , feath ered m arg in e x c e p t at its m o st su p erio r asp e ct, w h ere a co m m u n ic a tio n w ith th e soft tissu e in th e re tro m o lar pad re g io n w as ev id en t. T h e m a n d ib u la r ca n a l cu rv ed in terio rly but th e bon y m a r g in s w ere in ta ct. F u rth er q u estio n in g o f th e p a tien t after th e ra d io g ra p h ic ex a m in a tio n in d ica ted th at the m a n d ib u la r rig h t seco n d m o lar h ad b e e n ex tracted w ith o u t co m p lic a tio n s ap p ro x im ately 16 years ea r lier. O n th e b asis o f c lin ic a l and ra d io g ra p h ic ev id en ce, th e d iffe re n tia l d ia g n o sis in c lu d e d o d o n to g e n ic cy st; o d o n to g e n ic k e ra to c y st; a m e lo b la sto m a ; m y xo m a ; an d o th e r m o re s e r io u s le s io n s , in c lu d in g m u co e p id e rm o id ca rcin o m a , eith e r ce n tra l or p e rip h era l; and ep id erm o id carcin o m a. In flam m ato ry and g ran u lo m ato u s d isease co u ld n ot be ex clu d e d . A n in c is io n a l b io p sy sp e cim en w as tak en on Jan 2 1 , 1 9 8 0 . H isto lo g ic ev alu atio n d isc lo se d a w e ll-d iffe r en tiated m u co ep id erm o id ca rcin o m a (Fig 3). CASE 2. T h e p a tie n t, a 10-y ear-o ld H isp a n ic g irl, cam e for treatm en t b ec a u se o f a six -w ee k h isto ry o f firm sw ellin g over th e an g le o f th e le ft sid e o f th e m a n d i b le. O n set of th e sw ellin g w as su d d en an d w as a s so cia te d w ith a lo w -grad e fever. A c lin ic a l d ia g n o sis o f “ strep th ro a t” w as m ade at th at tim e. T re a tm e n t w ith an a n tib io tic p ro d u ced s u b je c tiv e r e lie f al772 ■ JADA, Vol. 101, November 1980
F ig 3 ■ F ie ld sh ow s u n e n ca p su la te d m a ss o f n e o p la s tic tis s u e c h a r a c te riz ed by n ests o f s tra tifie d sq u am o u s e p ith eliu m co n ta in in g m u cou ss e c re tin g c e lls u n d erg o in g c y s tic d e g en era tio n . N o tice c y s tic n est sh ow in g p a p illa ry c o n fo rm a tio n on rig h t c e n te r o f field (co u rtesy o f Dr. E lle n E isenb e rg , d iv isio n o f o ra l p a th o lo g y , U n iv ersity o f C o n n e cticu t H ea lth C en ter; h em a to x y lin & eo sin , o rig in a l m a g n ific a tio n X 2 4 0 .)
though the swelling remained. The patient was later referred to a community health center where a clini cal diagnosis of mumps was made. C o n v en tio n a l m e d ica l th erap y w as u n su cc e ssfu l and , w h en th e sw e llin g did n o t reso lv e, th e reg io n w as ex a m in ed ra d io g ra p h ica lly . A ra d io lu cen t le sio n , a p p ro x im a tely 2 .5 cm in d iam eter, w as see n at th e an g le of th e left sid e of th e m a n d ib le (Fig 4). T h e in ferio r, la tera l, and m e d ia l co rtex es h ad b een destroyed . A th in , slig h tly sca llo p e d , sh e ll-lik e co rtex w as v isib le at th e p e rip h e ry o f th e le sio n . In sev era l v iew s, th e fo llic le o f th e th ird m o lar w as n o tice d to b e iso la ted from th e m o re p ro m in en t ra d io lu c e n t area. A lth o u g h n o t ev id en t on co n v e n tio n a l rad io g rap h s, tra b ecu la r b o n e or o steo id w as seen w ith in th e ra d io lu c e n t cav ity on x ero ra d io g ra p h ic im ag es (Fig 5). Su b seq u en t r a d io n u c lid e s tu d ie s w ith
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F ig 4 ■ Left, d e stru ctio n o f a n g le o f m a n d ib le is ev id en t. L e sio n h a s ero d ed th ro u g h c o rte x and th e r e is n o ev id e n ce o f re a c tiv e b o n e at m a rg in s . R ig h t, o n c o n v e n tio n a l p e r ia p ic a l v iew , e v id e n c e o f p e rio s te a l re a ctio n an d p e rio s te a l n ew bon e is seen a t la te r a l m a r g in s o f lesio n .
te c h n e tiu m " sh o w ed rap id u p tak e d u rin g th e v as cu la r p h ase and n orm al u ptake d u rin g d elayed im a g ing (Fig 6). S e le c tiv e arterio g rap h y o f th e le ft e x tern a l ca ro tid artery w as done and fillin g sh o w ed latera l and o b liq u e p ro je c tio n s (Fig 7). A b n o rm al v ascu larity w as observ ed n ear th e reg io n o f th e m an d ib u lar le sio n w it h m u l t i p l e v e s s e l s s h o w in g a s e r p e n t i n e , co rk screw co n fig u ratio n . T h e se v e sse ls app eared to arise p re d o m in a n tly from th e p ro x im a l fa cia l artery and p o ssib ly from th e su b m en tal artery. D isp la ce m e n t o f b r a n c h e s o f th e m a x illa r y a r te r ie s w as n o ticed . H isto lo g ic ex a m in a tio n o f th e tu m or d is clo sed an o steo b lasto m a (Fig 8).
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D iscussion T h e o d o n to g e n ic k eratocyst, am e lo b lasto m a, o ste o b la sto m a, and ce n tra l m u co ep id erm o id carcin o m a are fou r ly tic le sio n s of the re g io n o f m an d ib u lar m o lar to ram u s that appear in fre q u e n tly but th at have d istin g u ish in g rad io g rap h ic a p p e aran ce s and requ ire fu rth er ra d io lo g ic ev alu atio n . T h e s e le sio n s are s im i lar in th a t th e y often cau se sw e llin g w ith o u t pain , o ften ap p ear ra d io g ra p h ica lly to be m o re co m p le x th a n a sim p le sm all c y stlik e ra d io lu c e n t area, are treated su rg ica lly , and m ay (F ig 9) re cu r w h en in co m p le te ly e x cise d . S o m e are o f co n c e rn b eca u se of th e h ig h m o rb id ity a sso ciate d w ith them . T h e o d o n to g e n ic k eratocy st, as a sp e c ific en tity , h as evolved o n ly d uring th e past 20 y ears. It w as first id e n tifie d in 1 9 6 0 by S h e a r2 as a le sio n w ith u n iq u e m ic ro sco p ic featu res; he d esig n ated it as a p rim ord ial
F ig 5 ■ T o p , la te ra l o b liq u e x e ro ra d io g ra p h fu rth e r sh o w s p ro m in en t p e rio s te a l n ew bo n e p ro d u ced a t p e rip h ery o f lesio n . B o tto m , tr a b e c u la r o r o steo id s tru c tu re w a s v is ib le w ith in le sio n s w h en v iew e d b y x e r o r a dio g rap h .
Reiskin-Valachovic : EVALUATION OF RADIOLUCENT LESIONS OF MANDIBLE ■ 773
F ig 7 ■ T op , h ig h ly v a s c u l a r le s io n is s e e n on s e le c tiv e a r t e r io g r a p h y . In a d d itio n to i n v o lv e m en t o f m a jo r v essels, c e n tr a l blu sh sh o w s ev id e n ce o f p r o life r a tio n o f m u lti p le s m a lle r v essels. B o t to m , s u b tr a c t e d
v ie w
s h o w s v a s c u l a r p a tte r n w it h o u t s u p e r i m p o s e d F ig 6 ■ F lo w stu d ies o b tain ed d u rin g bo n e s ca n
l
sh o w a re a o f ex c e s s iv e u p tak e in re g io n o f m a n d ib u la r a n g le.
Fig 8 ■ F ie ld sh o w s fib ro a n g io m a to u s stro m a c o n ta in in g m an y m u lti n u cle a te d g ia n t c e lls a s s o cia te d w ith tr a b e c u la e o f ce llu la r o steoid . N otice d e lic a te v a s cu la rity an d d ila te d c a p illa r ie s (co u rtesy o f D r. E lle n E isen b erg , d iv is io n o f o r a l p a th o lo g y , U n iv e r s ity o f C o n n e c tic u t H e a lth C e n ter; h e m a to x y lin & eo sin , o rig in a l m a g n ific a tio n X 2 50.) F ig 9 ■ L a te ra l o b liq u e v iew o f m a n d ib le a fte r ex c is io n o f a m elo b la sto m a sh o w s tw o ra d io lu c e n t a re a s , o n e n e a r lin g u la an d one
cy st. It has b een su b seq u en tly rev iew ed by B ro w n ,3'4 P in d b o rg and H a n se n ,5 H j0 rtin g -H a n se n ,6 P a y n e ,7 an d B ra n n o n .8 In ad d itio n to the u n u su al m icro sco p ic featu res, th e o d o n to g e n ic k era to cy st is re la tiv e ly ag g ressiv e and h as th e ca p a city to ra p id ly d estroy large areas o f bone. T h e e p ith e lia l lin in g m ay e x h ib it a high rate o f p ro lifera tio n , su g g estiv e o f a c y s tic n e o p la sm .9 T h e o d o n to g e n ic k era to cy st is treated su rg ica lly and h as a h ig h rate o f re cu rre n c e w h en in c o m p le te ly e x c is e d .3-4,l0‘ 12 T h is m ay be related to the fo rm atio n of sa te llite c y s ts .13 R e cu rre n ce has varied from 1 5 % to 6 0 % . A lth o u g h , by its n atu re, th e o d o n to g e n ic k era to cy st is asso cia te d w ith th e cro w n o f an im p acted or 774 ■ JADA, Vol. 101, November 1980
d ista l to la st m o la r. C o m p a riso n w ith p re v io u s e x a m in a tio n s su g g ests th a t ra d io lu c e n t a r e a s d o n ot re p re s e n t h ea lin g s u rg ic a l d e fects. P ro b a b ility o f re c u rre n c e is h ig h .
u n eru p ted to o th ap p ro x im a tely 5 0 % o f th e tim e, it also o ccu rs as a resid u a l le sio n up to 3 0 % o f th e tim e, m o st o ften ap p earin g in th e reg io n of th e m a n d ib u lar m o la r to th e ram u s. T h e im a g e th e o d o n to g e n ic k e r a t o c y s t u s u a lly s h o w s in c o n v e n t i o n a l r a d io g rap h y is a sm a ll, lo c a liz e d , w ell-d em a rcate d ly tic le sio n o f b o n e. H ow ever, it has b ee n estim ated that a p p ro x im a tely a th ird o f th e le sio n s are q u ite large
and may be m ultilocular or m ulticystic.8 Because of its rapid growth, reactive bone is rarely seen at its margins. The ameloblastoma has been well described in the literature.1418 Like the odontogenic keratocyst, it is a benign odontogenic neoplasm that often occurs in the region of the m andibular m olar to the ramus, fre quently recurs if inadequately excised, and is locally aggressive.18 Small and W aldron19 reviewed several cases of ameloblastomas and found that the mean age for appearance was 33 years and that the ameloblas tomas were detected in the mandible approxim ately 80% of the time. They said that these lesions consti tuted 1% to 2.3% of all tumors and cysts appearing in and about the jaws. Sehdev and others18 reviewed 92 cases of am eloblastom a treated during a 20-year period. They found that curettage was followed by local recurrence in approxim ately 90% of the m an dibular lesions and in all of the m axillary lesions. Subsequent resection could control 80% of the m an dibular lesions but only a fraction of the m axillary re currences. Radiographically, the ameloblastoma can appear in various ways— from a small cystlike ra diolucent lesion of bone to a large, m ultilocular, ag gressive and destructive lesion of bone that spreads to the soft tissue. Prim ary m ucoepiderm oid carcinom a of the jaws is an extremely uncom m on lesion. Strict criteria for the diagnosis of m ucoepiderm oid carcinom a of central origin have recently been proposed.20,21 Using these strict criteria, Frederickson and Cherrick21 found that fewer than 14 acceptable cases have been reported in the literature. Most of these docum ented lesions af fected the region of the mandibular molars to the ramus, and conservative therapy (local excision) was most often followed by local recurrence. In a review by Eversole and others,22 swelling was an initial symptom in 81.5% of the cases, whereas pain was an initial symptom in 40.7% of the cases. Recurrence of th e le s io n s w as a p p r o x i m a t e l y 3 0 % . R a d io graphically, the central m ucoepiderm oid carcinom a has been variously described as a small, circular cystlike lytic area23 to a m ultilocular radiolucent area with considerable destruction of bone.24 According to Gorlin and Goldman,17 osteoblastoma rarely arises from the periosteum or peripheral cortex. The condition is most com m on in children and ado lescents and seems to have a predilection for males. Osteoblastoma is significant because of its potential for growth and because it is usually a nonpainful le sion. As with the other lesions that have been dis cussed, sclerotic bone is rarely seen at the periphery. Careful radiographic evaluation of the jaws can clearly disclose the size and character of many lytic lesions. The quality of the boundaries around the le sion may provide important indications about the na ture of the pathologic process. In general, the pres ence of dense or sclerotic margins suggests lesions that are slow growing and benign by virtue of their tendency to provoke a host response. However, lytic
lesions that are multilocular and lack well-defined margins but show a tendency to destroy bone suggest a higher probability of aggressive benign or m alig nant lesions. When lesions in these latter categories are encountered, the value of com prehensive ra diologic evaluation should be given careful consid eration. In addition to conventional radiographs, other radiologic procedures including radionuclide scan, tom ography, xeroradiography, and arteriog raphy can increase the inform ation data base on which therapy is determined. Conventional radiographs provide high-resolution images of bone. They are of considerable value in the primary assessment of the size, location, and charac ter of most bony lesions. The radionuclide scan shows the pathophysiologic nature that may be important in the evaluation of rapidly progressing lesions. A ssum ing that 30% to 60% of the calcified material must be lost from bone to provide evidence of radiographic change, the image in conventional radiography may be somewhat deceptive in com parison with the ra dionuclide scan. Such radionuclide studies can show whether a lesion has a significant vascular com po nent. This is determined by exam ining the distribu tion of isotope immediately after an intravascular in jection. The metabolic activity of the lesion can also be established through images obtained after the isotope has been cleared from the vascular pool. An additional benefit of bone scanning is the ability to determine whether the biologic or m etabolic bound aries of a lesion coincide with those observed on a ra diograph and to establish w hether secondary or metastatic lesions are present elsewhere in the skele ton.25 A rte rio g ra p h y is often o b lig a to ry after a ra dionuclide study has established that a lesion is vas cular in nature. The radionuclide study can establish the relative size of the vascular pool but cannot iden tify the specific vessels involved. A rteriography, however, provides specific information on the ana tomic basis of the blood supply of the lesion so that appropriate steps can be taken during surgery to pre vent unexpected or excessive bleeding. In some in stances, embolization of the blood supply to the le sion can be achieved as a part of the angiographic procedure before surgical m anipulation. It should be recognized that each radiologic proce dure has limitations. Positive results of bone scans, for example, can occur as a result of infection, surgi cal manipulation, or both. The m argins of a lesion on conventional radiographs can be altered through changes in technique or by the use of specific com bi nations of the film and screen. Similarly, technical er rors can destroy the advantage of electrostatic im ag ing systems in defining fine detail and soft tissue. In selected cases, tom ography can more com pletely define the extent of bony le sio n s.26 H ow ever, it should be noted that the risk of false-positive and false-negative results is high when tom ography is the p rim a ry or o n ly ra d io g ra p h ic e x a m in a tio n .27
Reiskin-Valachovic : EVALUATION OF RADIOLUCENT LESIONS OF MANDIBLE ■ 775
Xeroradiographs require greater exposure than film but provide images with extraordinary detail.28 Edge enhancem ent that occurs with these electrostatic im ages enables soft tissue com ponents of lesions and poorly calcified structures that are otherwise missed to be viewed. In the second case, the presence of os teoid material was shown on xeroradiographs but was not evident on conventional radiographs.
Summary Careful attention to technique is of utmost impor tance in instances in w hich clinical evidence indi cates that the osteolytic or osteogenic margins of a le sion may extend beyond those visible on a conven tional radiograph. Procedures such as radionuclide scans should be used to establish the appropriate boundaries for surgical resection in such instances. Although early surgical intervention will usually lead to a definitive histopathologic diagnosis, there is some risk that manipulation will either compromise the validity of later radiological procedures or extend the disease by local dissemination or blood-borne métastasés. Appropriate radiologic evaluation of lytic lesions of the mandible can provide a m axim um amount of information so that surgical resection of the lesion will be com plete, and the possibility of re currence will be reduced.
Dr. R e isk in is p rofesso r, d iv isio n o f o ral rad io lo g y , U n iv ersity o f C o n n e c ticu t, F arm in g to n , an d Dr. V a la ch o v ic is re search fello w , H arvard U n iv ersity S ch o o l o f D en tal M e d icin e , B o sto n . A d d ress req u ests for re p rin ts to Dr. R e is kin.
C lin ica l and ro en tg e n o lo g ic a sp ects o f o d o n to g en ic k era to cy sts. A cta P atho l M icro b io l (S can d ) 5 8 :2 8 3 -2 9 4 , 1 9 6 3 . 6 . H j0 rtin g -H a n sen , E .; A n d rea sen , J.O .; and R o b in so n , L.H. A stud y of o d o n to g en ic cy sts, w ith sp e c ia l re feren ce to lo c a tio n o f k era to cy sts. B r J O ral S u rg 7 :1 5 -2 3 , 1 9 6 9 . 7. P ayn e, T .F . A n a n a ly sis o f th e c lin ic a l and h is to p a th o lo g ic p aram eters o f th e o d o n to g en ic k eratocyst. O ral S u rg 3 3 :5 3 8 -5 4 6 , 1 9 7 2 . 8 . B ra n n o n , R .B . T h e o d o n to g e n ic k era to cy st: a c lin ic o p a th o lo g ic stud y of 3 1 2 ca ses. C lin ica l featu res. O ral Surg 4 2 { l) :5 4 - 7 2 , 1 9 7 6 . 9. M ain , D.M . E p ith e lia l ja w cy sts: a clin ic o p a th o lo g ic a l rea p p ra isa l. B r J O ral Su rg 8 :1 1 4 -1 2 5 , 1 9 7 0 . 10. F o rsse ll, K .; S orv ari, T .E .; and O ksala, E. A c lin ic a l and rad iog rap h ic study o f o d o n to g en ic k era to cy sts in ja w s. P roc F in n D en t S o c 7 0 (4 ]:1 2 1 -1 3 4 , 1974. 11. B ram ley , P. T h e o d o n to g en ic k eratocyst— an a p p ro a ch to treatm ent. Int J O ral Surg 3 (5 ):3 3 7 -3 4 1 , 1 9 7 4 . 1 2. D onoff, R .B .; G u ra ln ick , W .C .; and C laym an , L. K era to cy sts o f the ja w s. J O ral S u rg 3 0 ( l l ) :8 0 0 - 8 0 4 , 1 9 7 2 . 1 3 . K eith , D .A. M a c ro sco p ic sa te llite cy st fo rm a tio n in th e o d o n to g en ic k eratocyst. R eport o f tw o ca se s. J O ral Surg 3 5 :2 1 -2 7 , 1 9 7 3 . 1 4 . G old w y n , R .; C o n sta b le, ).; and M u rray, J.E. A m e lo b la sto m a of the jaw — a c lin ic a l stud y. N E n g l J M ed 2 6 9 (3 ):1 2 6 -1 2 9 , 1 9 6 3 . 15. M e h lisch , D .R.; D a h lin , D.C.; and M asso n , J.K . A m elob lasto m a— a c lin ic o p a th o lo g ic rep o rt. J O ral Surg 3 0 :9 - 2 2 ,1 9 7 2 . 16. S h a tk in , S ., and H offm eister, F .S . A m elo b la sto m a — a ra tio n a l a p p ro a ch to th erapy. O ral S u rg 2 0 (4 ):4 2 1 -4 3 5 , 1 9 6 5 . 1 7 . G orlin , R .J., and G old m an , H .M . (ed s.j. T h o m a ’s o ral p a th o log y , ed 6 . St, L o u is, C. V. M osby, 1 9 7 0 . 18. S eh d ev , M .K ., an d o th ers. A m elo b la sto m a o f m a x illa and m an d ible. C an cer 3 3 (2 ):3 2 4 -3 3 3 , 1 9 7 4 . 1 9 . S m a ll, I.A ., and W ald ron , C.A. A m elo b la sto m a s o f th e jaw s. O ral Surg 8 :2 8 1 -2 9 7 , 1 9 5 5 . 2 0 . A lex a n d er, R .W .; D upu is, R.H .; and H olton , H. C entral m u co e p id er m oid tu m o r (carcin om a) o f th e m a n d ib le . J O ral Surg 3 2 {7 ):5 4 1 -5 4 7 , 1 9 7 4 . 2 1 . F re d rick so n , C., and C h errick , H .M . C entral m u co e p id erm o id ca r cin o m a o f th e jaw s. J O ral M ed 3 3 (3 ):8 0 -8 5 , 1 9 7 8 . 2 2 . E v ersole, L .R .; S a b es, W .R .; and R o v in , S . A g g re ssiv e g row th and n e o p la stic p o ten tia l o f o d o n to g en ic cy sts w ith sp ec ia l re feren ce to cen tra l ep id erm oid and m u co ep id erm o id ca rcin o m a s. C an cer 3 5 :2 7 0 -2 8 2 , 1 9 7 5 . 2 3 . B h ask ar, S.N . C entral m u co e p id erm o id tu m o rs o f th e m a n d ib le— report o f tw o ca se s. C an cer 1 6 {6 ):7 2 1 -7 2 6 , 1 9 6 3 . 2 4 . B row n , A .M ., and L u cch e si, F .J. C entral m u co e p id erm o id tu m o r o f the m an d ible: report of case. J Oral Surg 2 4 :3 5 6 -3 6 4 , 1 9 6 6 . 25. Lu rie, A .G ., and others. R a d io n u clid e b o n e im a g in g in th e su rg ica l
1. Jo s e ll, S.D .; R e isk in , A .B .; an d G ross, B.D . D en tig erou s cy st w ith m ural am elo blasto m a. JA D A 9 9 (1 0 ]:6 3 4 -6 3 6 , 19 7 9 . 2. S h ear, M . P rim ord ial cy sts. J D ent A sso c S A fr 1 5 :2 1 1 -2 1 7 , 1 9 6 0 . 3. B ro w n e , R.M . T h e o d o n to g en ic k eratocyst. C lin ica l asp ects. B r D en t J 1 2 8 :2 2 5 -2 3 1 , 1 9 7 0 . 4 . B ro w n e , R .M . T h e o d o n to g en ic k eratocy st. H isto lo g ic a l featu res and th e ir c o rrela tio n w ith c lin ic a l beh av io r. B r D en t J 1 3 1 :2 4 9 - 2 5 9 ,1 9 7 1 . 5. P in d borg , J.J., and H an sen , J. S tu d ies on o d o n to g en ic cy st ep ith eliu m .
776 ■ JADA, Vol. 101, November 1980
treatm en t p la n n in g o f o d o n to g en ic k eratocysts. O ral S u rg 4 2 {6 ):7 2 6 -7 3 0 , 1976. 2 6 . D u n sw orth , A .R .; By rd , D .L.; and A lle n , J.W . T o m o g ra p h y in oral surgery. J O ral Surg 3 2 (9 ):6 9 6 -7 0 1 , 1 9 7 4 . 2 7 . S ca n d rett, F .R ., and others. R a d io g ra p h ic e x a m in a tio n o f th e ed en tu lo u s p atien t. R eview o f th e litera tu re and p relim in a ry rep o rt co m p arin g th ree m etho d s. O ral Su rg 3 5 (2 ):2 6 6 -2 7 4 , 1 9 7 3 . 2 8. W olfe, J.N . X ero ra d io g ra p h y of th e b o n es, jo in ts , a n d soft tissu e s. R a d io l 9 3 ( 3 ) :5 8 3 - 5 8 7 ,1 9 6 9 .
Radiologic considerations in evaluation of radiolucent lesions of the mandible A llan B. Reiskin, DDS, D Phil R ichard W. V alachovic, DMD
j l n a re cen t issu e o f T h e J o u r n a l, w e rep o rted th e case o f a 14-year-o ld b la ck g irl w ho h ad a ly tic le sio n in the p o sterior reg io n o f th e m a n d ib le .1 T h e ca se illu strated th e value o f a co m p reh en siv e ra d io lo g ic ev alu atio n based on h isto ry and p h y sica l ex a m in a tio n and also sh o w ed th e risk asso cia te d w ith a failu re to give ad equ ate co n sid e ra tio n to a ll o f th e fin d in g s o f the data base. T h e ro le o f th e ra d io lo g ic ex a m in a tio n in th e ev alu atio n o f ly tic le sio n s w as d iscu ssed . Tw o a d d itio n al ca se s are cu rre n tly p resen ted in w h ich the treatm en t of serio u s ly tic le sio n s o f the m an d ib le w as clea rly in flu en ced by th e re su lts o f ra d io lo g ic fin d in g s. E ach ca se illu strated th e ad v an tag es of sp e c ific ty p es o f e x a m in a tio n s in th e ev a lu a tio n o f ly tic le sio n s an d th e fo rm u latio n o f treatm en t p lan s. A lth o u g h rad io g rap h s a lo n e rarely p rovide the c lin ic ia n w ith a d e fin itiv e d iag n o sis, th e co m b in ed v alu e o f d ifferen t ra d io lo g ic p ro ced u res ca n sig n ifi ca n tly ad v an ce a c lin ic ia n ’s u n d erstan d in g o f the b io lo g ica l ch a ra cte ristic s and bo u n d aries o f ly tic le sio n s of the m an d ib le. T h is in fo rm atio n is essen tia l in e s ta b lish in g th e m o st ap p ro p riate th e ra p e u tic a p proach.
Report of cases CASE l . T h e p a tien t, a 6 8 -y e a r-o ld w h ite m an , ca m e to th e U n iv e rs ity o f C o n n e c tic u t S c h o o l o f D e n ta l M e d icin e on Jan 1 4, 1 9 8 0 , for ro u tin e d en tal care. He w as in good h ealth at th at tim e; th e m e d ica l h isto ry w as n o n co n trib u to ry and did n ot co n tra in d ica te d e n ta l th e ra p y . P re v io u s d e n ta l ca r e a p p e a red to be e p iso d ic. E xtraoral e x a m in a tio n o f th e head and n eck d isc lo se d a fa cia l asy m m etry w ith en la rg em en t o f the rig h t m a n d ib u lar an g le. L y m p h a d en o p a th y , sw ellin g o f th e m ajo r salivary g lan d s, or p a re sth e sia o f an y area o f th e fa ce or n eck w as n o t ap p aren t. C lin ica l d en tal ex a m in a tio n d isclo se d m an y m issin g , fractu red , and ca rio u s teeth w ith m o d era tely in fla m ed gin g iv a. A n u lcera ted and in d u rated le sio n a p p ro x im a tely 1 m m in d iam eter w as p resen t d istal to th e m an d ib u la r righ t first m o lar on one ed en tu lo u s rid ge. R a d io g ra p h ic e x a m in a tio n d isclo sed a large, m u ltilo c u la r ra d io lu cen t area a p p rox im ately 2 .5 cm in d ia m e te r in th e re g io n o f th e righ t m an d ib u lar m o lar to th e ram us (Fig 1). T h e m ed ial p late o f m a n d ib u lar b o n e h ad b een d estroyed an d th ere w as no ra d io g ra p h ic e v id e n c e of re a ctiv e JADA, Vol. 101, November 1980 ■ 771
F ig 2 ■ Q u a lity o f p e rip h e ra l m a rg in s v a rie d fro m o n e p a rt o f le sio n to a n o th e r. No co rte x w as v isib le alo n g s u p e rio r a sp e c t o f le sion .
F ig 1 ■ T o p , p e ria p ic a l v iew o f re g io n o f m a n d ib u la r m o la r sh ow s m u ltilo c u la r ra d io lu c e n t d e fect in re g io n o f m issin g m o la rs. Bottom , p e ria p ic a l v iew o f m a n d ib le m ore c le a rly sh o w s m u ltilo c u la r an d d e s tru ctiv e n a tu r e o f lesio n .
fo rm a tio n o f b o n e at th e p erip h ery o f th e le sio n . A la t eral v iew (Fig 2) sh o w ed th at th e le sio n w as su r ro u n d ed by a th in , feath ered m arg in e x c e p t at its m o st su p erio r asp e ct, w h ere a co m m u n ic a tio n w ith th e soft tissu e in th e re tro m o lar pad re g io n w as ev id en t. T h e m a n d ib u la r ca n a l cu rv ed in terio rly but th e bon y m a r g in s w ere in ta ct. F u rth er q u estio n in g o f th e p a tien t after th e ra d io g ra p h ic ex a m in a tio n in d ica ted th at the m a n d ib u la r rig h t seco n d m o lar h ad b e e n ex tracted w ith o u t co m p lic a tio n s ap p ro x im ately 16 years ea r lier. O n th e b asis o f c lin ic a l and ra d io g ra p h ic ev id en ce, th e d iffe re n tia l d ia g n o sis in c lu d e d o d o n to g e n ic cy st; o d o n to g e n ic k e ra to c y st; a m e lo b la sto m a ; m y xo m a ; an d o th e r m o re s e r io u s le s io n s , in c lu d in g m u co e p id e rm o id ca rcin o m a , eith e r ce n tra l or p e rip h era l; and ep id erm o id carcin o m a. In flam m ato ry and g ran u lo m ato u s d isease co u ld n ot be ex clu d e d . A n in c is io n a l b io p sy sp e cim en w as tak en on Jan 2 1 , 1 9 8 0 . H isto lo g ic ev alu atio n d isc lo se d a w e ll-d iffe r en tiated m u co ep id erm o id ca rcin o m a (Fig 3). CASE 2. T h e p a tie n t, a 10-y ear-o ld H isp a n ic g irl, cam e for treatm en t b ec a u se o f a six -w ee k h isto ry o f firm sw ellin g over th e an g le o f th e le ft sid e o f th e m a n d i b le. O n set of th e sw ellin g w as su d d en an d w as a s so cia te d w ith a lo w -grad e fever. A c lin ic a l d ia g n o sis o f “ strep th ro a t” w as m ade at th at tim e. T re a tm e n t w ith an a n tib io tic p ro d u ced s u b je c tiv e r e lie f al772 ■ JADA, Vol. 101, November 1980
F ig 3 ■ F ie ld sh ow s u n e n ca p su la te d m a ss o f n e o p la s tic tis s u e c h a r a c te riz ed by n ests o f s tra tifie d sq u am o u s e p ith eliu m co n ta in in g m u cou ss e c re tin g c e lls u n d erg o in g c y s tic d e g en era tio n . N o tice c y s tic n est sh ow in g p a p illa ry c o n fo rm a tio n on rig h t c e n te r o f field (co u rtesy o f Dr. E lle n E isenb e rg , d iv isio n o f o ra l p a th o lo g y , U n iv ersity o f C o n n e cticu t H ea lth C en ter; h em a to x y lin & eo sin , o rig in a l m a g n ific a tio n X 2 4 0 .)
though the swelling remained. The patient was later referred to a community health center where a clini cal diagnosis of mumps was made. C o n v en tio n a l m e d ica l th erap y w as u n su cc e ssfu l and , w h en th e sw e llin g did n o t reso lv e, th e reg io n w as ex a m in ed ra d io g ra p h ica lly . A ra d io lu cen t le sio n , a p p ro x im a tely 2 .5 cm in d iam eter, w as see n at th e an g le of th e left sid e of th e m a n d ib le (Fig 4). T h e in ferio r, la tera l, and m e d ia l co rtex es h ad b een destroyed . A th in , slig h tly sca llo p e d , sh e ll-lik e co rtex w as v isib le at th e p e rip h e ry o f th e le sio n . In sev era l v iew s, th e fo llic le o f th e th ird m o lar w as n o tice d to b e iso la ted from th e m o re p ro m in en t ra d io lu c e n t area. A lth o u g h n o t ev id en t on co n v e n tio n a l rad io g rap h s, tra b ecu la r b o n e or o steo id w as seen w ith in th e ra d io lu c e n t cav ity on x ero ra d io g ra p h ic im ag es (Fig 5). Su b seq u en t r a d io n u c lid e s tu d ie s w ith
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F ig 4 ■ Left, d e stru ctio n o f a n g le o f m a n d ib le is ev id en t. L e sio n h a s ero d ed th ro u g h c o rte x and th e r e is n o ev id e n ce o f re a c tiv e b o n e at m a rg in s . R ig h t, o n c o n v e n tio n a l p e r ia p ic a l v iew , e v id e n c e o f p e rio s te a l re a ctio n an d p e rio s te a l n ew bon e is seen a t la te r a l m a r g in s o f lesio n .
te c h n e tiu m " sh o w ed rap id u p tak e d u rin g th e v as cu la r p h ase and n orm al u ptake d u rin g d elayed im a g ing (Fig 6). S e le c tiv e arterio g rap h y o f th e le ft e x tern a l ca ro tid artery w as done and fillin g sh o w ed latera l and o b liq u e p ro je c tio n s (Fig 7). A b n o rm al v ascu larity w as observ ed n ear th e reg io n o f th e m an d ib u lar le sio n w it h m u l t i p l e v e s s e l s s h o w in g a s e r p e n t i n e , co rk screw co n fig u ratio n . T h e se v e sse ls app eared to arise p re d o m in a n tly from th e p ro x im a l fa cia l artery and p o ssib ly from th e su b m en tal artery. D isp la ce m e n t o f b r a n c h e s o f th e m a x illa r y a r te r ie s w as n o ticed . H isto lo g ic ex a m in a tio n o f th e tu m or d is clo sed an o steo b lasto m a (Fig 8).
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D iscussion T h e o d o n to g e n ic k eratocyst, am e lo b lasto m a, o ste o b la sto m a, and ce n tra l m u co ep id erm o id carcin o m a are fou r ly tic le sio n s of the re g io n o f m an d ib u lar m o lar to ram u s that appear in fre q u e n tly but th at have d istin g u ish in g rad io g rap h ic a p p e aran ce s and requ ire fu rth er ra d io lo g ic ev alu atio n . T h e s e le sio n s are s im i lar in th a t th e y often cau se sw e llin g w ith o u t pain , o ften ap p ear ra d io g ra p h ica lly to be m o re co m p le x th a n a sim p le sm all c y stlik e ra d io lu c e n t area, are treated su rg ica lly , and m ay (F ig 9) re cu r w h en in co m p le te ly e x cise d . S o m e are o f co n c e rn b eca u se of th e h ig h m o rb id ity a sso ciate d w ith them . T h e o d o n to g e n ic k eratocy st, as a sp e c ific en tity , h as evolved o n ly d uring th e past 20 y ears. It w as first id e n tifie d in 1 9 6 0 by S h e a r2 as a le sio n w ith u n iq u e m ic ro sco p ic featu res; he d esig n ated it as a p rim ord ial
F ig 5 ■ T o p , la te ra l o b liq u e x e ro ra d io g ra p h fu rth e r sh o w s p ro m in en t p e rio s te a l n ew bo n e p ro d u ced a t p e rip h ery o f lesio n . B o tto m , tr a b e c u la r o r o steo id s tru c tu re w a s v is ib le w ith in le sio n s w h en v iew e d b y x e r o r a dio g rap h .
Reiskin-Valachovic : EVALUATION OF RADIOLUCENT LESIONS OF MANDIBLE ■ 773
F ig 7 ■ T op , h ig h ly v a s c u l a r le s io n is s e e n on s e le c tiv e a r t e r io g r a p h y . In a d d itio n to i n v o lv e m en t o f m a jo r v essels, c e n tr a l blu sh sh o w s ev id e n ce o f p r o life r a tio n o f m u lti p le s m a lle r v essels. B o t to m , s u b tr a c t e d
v ie w
s h o w s v a s c u l a r p a tte r n w it h o u t s u p e r i m p o s e d F ig 6 ■ F lo w stu d ies o b tain ed d u rin g bo n e s ca n
l
sh o w a re a o f ex c e s s iv e u p tak e in re g io n o f m a n d ib u la r a n g le.
Fig 8 ■ F ie ld sh o w s fib ro a n g io m a to u s stro m a c o n ta in in g m an y m u lti n u cle a te d g ia n t c e lls a s s o cia te d w ith tr a b e c u la e o f ce llu la r o steoid . N otice d e lic a te v a s cu la rity an d d ila te d c a p illa r ie s (co u rtesy o f D r. E lle n E isen b erg , d iv is io n o f o r a l p a th o lo g y , U n iv e r s ity o f C o n n e c tic u t H e a lth C e n ter; h e m a to x y lin & eo sin , o rig in a l m a g n ific a tio n X 2 50.) F ig 9 ■ L a te ra l o b liq u e v iew o f m a n d ib le a fte r ex c is io n o f a m elo b la sto m a sh o w s tw o ra d io lu c e n t a re a s , o n e n e a r lin g u la an d one
cy st. It has b een su b seq u en tly rev iew ed by B ro w n ,3'4 P in d b o rg and H a n se n ,5 H j0 rtin g -H a n se n ,6 P a y n e ,7 an d B ra n n o n .8 In ad d itio n to the u n u su al m icro sco p ic featu res, th e o d o n to g e n ic k era to cy st is re la tiv e ly ag g ressiv e and h as th e ca p a city to ra p id ly d estroy large areas o f bone. T h e e p ith e lia l lin in g m ay e x h ib it a high rate o f p ro lifera tio n , su g g estiv e o f a c y s tic n e o p la sm .9 T h e o d o n to g e n ic k era to cy st is treated su rg ica lly and h as a h ig h rate o f re cu rre n c e w h en in c o m p le te ly e x c is e d .3-4,l0‘ 12 T h is m ay be related to the fo rm atio n of sa te llite c y s ts .13 R e cu rre n ce has varied from 1 5 % to 6 0 % . A lth o u g h , by its n atu re, th e o d o n to g e n ic k era to cy st is asso cia te d w ith th e cro w n o f an im p acted or 774 ■ JADA, Vol. 101, November 1980
d ista l to la st m o la r. C o m p a riso n w ith p re v io u s e x a m in a tio n s su g g ests th a t ra d io lu c e n t a r e a s d o n ot re p re s e n t h ea lin g s u rg ic a l d e fects. P ro b a b ility o f re c u rre n c e is h ig h .
u n eru p ted to o th ap p ro x im a tely 5 0 % o f th e tim e, it also o ccu rs as a resid u a l le sio n up to 3 0 % o f th e tim e, m o st o ften ap p earin g in th e reg io n of th e m a n d ib u lar m o la r to th e ram u s. T h e im a g e th e o d o n to g e n ic k e r a t o c y s t u s u a lly s h o w s in c o n v e n t i o n a l r a d io g rap h y is a sm a ll, lo c a liz e d , w ell-d em a rcate d ly tic le sio n o f b o n e. H ow ever, it has b ee n estim ated that a p p ro x im a tely a th ird o f th e le sio n s are q u ite large
and may be m ultilocular or m ulticystic.8 Because of its rapid growth, reactive bone is rarely seen at its margins. The ameloblastoma has been well described in the literature.1418 Like the odontogenic keratocyst, it is a benign odontogenic neoplasm that often occurs in the region of the m andibular m olar to the ramus, fre quently recurs if inadequately excised, and is locally aggressive.18 Small and W aldron19 reviewed several cases of ameloblastomas and found that the mean age for appearance was 33 years and that the ameloblas tomas were detected in the mandible approxim ately 80% of the time. They said that these lesions consti tuted 1% to 2.3% of all tumors and cysts appearing in and about the jaws. Sehdev and others18 reviewed 92 cases of am eloblastom a treated during a 20-year period. They found that curettage was followed by local recurrence in approxim ately 90% of the m an dibular lesions and in all of the m axillary lesions. Subsequent resection could control 80% of the m an dibular lesions but only a fraction of the m axillary re currences. Radiographically, the ameloblastoma can appear in various ways— from a small cystlike ra diolucent lesion of bone to a large, m ultilocular, ag gressive and destructive lesion of bone that spreads to the soft tissue. Prim ary m ucoepiderm oid carcinom a of the jaws is an extremely uncom m on lesion. Strict criteria for the diagnosis of m ucoepiderm oid carcinom a of central origin have recently been proposed.20,21 Using these strict criteria, Frederickson and Cherrick21 found that fewer than 14 acceptable cases have been reported in the literature. Most of these docum ented lesions af fected the region of the mandibular molars to the ramus, and conservative therapy (local excision) was most often followed by local recurrence. In a review by Eversole and others,22 swelling was an initial symptom in 81.5% of the cases, whereas pain was an initial symptom in 40.7% of the cases. Recurrence of th e le s io n s w as a p p r o x i m a t e l y 3 0 % . R a d io graphically, the central m ucoepiderm oid carcinom a has been variously described as a small, circular cystlike lytic area23 to a m ultilocular radiolucent area with considerable destruction of bone.24 According to Gorlin and Goldman,17 osteoblastoma rarely arises from the periosteum or peripheral cortex. The condition is most com m on in children and ado lescents and seems to have a predilection for males. Osteoblastoma is significant because of its potential for growth and because it is usually a nonpainful le sion. As with the other lesions that have been dis cussed, sclerotic bone is rarely seen at the periphery. Careful radiographic evaluation of the jaws can clearly disclose the size and character of many lytic lesions. The quality of the boundaries around the le sion may provide important indications about the na ture of the pathologic process. In general, the pres ence of dense or sclerotic margins suggests lesions that are slow growing and benign by virtue of their tendency to provoke a host response. However, lytic
lesions that are multilocular and lack well-defined margins but show a tendency to destroy bone suggest a higher probability of aggressive benign or m alig nant lesions. When lesions in these latter categories are encountered, the value of com prehensive ra diologic evaluation should be given careful consid eration. In addition to conventional radiographs, other radiologic procedures including radionuclide scan, tom ography, xeroradiography, and arteriog raphy can increase the inform ation data base on which therapy is determined. Conventional radiographs provide high-resolution images of bone. They are of considerable value in the primary assessment of the size, location, and charac ter of most bony lesions. The radionuclide scan shows the pathophysiologic nature that may be important in the evaluation of rapidly progressing lesions. A ssum ing that 30% to 60% of the calcified material must be lost from bone to provide evidence of radiographic change, the image in conventional radiography may be somewhat deceptive in com parison with the ra dionuclide scan. Such radionuclide studies can show whether a lesion has a significant vascular com po nent. This is determined by exam ining the distribu tion of isotope immediately after an intravascular in jection. The metabolic activity of the lesion can also be established through images obtained after the isotope has been cleared from the vascular pool. An additional benefit of bone scanning is the ability to determine whether the biologic or m etabolic bound aries of a lesion coincide with those observed on a ra diograph and to establish w hether secondary or metastatic lesions are present elsewhere in the skele ton.25 A rte rio g ra p h y is often o b lig a to ry after a ra dionuclide study has established that a lesion is vas cular in nature. The radionuclide study can establish the relative size of the vascular pool but cannot iden tify the specific vessels involved. A rteriography, however, provides specific information on the ana tomic basis of the blood supply of the lesion so that appropriate steps can be taken during surgery to pre vent unexpected or excessive bleeding. In some in stances, embolization of the blood supply to the le sion can be achieved as a part of the angiographic procedure before surgical m anipulation. It should be recognized that each radiologic proce dure has limitations. Positive results of bone scans, for example, can occur as a result of infection, surgi cal manipulation, or both. The m argins of a lesion on conventional radiographs can be altered through changes in technique or by the use of specific com bi nations of the film and screen. Similarly, technical er rors can destroy the advantage of electrostatic im ag ing systems in defining fine detail and soft tissue. In selected cases, tom ography can more com pletely define the extent of bony le sio n s.26 H ow ever, it should be noted that the risk of false-positive and false-negative results is high when tom ography is the p rim a ry or o n ly ra d io g ra p h ic e x a m in a tio n .27
Reiskin-Valachovic : EVALUATION OF RADIOLUCENT LESIONS OF MANDIBLE ■ 775
Xeroradiographs require greater exposure than film but provide images with extraordinary detail.28 Edge enhancem ent that occurs with these electrostatic im ages enables soft tissue com ponents of lesions and poorly calcified structures that are otherwise missed to be viewed. In the second case, the presence of os teoid material was shown on xeroradiographs but was not evident on conventional radiographs.
Summary Careful attention to technique is of utmost impor tance in instances in w hich clinical evidence indi cates that the osteolytic or osteogenic margins of a le sion may extend beyond those visible on a conven tional radiograph. Procedures such as radionuclide scans should be used to establish the appropriate boundaries for surgical resection in such instances. Although early surgical intervention will usually lead to a definitive histopathologic diagnosis, there is some risk that manipulation will either compromise the validity of later radiological procedures or extend the disease by local dissemination or blood-borne métastasés. Appropriate radiologic evaluation of lytic lesions of the mandible can provide a m axim um amount of information so that surgical resection of the lesion will be com plete, and the possibility of re currence will be reduced.
Dr. R e isk in is p rofesso r, d iv isio n o f o ral rad io lo g y , U n iv ersity o f C o n n e c ticu t, F arm in g to n , an d Dr. V a la ch o v ic is re search fello w , H arvard U n iv ersity S ch o o l o f D en tal M e d icin e , B o sto n . A d d ress req u ests for re p rin ts to Dr. R e is kin.
C lin ica l and ro en tg e n o lo g ic a sp ects o f o d o n to g en ic k era to cy sts. A cta P atho l M icro b io l (S can d ) 5 8 :2 8 3 -2 9 4 , 1 9 6 3 . 6 . H j0 rtin g -H a n sen , E .; A n d rea sen , J.O .; and R o b in so n , L.H. A stud y of o d o n to g en ic cy sts, w ith sp e c ia l re feren ce to lo c a tio n o f k era to cy sts. B r J O ral S u rg 7 :1 5 -2 3 , 1 9 6 9 . 7. P ayn e, T .F . A n a n a ly sis o f th e c lin ic a l and h is to p a th o lo g ic p aram eters o f th e o d o n to g en ic k eratocyst. O ral S u rg 3 3 :5 3 8 -5 4 6 , 1 9 7 2 . 8 . B ra n n o n , R .B . T h e o d o n to g e n ic k era to cy st: a c lin ic o p a th o lo g ic stud y of 3 1 2 ca ses. C lin ica l featu res. O ral Surg 4 2 { l) :5 4 - 7 2 , 1 9 7 6 . 9. M ain , D.M . E p ith e lia l ja w cy sts: a clin ic o p a th o lo g ic a l rea p p ra isa l. B r J O ral Su rg 8 :1 1 4 -1 2 5 , 1 9 7 0 . 10. F o rsse ll, K .; S orv ari, T .E .; and O ksala, E. A c lin ic a l and rad iog rap h ic study o f o d o n to g en ic k era to cy sts in ja w s. P roc F in n D en t S o c 7 0 (4 ]:1 2 1 -1 3 4 , 1974. 11. B ram ley , P. T h e o d o n to g en ic k eratocyst— an a p p ro a ch to treatm ent. Int J O ral Surg 3 (5 ):3 3 7 -3 4 1 , 1 9 7 4 . 1 2. D onoff, R .B .; G u ra ln ick , W .C .; and C laym an , L. K era to cy sts o f the ja w s. J O ral S u rg 3 0 ( l l ) :8 0 0 - 8 0 4 , 1 9 7 2 . 1 3 . K eith , D .A. M a c ro sco p ic sa te llite cy st fo rm a tio n in th e o d o n to g en ic k eratocyst. R eport o f tw o ca se s. J O ral Surg 3 5 :2 1 -2 7 , 1 9 7 3 . 1 4 . G old w y n , R .; C o n sta b le, ).; and M u rray, J.E. A m e lo b la sto m a of the jaw — a c lin ic a l stud y. N E n g l J M ed 2 6 9 (3 ):1 2 6 -1 2 9 , 1 9 6 3 . 15. M e h lisch , D .R.; D a h lin , D.C.; and M asso n , J.K . A m elob lasto m a— a c lin ic o p a th o lo g ic rep o rt. J O ral Surg 3 0 :9 - 2 2 ,1 9 7 2 . 16. S h a tk in , S ., and H offm eister, F .S . A m elo b la sto m a — a ra tio n a l a p p ro a ch to th erapy. O ral S u rg 2 0 (4 ):4 2 1 -4 3 5 , 1 9 6 5 . 1 7 . G orlin , R .J., and G old m an , H .M . (ed s.j. T h o m a ’s o ral p a th o log y , ed 6 . St, L o u is, C. V. M osby, 1 9 7 0 . 18. S eh d ev , M .K ., an d o th ers. A m elo b la sto m a o f m a x illa and m an d ible. C an cer 3 3 (2 ):3 2 4 -3 3 3 , 1 9 7 4 . 1 9 . S m a ll, I.A ., and W ald ron , C.A. A m elo b la sto m a s o f th e jaw s. O ral Surg 8 :2 8 1 -2 9 7 , 1 9 5 5 . 2 0 . A lex a n d er, R .W .; D upu is, R.H .; and H olton , H. C entral m u co e p id er m oid tu m o r (carcin om a) o f th e m a n d ib le . J O ral Surg 3 2 {7 ):5 4 1 -5 4 7 , 1 9 7 4 . 2 1 . F re d rick so n , C., and C h errick , H .M . C entral m u co e p id erm o id ca r cin o m a o f th e jaw s. J O ral M ed 3 3 (3 ):8 0 -8 5 , 1 9 7 8 . 2 2 . E v ersole, L .R .; S a b es, W .R .; and R o v in , S . A g g re ssiv e g row th and n e o p la stic p o ten tia l o f o d o n to g en ic cy sts w ith sp ec ia l re feren ce to cen tra l ep id erm oid and m u co ep id erm o id ca rcin o m a s. C an cer 3 5 :2 7 0 -2 8 2 , 1 9 7 5 . 2 3 . B h ask ar, S.N . C entral m u co e p id erm o id tu m o rs o f th e m a n d ib le— report o f tw o ca se s. C an cer 1 6 {6 ):7 2 1 -7 2 6 , 1 9 6 3 . 2 4 . B row n , A .M ., and L u cch e si, F .J. C entral m u co e p id erm o id tu m o r o f the m an d ible: report of case. J Oral Surg 2 4 :3 5 6 -3 6 4 , 1 9 6 6 . 25. Lu rie, A .G ., and others. R a d io n u clid e b o n e im a g in g in th e su rg ica l
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treatm en t p la n n in g o f o d o n to g en ic k eratocysts. O ral S u rg 4 2 {6 ):7 2 6 -7 3 0 , 1976. 2 6 . D u n sw orth , A .R .; By rd , D .L.; and A lle n , J.W . T o m o g ra p h y in oral surgery. J O ral Surg 3 2 (9 ):6 9 6 -7 0 1 , 1 9 7 4 . 2 7 . S ca n d rett, F .R ., and others. R a d io g ra p h ic e x a m in a tio n o f th e ed en tu lo u s p atien t. R eview o f th e litera tu re and p relim in a ry rep o rt co m p arin g th ree m etho d s. O ral Su rg 3 5 (2 ):2 6 6 -2 7 4 , 1 9 7 3 . 2 8. W olfe, J.N . X ero ra d io g ra p h y of th e b o n es, jo in ts , a n d soft tissu e s. R a d io l 9 3 ( 3 ) :5 8 3 - 5 8 7 ,1 9 6 9 .