Dentomaxillofacial Radiology (2007) 36, 121–124

q 2007 The British Institute of Radiology

http://dmfr.birjournals.org

CASE REPORT
Radiographic assessment of Gardner’s syndrome
LC Fonseca1,2, NK Kodama1, FCF Nunes2, PH Maciel3, FA Fonseca4, M Roitberg5, JX de Oliveira1
and MGP Cavalcanti*,1
1
Department of Radiology, College of Dentistry, University of São Paulo, São Paulo, Brazil; 2College of Dentistry, PUC of Belo
Horizonte, Brazil; 3Hospital of Public Employees at the State of Minas Gerais, Brazil; 4Private Practice, Belo Horizonte, Brazil;
5
Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil

The detection of osteomas in the maxillofacial region may be the initial clinical finding in Gardner’s
syndrome (GS). The most common location of osteomas is in the skull, but the lesion can also occur
in the jaws. We present a case of a 47 year old male patient with GS who was referred for
radiological evaluation. Extraoral examination revealed an epidermoid cyst and the patient had a
history of intestinal polyps. A panoramic radiograph demonstrated numerous osteomas and diffuse
sclerosis of the mandible, and compound odontomas with impacted teeth. CT scan allowed the
localization and extension of the osteomas, and showed other sites in the maxillofacial region as
well. CT images also revealed a different behaviour of osteoma, invading the mandibular canal.
Dentomaxillofacial Radiology (2007) 36, 121–124. doi: 10.1259/dmfr/18554322

Keywords: Gardner’s syndrome; tomography; X-ray computed; osteoma

Case report

A 47 year old white male patient was referred for
radiological evaluation, with a medical history of Gardner’s
syndrome (GS). The patient reported a clinical history of
intestinal polyps and an extraoral examination revealed an
epidermoid cyst localized in the forehead (Figure 1a) and in
the right leg (Figure 1b). He did not complain of any
symptoms.
A panoramic radiograph (Figure 2) revealed multiple
radiopaque masses at the right ascending ramus and at the
bilateral angle of the mandible, also into the left maxillary
sinus and in the right zygomatic – maxillary process,
suggesting osteomas. Diffuse sclerosis was also noted
throughout the mandibular body. A radiopaque mass
appeared close to the mandibular canal at the left side,
displacing the superior cortex. A large radiopaque mass was
distinguished at the right ascending ramus, near the condyle
and the mandibular foramen. Compound odontomas were
observed in both jaws, which were better visualized by
periapical radiograph (Figures 3a and b). Moreover, the
right superior canine had suffered impaction by a small
compound odontoma (Figure 3b).
To determine the exact location of the lesions, a CT scan
was performed. Axial CT images demonstrated several
*Correspondence to: MGP Cavalcanti, Department of Stomatology, College of
Dentistry, University of São Paulo, Avenida Prof. Lineu Prestes, 2227, Cidade
Universitária, São Paulo 05508-900, SP, Brazil; E-mail: mgpcaval@usp.br
Received 6 October 2005; revised 14 March 2006; accepted 24 March 2006
hyperdense areas in both sides of the mandible (Figure 4a),
and also showed an osteoma in the lingual cortex involving
the mandibular foramen and invading the right mandibular
canal (Figure 4b). The same lesion was detected in coronal
reconstructed image in the right ascending ramus, near to
the inferior-medial portion of the condyle, invading the
medial cortex (Figure 4c), even though the patient did not
suffer paraesthesia. Other osteomas were also seen in the left
maxillary sinus and in the right zygomatic bone (Figure 5).
No treatment was carried out and subsequently the patient
was lost to follow-up.
Discussion
The early detection of GS is extremely important because
patients can develop colorectal adenocarcinoma.1 The
maxillofacial features of the syndrome can appear many
years before the intestinal polyposis, so dentists should be
familiar with the significance of GS as a pre-cancerous
condition.1 The presence of multiple bone changes of the
skull and abnormal dental findings should alert the
clinician to initiate further investigation.2 Ida, Nakamura
and Utsunomiya3 revealed that patients with more than
three osteomas need to have the familial history checked,
with an emphasis on intestinal disease, because this is
highly suggestive of GS. Utsunomiya and Nakamura4
reported that osteomatous changes in the jaws were more
 Gardner’s syndrome
122 LC Fonseca et al.
Figure 1 (a) Facial appearance showing an epidermoid cyst in the
forehead (arrow). (b) Ulcerated epidermoid cyst in the right leg
frequent than dental abnormalities. Our case showed the
classical clinical features associated with GS: multiple
osteomas and odontomas, adenomatous polyps, epider-
moid cyst and impacted tooth.
The understanding of the behaviour of the osteoma is
essential, since it can cause clinical problems. Furthermore,
it might be the only extracolonic manifestation related to the
Figure 2 Panoramic radiograph depicting multiple osteomas at the right
ascending ramus and at the bilateral angle of the mandible, also into the
left maxillary sinus and in the right zygomatic – maxillary process
(arrows), and diffuse sclerosis in the mandible
Dentomaxillofacial Radiology
Figure 3 Periapical radiography showing (a) compound odontomas in
the mandibular premolar region (arrows) and (b) an impaction of right
maxillary canine by odontoma (arrow)
disease.4 Lew et al5 reported a case in which an osteoma of
the condyle caused a limitation of mouth opening. In
addition, Baykul et al6 reported that this lesion can reach a
considerable size causing disfigurement. In our case, we did
not find a relevant disfigurement and the invasion of the
mandibular canal by the osteoma did not cause any clinical
alteration. The absence of paraesthesia could be explained
because the osteoma in the right ascending ramus was
invading the entrance of the mandibular foramen, but did
not obstruct the nerve pathway. However, Takeuchi et al7
verified that an increase in the number and size of the jaw
lesions, including osteomas, in GS patients can occur
gradually even in adulthood. Thus, in our reported case, the
osteoma near to the right mandibular canal could enlarge
and produce some symptomatology in the future. Conse-
quently, a careful follow-up radiological examination of the
jaws must be performed.

Figure 4 (a) Axial CT image showing several hyperdense areas in the mandible and osteomas (arrows) and (b) an osteoma in the lingual cortex involving
the mandibular foramen and invading the right mandibular canal (arrow). (c) Coronal reconstructed image revealing the involvement of medial cortex by
the same lesion (arrow)
Skeletal abnormalities appear in approximately 90%
of patients with GS, and osteoma is considered to be the
most common.5 The frequent sites for these tumours are
the outer cortex of the skull, paranasal sinuses and the
mandible.5 Supernumerary teeth, compound odontomas
and/or impacted teeth were seen in 30% of the patients
with this disease.8,9 In a normal population, the incidence
of osteosclerosis in the mandible or maxilla is low,
whereas in some studies these are detected in more than
70% of cases of familial adenomatosis coli or GS.3,9 In
our case there were no supernumerary teeth, but we did
find some compound odontomas in the mandible and in
the maxilla. The compound odontomas in the maxilla
caused the impaction of the right superior canine, and the
patient also had diffuse sclerosis of the mandible.
Panoramic radiography can be useful for early detection
of GS by the dentist, because the components of this entity,
like osteoma, odontoma, supernumerary and impacted
teeth, can be detected in the routine radiological examin-
ation.9 Nevertheless, panoramic radiography is of limited
value in evaluation, localization and extension of the
tumour mass, considering the superimposition of bony
structures and that it is a bidimensional image. DelBalso
and Werning10 related that CT is the best imaging modality
for the diagnosis of osteoma. Halling et al2 reported a case
of GS studied by panoramic radiography that showed
multiple widespread osteomas in the mandible associated
with composite odontomas. Furthermore, this patient was
submitted to a CT scan that demonstrated enostoses in the
inner surface of both cortices and the full extent of the
osteomas at the angles of the mandible and the ethmoidal
sinuses, as well as smaller lesions lingual to the lower right
first premolar. Yuasa et al11 reported that the osteomas of
the maxilla were described correctly when studied in CT
Gardner’s syndrome
LC Fonseca et al. 123
scans because the panoramic radiography was a less
adequate technique for detecting maxillary lesions.
CT provides better delineation of the bony structures of
the skull base and facial skeleton than conventional
radiography. In addition, it allows the visualization of
cross-sectional images and it is the only examination that
provides details of the extension and localization of the
osteomas.11 Owing to this, CT scan has become an
important diagnostic tool for maxillofacial lesions,10 but
only a few cases of GS have been studied using this
technique. In our case report, using CT images we could
identify an osteoma in the maxillary sinus and in the
zygomatic bone accurately. In addition, CT showed a
modified pattern of the bone in the mandible. All of these
manifestations in the mandible were more clearly eluci-
dated by CT than panoramic radiography. Also, the
localization and extension of the osteoma in the mandible
was determined by CT scan, which revealed a particular
behaviour of the osteoma that invaded the mandibular
canal. This invasion of the mandibular canal is a new
finding in GS. Furthermore, a CT examination can be
useful to the clinicians in diagnosis of this lesion, the
Figure 5 Coronal CT image of the maxilla demonstrating osteoma in the
left maxillary sinus and in the right zygomatic bone (arrows)
Dentomaxillofacial Radiology
 Gardner’s syndrome
124 LC Fonseca et al.
establishment of appropriate treatment plan and follow-up
for the patient.
The present case illustrated the importance of CT
examination in GS with multiple osteomas. CT revealed a
new behaviour of osteoma, invading the mandibular canal,
but without a clinical manifestation.
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Dentomaxillofacial Radiology
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