Stafne's bone cyst (SBC) is an asymptomatic, round or oval-shaped, well-defined, uniform radiolucent

lesion, usually incidentally observed in the posterior aspects of the mandible. Radiographical
appearance may be confusing though.

Causes. It was originally proposed by Stafne that some parts of the submandibular gland could be
trapped during mandibular ossification, causing well-circumscribed bony depression. This theory is
supported by the observation that ectopic salivary glands are found in the cavity.

In most cases, Stafne bone cavity does not require surgical treatment. In rare cases where persistent
infection or malignant changes occur, biopsy or surgical exploration must be performed [4].
Stafne Bone Cavity with expansion at
posterior mandible: A case report and review
of the literature
Highlights
 •

Stafne Bone Cavities (SBC) can cause expansion at the buccal cortical plate when they
reach large sizes.

 •

In cases where SBC extends to the superior of the mandibular canal, the canal may not
be observed.

 •

SBCs may appear as a multilocular lesion when they have irregular borders which may
cause a misdiagnosis in 2D images.

 •

This case report with review is the first and only review about type-3 SBCs.
Abstract
Stafne Bone Cavity (SBC) is a radiolucent lesion usually located in the posterior region of the
mandible, inferior to the mandibular canal and some SBCs take place in the anterior region or
ascending ramus unilaterally. Etiopathogenesis of SBC is still not certain despite there are
various theories. SBCs usually do not have any clinical symptoms hence radiographic
examinations will be the first step in the diagnosis. It is important to do differential diagnosis
properly when the lesions are atypical just as it is in our case. This case report with type-3 SBCs
review, aims to define the characteristic features of a giant Type-3 Stafne Bone Cavity with
orthopantomography, cone beam computed tomography (CBCT), magnetic resonance imaging
(MRI) and histopathological examination.

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1. Introduction
Stafne Bone Cavity (SBC) or Lingual Mandibular Bone Depression is a radiolucent lesion
usually located in the posterior region of the mandible unilaterally, inferior to the mandibular
canal and was described firstly by Edward Stafne in 1942 [1]. Etiopathogenesis of SBC is still
not certain but the theory, which suggests the lingual mandibular plate's atrophy due to adjacent
submandibular salivary gland's depression, is asserted [2]. SBCs are seen mainly in men aged
between 50 and 60, and the prevalence varies between 0.10% and 0.48% [2]. The lesion is
usually observed between 1 and 3 cm in diameter in terms of size and presents as round or oval
[3]. Generally seen in the posterior region of the mandible, some SBCs take place in the anterior
region [4,5] or ascending ramus [6,7]. SBCs are more commonly seen unilaterally but some
authors described bilateral SBCs as well [8]. Histopathologically normal saliva tissue and
sometimes muscle tissue, fibrous connective tissue, fat tissue and vascular tissue may be seen
[9]. Since most of the SBCs are asymptomatic, the diagnosis may be made on routine oral
radiographic examinations [1,4]. There are two classifications for SBCS. First one classifies the
lesion's extension while the second one classifies its content [7].

1.1. Extension classification

 Type I: Cavity depth does not extend to the cortical plate of the mandible
 Type II: Cavity depth extends to the cortical plate of mandible
 Type III: Cavity depth extends to the cortical plate of mandible and causes expansion

1.2. Content classification

 Type F: Fat content

 Type S: Soft tissue content (Conjunctive tissue, lymph node, vessels)
 Type G: Salivary gland content
This case report with type-3 SBCs review, aims to define the characteristic features of a giant
Type-3 Stafne Bone Cavity with orthopantomography, cone beam computed tomography
(CBCT), magnetic resonance imaging (MRI) and histopathological examination.

2. Case presentation
A 51-year-old asymptomatic male patient was referred to Istanbul University, Faculty of
Dentistry, Department of Periodontology for periodontal treatment. An orthopantomographic
image was taken for evaluation. The orthopantomographic image revealed a multilocular cystic
lesion in the right posterior mandible, anterior to the right mandibular angle and below the third
molar (Fig. 1). The mandibular canal could not be observed due to the superposition of the
lesion. There was no significant medical/dental history.

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Fig. 1. Initial orthopantomograph of the patient.

CBCT, for advanced analysis, was performed. CBCT cross-sections revealed the mandibular
canal at the superior border of the lesion without any pressure effect. The inferior border was
partially intact but had some destruction at the inferior-lingual site (Fig. 2).
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Fig. 2. CBCT Cross-sectional images.

The lesion was measured 25.3mm*20.5mm*14.8mm (width x height x length) and It destroyed
the lingual cortical bone while expanding the buccal cortical bone with no visible trabecular bone
(Fig. 3a). Radiologic differential diagnosis advised Stafne Bone Cavity but because of the
irregular border formation and expansion, an MRI was advised to undergo. MR sections showed
a cystic-like lesion which has a lobulated contour and expansile character. The lesion had
isointense contrast with submandibular gland in T1-A sequence and has no contrast retention in
contrasted axial sections (Fig. 3b and c).
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Fig. 3. A: Cbct axial slice image/B: Mri T1 – FSE axial slice image/C: Mri T1 +C axial slice
image.

The submandibular gland's extension was observed in the relevant cystic lesions cavity thus
Stafne's Bone Cavity was considered as the final radiological diagnosis. For the definite
histopathologic diagnosis, a biopsy was performed and photomicrograph of the removed tissue
showed normal salivary gland tissue, mucous acini and inflammatory cells (Fig. 4).

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Fig. 4. Photomicrographs of the removed tissue showed normal salivary gland tissue, mucous
acini and inflammatory cells (H&E x100).

The lesion is defined as Stafne Bone Cavity: Type 3 and the patient was recommended for
regular follow-up. After 6 months and 18 months from the diagnosis, two orthopantomographic
images were taken and showed no difference in terms of size and effect on surrounding tissues
(Fig. 5).
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Fig. 5. A – 6 months after the first OPG/B- 18 months after the first OPG.

3. Discussion
Since the first description of Stafne Bone Cavity by Edward Stafne is made, many authors
described this lesion with different sizes and effects on surrounding tissues. SBC has a
predilection for men who are aged between 50 and 70 years and our 51-years-old male patient is
in this range [7]. Depending on their effects on cortical and trabecular bone, SBCs are divided
into three types: Our patient has an SBC with buccal wall expansion also known as type 3. The
other 2 types are; Type 1 in which the cavity does not resolve the trabecular bone completely and
does not extend to the cortical bone, Type 2 in which the cavity extends to the cortical bone but
cause no expansion [9]. It is important to do differential diagnosis properly when the lesions are
atypical. The differential diagnosis of these cases is usually straightforward although some
difficulties may appear when this lesion is located near the apical areas of the mandibular teeth
[2]. The differential diagnosis of SBC should be done with several pathologies such as
odontogenic cystic lesions, ameloblastoma, fibrous dysplasia, vascular malformations, giant cell
granuloma, odontogenic keratocyst, aneurysmal bone cyst, eosinophilic granuloma, benign
salivary gland tumours, neurogenic tumours, myxoma, multiple myeloma, and metastatic
diseases [3]. Orthopantomographic images may be sufficient for diagnosis in some cases but
atypical forms of SBC, such as Type 3, should be evaluated with advanced imaging techniques
such as MRI, CBCT, CT or sialography [10]. Sialography exposes the patient to radiation and It
is accepted as an invasive procedure. Therefore it is rarely used to diagnose SBC [10]. MRI can
provide adequate information about SBC without any intravenous contrast material application
or radiation exposure thus rather than CBCT, MRI is suggested as the primary diagnosis method
for SBC [3]. Even though the MRI sections revealed that the submandibular gland's extension
was located in the lesion's cavity, for the sake of definite diagnosis a biopsy was performed. SBC
mainly contains ectopic salivary gland tissue, however, in some cases, it has been reported to
contain muscle, fibrous connective tissue, blood vessels, fat, or lymphoid tissue. In our case,
normal salivary gland tissue, mucous acini, and inflammatory cells were seen in the
photomicrograph [8].

Although there are dozens of type-1 and type-2 SBCs in the literature, only 7 type-3 SBCs were
reported [[9], [10], [11], [12]] (Table 1).

Table 1. Type-3 Stafne Bone Cavities in the Literature (* The Case that is mentioned in this
paper).

Case Depth Wide Height

Author Age Sex Imaging Technique
Number (mm) (mm) (mm)
1 Ariji et al. 36 Male 18 23 x
2 Ariji et al. 44 Female 10 24 x OPG/CT-Sialography
3 Ariji et al. 53 Male 10 22 x
4 Schneider et al. 66 Male 12 23 17 OPG/CBCT/MRI
Flores Campos
5 49 Male x x x OPG/CT/Scintigraphy
et al.
6 More et al. 57 Male x x x
OPG/CT
7 More et al. 45 Male x x x
*8 Ünsal et al. 51 Male 14.8 25.3 20.5 OPG/CBCT/MRI

Male: Female ratio is 7:1 and the patients' ages were ranged between 36 and 66. The depth of the
cavities ranged between 10 and 18mm, the wide of the cavities ranged between 22 and 25.3mm,
the height of the cavities ranged between 17 and 20.5mm. There was no information about the
height of the cavities at Ariji et al.'s study. More et al. and Flores Campos et al. did not mention
any measurement at their studies. Compared to other cases in terms of width and height, our SBC
was a larger lesion than others.