2. Case presentations A 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.

3. 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.

4. 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.

5. Immediately before the CT-investigation that we saw in the first picture, the following radiographs were also exposed

6. 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

7. 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!

8. 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

9. 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

10. 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

11. Yes, quite correct. Now, please proceed with the next slide and patient

12. 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

13. 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

14. A CT-investigation is also performed in this patient and downunder is one of the slices from the maxillae, apical of the toothroots.

15. 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

16. 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

17. 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)

18. 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)

19. 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)

20. Yes, this must be the most probable diagnosis and it was PAD confirmed for this patient Now you can proceed with the next case

21. 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

22. As can be seen, the swelling is remarkable, it is surprising that the patient not has came to her dentist earlier

23. A CT-investigation is also performed, some of the slices are seen downunder

24. In order to establish the most probable differential diagnosis a MRI investigation is finally performed. Here is some of the frontal views

25. Now, nominate your proposal to the most probable diagnosis ameloblastoma cherubism aneurysmal bone cyst odontogenic keratocyst dentigerous cyst

26. 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

27. 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

28. Yes, congratulations your answer now is the most probable according to the radiological appearance and the patient´s age and history. Procced until next case, please!

29. 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 34…36. Her dentist then adjusted the denture since it seemed to be overextended.

30. 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

31. 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

32. 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.

33. 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.

34. This patient is a middle -aged woman, when her general practitioner (GP) discovers a divergent bone structure in regio 21 to 22.

35. 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.

36. 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.

37. 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

38. Quite, correct. And hopefully, you´ll 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!

39. 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.

40. Thanks for your visit. If you have any suggestions or have find any bug in this software, please inform me. The adress is lkullman@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)