Pe d i a t r i c I m a g i n g • R ev i ew

Plunk et al.
Benign Pediatric Mandible Disorders

Pediatric Imaging
Review

Focal Benign Disorders of

the Pediatric Mandible With
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Radiologic-Histopathologic
Correlation: Mandibular
Development and Lucent Lesions
Matthew R. Plunk1,2 OBJECTIVE. Lucent lesions of the pediatric mandible may present variably. Cysts, neo-
Dolphine Oda3 plasms, and developmental and inflammatory conditions have a host of possible causes. There
Shawn E. Parnell1,4 is also substantial overlap in the imaging appearance of cysts and that of benign but locally
Jason N. Wright 1,4 aggressive tumors that need to undergo resection.
Bonnie L. Cole 3,5 CONCLUSION. The purpose of this article is to present common and uncommon lucent
lesions of the mandible in children, with an emphasis on benign abnormalities. Discussions of
Ramesh S. Iyer 1,4
imaging and histopathologic features are provided.
Plunk MR, Oda D, Parnell SE, Wright JN, Cole BL,
bnormalities of the mandible in

A
Iyer RS
children are frequently identified
and treated exclusively by dentists
and oral surgeons with in-office
imaging (e.g., panoramic radiography) and
procedures. Radiologists may also be called
on to characterize a mandibular abnormality,
either when a patient presents with symptoms
to a health care facility or when the abnormal-
ity is incidentally found on an imaging study
performed for another purpose.
Keywords: lucent lesions, mandibular tumors, nonlucent The mandible represents an intersection of
lesions, pediatric mandible, radiologic-histopathologic two separate realms of disease: one associated
correlation with tooth development and the other a prima-
ry bone process. Odontogenic neoplasms, in
DOI:10.2214/AJR.16.16587
particular, can be troublesome because of sim-
Received April 21, 2016; accepted after revision ilarities in nomenclature and because several
July 18, 2016. entities have been reclassified, renamed, and
1
discovered with recent advances in molecular
Department of Radiology, University of Washington
School of Medicine, Seattle, WA.
biology and immunohistochemistry [1, 2].
This article reviews the radiographic and
2
Present address: Department of Radiology, T­ exas  pathologic features of acquired odontogenic
Children’s Hospital, Houston, TX. and nonodontogenic abnormalities, with the
3 goal of helping generate a reasonable differ-
Department of Anatomic Pathology, University of
Washington School of Medicine, Seattle, WA. ential diagnosis. There is an emphasis on be-
nign disorders, particularly cysts and nonma-
4
Department of Radiology, Seattle Children’s Hospital, lignant tumors, which may be distinguished
4800 Sand Point Way NE, MA.7.220, Seattle, WA 98105. by particular patient age ranges, their rela-
Address correspondence to R. S. Iyer (riyer@uw.edu).
tionship to teeth, and their location within
5
Department of Laboratories, Seattle Children’s Hospital, the mandible. A summary of the lucent le-
Seattle, WA. sions presented in this article appears in Ta-
ble 1. Malignant and malignantlike abnor-
AJR 2017; 208:1–13 malities producing lucency in the pediatric
0361–803X/17/2081–1
mandible, such as osteosarcoma and Langer-
hans cell histiocytosis, are beyond the scope
© American Roentgen Ray Society of this article.
Mandibular and Dental Development
and Terminology
A basic understanding of the develop-
ment of the jaw and dentition will be useful
for framing future discussions [3, 4]. During
the fourth week of gestation, the embryon-
ic maxilla and mandible arise from enlarge-
ment and fusion of paired bilateral promi-
nences derived from neural crest cells around
the primitive mouth, known as the stomode-
um. The skeleton of the mandible is derived
using Meckel cartilage of the first pharynge-
al arch as a template for membranous ossifi-
cation. Interestingly, this cartilage does not
contribute to the final mandible, but portions
are retained as middle ear structures, includ-
ing the malleus and incus.
The teeth are derived from a combination
of ectoderm and ectomesenchyme of the head,
which is itself derived from neural crest cells.
Tooth development is a complex process that is
beyond the scope of this review. Simplified, the
overlying ectoderm, or dental lamina, invag-
inates into the underlying ectomesenchyme.
This invagination induces cellular prolifera-
tion in the ectomesenchyme, which subse-
quently forms the dental papilla. These devel-
oping ectomesenchymal cells are contained in
a sac known as the dental follicle. Eventually,
the overlying dental lamina forms the amelo-
blasts (which produce the outer tooth enamel),
the dental papilla forms the dental pulp and
the odontoblasts (which produce dentin), and
the follicle forms the cementum as well as the
periodontal ligament (which anchors the tooth
to the underlying alveolar bone).

AJR:208, January 2017 1

 Plunk et al.

TABLE 1: Summary of Focal Lucent Lesions

Name Imaging Features Presentation and Associations
Dentigerous cyst Expansile well-circumscribed radiolucency Most common pediatric mandible lesion after dental caries;
most common odontogenic cyst
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Periapical cyst
Keratocystic odontogenic tumor
Ameloblastoma
Odontogenic myxoma
Adenomatoid odontogenic tumor
Bone cyst (simple and aneurysmal)
Central giant cell granuloma
Often associated with crown of unerupted tooth May be multiple in cleidocranial dysplasia or Maroteaux-
Lamy syndrome
Round or ovoid lucency associated with root of the tooth Associated with dental caries
May be multiple; may be large if untreated If painful, may be periapical granuloma or abscess
Unilocular, expansile, usually solitary lucency growing Previously known as odontogenic keratocyst
along axis of mandible with mass effect on adjacent teeth
If MRI performed, no solid enhancing components and may Jaw swelling and pain are common because of expansion
be intrinsically T1 hyperintense
Multiple lesions in basal cell nevus syndrome
Variable appearance given tissue composition heterogeneity Overall the most common primary mandibular tumor in
children
Uni- or multilocular expansile lucent lesion of posterior Unicystic tumors are most common in children, though solid
mandible, often associated with impacted tooth (unicystic tumors are overall most common subtype
subtype)
Aggressive features such as tooth resorption may be
present but can also mimic benign lesion
Avidly enhancing solid components may be present on
cross-sectional imaging
Imaging appearance similar to ameloblastoma Uncommon tumor often distinguished from ameloblastoma
only by pathologic analysis
Benign but locally aggressive lesion
More common in anterior maxilla and mandible, a Rare tumor
distinguishing feature
Unilocular lucency sometimes associated with unerupted Two-thirds tumor
tooth, which can mimic a dentigerous cyst
Simple bone cysts have unilocular lucency; may displace Simple bone cysts often asymptomatic; pathologic fracture
teeth but without cortical expansion uncommon in mandible
Aneurysmal bone cysts are expansile and multilocular, with Aneurysmal bone cyst may have indolent or rapid growth
fluid-fluid levels
Unilocular lucency located in the anterior mandible, often Histologically indistinguishable from cherubism or brown
parasymphyseal tumors of hyperparathyroidism
May have aggressive or nonaggressive radiographic
appearance

Humans have 20 primary teeth and 32
permanent teeth that replace them. The per-
manent teeth arise from a secondary dental
lamina that is located lingual and deep to the
primary lamina, with the exception of the
first through third adult molars, which arise
from the primary lamina. All the developing
tooth buds are typically present at birth ex-
cept those for the second and third molars.
The crown is the enamel-covered superior
portion of the tooth that is visible after a tooth
has erupted. The root is the inferior portion
that is covered with cementum and is not usu-
ally visible. The term “pericoronal” is used to
refer to a finding associated with the crown of
the tooth, whereas the terms “periradicular”
and “periapical” refer to the apex of a root.
Lucent Lesions
Radiolucent lesions are frequent in the
mandible. The lucent appearance of these le-
sions may be a consequence of cystic expan-
sion or erosion of adjacent bone. Making this
distinction is difficult with radiography, and
cross-sectional imaging such as CT or MRI
may be helpful. For example, at many centers,
the use of panoramic radiography for imaging
lucent lesions of the jaws has been replaced
by cone-beam CT for greater anatomic detail.
When characterizing a lucent lesion of
the mandible, it is important to recognize
that the imaging appearances of these enti-
ties frequently overlap and further character-
ization may not be possible. However, a rea-
sonable differential diagnosis can often be
formulated. Lucent lesions of the pediatric
mandible incorporate both odontogenic and
nonodontogenic lesions and both cystic and
neoplastic processes.
Odontogenic Cysts
Dentigerous Cyst
Dentigerous cyst, or follicular cyst, is not
only the most common pediatric odontogen-
ic cyst, it is the most frequently encountered
lesion of the mandible in children after den-
tal caries [5, 6]. It results from expansion
and fluid accumulation within remnants of
the dental lamina and usually presents in the
second decade of life [7]. Dentigerous cysts
are typically asymptomatic unless they are
large with associated mass effects on the

2 AJR:208, January 2017


teeth, are infected, or are complicated by
pathologic fracture.
These cysts appear radiographically as uni-
locular well-circumscribed radiolucencies
that classically are associated with the crown
of an unerupted tooth (Figs. 1 and 2). They
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are frequently expansile and can resorb or dis-
place the roots of adjacent teeth, but the over-
lying cortex is preserved. The third molar is
the most common location [7]. Although den-
tigerous cysts typically have a nonaggressive
appearance, more aggressive or malignant
conditions can coexist within or mimic their
appearance, and histologic analysis is recom-
mended for suspected cases [8, 9].
Histologically, dentigerous cysts are sim-
ple epithelium-lined unilocular cystic lesions
surrounded by a connective tissue wall (Fig.
1C). The cysts are usually lined by nonkera-
tinizing squamous epithelium, but occasion-
ally columnar or cuboidal epithelium with
mucous-producing cells is a prominent com-
ponent of the cyst lining. The connective tis-
sue wall ranges from loose and myxoid with
very little inflammation, in children, to fi-
brotic and inflamed, in adults.
Multiple or bilateral dentigerous cysts are
rare in isolation and typically are associated
with such syndromes as cleidocranial dyspla-
sia and Maroteaux-Lamy syndrome [10, 11].
In general, dentigerous cysts associated with
a supernumerary tooth are uncommon [12].
Special note should be made of the erup-
tion cyst, which had previously been consid-
ered a subtype of dentigerous cyst, because it
shares the same histologic appearance. Erup-
tion cysts are apparent clinically as mucosal
swelling and discoloration overlying a soon-
to-erupt tooth, and they are managed expec-
tantly [13, 14]. If a radiograph is obtained for
characterization, no osseous abnormalities
will be present.
Periapical Cyst
Periapical cysts, also known as radicular
cysts, are the most common dental lesions in
adults [15]. Periapical cysts are most com-
mon in the fifth decade of life, and only about
10% of all periapical cysts in one series oc-
curred in patients younger than 17 years [16–
18]. Although they also occur commonly in
children, they occur less frequently in the
pediatric population than in older patients.
These acquired odontogenic cysts are the re-
sult of cytokine production by inflamed or
necrotic pulp in the involved tooth after den-
tal caries or trauma. The cytokines induce
proliferation of residual epithelial cells in
AJR:208, January 2017 3
Benign Pediatric Mandible Disorders
the periodontal ligament, producing an epi-
thelium-lined cavity filled with sterile fluid
[19]. Although radiographs are typically per-
formed to aid in diagnosis, it can be difficult
to differentiate periapical cysts from periapi-
cal granulomas or abscesses on the basis of
radiographic appearance, although lesions
greater than 1 cm in diameter are more likely
to be periapical cysts [20, 21].
Periapical cysts usually present as round
or ovoid lucencies associated with the root of
the tooth (Fig. 3) but occasionally can be lo-
cated lateral to a tooth, where they are called
“lateral radicular cysts.” They may be mul-
tiple in the case of multiple dental caries.
They are typically small but may exceed 1
cm in diameter if left untreated. At this size,
they can result in resorption of adjacent tooth
roots, as well as possible pathologic fracture
and rupture of the cyst contents into adjacent
soft tissues [22].
The histologic appearance of periapical
cysts is similar to that of dentigerous cysts,
and clinical and radiographic correlations
are often needed to discriminate between
these two lesions. Under the microscope,
nonkeratinizing squamous epithelium is seen
to form the cystic lining, which is surround-
ed by a wall of connective tissue in which
inflammation and hemorrhage are prominent
(Fig. 3C). Foci of foreign body giant cell re-
action and cholesterol clefts may be present.
Lucent Odontogenic Neoplasms
Keratocystic Odontogenic Tumor
Because of their more aggressive nature
compared with other odontogenic cysts [23,
24], lesions formed by neoplastic prolifera-
tion of remnants of the dental lamina, pre-
viously known as odontogenic keratocysts
(OKCs), were reclassified in 2005 by the
World Health Organization as tumors [2].
These lesions are now identified as kerato-
cystic odontogenic tumors. At the same time,
the orthokeratinized subtype of OKC was re-
named “orthokeratinized odontogenic cyst”
[25, 26], retaining its classification as a non-
tumor cyst. The peak incidence of keratocys-
tic odontogenic tumors occurs in the third
decade of life, but these tumors may also be
seen in children and adolescents.
On radiography, the keratocystic odonto-
genic tumor will appear as a unilocular radio-
lucency with a scalloped margin, usually lo-
cated in the posterior mandible [27] (Fig. 4A).
There will often be mass effect on the adja-
cent teeth with splaying, displacement, or re-
sorption of their roots. Keratocystic odonto-
genic tumor tends to grow along the axis of
the mandible with anterior-posterior hollow-
ing of the bone and relatively less transverse
expansion (Figs. 4B and 4C). Keratocystic
odontogenic tumor can be associated with the
crown of an unerupted tooth but not as com-
monly as dentigerous cysts [23]. CT will often
better show the thinning of the surrounding
mandibular cortex. If MRI is performed, ker-
atocystic odontogenic tumor has been shown
to show intrinsic high T1 signal and hetero-
geneous T2 signal, attributed to high keratin
and cholesterol contents in the lumen, and rim
enhancement. The lack of solid enhancing
components can help distinguish a keratocys-
tic odontogenic tumor from ameloblastoma
[28, 29]. The dense contents of a keratocys-
tic odontogenic tumor have been shown to re-
strict diffusion, which may further distinguish
them from other cystic lesions [30].
Keratocystic odontogenic tumors, as the
name suggests, have a cystic appearance un-
der the microscope, with cysts lined by ke-
ratinized squamous epithelium (Fig. 4D).
The epithelial lining is typically uniform in
thickness, has a prominent parakeratin cell
layer, and lacks rete pegs. The basal layer is
usually palisaded, with hyperchromatic nu-
clei present in the cells. The cystic wall con-
nective tissue shows a cellular to fibrotic ap-
pearance, whereas in the cystic lumen, layers
of sloughed keratin fibers may be present.
Keratocystic odontogenic tumors are usu-
ally solitary. However, if multiple tumors are
detected, the possible diagnosis of nevoid bas-
al cell carcinoma (Gorlin-Goltz syndrome)
should be entertained, because multiple kera-
tocystic odontogenic tumors may be the first
recognized manifestation of this syndrome
[31]. Up to 75% of patients with nevoid bas-
al cell carcinoma syndrome may have multi-
ple keratocystic odontogenic tumors, so when
they are present, a search should be made for
other manifestations of Gorlin-Goltz syn-
drome, including dural calcifications, axial
skeletal abnormalities, and medulloblastoma.
A solitary keratocystic odontogenic tumor
does not have malignant potential but may be
locally aggressive, grow rapidly, and perfo-
rate bone. It also carries a higher risk of local
recurrence after simple enucleation than that
seen with other odontogenic cysts [32].
Ameloblastoma
Ameloblastoma is overall the most com-
mon primary mandibular tumor in children,
and it may have a variety of appearances de-
pending on its tissue composition. Amelo-

blastomas are divided into four categories:
unicystic, solid, desmoplastic, and peripheral
(extraosseous). All types of ameloblastomas
are benign, but locally aggressive, neoplasms
with a high risk of local recurrence.
Unicystic ameloblastomas are the most
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common type of mandibular tumor in chil-
dren. They are associated with the crown of
an impacted tooth in about 90% of cases. The
radiographic appearance in these cases is sim-
ilar to that of a dentigerous cyst, possibly ac-
companied by a small amount of enhancing
soft tissue (Figs. 5 and 6). The other 10% of
unicystic ameloblastomas are unilocular ra-
diolucencies usually present between teeth.
Around 10–20% of all ameloblastomas occur
in patients 14–20 years old, with rare cases in
children as young as 2–3 years old [33–36].
Three histologic subtypes of unicystic am-
eloblastomas have been described: luminal,
intraluminal unicystic (plexiform), and mural
unicystic (Fig. 5C). Unicystic ameloblastomas
behave less aggressively than do multilocular
solid ameloblastomas. Curettage is therefore
the preferred treatment of the luminal and
intraluminal histologic subtypes of unicys-
tic ameloblastomas, whereas en bloc removal
or resection is the treatment of choice for the
mural subtype. Recurrence rates range from
6% to 35%, depending on the type.
Solid (multicystic) ameloblastomas, pre-
viously referred to as adamantinomas of
the jaw, constitute over 80% of all amelo-
blastomas. Multicystic ameloblastoma is a
slow-growing locally aggressive neoplasm
that originates from odontogenic epitheli-
um. It generally affects adults, with a mean
age of onset of 33 years, and is rare in pa-
tients younger than 12 years. About 85% of
solid ameloblastomas occur in the posterior
mandible in the molar-ramus area [35]. The
radiologic appearance of solid ameloblasto-
ma comprises a well-corticated, expansile,
multilocular, and radiolucent lesion, often
accompanied by enhancing soft tissue [33]
(Fig. 6A). Solid ameloblastoma often has a
nonaggressive appearance on radiographs
and may be indistinguishable from other
odontogenic lesions, although more aggres-
sive features, such as resorption of adjacent
roots, may suggest the diagnosis. If left un-
treated, solid ameloblastoma, even if other-
wise asymptomatic, can enlarge substantial-
ly, causing facial disfigurement. At least five
histologic subtypes of solid ameloblastoma
have been described, all appearing as vari-
ably shaped and sized odontogenic epitheli-
al islands, surrounded by mature and cellu-
4 AJR:208, January 2017
Plunk et al.
lar connective tissue (Fig. 6B). Inflammation
is usually absent. The epithelial islands are
lined by a single layer of palisaded cuboidal
and columnar cells with reversed polariza-
tion and hyperchromatic nuclei. Because the
recurrence rate of these lesions ranges from
50% to 90%, the treatment of choice for the
solid ameloblastoma is en bloc resection with
adequate clean margins.
MRI has been investigated in character-
izing ameloblastoma and distinguishing it
from other similar-appearing cystic man-
dibular lesions, though use of this modality
is not currently widespread. The cystic por-
tions of ameloblastoma typically show low-
to-intermediate T1-weighted signal and high
T2-weighted and STIR signal [37]. Gado-
linium-enhanced sequences can be helpful
in identifying ameloblastoma: Although the
cystic portions are typically nonenhancing,
an enhancing solid mural component may
be identified even in predominantly cys-
tic lesions, which favors ameloblastoma as
the diagnosis [38, 39]. Ameloblastoma has
been shown to enhance more rapidly and
avidly than keratocystic odontogenic tumor
in adults [40, 41]. DWI may also have some
utility in ameloblastoma, because the non-
enhancing portions of ameloblastoma have
been found to have higher apparent diffu-
sion coefficient values compared with kera-
tocystic odontogenic tumor [42]. This find-
ing presumably reflects that the cystic spaces
of ameloblastoma are less densely packed
and viscous compared with the accumulat-
ed keratin in a keratocystic odontogenic tu-
mor. Other MRI parameters have been inves-
tigated to discriminate cystic ameloblastoma
from other causes, including dynamic con-
trast enhancement, signal uniformity, and T2
relaxation times [29, 42, 43].
Odontogenic Myxoma
Fibromyxoma or myxofibroma, better
known as odontogenic myxoma, is an un-
common neoplasm of odontogenic mes-
enchymal origin [44]. Although they are
benign, odontogenic myxomas, like amelo-
blastomas, may be locally aggressive, with a
potential for extensive bony destruction and
extension into surrounding structures [45].
Almost 75% of odontogenic myxomas are
diagnosed in young adults 23–30 years old.
Odontogenic myxomas occur only rarely in
patients younger than 10 years. These lesions
are found almost equally in the maxilla and
mandible, showing a slight predilection for
the posterior mandible. When they occur in
the maxilla, they usually invade the maxil-
lary sinuses and may rarely cross the midline
to involve the opposite sinus. Most such tu-
mors are expansile multilocular lesions with
internal trabeculations; they can displace
and resorb teeth [46]. Microscopic examina-
tion shows the lesions to be made up of loose
and delicate fibrous connective tissue. The
lesions are typically gelatinous, making cu-
rettage alone difficult. Surgical excision with
adequate margins is the preferred interven-
tion to prevent local recurrence.
Adenomatoid Odontogenic Tumor
Often detected as an incidental finding on
dental radiographs, adenomatoid odontogen-
ic tumor is a rare benign slow-growing neo-
plasm of odontogenic epithelium that is often
initially misdiagnosed as a more common
dentigerous cyst, which has a similar radio-
logic appearance. Adenomatoid odontogenic
tumor is sometimes referred to as the two-
thirds tumor, because two-thirds of cases
occur in young female patients aged 10–19
years, two-thirds occur in the maxilla, two-
thirds are located anteriorly in the jaw, and
two-thirds occur in association with an un-
erupted tooth [47]. One unique feature that
may suggest the diagnosis is that adenoma-
toid odontogenic tumor is one of the few le-
sions that favor the anterior maxilla over the
posterior mandible. The typical radiographic
appearance of adenomatoid odontogenic tu-
mor is a unilocular corticated radiolucency
around the crown, which can extend inward
to involve the root of the tooth.
The histologic profile of adenomatoid odon-
togenic tumor shows epithelial cells arranged
in two patterns: some are spindle shaped, ar-
ranged in whorls, nests, and bundles, whereas
others are cuboidal and arranged in ductlike
structures, with the epithelial proliferations
supported by a thick fibrous connective tissue
capsule. Globules of a homogeneous materi-
al, which may represent amyloid, have been
described in some adenomatoid odontogenic
tumor specimens. The thick connective tissue
capsule makes separation of the lesion from
the tooth and surrounding connective tissue
easy, allowing the clinician to save the tooth.
Therefore, the treatment of choice is either
enucleation or simple curettage.
Nonodontogenic Lucent Lesions
Simple Bone Cyst
Simple bone cysts of the same type that
may arise in the proximal humerus (50%)
and femur may also arise in the mandible.

Although some simple bone cysts may be
related to prior trauma, which explains why
simple bone cysts are sometimes referred
to as traumatic bone cavities, other possible
causes for simple bone cysts include cystic
degeneration of a preexisting tumor, loss of
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the fatty marrow in the involved area, or vas-
cular abnormality resulting from high ve-
nous pressure in the medullary space [48–
51]. Simple bone cysts are most commonly
discovered in the second decade of life [48].
The most common location for simple bone
cyst [49] is the posterior mandible, particu-
larly the premolar-molar region. If locat-
ed anteriorly, they can sometimes cross the
midline. Those arising in the premolar-molar
area are typically located above the alveolar
canal, usually are unilocular and radiolucent,
and, in many cases, have a scalloped superior
border insinuating between the roots of teeth.
The associated teeth may, in fact, be found
dangling within the cavity. The 25% of the
lesions occurring in the anterior mandible,
apical to the canine tooth, are usually round
and unilocular radiolucencies with an ap-
pearance similar to that of periapical cysts.
In contrast to simple bone cysts of the long
bones, most simple bone cysts that arise in
the mandible are asymptomatic, and patho-
logic fractures are uncommon. At surgery,
an empty cavity is found at the cyst entrance
in about two-thirds of cases, and cavities
filled with straw-colored fluid are observed
in about one-third of cases. The treatment
of choice for this condition is scraping the
bone cavity to generate bleeding, but other
accepted treatments include the injection of
corticosteroids and curettage of the cavity
followed by packing with autogenous blood,
autogenous bone, and hydroxyapatite [50].
Aneurysmal Bone Cyst
The aneurysmal bone cyst (ABC), like the
simple bone cyst, is not a true epithelium-
lined cyst. In recent years, studies have found
that these tumors harbor USP6 translocations,
which more strongly suggest that these lesions
are truly neoplastic rather than reactive [52].
A rare lesion, ABC accounts for only 1.5% of
mandibular lesions across all age groups but
is more common in children and adolescents
[53, 54]. ABCs may present with pain, pain-
less slow swelling, or rapid growth but may
also be found incidentally on examination
[55]. Like simple bone cysts, ABCs can occur
anywhere within the mandible but are more
commonly found in the posterior mandible,
including the condyle, with involvement of
AJR:208, January 2017 5
Benign Pediatric Mandible Disorders
the temporomandibular joint [56]. The radio-
graphic appearance of ABCs can be variable
as well, but they are most commonly seen as
multilocular radiolucencies with cortical thin-
ning leading to ballooning or blown-out dis-
tention of bone [57] (Fig. 7). If MRI is per-
formed, ABCs will typically show multiple
fluid-fluid levels secondary to the sediment of
blood products that is characteristic of these
lesions. Of note, fluid-fluid levels can occur in
other lesions of the jaw, including osteosarco-
ma and fibrous dysplasia [58, 59].
Central Giant Cell Granuloma
Central giant cell granuloma of the jaw is a
separate entity from the giant cell tumor seen
in long bones, despite their similar names.
Although these lesions may have a similar
radiologic appearance, they are distinct enti-
ties histologically [60]. It is unclear whether
giant cell granuloma represents a neoplastic
or reactive process, and the variable opin-
ions about cause are reflected in the variety
of names for this entity. The term “giant cell
granuloma” will be used in the current arti-
cle for simplicity [61]. Although giant cell tu-
mors typically occur in the long bones, giant
cell granulomas occur most commonly in the
mandible and maxilla, followed by the digi-
tal bones. Giant cell granulomas are indistin-
guishable from cherubism and brown tumors
of hyperparathyroidism histologically, and
are therefore simply called central giant cell
lesions by many pathologists. Twice as many
cases of giant cell granuloma occur in female
patients as compared with male patients, and
over 60% of giant cell granuloma cases are
seen in patients younger than 30 years [62].
Like many other mandibular lesions, gi-
ant cell granulomas may vary in their clin-
ical presentation and radiographic appear-
ance. The more aggressive type of giant cell
granuloma tends to occur in patients younger
than 10 years [63]. Central giant cell granu-
loma, as the central designator indicates, is
one of a few lesions that are more common
anterior to the first molars. Those giant cell
granuloma lesions occurring in the mental
region may cross the midline [64]. CT can
reveal an expansile mass that can have fea-
tures of both bony expansion and frank de-
struction [65] (Figs. 8A and 8B). On MRI,
it has been described as exhibiting both T1-
and T2-weighted hypointensity, with avid en-
hancement [66].
The histologic appearance of giant cell
granuloma shows vascular and cellular gran-
ulation tissue interspersed with many hap-
hazardly distributed giant cells of variable
shapes and sizes (Fig. 8C). Extravasated
erythrocytes with hemosiderin deposition
are commonly present. On gross examina-
tion, the dark brown color of giant cell gran-
uloma may resemble liver.
Other Lesions
Multiple other lesions that occur elsewhere
in the body can also present in the mandible.
These include intraosseous vascular malfor-
mations and chondroid lesions [67–69]. Non-
ossifying fibromas are rare in the mandible
but can be multiple in the context of Jaffe-
Campanacci syndrome [70]. Finally, the mel-
anotic neural ectodermal tumor of infancy
is a rare neoplasm of neural crest cells that
presents in the first year of life. It most com-
monly affects the maxilla and skull but can
also involve the mandible [71, 72].
Conclusion
The differential diagnosis of a lucent man-
dibular lesion is broad, because there is a
broad spectrum of both odontogenic and
osseous pathologic abnormalities that can
manifest in this fashion. Although the imag-
ing appearance of these lesions can be quite
similar, using the location and the provid-
ed clinical history can help tailor the differ-
ential considerations. It should also be not-
ed that, in addition to the benign but locally
aggressive neoplasms discussed here, both
odontogenic and nonodontogenic malignan-
cies can present as a lucent lesion as well.
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Fig. 1—6-year-old boy
with dentigerous cyst.
A and B, Axial (A)
and sagittal (B) CT
images show unilocular
expansile lucent lesion
(arrows, A) with intact
cortex. Note cyst’s
association with crown
of unerupted tooth
(black arrow, B) and
absorption of roots of
adjacent teeth (white
arrow, B).
(Fig. 1 continues
on next page)
 Plunk et al.

Fig. 1 (continued)—6-year-old boy with dentigerous cyst.

C, Histologically, dentigerous cysts are simple epithelium-lined unilocular
cystic lesions surrounded by connective tissue wall. Usually, they are lined by
nonkeratinizing squamous epithelium, but occasionally columnar or cuboidal
epithelium, or mucous-producing cells, are prominent component of cyst lining.
Photomicrograph (H and E, ×200) shows that connective tissue is infiltrated by
lymphocytes and plasma cells.
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A B

C D
Fig. 2—14-year-old boy with dentigerous cyst.
A and B, Axial (A) and coronal (B) CT images show expansile lucent lesion in left mandible with thinned but otherwise intact cortex (arrows), associated
with crown of unerupted tooth.
C, Coronal STIR image shows uniformly high-signal simple fluid within cyst (arrow).
D, Axial T1-weighted fat-suppressed contrast-enhanced MR image illustrates thin marginal enhancement (arrows).

8 AJR:208, January 2017

 Benign Pediatric Mandible Disorders
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A B
Fig. 3—13-year-old boy with periapical (or
radicular) cyst.
A and B, Axial (A) and sagittal (B) CT
images show ovoid cyst with intact cortex
(arrows). Sagittal image (B) shows cyst’s
association with root of anterior incisor.
C, Photomicrograph (H and E, ×100)
shows that this periapical cyst has
typical nonkeratinizing squamous lining
surrounded by inflamed hemorrhagic
connective tissue wall, infiltrated
by sheets of foamy macrophages,
lymphocytes, and plasma cells. Histologic
profile of periapical cyst is similar to that
of dentigerous cyst. Clinical and imaging
correlation is needed for definitive
diagnosis.

AJR:208, January 2017 9

 Plunk et al.
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B C
Fig. 4—20-year-old man with
keratocystic odontogenic tumor.
A, Panoramic radiograph depicts
multiloculated lytic lesion (black
arrow) extending longitudinally
along left mandibular body (white
arrows).
B and C, Axial CT images reveal
expansion and thinning of cortex
(arrows, B), greatest laterally where
it protrudes into overlying soft
tissues (arrow, C).
D, Photomicrograph (H and E, ×100)
shows that these cysts are lined by
stratified squamous epithelium with
corrugated surface. Basal cells are
hyperchromatic and have palisaded
appearance. Cystic spaces may be
filled with amorphous keratin debris.
These diagnostic histologic features
may be lost in cases where cyst
becomes inflamed.
D

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 Benign Pediatric Mandible Disorders
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A B
Fig. 5—17-year-old girl with ameloblastoma (unicystic).
A and B, Axial contrast-enhanced CT images show large septate cystic lesion
centered within right posterior mandibular body, with enhancing soft tissue along
cyst’s anteromedial aspect (arrowheads, A; arrows, B).
C, Ameloblastomas are composed of multiple variably sized islands of epithelium
in backgrounds of fibrovascular tissue. Characteristic features include basal
columnar cells with reversed nuclear polarization and central zones of loose
stellate epithelium, as seen on photomicrograph (H and E, ×400).

A B
Fig. 6—20-year-old woman with ameloblastoma (solid).
A, Axial contrast-enhanced CT image illustrates enhancing soft tissue (white arrow) in central portion of left mandibular lytic lesion. Note erosion through lateral cortex
(black arrow).
B, Photomicrograph (H and E, ×200) shows typical histologic features of solid ameloblastoma. There are odontogenic epithelial islands of variable shapes and sizes.
Islands are lined by single layer of palisaded columnar cells exhibiting reverse polarization. Center of islands is filled with stellate reticulum type of epithelial cells.
Connective tissue stroma is mature and cellular.

AJR:208, January 2017 11

 Plunk et al.
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A B
Fig. 7—18-year-old man with aneurysmal bone cyst.
A and B, Axial (A) and coronal (B) contrast-enhanced
CT images show multicystic expansile lesion in left
mandibular ramus and condyle (arrows, B). Fluid
exhibits variable attenuation above that of water,
reflecting proteinaceous contents or blood products,
including fluid-fluid level (arrow, A).
C, Aneurysmal bone cysts are composed of irregular
pseudocystic spaces that may contain blood. Fibrous
septa in aneurysmal bone cysts contain bland
fibroblasts, capillaries, multinucleated giant cells
without cytologic atypia, and seams of osteoid. Mitotic
figures may be prominent focally, but atypical mitotic
figures are not seen in photomicrograph (H and E, ×200).

A B
Fig. 8—10-year-old girl with central giant cell granuloma.
A and B, Axial (A) and coronal (B) CT images depict expansile lucency in right parasymphyseal mandible (arrows). Overlying cortex is very thin
and has been fully eroded in parts, giving lesion aggressive appearance.
(Fig. 8 continues on next page)

12 AJR:208, January 2017

 Benign Pediatric Mandible Disorders

Fig. 8 (continued)—10-year-old girl with central giant

cell granuloma.
C, Photomicrograph (H and E, ×200) shows numerous
osteoclastlike multinucleated giant cells admixed
with spindled and cellular granulation tissue. Patchy
regions of hemorrhage are common.
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AJR:208, January 2017 13