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Case of the Month Archives

COM Jan. 2017 Diagnosis

Unilocular radiolucency between teeth #s 26 & 27

Can you make the correct diagnosis?

This is a 43-year-old white female who was referred to Dr. Bobek for the evaluation of a slowly growing swelling in the right anterior mandible.

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Radiolucency between teeth should make one think of a tooth-related cyst and in this case, a large lateral periodontal cyst (LPC) or its variant “botryoid odontogenic cyst (BOC) should be on the radiographic/clinical differential diagnosis.” Botryoid odontogenic cyst is usually multilocular radiolucency but can be unilocular. This lesion shows evidence of scalloping at the periphery and a hint of multilocular appearance which would be radiographically consistent with BOC. The site, the age and the radiographic findings are all consistent with both BOC but the histology is not consistent with that condition.

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Odontogenic Keratocyst (OKC) is also high up of the differential although the site of anterior mandible is not a common location for OKC. The well-demarcated radiolucent lesion with scalloped border is typical radiographic presentation for OKC. However, OKC when presenting between teeth, they tend to occur on the lower aspect of the roots which this lesion is not. The histology is not consistent with OKC.

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Glandular Odontogenic Cyst (GOC) is also high up on the list given the site of anterior mandible. The age and the radiographic findings are all consistent with GOC but not the histology.

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There are few odontogenic neoplasms that occur in the anterior jaws (mandible or maxilla); among those would be adenomatoid odontogenic tumor, squamous odontogenic tumor and the desmoplastic subtype of solid ameloblastoma. Although solid ameloblastoma (acanthomatous/follicular) subtype is included on the above list, neither the site nor the clinical findings are consistent with the typical presentation of solid ameloblastoma but is consistent with desmoplastic ameloblastoma.

Solid ameloblastomas occur in the posterior mandible and ramus in about 85% of the time. However, the histologic subtype known as desmoplastic ameloblastomas tend to occur in the anterior jaws, more so in the anterior maxilla but also in the anterior mandible. The age of the patient is also consistent with desmoplastic ameloblastoma. The radiographic findings are somewhat consistent with solid ameloblastoma but the lack of obvious expansion of jaw is not typical of solid ameloblastoma. In general, they tend to behave aggressively as in obvious expansion and pushing of teeth apart. In some cases, especially in smaller cases, they may present looking less aggressive. The histology was consistent with solid ameloblastoma. Figure 4 raises the question of desmoplastic ameloblastoma but the rest of the histology was not definitive for desmoplastic ameloblastoma.

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Squamous odontogenic tumor (SOT) can occur anywhere in the jaws including the anterior mandible and maxilla and usually occurs in individuals around 40 years of age but no gender predilection. The radiographic findings are consistent with SOT but lack of clinical symptoms such as pain or tooth mobility argues against SOT. Ten days after the biopsy was performed, the patient complained of pain and tooth mobility was noted. These symptoms were absent before the biopsy. The histology is not consistent with SOT.

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The reason CGCG is considered on the differential diagnosis is the site being anterior to the first molar which is consistent with that of CGCG more common occurrence. The gender is also consistent but not the age of this patient who is on the older age range for CGCG. About 60% of CGCG occurs in patients below 30 years of age. The radiographic presentation of radiolucency between teeth with a hint of multilocular appearance is also consistent with CGCG. The histology however is not consistent with CGCG.

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