Benlloch, D

IEZZI, GIOVANNA

Orsini, M

PIATTELLI, Adriano

English

ARUd’A (Università “G. d’Annunzio CHIETI -PESCARA)

ZEBRA HUNTZebra XXIII, Part 2Marco Orsini, MD, DDS, Dunia Benlloch, DDS, Giovanna Iezzi, DDS, and Adriano Piattelli, MD, DDSIn the last issue of the Journal the case of a 66-yr-old femalepatient, with a noncontributory medical history, presented with a1-cm unilocular radiolucency located in the anterior mandible (Fig.1). The radiolucency was painless, round, with distinct margins,and was not in contact with the roots of the adjacent teeth. Underlocal anesthesia the lesion was separated with some difficulty fromthe bone tissue and enucleated. Macroscopically the lesion had ahard consistency.The following conditions were considered in the differentialdiagnosis: periapical granuloma, radicular cyst, periapical ce-mento-osseous dysplasia in the early lytic stage, traumatic bonecyst, odontogenic fibroma, unilocular ameloblastoma, unicysticameloblastoma, adenomatoid odontogenic tumor, calcifying odon-togenic cyst, ameloblastic fibroma, myxoma, and central giant cellgranuloma.PERIAPICAL GRANULOMAPeriapical granuloma represents the most common type ofpathological radiolucency, accounting for approximately one-halfof these lesions. Radiographically the lesion is a rather well-circumscribed radiolucency, somewhat rounded in shape, and sur-rounding the apex of a tooth. The periapical radiolucency may haveor may not have a thin radiopaque hyperostotic border.RADICULAR CYSTThis is the second most common pathological periapical radi-olucency after granuloma. The X-ray shows a well-defined peria-pical radiolucency at tooth apex. A periapical lesion is more likelyto be a radicular cyst than a periapical granuloma when the lesionmeasures more than 1.5 cm in diameter.PERIAPICAL CEMENTO-OSSEOUS DYSPLASIA IN THEEARLY LYTIC STAGEThe dental pulp of the affected tooth is vital. Radiolucencies,somewhat rounded, with well-defined borders and continuous withthe periodontal ligament space, are present. Ninety percent occur inthe mandible, with the periapical region of the incisors the mostfrequently involved site. The lesions may be solitary or multiple,and are completely asymptomatic. They seldom exceed 1 cm indiameter. Middle-aged black women are affected more often thanmales. It is unusual for a periapical cemento-osseous dysplasia tobecome large enough to produce a detectable expansion of thecortical plate.TRAUMATIC BONE CYSTIt has a peak frequency in the 2nd decade. About 90% of thecases are located in the mandible, especially in the molar area.Radiographically it is possible to observe a well-demarcated radi-olucency with an irregular but defined edge; interradicular scal-loping may be present. Sometimes there is minimal external rootresorption.ODONTOGENIC FIBROMARadiographically odontogenic fibroma typically appears assharply defined, rounded areas of lucency in a tooth-bearing area.Small lesions are usually unilocular, whereas larger ones tended toshow scalloped margins or multiloculation. All have scleroticmargins. Occasionally it is possible to find small foci of radiopac-ity, sometimes giving a ground-glass appearance to the lesion. Inone third of the cases the roots of teeth in contact with the tumorare resorbed, whereas their displacement is less common. Mostodontogenic fibromas are located in the mandible, especially in theFIG. 1. A small, unilocular radiolucency is present in the anterior partof the mandible (arrow).JOURNAL OF ENDODONTICS Printed in U.S.A.Copyright © 2002 by The American Association of Endodontists VOL. 28, NO. 2, FEBRUARY 2002127molar and premolar areas. In the maxilla the anterior area is mostcommonly involved. In about one-fourth of the cases the lesionsare associated with a crown of an unerupted tooth, a molar in themandible, or a premolar or incisor in the maxilla. In some patientsit is possible to observe a considerable buccal or lingual expansion.UNILOCULAR AMELOBLASTOMAAn infiltrating, solid ameloblastoma appears as a multiloculatedradiolucency. However when the tumors have a prominent cysticcomponent the bulk of the lesion may appear as a unilocularradiolucent lesion. The clinicians must observe carefully the bor-ders of these unilocular lesions, and very often there will beevidence of peripheral multilocularity.UNICYSTIC AMELOBLASTOMAThese lesions tend to occur more than one decade earlier thaninfiltrating ameloblastomas with a peak in the second decade. Thetumors are usually asymptomatic, but large lesions can produce aswelling of the affected jaw. The radiographic appearance is that ofa demarcated unilocular radiolucency, usually associated with animpacted tooth.ADENOMATOID ODONTOGENIC TUMORIt is possible to observe a well-demarcated radiolucency sur-rounding the crown of an impacted tooth. Small foci of radiopaquematerial are often present in the radiolucent lesion. Also the tumorsthat are not associated with an impacted tooth present as a well-demarcated radiolucency containing small-to-moderate amounts ofradiopaque material. This tumor is most frequently located in theanterior maxilla.CALCIFYING ODONTOGENIC CYSTThis lesion is found in the tooth-bearing region of the jaws, andmost cases are located anteriorly to the first permanent molars.Seventy-four percent of maxillary lesions affect the anterior max-illa, whereas 56% of lesions are in the anterior area. Radiograph-ically the lesions appear as unilocular or multilocular well-definedradiolucencies, and may be associated with an unerupted tooth.AMELOBLASTIC FIBROMAThis tumor has a peak occurrence in the second decade. Malesare more frequently affected. More than 80% of the lesions occurin the mandible, usually in the canine-molar region. It produces anasymptomatic swelling of the jaw. Ameloblastic fibroma does nottend to infiltrate between the bone trabeculae, but it grows bygradual expansion. Radiographically it appears as a unilocular ormultilocular radiolucent region with a smooth outline, often with asclerotic border, associated with an unerupted tooth.MYXOMAA great variation in their radiographic appearance exists; bothsmall unilocular lesions between the roots of teeth and largemultilocular tumors which displace teeth and less frequently tendto resorb the roots are found. Expansion of cortical bone is presentin the majority of cases. When the lesions are large or multinu-cleated, their appearance can be similar to an ameloblastoma. Veryoften it is possible to observe very fine-bone trabeculae inside theradiolucencies. Also the borders show a great variation, and theymay be well demarcated or ill defined.CENTRAL GIANT CELL GRANULOMAThis is a reactive bone lesion that is microscopically character-ized by multinucleated giant cells immersed in a stroma composedby spindle-shaped mesenchymal cells. Its most common location isthe anterior portion of the mandible, and it affects mainly youngpatients, especially females. Its radiographic appearance is aunilocular or multilocular radiolucent lesion with distinct margins.DISCUSSIONThe microscopic appearance of the tumor was that of a fibrousconnective tissue with a large quantity of ground substance givinga fibromyxoid quality. Cords of odontogenic epithelium were alsopresent (Fig. 2). These cords were composed of small, roundepithelial cells not exhibiting stellate reticulum and peripheralpalisading. The definitive microscopic diagnosis was odontogenicfibroma. The great variability of radiological appearances in odon-togenic fibroma emphasizes that despite its rarity this tumor shouldbe considered in the differential diagnosis of all abnormal radiolu-cencies of the jaws.Drs. Orsini and Benlloch are currently in private practice, L’Aquila, Italy. Dr.Iezzi is a research fellow, Dental School, University of Chieti, Chieti, Italy. Dr.Piattelli is professor of Oral Medicine and Pathology, Dental School, Universityof Chieti, Chieti, Italy. He is also honorary senior lecturer, Eastman DentalInstitute for Oral Health Care Sciences, London, UK. Address requests forreprints to Dr. Adriano Piattelli, Via F. Sciucchi 63, 66100 Chieti, Italy.FIG. 2. Microscopic appearance of the tumor. It is possible to ob-serve a fibromyxoid stroma and the presence of cords of odonto-genic epithelium. Hematoxylin-eosin 100.128 Zebra Hunt Journal of Endodontics

Zebra XXIII, Part 2.

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Zebra XXIII, Part 2.

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