Case presentations A computerized education programme. Some benign and malignant lesions in dentistry by

1
Case presentationsA computerized education
programme.Some benign and malignant lesions in
dentistry by

• Leif Kullman DDS, PhD
• Please observe, that your monitor must have some
  basic requirements, if you should be able to view
  the radiographs with an acceptable resolution.

2

• The first patient is a male, about 30 years old
  and has noticed some swelling in his right
  maxilla, but he has no pain. He is complete
  healthy, except for the mentioned symptoms in
  the upper jaw. A computer tomography examination
  has been performed.

3

• He first noticed this swelling about six months
  before the CT investigation we saw in the
  foregoing image. At that point of time, the
  following panoramic image was taken.

4
Immediately before the CT-investigation that we
saw in the first picture, the following
radiographs were also exposed
5
Click on the most probable differential diagnosis
of this lesion according to your opinion

• A benign tumor
• An odontogenic cyst
• A fibro-osseous lesion
• A malign tumor
• A nonodontogenic cyst

6

• No, this answer is not the most probable. A cyst
  or a benign tumor has usually not a worm eaten or
  dissolved border like this lesion has.Go back
  and try once more!

7
Yes, congratulations...your answer is correct
(and it was a difficult one)!The final PAD diff.
diagnosis was a fibrosarcoma

• There are some malignant signs in the images
• These are
• Diffuse destruction of the bony walls surrounding
  the lesion

8
No your answer is wrong. A fibro-osseous lesion
usually fades more imperceptibly into normal bone
tissue

• Think after again and click the button and choose
  another alternative

9
Which one, of the characteristics downunder is
also most correct for a malign tumor?

• Has a rapid development. If there are affected
  teeth in the surroundings of the tumour,
  resorption in these are seldom seen. The tooth
  suddenly feels movable
• Has a slow development and nearby situated teeth
  are slowly displaced

10
Yes, quite correct. Now, please proceed with the
next slide and patient
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No, a slow developing lesion is usually
benign.You should have chosen the other
alternative. Proceed to the next patient or
return to check up the right alternative
12
The following patient is a middleaged woman, hale
and hearty, but with some problem from her right
maxillae as well. She pays a visit to her
dentist, who finds a fistula in regio 13/14 and
he also takes the following radiograph
13
A CT-investigation is also performed in this
patient and downunder is one of the slices from
the maxillae, apical of the toothroots.
14
The following view is disclosed during the
following operation, when a flap is opened up
The facial bone compact is very thin and an
interior cavity can be seen
15
Which one of the following diagnosis do you
propose as the most probable (the correct answer
will usually -well almost always-be given after
the PAD examination)

• An ameloblastoma
• A radicular or residual cyst
• A lateral periodontal cyst
• A dentigerous cyst

16
No, an ameloblastoma has usually not a well
demarcated border, as this lesion seems to have.
And ameloblastoma is seldom seen in the frontal
maxillary region.

• Go back and try again (and think over your
  differential diagnosis once more)

17
No, a lateral periodontal cyst seems not so
probable, they are usually smaller and situated
near the cortical marginal bone

• Go back and try again (and think over your
  differential diagnosis once more)

18
No, a dentigerous or follicular cyst forms around
the crown of an unerupted tooth

• Go back and try again (and think over your
  differential diagnosis once more)

19
Yes, this must be the most probable diagnosisand
it was PAD confirmed for this patient

• Now you can proceed with the next case

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The young lady in this radiograph is only about
eleven to twelwe years and has a large swelling
in her right ramus area. She has not directly any
symptoms, except this swelling. There are no
signs of sickness or growth disturbances in her
history
21
As can be seen, the swelling is remarkable, it
is surprising that the patient not has came to
her dentist earlier
22
A CT-investigation is also performed, some of
the slices are seen downunder
23
In order to establish the most probable
differential diagnosis a MRI investigation is
finally performed. Here is some of the frontal
views
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Now, nominate your proposal to the most probable
diagnosis

• ameloblastoma
• cherubism
• aneurysmal bone cyst
• odontogenic keratocyst
• dentigerous cyst

25
No your answer is not the most probable. You
must pay attention to all relevant factors..age,
history and so on. Go back and try once more
26
No your answer is not the most probable.
Cherubism is most often occuring bilaterally. Pay
attention to all relevant factors..age, history,
radiological appearence and so on. Go back and
try once more
27
Yes, congratulations your answer now is the most
probable according to the radiological appearance
and the patients age and history.Procced until
next case, please!
28
This is an elderly lady with a partial denture in
the lower jaw. The patient first visited her
dentist two weeks ago, due to problem from this
denture, regio 3436. Her dentist then adjusted
the denture since it seemed to be overextended.
29
Today you can still view the sore in the same
place, and we have now no natural explanation for
it.In an intraoral radiograph the area looks
like this
30
What is your proposal about following up this
case? After all the patient tells you that she
feels a little better today compared with the
last time she visited you. First of all will
you do something right now or will you wait and
check up the patient later on I believe there
are some ill signs and I will therefore refer
the patient to a specialist clinic I think I
can wait some time and check up the patient in
some months
31
Quite correct, the sore should have healed now,
when the denture has been adjusted. When you
consider the history of the patient, the age
and the radiological appearance you cannot rule
out that a malign tumor with bone involvement is
growing in the area. There is for example a lack
of cortical bone at the bone margin in the area
and an underlying diffuse radioluscence. In this
case the diagnosis was a carcinoma.
32
No, you should definitely not keep waiting.
All natural causes to the sore are removed and
still it exists. Check up your knowledge about
radiographic and clinical signs of malignicies,
please. Now you can proceed to next case.
33
This patient is a middle -aged woman, when her
general practitioner (GP) discovers a divergent
bone structure in regio 21 to 22.
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There is no history of pain or other clinical
symptoms. The adjacent teeth are checked and
proved to be vital and sensibel. The GP, then
refers the patient to a specialist for assistance
in diagnosing and prospective treatment. However,
since there are no symptoms, and there definitely
are no malignant signs in the radiographs, it is
determined to wait a little.
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About one year later the following radiograph is
taken and it is determined to make an explorative
operation since the patient also has some slight
symptoms from the area.
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This was a difficult case to diagnose and even
the surgeon was a bit surprised, when the PAD
answer arrived. Therefore you will have the
following help before your answer The majority
(75 )of these lesions appear in the mandible and
posterior to the canine (90). Tooth displacement
is common and the majority are unilocular with
smooth borders but sometimes scalloped. Now,
choose the correct alternative downunder a
myxoma a keratocyst a central giant cell
granuloma
37
Quite, correct. And hopefully, youll already
know that these cysts have a very high
reccurrence rate and a more aggressive growth
than other odontogenic cysts. In this case a
recurrence was seen after two years and a
reoperation was performed. Now, please proceed
until next page!
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You chose one of the two most unprobable
differential diagnosis . a myxoma or a giant
cell granuloma These two have the following
characteristics in radiographs Myxoma Seen
often in younger age groups (10-30 years), and
most often the mandible, as a multilocular lesion
with a honeycomb appearance. Giant cell
granuloma Mostly in younger (30 years or
younger) and also mostly the anterior part of the
mandible. Variable appearance from uni- to
multilocular (becomes multi after some growth).
Seldom any corticated margin. The correct answer
should have been keratocyst. Please, proceed to
next page.
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Thanks for your visit. If you have any
suggestions or have find any bug in this
software, please inform me. The adress is
lkullman_at_ksu.edu.sa Bye for now! (for several
cases in this presentation, courtesery of the
Department of Maxillo Facial Surgery, Akademiska
Sjukhuset, Uppsala, Sweden. Dr. Eva Birring in
particular)