Healing after removal of benign cysts and tumors of the jaws

A radiologic appraisal
Tadahiko Kawai, DDS, PhD, a Shumei Murakami, DDS, PhD?
Hiroko Hiranuma, DDS, c and Masayoshi Sakuda, DDS, PhD, d Osaka, Japan
OSAKA UNIVERSITY, FACULTY OF DENTISTRY

A retrospective review of the radiographic findings after removal of benign jaw cysts (n = 31) and ameloblastomas
(n = 24) was carried out. The radiographic features of the site margins and interior contents were classified into four categories.
In most patients radiographic changes were detected between 1 and 4 months after removal of the lesion, and complete bone
healing was found 4 months or more after surgery. Radiographic changes included "spiculed" or "trabecular" contents within
the interior of the surgical site. The fourth month was found to be the optimum time for follow-up radiographic examination for
the early detection of residual lesions. In nine (53%) of the patients who had ameloblastoma, recurrent lesions were noted
within or at the periphery of the original surgical sites 6 to 10 years after the initial tumor removal. (ORALSURGORAL/IVIEDORAL
PATHOLORALRADIOLENDOD1995;79:517-25)

Whereas the local recurrence rate and time to recur-
rence after removal of ameloblastoma have been
evaluated and described,Ill the treatment choices for
ameloblastoma remain controversial. 14,12q7 The
long-term elimination of ameloblastoma has not been
completely successful regardless of the treatment. For
surgery the recurrence rate is about 10% for the uni-
cystic type of this tumor when it is treated by enucle-
ation and curettage, and the recurrence rate is 50% to
90% in ameloblastomas in general.2"7 Nevertheless
enucleation with curettage still remains a treatment
of choice for patients with unicystic ameloblasto-
ma,5, 13, 14, 16, 18 and enucleation with marginal resec-
tion of healthy bone is recommended for young
patients with ameloblastoma regardless of the histo-
logic pattern. 2, 4 The follow-up program for patients
who have such tumors should include monitoring for
the early detection of recurrence in an effort to reduce
morbidity and medical expense.
Although animal experiments and clinical studies
have thoroughly elucidated the histologic condition
and biochemistry of healing after bone injury, 19-29
relatively few reports have described the radiology of
postsurgical bone healing in animals and humans, 28"39
and even fewer have described the radiographic
alterations during the healing process after conserva-
tive removal of benign jaw lesions. Furthermore the
few clinical reports describing bone healing after re-
aDepartment of Oral and Maxillofacial Radiology.
bDepartment of Oral and Maxillofacial Radiology.
CDepartment of Oral and Maxillofacial Radiology.
dprofessor, Department of Oral and Maxillofacial Surgery.
Copyright | 1995 by Mosby-Year Book, Inc.
1079-2104/95/$3.00 + 0 7/16/60705
moval of benign jaw cysts or tumors generally de
scribe small samples of patients or of even single in-
dividuals. Additionally most of these reports have il-
lustrated only the final result of bone healing by
radiographs obtained years after surgery and have not
described the early stages of the healing process in
detail), 7, 9, 11, 17, 18, 40-45 To our knowledge no report
has described the radiographic alterations observed at
various time intervals throughout the entire process
until complete healing after removal of such benign
lesions. To study the radiographic features of bone
healing, we conducted the present retrospective re-
view of radiographs made after the removal of benign
jaw cysts and ameloblastomas. The purpose was to
investigate radiographic alterations at specific time
intervals throughout the entire healing process until
complete bone healing occurred. This study was also
conducted to determine the optimum time of fol-
low-up examination after surgery for the early detec-
tion of retained, residual, or recurrent lesions.
MATERIAL AND METHODS
The 55 patients included in this study had been
treated for dentigerous cyst (13), odontogenic kera-
tocyst (18), and ameloblastoma (24) by fenestration,
currettage, or enucleation at Osaka University Den-
tal Hospital during the past 10 years (Table I).
Patients were excluded, if they had secondary infec-
tion, if they were lost to follow-up examination, or if
the radiographic image quality was poor.
A total of 374 follow-up radiographs including
panoramic (n = 178), posteroanterior skull (n = 175),
lateral oblique projection of the mandible (n = 13),
panagraphs (n = 4), and occlusal radiographs (n = 4)
were reviewed from the selected 55 patients. The ra-
5/7
518 Kawai et al. ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
A p r i l 1995

Table I. The study population

~ ibuao.

patients Male Female (yr) SD

Odontogenic 31 20 11 28.6 18.6

cyst
I. unchanged H. slightly changed Ameloblastoma 24 16 8 25.7 12.7

diographic features of the lesion margin and of the

III. partly reduced IV. entirely absent
Fig. 1. Diagramatic representations of radiographic fea-
tures of surgical site margin observed during course of bone
healing after removal of odontogenic cyst or ameloblas-
toma. Original cystic margin is I, completely preserved; II,
partly decreased in width and clarity; III, partly absent; and
IV, entirely absent.
internal portion of the postsurgical area were evalu-
ated on the basis of the criteria illustrated in Figs. 1
and 2.
The postsurgical radiographic pattern of the surgi-
cal margins in patients who had odontogenic cysts and
ameloblastomas was classified as unchanged when the
original radiopaque margin of the lesion was unal-
tered, slightly changed when the clarity and width of
the original margin were reduced, partly reduced
when the clarity of the original margin was decreased
or when the original margin had partially disappeared
or was partly displaced inward toward the center of
the surgical area, and entirely absent when the entire
margin of the lesion was completely absent (Fig. 1).
The postsurgical radiographic appearance of the

~
X spicules were visible from the periphery to the center
X
X
X enclosing marrow spaces were observed (Fig. 2).
H. ground glass appearance
X
III. spiculed IV. trabecular
Fig. 2. Schematic drawings of radiographic features of
interior of surgical site observed during course of bone
healing after removal of odontogenic cyst or ameloblas-
toma. I, Unchanged; radiographic features of internal
surgical site show no change after operation. II, Ground
glass appearance; periphera ! portion of surgical site shows
ground glass appearance. III, Spiculed; radial bone spic-
ules are found in peripheral portion. IV, Trabecular; surgi-
cal site is regenerated with normal cancellous bone archi-
tecture.
internal portion of the surgical site was classified as
unchanged when no change from the presurgical ap-
pearance was observed, "ground glass" when a slight
increase in radiopacity was noted, spiculed when bone
of the site, and trabecular when radiating trabeculae
When both ground glass appearance and spicules
were observed at the same surgical site, the radio-
graphic appearance was categorized as "spiculed"
because of the more calcified feature. When both sp-
icules and trabeculation were observed at the same
surgical site, the appearance was classified as "tra-
becular" for the same reason. "Trabecular" as used
here does not always indicate "complete bone heal-
ing" but rather a stage in the bone healing process.
The features of the presurgical and postsurgical ra-
diographs in six patients are illustrated in Figs. 3 to 8.
All of the radiographs in this study were evaluated
by three of the authors independently. Each was
blinded to the time interval the radiograph was taken
after surgery. The images at recall and baseline were
viewed and compared side by side. When a marked
density difference between presurgical and postsurgi-
cal radiographs was noted, comparison of the images
was performed with a variable intensity light.
For radiologic tracking of the progression of site
healing after conservative removal of benign lesions,
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Volume 79, Number 4
Fig. 3. Panoramic radiographs in patient with dentigerous
cyst patient, a, Presurgical panoramic radiograph reveals
well-defined radiolucency including left lower second mo-
lar. b, Two-month postsurgical panoramic radiograph show-
ing ground glass appearance along inferior border of surgi-
cal site (white arrows). Ghost image, more radiopaque zone
in ascending ramus of mandible, is clearly visible, but does
not hinder accurate interpretation of this image.
we analyzed the occurrence of radiographic changes
in the margin and interior of the surgical site at spe-
cific time intervals after surgery with a matched-pair
chi-squared test.
RESULTS
The 31 patients with od0ntogenic cyst underwent a
total of 74 follow-up radiographic examinations, and
the 24 patients with ameloblastoma underwent 49.
Radiographic changes in the margin of the surgical
site (Tables II and III)
Surgical sites categorized as "unchanged" were
observed in 21 of the 31 observations within the first
month of the postsurgical follow-up period. The "un-
changed" category was seen in a high percentage
(68%) of the observations during the first month af-
ter surgery (Table II). The hypothesis that radio-
graphic changes would not occur during the first
month after surgery was assessed by a chi-squared
Kawai et al. 519
Fig. 4. Panoramic view in patient with dentigerous cyst
involving left upper lateral incisor, a, Presurgical radio-
graph showing uniform radiolucency with well-defined
margin, b, Two-month postsurgical panagraphy showing
bony spicules in peripheral portion of surgical site (white
arrows).
test analysis of the incidence of "unchanged" cate-
gory in this period. The results shown in Table III in-
dicate that the high incidence of the "unchanged"
category is significantly associated with this period
(p = 0.0001). It is suggested that most follow-up ra-
diographic features in comparison with those seen
immediately after surgery will not show in the first
month. Of the sites examined at 1 to 2 months after
surgery, those categorized as "slightly changed" or
"partly reduced" accounted for 79%, indicating that
the incidence of change of radiographic appearance is
high during this period (p = 0.011). Of the observa-
tions made in the second and third month after sur-
gery, 88% revealed alteration of the site margin,
indicating that in most patients some kind of ra-
diographic alteration will be detectable in this
period (/9 = 0.0001). Furthermore 97% of the sites
observed more than 3 months after surgery were
categorized as "partly reduced" or "entirely absent,"
indicating that bone changes will almost always be
apparent in the site margin after a postsurgical inter-
val of more than 3 months has elapsed (p = 0.0001).
Of the observations made more than 4 months after
520 Kawai et al. ORAL SURGERYORALMEDICINEORALPATHOLOGY
April 1995

Fig. 5. Follow-upradiographs in patient with odontogenickeratocyst, a, Preoperative radiograph, b, Sec-

tion of posteroanterior skull radiograph obtained 6 months after surgery reveals regenerated bone architec-
ture excludingcentral portion of surgical site (trabecular). c, This radiograph obtained 17 months after sur-
gery reveals complete bone healing (trabecular).

Table II. Follow-up radiographic features of the surgical site margin in patients with odontogenic cyst and
ameloblastoma
Month after surgery
Radiographic Category total
categorization ~1 ~2 ~3 ~4 ~5 ~6 ---->6 (n)
Unchanged 21 1 3 1 0 0 0 26
Slightly changed 5 5 3 0 0 0 1 14
Partly reduced 5 6 7 4 0 3 1 26
Entirely absent 0 2 5 3 6 4 37 57
Month total (n) 31 14 18 8 6 7 39 123

surgery, 90% were classified as entirely absent, indi-
cating that the site margin in most patients will
be completely remodeled during this period (p =
0.0001).
These results indicate that the follow-up radio-
graphic appearance of the margin is characterized by
significant progression from "unchanged" through
"slightly changed" and "partly reduced" to entirely
absent.
Radiographic changes in the interior of the
surgical site (Tables IV and V)
The "unchanged" category was seen in a high per-
centage (74%) of observations made during the first
month after surgery (Table IV). The hypothesis that
radiographic changes would not occur during the first
month after surgery was assessed by a chi-squared
test to analyze the incidence of the "unchanged" cat-
egory in this period. The results shown in Table V in-
dicate that the high incidence of "unchanged" cate-
gory is significantly associated with this period
(p = 0.0001). In other words it is suggested that most
follow-up radiographic features in comparison with
those seen immediately after surgery will not show
changes in the first month. Of those cases observed
during the second month after surgery, 79% were
classified as "ground glass" appearance or spiculed,
suggesting that newly formed bone tissues will be vis-
ible on radiographs during the second month after the
operation (p = 0.0001). Of the site interiors observed
ORAL SURGERYORAL MEDICINE ORAL PATHOLOGY
Volume 79, Number 4
Fig. 6. Panoramic radiographs in 22-year-old woman with
odontogenic keratocyst, a, Presurgical radiograph shows
well-defined radiolucency with sharp white lines, b, Radio-
graph obtained 3 months and 3 weeks after surgery shows
apparent increased radiodensity of surgical site interior and
loss of white margin.
in the second and third month after surgery, 75% were
classified as one of the three categories of radio-
graphic change, suggesting that in most patients some
kind of radiographic alteration will be detectable in
this period (p = 0.0001).
Of those site interiors observed more than 3 months
after surgery, 97% were classified as spiculed or tra-
becular, indicating that apparent osteogenic changes
will be detectable in this period (p---0.0001). Of
those observed 4 or more months after surgery, 85%
were classified as showing trabecular features. This
finding suggests that bone regeneration and remodel-
ing of the site will occur 4 months or more after sur-
gery (p = 0.0001). These results indicate that the fol-
low-up radiographic appearance of the site interior
progressed from unchanged to ground glass appear-
ance to spiculed and trabecular. The rate of interob-
server discrepancy for the three raters in radiographic
categorization was 2.4% (3 of 123) for the site mar-
gin and 1.6% (2 of 123) for the site interior. The five
observations in which disagreement occurred were
Kawai et al. 521
Fig. 7. Panoramic radiographs in patient with ameloblas-
toma. a, Presurgical panoramic radiograph reveals well-de-
fined, expansive area of radiolucency in left lower molar to
ramus region, b, This panoramic radiograph obtained 6
months after surgery reveals complete bone healing of sur-
gical site. Note tooth germ of left lower third molar visible
at upper area of surgical site (arrows).
made during the first 3 months and were between
"unchanged" and "slight change" at the site margin
or "unchanged" and "ground glass" appearance at
the site interior. Part of the original cystic margin of
the lesion was retained in the bony healing area in sev-
eral sites. In addition three of the surgical sites studied
that remained at the "trabecular" stage after a long fol-
low-up period showed an area of incomplete healing in
their central portion. They had a well-localized lucent
area but did not have a clearly depicted sclerotic mar-
gin. These lucent areas were static for a prolonged pe-
riod of time, ranging from 1 to several years. Increased
calcification of the site interior compared with the sur-
rounding normal bone was observed in two cases. One
was observed on radiographs obtained 4 months, 17 days
after surgery, and the other was observed on radiographs
obtained 5 months, 23 days after surgery. However, in
both sites these calcified areas had vanished within the
following 7 or 8 months.
522 Kawai et al.
Fig. 8. Radiographs of recurrent lesion in patient with
ameloblastoma, a, Preoperative radiograph showing man-
dibular ameloblastoma lesion, b, Radiograph obtained 11
months after surgery showingcomplete local bone healing
of surgical site. Arrowheads indicate original surgical site
margin, e, Radiograph obtained 6 years after surgery
showing recurrent ameloblastoma lesion (white and black
arrow).
DISCUSSION
The categorization of radiologic progression used
in this study is compatible with the histologic phasing
of extraction wound or fracture healing previously
described in animal and clinical studies. 19"22,24-28,29
The category of "unchanged" in this study corre-
sponds to the early stage of healing in such injuries in
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1995
which hematoma, blood clots, coagulation, granula-
tion tissue, or immature fibrous connective tissue for-
mation generally develops during the first 2 weeks af-
ter surgery.2~ 2t, 25 In this study the unchanged status
sometimes persisted for up to 1 month after surgery.
This situation was probably due to the failure of ra-
diography to depict the slight initial calcification in
the wounds, which should have already been formed
histologically. The categories of "slightly changed"
and "ground glass appearance" in the site margin and
interior corresponded to the second stage of wound
healing after extraction or fracture. In this stage con-
comitant bone apposition in well-organized fibrous
connective tissues and necrotic bone resorption are
seen.19-22, 28, 29 This process develops 1 to 4 weeks af-
ter dental extractions in animals or humans and 3 to
4 weeks after fracture in humans. The features of
"slightly changed" and "ground glass" appearance
were not observed in this study until 2 months after
surgery, which is twice the interval found after dental
extraction or jaw fracture. In addition it has been re-
ported that in this stage new bone formation does not
occur randomly within the site but rather extends
from outside the marrow spaces to the socket wallzS' 26
or fracture ends. 28 It is readily apparent that these
phenomena are visualized with radiography as pe-
ripheral opacification of the site and decrease of the
site margin exactly as illustrated in the diagrammatic
representations in this article. The categories of
"partly reduced" for the site margin and "spiculed"
for the site interior correspond to the third stage o f
extraction wound or fracture healing. In this stage
bone formation develops from the wall and base of the
socket to the socket mouth, 19,21 and a hard internal
or external callus develops into' more organized bone
tissues during fracture healing.28,29 These phases
continue for 3 to 5 weeks in extraction wound
healing 19-22 and for 3 or 4 months in fracture heal-
ing. 28'29 Heppenstalles described that the average
duration at the hard callus stage for major long bones
in an adult was 3 to 4 months, which is consistent with
our results. The categories of entirely absent for the
site margin and trabecular for the site interior corre-
spond to the stage of remodeling in fracture healing
in which mature bone tissues still show temporarily
increased calcification followed by remodeling of
these areas in angular deformities during the frac-
ture-heating process. These calcifications and angu-
larities are ultimately remodeled into bone with nor-
mal density or the original contour that existed before
the fractureY It is very interesting that these phe-
nomena have not been described in previous studies of
extraction wound healing. This lack of information
may be due to the difficulties in perceiving these phe-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Kawai et al. 523
Volume 79, Number 4

Table IlL Radiographic progression in the site margin

Time interval
after surgery Chi-squared Degree of
Category (too) Ratio Percent analysis freedom p Value

Unchanged <1 21/31 68 50.723 1 0.0001

Slightly changed
Partly reduced 1 ~ ~ <2 11/14 79 6.471 1 0.011
Slightly changed
Partly reduced 1 < ~ <3 28/32 88 20.076 1 0.0001
Entirely absent =
Partly reduced
_->3 58/60 97 94.831 1 0.0001
Entirely absent
Entirely absent >4 47/52 90 70.275 1 0.0001

Table IV. Follow-up radiographic appearance of the surgical site interior in patients with odontogenic cyst
and ameloblastoma
Month after surgery
Radiographic Category total
categorization ~1 ~2 ~3 ~4 ~5 ~6 ->_6 (n)
Unchanged 23 3 5 0 1 0 32
Ground glass appearance 7 5 7 1 0 0 20
Spiculed 1 6 3 3 1 5 20
Trabecular 0 0 3 4 6 33 51
Month total (n) 31 14 18 8 8 38 123

Table V. Radiographic progression in the site interior

Time interval
after surgery Chi-squared Degree of
Category (mo) Ratio Percent analysis freedom p Value

Unchanged <1 23/31 74 49.978 1 0.0001

Ground glass appearance
Spiculed 1 < ~ <2 11/14 79 15.267 1 0.0001
Ground glass appearance
Spiculed 1 < ~ <3 24/32 75 15.246 1 0.0001
Trabecular
Spiculed _->3 58/60 97 72.799 1 0.0001
Trabecular
Trabecular _->4 44 / 52 85 69.113 1 0.0001

nomena because of the short time span of extraction
wound healing. 19-22,24-26 Difficulties may also exist in
distinguishing the density of the healed socket, which
is presumably increased, from that of the surrounding
bone tissues, which is also overcalcified, because ini-
tial bone apposition is laid down in the marrow spaces
adjacent to the socket. 25, 26 Furthermore the decrease
of the socket volume in both the verticaP 9-22,24-26and
horizontal dimensions in patients may obscure the
overcalcified density of the socket. In this study, 4
months after surgery the overall radiographic appear-
ance was almost the same as that of subsequent ob-
servations; the radiolucencies of the surgical site inte-
rior converted wholely to normal trabeculae. Two
surgical sites in this study, however, showed overcal-
cification of the site interior like that in the remodel-
ing stage of fracture healing. Both sites showed
remodeling of this feature and normal bone density
about 1 year after surgery, two traits that are very
similar to the phenomena observed in the remodeling
stage of fracture healing.28 Based on these observa-
tions we consider that the present radiographic cate-
gorization of the site margin and interior after
removal of benign jaw cysts and ameloblastomas is in
general an appropriate and useful method of fol-
low-up examination of patients with these diseases.
524 Kawai et al.
S u b t l e changes including either " s l i g h t l y c h a n g e d "
or " g r o u n d g l a s s " a p p e a r a n c e m a y not be demon-
s t r a t e d without a d e q u a t e x - r a y exposure settings and
p r o p e r viewing conditions. A c c o r d i n g l y , in the evalu-
ation of r a d i o g r a p h s o b t a i n e d within 2 m o n t h s after
surgery, which m i g h t reveal slight changes, a v a r i a b l e
intensity light source is r e c o m m e n d e d . O u r d a t a sug-
gest t h a t the o p t i m a l t i m e for e a r l y detection of resid-
ual lesions m a y be the fourth m o n t h after surgery,
when r a d i o g r a p h i c changes of both the site m a r g i n
and interior are apparent.
In the evaluation of a r a d i o g r a p h o b t a i n e d 3 or
m o r e m o n t h s after surgery, a s h a r p l y defined site
m a r g i n like t h a t of the p r e o p e r a t i v e lesion m a r g i n or
a clear lucent site interior like t h a t of the original le-
sion l u m e n should suggest a residual lesion. W h e n
bone resorption is observed within or outside the site
m a r g i n within this period after surgery, a s e c o n d a r y
infection should be suspected. A g a i n , m a r k e d d e l a y of
r a d i o g r a p h i c changes m a y indicate unsuccessful sur-
gery, secondarY infection, or m e t a b o l i c disease. Fol-
low-up r a d i o g r a p h i c features t h a t deviate from the
p a t t e r n p r e s e n t e d here should be suspected to indicate
residual lesion, s e c o n d a r y infection, or m e t a b o l i c dis-
ease. T h e r e c u r r e n c e r a t e in our patients with amelo-
b l a s t o m a s 6 to 10 years after surgery was 53% (9 of
17), which is within the r e p o r t e d r a n g e for such pa-
tients. A persistent r a d i o l u c e n c y seen in a few patients
suggests t h a t such lucencies should be differentiated
f r o m t u m o r recurrence. R a d i o l u c e n c i e s t h a t precede
b o n y h e a l i n g a r e localized in the central a r e a of the
site b u t a r e m a r g i n a t e d and lack clearly visualized
white lines in c o n t r a s t to a r e c u r r e n t lesion. Because
a m e l o b l a s t o m a has the potential for local recurrence,
follow-up r a d i o g r a p h i c e x a m i n a t i o n should be per-
f o r m e d every y e a r for at least ! 0 years a f t e r local bone
healing. 14
CONCLUSION
A f t e r benign j a w cysts or a m e l o b l a s t o m a s a r e
removed t h e t i m e course of changes in the surgical
m a r g i n parallels t h a t of the surgical site interior. T h e
f o u r t h m o n t h after s u r g e r y was found to be the opti-
m u m t i m e for follow-up r a d i o g r a p h i c e x a m i n a t i o n to
e v a l u a t e w h e t h e r healing is normal. R a d i o g r a p h i c
observation 3 or m o r e m o n t h s after surgery of s h a r p l y
defined site m a r g i n s like t h a t of the p r e o p e r a t i v e le-
sion m a r g i n or of a clear lucent interior like t h a t of the
original lesion l u m e n m a y indicate a residual lesion.
R a d i o l u c e n c i e s associated with b o n y h e a l i n g a r e
localized in the c e n t r a l a r e a of the site b u t a r e m a r -
g i n a t e d without c l e a r l y visualized white lines in con-
t r a s t to a r e c u r r e n t lesion. Follow-up r a d i o g r a p h i c
e x a m i n a t i o n of p a t i e n t s with a m e l o b l a s t o m a s should
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
April 1995
be p e r f o r m e d every y e a r for at least 10 years after lo-
cal bone healing.
REFERENCES
1. Shatkin S, Hoffmeister FS. Ameloblastoma: a rational ap-
proach to therapy. ORAL SURG ORAL MED ORAL PATHOL
1965;20:421-35.
2. Sehdev MK, Huvos AG, Strong EW, Gerold FP, Willis GW.
Proceedings: ameloblastoma of maxilla and mandible. Cancer
1974;33:324-33.
3. Adekeye EO. Ameloblastoma of the jaws: a survey of 109 Ni-
gerian patients. J Oral Surg 1980;38:36-41.
4. Molla MR, Shaheed I, Shrestha P. Ameloblastoma: a clinical
study of 13 cases. Bangladesh Med Res Counc Bull 1991;17:29-
35.
5. Robinson L, Martinez MG. Unicystic ameloblastoma: a prog-
nostically distinct entity. Cancer 1977;40:2278-85.
6. Waldron CA. Ameloblastoma in perspective. J Oral Surg
1966;24:331-3.
7. Gardner DG, Corio RL. The relation~-'-ipof plexiform unicys-
tic amelohlastoma to conventional ameloblastoma. ORAL
SURG ORAL MED ORALPATHOL1983;56:54-60.
8. E1-Mofty SK, Gerard NO, Farish SE, Rodu B. Peripheral
ameloblastoma: a clinical and histologic study of 11 cases. J
Oral Maxillofac Surg 199l;49:970-4.
9. Minami M, Kaneda T, Yamamoto H, et al. Ameloblastoma in
the maxillomandibular region: MR imaging. Radiology 1992;
184:389-93.
10. Thompson IOC, Ferreira R, van Wyk CW. Recurrent unicys-
tic ameloblastoma of the maxilla. Br J Oral Maxillofac Surg
1993;31:180-2,
l 1. Collings SJ, Harrison A. Recurrent ameloblastoma? An his-
toric case report and a review of the literature. Br Dent J
1993;174:202-6.
12. Gardner DG, Pecak AMJ. The treatment of ameloblastoma
based on pathologic and anatomic principles. Cancer 1980;
46:2514-9.
13. Gardner DG. Plexiform unicystic ameloblastoma: a diagnos-
tic problem in dentigerous cysts. Cancer 198l;47:1358-63.
14. Gardner DG, Corio RL. Plexiform unicystic ameloblastoma:
a variant of ameloblastoma with a low-recurrence rate after
enucleation. Cancer 1984;53:1730-5.
15. Mtiller H, SlootWegPJ. The growth characteristics of multi-
locular ameloblastomas: a histological investigation with some
inferences with regard to operative procedures. J Maxillofac
Surg 1985;13:224-30.
16. Leider AS, Eversole LR, Barkin ME. Cystic ameloblastoma:
a clinicopathologic analysis. ORAL SURG ORAL MED ORAL
PATHOL 1985;60:624-30.
17. Pogrel MA. The use of liquid nitrogen cryotherapy in the
management of locally aggressive bone lesions. J Oral Maxil-
lofac Surg 1993;51:269-73.
18. Shteyer A, Lustmann J, Lewin-Epstein J. The mural amelo-
blastoma: a review of the literature. J Oral Surg 1978;36:866-
72.
19. Huebsch RF, Coleman RD, Frandsen AM, Becks H. The
healing process following molar extraction: I Normal male rats
(Long-Evans strain). ORALSURGORAL MED ORALPATHOL
1952;5:864-76.
20. Huebsch RF, Hansen LS. A histopathologic study of extrac-
tion wounds in dogs. ORAL SURG ORAL MED ORALPATHOL
1969;28:187-96.
21. Simpson HE. The healing of extraction wound. Br Dent J
1969;126:550-7.
22. Johansen JR. Repair of the postextraction alveolus in Wister
rat: a histologic and autoradiographic study. Acta Odontol
Scand 1970;28:441-6l.
23. Tsuchimoehi M, Hosain F, Engelke W, Zeicher SJ. Studies on
focal alveolar bone healing with technetium (Tc)-99m labeled
methylene diphosphonate and gold-collimated cadmium tellu-
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY Kawai et al. $25
Volume 79, Number 4

ride probe. ORAL SURG ORAL MED ORAL PATHOL 1991; nal rigid fixation of subcondylar fractures via an intraoral ap-
71:110-5. proach. ORAL SURG ORAL MED ORAL PATHOL 1991;71:257-
24. Bodner L, Kaffe I, Littner MM, Cohen J. Extraction site heal- 61.
ing in rats: a radiologic densitometric study. ORAL SURGORAL 38. Williams MD, Pearson MH, Milner SM. Complications in
MED ORAL PATHOL 1993;75:367-72. the use of compression plates in the treatment of mandibular
25. Amler MH, Johnson PL, Salman I. Histological and his- fractures. ORAL SURG ORAL MED ORAL PATHOL 1991;72:
tochemical investigation of human alveolar socket healing in 159-61.
undisturbed extraction wounds. J Am Dent Assoc 1960;61:32- 39. Iizuka T, Lindqvist C, Hallikainen D, Mikkonen P, Paukku P.
44. Severe bone resorption and osteoarthrosis after rniniplate fix-
26. Boyne PJ. Osseous repair of the postextraction alveolus in man. ation of high condylar fractures. ORAL SURGORAL MED ORAL
ORAL SURG ORAL MEn ORAL PATHOL 1966;21:805-13. PATHOL 1991;72:400-7.
27. Amler MH. The age factor in human extraction wound heal- 40. Heimdal A, Isacsson G, Nilsson L. Recurrent central odonto-
ing. J Oral Surg 1977;35:193-7. genie fibroma. ORAL SURG ORAL MED ORAL PATHOL
28. Heppenstall RB. Fracture treatment and healing, 1st ed. Phil- 1980;50:140-5.
adelphia: WB Saunders, 1980:41-52,80-5,98-100. 41. Kerley TR, Sehow CE. Central giant cell granuloma or
29. Wilson JN. Watson-Jones fractures and Joint Injuries, 6th ed. cherubism: report of a case. ORAL SURG ORAL MED ORAL
Vol 1. London: Churchill Livingstone, 1982:14-28. PATHOL 1981;51:128-30.
30. Vose GP, Mack PB, Brown SO, Medlen AB. Radiologic 42. Eversole LR, Leider AS, Strub D. Radiographic characteris-
determination of the rate of bone healing. Radiology 1961; tics of cystogenic ameloblastoma. ORAL SURG ORAL MED
76:770-6. ORAL PATHOL 1984;57:572-7.
31. Nicholls P J, Berg E, Bliven-JR FE, Kling JM. X-ray diagno- 43. Freedman GL, Beigleman MB. The traumatic bone cyst: a new
sis of healing fractures in rabbits. Clin Orthop 1979; 142:234-6. dimension. ORAL SURG ORAL MED ORAL PATHOL 1985;
32. K/ilebo P, Strid KG. Radiographic videodensitometry for 59:616-8.
quantitative monitoring of experimental bone healing. Br J 44. Mills WP, Davila MA, Beuttenmuller EA, Koudelka BM.
Radiol 1989;62:883-9. Squamous odontogenic tumor: report of a case with lesions in
33. Marmary Y, Brayer L, Tzukert A, Feller L. Alveolar bone re- three quadrants. ORAL SURG ORAL MED ORAL PATHOL
pair following extraction of impacted mandibular third molars. 1986;61:557-63.
ORAL SURG ORAL MED ORAL PATHOL 1985;60:324-6. 45. Horner K, Forman GH, Smith NJ. Atypical simple bone cysts
34. Allard RHB, Lekkas C. Unusual healing of a fracture of an of the jaws. I: Recurrent lesions. Clin Radiol 1988;39:53-7.
atrophic mandible: report of a case. ORAL SURG ORAL MED
ORAL PATHOL 1983;55:560-63. Reprint requests:
35. Schwimmer AM, Greenberg AM. Management of mandibu- Tadahiko Kawai, DDS, PhD
lar trauma with rigid internal fixation. ORAL SURG ORAL MED Department of Oral and Maxillofacial Radiology
ORAL PATHOL 1986;62:630-7. Osaka University
36. Shufford EL, Kraut RA. Passive rigid fixation of sagittal split Faculty of Dentistry
osteotomy. ORAL SURG ORAL MED ORAL PATHOL 1989; 1-8 Yamadaoka
68:150-3. Suita City
37. Lachner J, Clanton JT, Waite PD. Open reduction and inter- Osaka 565, Japan

CALL FOR REVIEWARTICLES

The January 1993 issue of ORALSURGERY,ORALMEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY,
AND ENDODONTICScontained an Editorial by the Journal's Editor in Chief, Larry J. Peterson, that called
for a Review Article to appear in each issue.
These Review Articles should be designed to review the current status of matters that are important
to the practitioner. These articles should contain current developments, changing trends, as well as re-
affirmation of current techniques and policies.
Please consider submitting your article to appear as a Review Article. Information for authors appears
in each issue of ORAL SURGERy, ORAL MEDICINE, ORAL PATHOLOGY, ORAL RADIOLOGY, AND
ENDODONTICS.
We look forward to hearing from you.