Ahead in Imaging

The British Society of Dental and Maxillofacial Radiology

Ahead in Imaging

The British Society of Dental and Maxillofacial Radiology


1. Buccal Bifurcation Cysts; The significance of CBCT where an OPT is inconclusive

E.Rae, O Mcpolin, A Graham, E Connor

Buccal bifurcation cysts (BBCs) are inflammatory cysts, usually associated with the  first permanent mandibular molars in children under ten (1) (2). We report an unusual case of bilateral mandibular BBCs, where the leading provisional diagnosis was osteosarcoma; discussing clinical, radiographic and histological features of BBCs, differential diagnoses and management.


  • Demonstrate pitfalls of orthopantomograms and significance of CBCT in this case
  • Educate on BBCs (Methods)

A 12 year old male presented, as an emergency, with a left submandibular swelling and lack of attention-grabbing history. The patient sustained trauma to the area 4 weeks prior but localised pain and swelling resolved after 5 days. The swelling returned, without precipitation, one day before presentation; he had no pain or paraesthesia. 

A 3x3cm non-tender, firm bony swelling was present along the left mandible. Intra-orally bucco-lingual expansion was evident distal to the last standing molar – 36, and delayed eruption of 37 and 47 with normal overlying mucosa.

An orthopantomogram and PA mandible revealed no fracture or obvious odontogenic causation.

Differential diagnoses were considered including malignant processes such as sarcoma. CBCT was carried out. It showed a unilocular, corticated radiolucency buccal to 37 roots, which had expanded and breached the buccal cortex, displaced the apices lingually and caused periosteal reaction. Interestingly, 47 had a similar, smaller radiolucency in the same position. This was an incidental finding – not uncommon with BBC.

Following enucleation the teeth should erupt normally; the patient will be monitored to ensure bony healing and eruption.

Painless, bony swellings in children raise concern; osteosarcoma should be excluded. 

Here, two-dimensional imaging failed to demonstrate causation; three-dimensional imaging was crucial, and lead to incidental finding of the same pathology on the contralateral side.

Diagnosis is based on correlation of clinical, radiological and histopathological examination. 

As 25% of cases are bilateral, the contralateral tooth must be examined. 

Treatment should involve enucleation with retention of affected teeth, as in this case (2).


  1. (1) El-Naggar AK, Chan JKC, Grandis JR, Takata T, Slootweg PJ. WHO classification of head and neck tumours. 4th ed. Lyon: IARC; 2017. p. 232-33: Odontogenic cysts of inflammatory origin English
  2. (2) Ramos, L.M.A., Vargas, P.A., Coletta, R.D. et al. Bilateral Buccal Bifurcation Cyst: Case Report and Literature Review. Head and Neck Pathol 6, 455–459 (2012).

2. Glomangiopericytoma resembling odontogenic pathology

Presenting author: Brandon Owen, DCT3 Oral Medicine and Oral Surgery, Glasgow Dental Hospital


Glomangiopericytoma (GPC) is a borderline or low malignant potential tumour accounting for less than 0.5% of all sinonasal tumours. The case of a GPC resembling odontogenic pathology will be presented.

A 24-year-old male was referred to the oral surgery department regarding an incidental finding noted in the anterior maxilla of a CT taken for the assessment of facial trauma. On examination, an anterior edentulous span was present with a history of trauma resulting in the loss of three maxillary incisors. The CT identified a well-defined soft tissue mass extending across the midline of the anterior maxilla with early resorption of adjacent teeth. A review of a previous OPT and CBCT identified a soft tissue radiopacity in the corresponding region. The provisional diagnosis was that of a radicular or residual cyst. Under general anaesthesia the lesion was enucleated resulting in an oronasal and oroantral communication. Histopathological examination identified a GPC but could not confirm complete removal. Due to the malignant potential and chance of recurrence, the patients care was transferred to OMFS. A CT and MRI scan were requested to investigate the presence of residual lesion and metastasis. Partial bony healing was noted at the site with no metastasis detected. The patient remains under close observation.

The imaging and pathology will be discussed further within this case presentation.


Rory Croft (DCT1), Nicola Docherty (Oral surgery specialty dentist, Glasgow Dental Hospital), Kirsty Young (Consultant pathologist, Greater Glasgow and Clyde), Kirstyn Donaldson (Consultant dental and maxillofacial radiologist, Glasgow Dental Hospital).

3. Fibrodysplasia ossificans progressive: a rare cause of trismus

Presenting author: Simon Howarth, ACF/ST2, University Hospitals Bristol & Weston

Brief description

Fibrodysplasia ossificans progressiva is a rare disease which results in progressive soft tissue calcification and ossification. This case describes the CT findings and subsequent management of a patient with trismus secondary to fibrodysplasia ossificans progresssiva..


4. A deteriorating dentition and not so simple cyst  

Orlagh McPolin (presenting), Donald Thomson
Edinburgh Dental Institute


Dentigerous cysts (DCs) are the second most common jaw cyst; typically DC presenting as asymptomatic, unilocular radiolucencies extending from the cement-enamel junction of  an unerupted or impacted tooth. In most cases, the diagnosis is straightforward; but even a radiographically ‘typical’ DC can be found to be something else on histological analysis. There are roughly 150 breast cancer diagnoses in the UK each day; the risk of metastases is dependent on the subtype. We are aware of breast cancers, among others, metastasizing to the bones including the maxillofacial skeleton; however, metastases within cystic lesions are a rarity. We present a case of a 46 year old Caucasian female, with metastatic ER Positive HER2 Negative breast cancer and failing dentition, referred for exclusion of focal and potential infection prior to intravenous bisphosphonate treatment, with an incidental finding of a radiographically typical DC. Enucleation was advocated to ensure dental fitness prior to bisphosphonate treatment. 


Review the literature regarding metastasis into odontogenic cysts and highlight this rare entity with the help of a clinical case


Histopathological examination confirmed a DC with coexisting metastatic breast carcinoma. About 1% of all oral cancers are metastases to the jawbones and surrounding soft tissues. These are mainly caused by malignant tumors of the breast, lung, kidney, bone and colon in advanced disease. Even rarer are metastases into odontogenic cysts.


The patient continues to be reviewed clinically. Due to persistent symptoms follow up imaging was taken, which revealed widespread bony metastases throughout the mandible and, as anticipated, abnormal bony infill within the surgical site. 

Pathogenesis of metastasis within the jawbones is unclear, however, bones with active marrow are susceptible sites for deposits; most likely because of the sinusoidal nature of the blood spaces and presence of growth factors. 

Active red bone marrow within the posterior mandible explains why metastatic tumours tend to be more prevalent in the molar and premolar area. 

The development and expansion of any cyst is complicated and involves growth factors and inflammatory mediators developing a rich capillary network in tissue which could entrap tumour cells. This could help explain the presence of metastatic deposits in the dentigerous cyst lining here.

​This case stresses that histological diagnosis of these lesions is critical and metastasis in an odontogenic cyst may be the first indication of malignancy elsewhere in the body.

5. A Significant Palatal Lesion 

Phillip Seenan
T2 Dental & Maxillofacial Radiology, Guy’s & St Thomas’ NHS Foundation Trust

Acknowledgements: John Rout, Kiran Beneng, Jerry Kwok, Alisdair Fry

6. Loose bridge

Mohamed El-Belihy
ST4 Dental & Maxillofacial Radiology, University College London Hospitals, Guy’s & St Thomas’, Queen Victoria Hospital