Abstract
Background and aims
The jaw can be affected by many neoplastic and non-neoplastic lesions. The purpose of this study was to analyze the frequency of jaw lesions in relation to histopathological diagnosis, patient characteristics, and the site of involvement and correlate the histopathological results with the clinical impression.
Methods
This retrospective study included jaw lesions that were diagnosed at a major tertiary care center in Central Jordan from 2020 to 2024. The clinicopathological information was gathered from the histopathology department.
Results
A total of 169 cases were studied. Of these, 78.7% were in the odontogenic cyst category, in which radicular cyst was the most common diagnosis, followed by dentigerous cyst. Ameloblastoma was the most common diagnosis in the odontogenic tumor category. All types of odontogenic cysts were most common in males. Most dentigerous cysts and odontogenic keratocysts occurred in the mandible, while radicular cysts occurred equally in the mandible and maxilla. The maxilla was more commonly involved in odontogenic myxoma, cemento-ossifying fibroma, adenomatoid odontogenic tumor, and inflammatory myofibroblastic tumor. We found a limited number of osteomyelitis cases compared to primary intraosseous carcinoma, not otherwise specified (NOS). In addition, ameloblastoma was much more common than odontoma. We also documented a case of an intraosseous inflammatory myofibroblastic tumor. There was substantial agreement between the histopathological diagnosis and the clinical impression.
Conclusion
Our study demonstrated that radicular cyst was the most common intraosseous lesion of the jaw, whereas adenomatoid odontogenic tumor and inflammatory myofibroblastic tumor were the least common, with each observed only once.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12903-026-08266-x.
Keywords: Odontogenic cyst, Jaw, Biopsy, Differential diagnosis
Background
Several non-neoplastic and neoplastic lesions can affect the jaw [1]. These lesions are clinically significant, although they are relatively uncommon in histopathology practice. The aggressive nature of certain benign lesions and the indolent behavior of certain malignancies can result in devastating consequences in this sensitive anatomical location, if left untreated [2].
The jaw can be affected by many of the different neoplastic and non-neoplastic lesions that affect other bones in the body. However, some entities occur predominantly or exclusively in the jaw. Intraosseous jaw lesions are categorized into odontogenic and non-odontogenic lesions. Supplementary Table 1 provides a summary of odontogenic and maxillofacial bone tumors according to the 2022 World Health Organization (WHO) classification [3].
The most common intraosseous lesions of the jaw are odontogenic cysts [4]. However, many lesions can be cystic or included in the differential diagnosis of odontogenic cysts. These include non-neoplastic and inflammatory lesions, such as hyperplastic dental follicles, periapical granulomas, and osteomyelitis, as well as neoplasms such as ameloblastoma and malignant tumors [5].
The most common type of odontogenic cysts is radicular cysts, followed by dentigerous cysts and OKCs, while nasopalatine duct cysts are the most common type of non-odontogenic cyst [6, 7].
Odontogenic tumors constitute the other major category of lesions occurring primarily in the jawbone and occasionally in the gingiva. These tumors arise from the epithelial or ectomesenchymal remnants associated with tooth development and their incidence varies depending on geographic location. For example, their incidence ranges from 1% of oral pathologies in North America to 19% in Africa [8–10]. Several studies have reported that odontoma is the most common odontogenic tumor, followed by ameloblastoma [11]. However, ameloblastoma was reported to be the most common odontogenic tumor in some studies, including those from our region [12, 13].
Non-odontogenic jaw tumors constitute a broad category that encompasses entities such as central giant-cell granuloma, osteosarcoma, osteoblastoma, fibrous dysplasia, osteoma, and osteochondroma, among others. These tumors are rare, but are still encountered and easily overlooked [14].
The literature on the demographics and frequency of jaw lesions in Jordan is sparse. We only managed to find two old studies from Jordan which are more than 20 years old; one only focused on child and adolescent populations in Northern Jordan [15] and the other only focused on odontogenic cysts [16]. Moreover, there are only few recent studies from this region: two tricentric studies from Al-Mazyad et al., both of which studied the population of Riyadh city, Saudi Arabia, with the 2024 study focused on odontogenic tumors (92 cases) and not intraosseous tumors in general [13]. The other study was on odontogenic cysts (362 cases) and was published in 2023 [17]. An additional study from Basrah, Iraq, only studied cystic lesions [18]. In these studies, the correlation between the clinical impression and histopathological diagnosis was not determined.
In this retrospective study, we focus on patient characteristics in relation to the different types of jaw lesions and compare our findings with reports from around the world. In addition, we also investigate the correlation between the clinical impression and the confirmed histopathological diagnosis.
Methods
In this retrospective study, we reviewed the biopsied jaw lesions that were diagnosed at Al-Hussein Salt Hospital, Al-Salt, Jordan, over a 5-year period (January 2020–December 2024). After obtaining the approval from the institutional review board of Al-Balqa Applied University (Number: 2024/2023/3/20, Date: 27/12/2023), whose protocols are applied by the university teaching hospital (Al-Hussein Salt Hospital), we collected the following data from histopathology reports: patient age and sex, lesion site (mandible or maxilla), clinicoradiological impression, and final diagnosis. The histopathology slides were reviewed by 2 experienced histopathologists.
The diagnoses were generally classified into 9 major categories: odontogenic cysts, odontogenic epithelial tumors (non-malignant), odontogenic carcinoma, odontogenic mesenchymal tumors, non-odontogenic cysts, osteomyelitis, giant-cell lesions, non-odontogenic mesenchymal tumors, and other odontogenic lesions. Cases with non-specific histopathological findings, such as granulation tissue or fibrous tissue with non-specific inflammation, were excluded.
We followed the 2022 WHO classification of odontogenic and maxillofacial bone tumors to categorize the lesions [3].
The Statistical Package for Social Science (SPSS) v20 was used. Descriptive statistics and a Pearson chi-squared test were used, and p<.05 was considered significant. A contingency table was used to demonstrate the exact statistical relationship. Cohen’s kappa test was used to determine the degree of diagnostic agreement between the clinicoradiological impression and histopathologic outcome.
The frequency of each general and specific diagnostic category was calculated, and the values were correlated with age group (in addition to mean age), sex, and site of involvement (mandible or maxilla). The patients were categorized into 8 age groups: 10 or under, 11–20, 21–30, 31–40, 41–50, 51–60, 61–70, and over 70 [19].
As many cases had multiple clinicoradiological impressions, we compared the top clinicoradiological differential diagnosis with the final histopathological diagnosis to allow for application of the Cohen’s kappa test and to avoid bias. We excluded the cases with insufficient clinical information from the diagnostic agreement analysis. We also calculated the percentages of clinicoradiological impressions that agreed with the histopathological diagnosis, regardless of their order in the differential diagnosis.
Results
A total of 169 cases were analyzed. The age range was 3–87 years, and the mean age was 32.76 (± 18.19). The largest age group was 41–50 years (n = 36, 21.3%). In total, 56.8% of the patients were male, with a male-to-female ratio of 1.32 to 1. A total of 59.2% of the lesions were localized to the mandible, while 40.8% of the cases were localized to the maxilla.
The most common general diagnostic category was odontogenic cysts (78.7%). The most common diagnosis in this group was radicular cysts, followed by dentigerous cysts and OKCs. Table 1 shows the relative frequencies of the general diagnostic categories as well as the specific histopathological types.
Table 1.
Relative frequencies of general diagnostic categories and specific histopathologic types
| General category (Percent) | Diagnosis | Number (% within the respective category) |
|---|---|---|
| Odontogenic cyst (78.7%) | Dentigerous cyst | 50 (37.6) |
| Radicular cyst | 58 (43.6) | |
| Residual cyst | 2 (1.5) | |
| OKC | 23 (17.3) | |
| Total | 133 (100.0) | |
| Odontogenic tumor – epithelial (non-malignant) (4.7%) | Ameloblastoma (conventional) | 4 (50.0) |
| Ameloblastoma (unicystic) | 3 (37.5) | |
| Adenomatoid odontogenic tumour | 1 (12.5) | |
| Total | 8 (100.0) | |
| Odontogenic carcinoma (1.77%) | Primary intraosseous carcinoma, NOS | 3 (100.0) |
| Total | 3 (100.0) | |
| Odontogenic tumor – mesenchymal (2.9%) | Odontogenic myxoma | 3 (60.0) |
| Cemento-ossifying fibroma | 2 (40.0) | |
| Total | 5 (100.0) | |
| Non-odontogenic cyst (3.6%) | Nasopalatine duct cyst | 6 (100.0) |
| Total | 6 (100.0) | |
| Osteomyelitis (1.77%) | Suppurative osteomyelitis | 3 (100.0) |
| Total | 3 (100.0) | |
| Giant cell lesion (3.6%) | Central giant cell granuloma | 6 (100.0) |
| Total | 6 (100.0) | |
| Non-odontogenic mesenchymal tumor (0.6%) | Inflammatory myofibroblastic tumor | 1 (100.0) |
| Total | 1 (100.0) | |
| Other odontogenic lesions (2.36%) | Periapical granuloma | 4 (100.0) |
| Total | 4 (100.0) |
Figure 1 summarizes the main lesion categories.
Fig. 1.
Main lesion categories
The peak age groups (by year) for radicular cysts, dentigerous cysts, OKCs, and residual cysts were 41–50, 10 or under, 31–40, and both 41–50 and 61–70, respectively.
In all cases of odontogenic cysts (radicular cysts, dentigerous cysts, OKCs, and residual cysts), males were affected more than females.
Most dentigerous cysts and OKCs occurred in the mandible (72% and 78.3%, respectively), while radicular cysts were equally distributed between the mandible and maxilla. The maxilla was more commonly involved in odontogenic myxoma (3/3), cemento-ossifying fibroma (2/2), adenomatoid odontogenic tumor (1/1), and inflammatory myofibroblastic tumor (1/1).
Ameloblastoma was the most common diagnosis in the odontogenic tumor category, representing 43.75% of the cases. It occurred in females more than males (57.1%), and mainly occurred in the mandible (85.7%). The mean age of the ameloblastoma patients was 26.29 (± 18.29).
The histopathological diagnosis was significantly associated with patient age group and the site of involvement (p=.006 and 0.004, respectively) but there was no significant association between histopathological diagnosis and sex.
After comparing the observed-versus-expected counts using the contingency tables and standardized residuals, we found the following significant associations: nasopalatine duct cysts occurred in the maxilla, as expected; dentigerous cysts occurred more frequently in the 10-or-under age group and less frequently in the 21–30 and 31–40 age groups; radicular cysts occurred less frequently in the 10-or-under age group; residual cysts occurred more frequently in the 61–70 age group; central giant-cell granuloma occurred more frequently in those over 70; ameloblastoma occurred more frequently in the 11–20 age group; suppurative osteomyelitis occurred more frequently in those aged 51–60; and primary intraosseous carcinoma, NOS, occurred more frequently in the 61–70 age group.
Table 2 shows the distribution of the biopsied lesions in relation to patient demographics and location (mandible or maxilla).
Table 2.
Histopathological diagnoses in relation to patient demographics and anatomic site
| Diagnosis | Mean age in years (SD) | Peak age group in years (%) | Sex | Location | ||||
|---|---|---|---|---|---|---|---|---|
| Male (%) | Female (%) | Total | Mandible (%) | Maxilla (%) | Total | |||
| Dentigerous cyst | 25.44 (19.88) | 10 or under (34.0) | 29 (58.0) | 21 (42.0) | 50 | 36 (72.0) | 14 (28.0) | 50 |
| Radicular cyst | 36.97 (13.57) | 41–50 (31.0) | 33 (56.9) | 25 (43.1) | 58 | 29 (50.0) | 29 (50.0) | 58 |
| Residual cyst | 54.5 (9.19) | 41–50 (50.0) and 61–70 (50.0) | 2 (100.0) | 0 (0.0) | 2 | 1 (50.0) | 1 (50.0) | 2 |
| OKC | 33.83 (15.2) | 31–40 (30.4) | 13 (56.5) | 10 (43.5) | 23 | 18 (78.3) | 5 (21.7) | 23 |
| Ameloblastoma (conventional) | 31.5 (23.95) | 11–20 (50.0) | 2 (50.0) | 2 (50.0) | 4 | 3 (75.0) | 1 (25.0) | 4 |
| Ameloblastoma (unicystic) | 19.33 (4.04) | 11–20 (66.7) | 1 (33.3) | 2 (66.7) | 3 | 3 (100.0) | 0 (0.0) | 3 |
| Adenomatoid odontogenic tumor | 13 | 11–20 (100.0) | 1 (100.0) | 0 (0.0) | 1 | 0 (0.0) | 1 (100.0) | 1 |
| Primary intraosseous carcinoma, NOS | 48.67 (11.93) | 31–40 (33.3), 41–50 (33.3), and 61–70 (33.3) | 2 (66.7) | 1 (33.3) | 3 | 2 (66.7) | 1 (33.3) | 3 |
| Odontogenic myxoma | 25.67 (8.39) | 11–20 (33.3), 21–30 (33.3), 31–40 (33.3) | 0 (0.0) | 3 (100.0) | 3 | 0 (0.0) | 3 (100.0) | 3 |
| Cemento-ossifying fibroma | 7 (5.66) | 10 or under (50.0) and 11–20 (50.0) | 1 (50.0) | 1 (50.0) | 2 | 0 (0.0) | 2 (100.0) | 2 |
| Nasopalatine duct cyst | 35.67 (15.64) | 41–50 (33.3) | 5 (83.3) | 1 (16.7) | 6 | 0 (0.0) | 6 (100.0) | 6 |
| Suppurative osteomyelitis | 41.33 (22.14) | 51–60 (66.7) | 2 (66.7) | 1 (33.3) | 3 | 2 (66.7) | 1 (33.3) | 3 |
| Central giant cell granuloma | 36.5 (33.07) | 10 or under (33.3) | 2 (33.3) | 4 (66.7) | 6 | 3 (50.0) | 3 (50.0) | 6 |
| Periapical granuloma | 47.75 (20.4) | 21–30 (25.0), 41–50 (25.0), 51–60 (25.0), and 61–70 (25.0) | 3 (75.0) | 1 (25.0) | 4 | 3 (75.0) | 1 (25.0) | 4 |
| Inflammatory myofibroblastic tumor | 51 | 51–60 (100.0) | 0 (0.0) | 1 (100.0) | 1 | 0 (0.0) | 1 (100.0) | 1 |
Upon correlating each clinical impression with the corresponding histopathological diagnosis, we found that 92.2% of the cases for which a radicular cyst was mentioned in the differential diagnosis were confirmed to be radicular cysts on biopsy. The percentage was lower for dentigerous cysts (67.4%), nasopalatine duct cysts (66.7%), OKCs (64.7%), cemento-ossifying fibromas (40%), periapical granulomas (50%), central giant-cell granulomas (50%), odontogenic myxomas (50%), ameloblastomas (33.3%), residual cysts (28.6%), adenomatoid odontogenic tumors (0%), ameloblastic fibromas (0%), and brown tumors (0%). However, there were very few cases for the diagnoses with 0% accuracy. Table 3 shows the entities in clinical impression that did not match the final diagnosis for certain cases. As cases with clinical impressions came with multiple differentials, it is important to mention that each entity was taken in isolation and checked when it agreed with the final diagnosis of cases that were also checked for agreement with other clinical differentials.
Table 3.
Clinical impressions in the differential diagnosis for certain cases that were found to be discordant with the histopathological diagnosis
| Clinical impression | Histopathologic diagnosis (number of cases) |
|---|---|
| Ameloblastoma | Dentigerous cyst (5) |
| OKC (8) | |
| Nasopalatine duct cyst (1) | |
| Dentigerous cyst | OKC (7) |
| Ameloblastoma (unicystic) (3) | |
| Nasopalatine duct cyst (3) | |
| Adenomatoid odontogenic tumor (1) | |
| Radicular cyst | Nasopalatine duct cyst (3) |
| Periapical granuloma (1) | |
| Ameloblastic fibroma | Dentigerous cyst (1) |
| Ameloblastoma (1) | |
| Adenomatoid odontogenic tumor | Nasopalatine duct cyst (1) |
| Brown tumor | Central giant cell granuloma (1) |
| OKC (2) | |
| Central giant cell granuloma | Dentigerous cyst (2) |
| OKC (1) | |
| Fibrous dysplasia | Cemento-ossifying fibroma (1) |
| Odontogenic myxoma | OKC (1) |
| OKC | Dentigerous cyst (7) |
| Ameloblastoma (3) | |
| Nasopalatine duct cyst (1) | |
| Central giant cell granuloma (1) | |
| Ossifying fibroma | Odontogenic myxoma (2) |
| Dentigerous cyst (1) | |
| Osteomyelitis | Primary intraosseous carcinoma, NOS (1) |
| Periapical granuloma | Radicular cyst (2) |
| Residual cyst | OKC (2) |
| Nasopalatine duct cyst (2) | |
| Radicular cyst (1) | |
| Sarcoma | Suppurative osteomyelitis (1) |
| Squamous cell carcinoma | Suppurative osteomyelitis (1) |
When we applied Cohen’s kappa to determine the agreement between the clinical impression (in this case, we selected the top differential diagnosis to avoid bias; this was applied to 120 cases) and the histopathological diagnosis, we found substantial agreement (0.76).
Table 4 shows the radiological and histopathological features of each diagnostic category and highlights the overlapping radiological features among many intraosseous lesions and the significance of histopathological diagnosis.
Table 4.
Radiological and histopathological features of the studied lesions
Discussion
This study focused on the clinicopathological features of jaw lesions. In addition, we emphasized the concordance between the clinical impression and the final histopathological diagnosis. Lesions of the jaw can be classified as cystic and solid or neoplastic and non-neoplastic. Non-neoplastic lesions can be further categorized into developmental or reactive (infective or inflammatory) in nature [16, 20]. Although some jaw lesions can be diagnosed clinically, histopathological examination remains the standard confirmatory test for such lesions.
The entities covered in this study fall within a large range of diagnostic categories. We start our discussion with odontogenic cysts, as they are the most common intraosseous lesions of the jaw [4]. This fact is concordant with our results, which showed that 78.7% of the lesions were odontogenic cysts. Radicular cysts are the most common odontogenic cysts [21]. In the present study, radicular cysts represented 43.6% of the odontogenic cysts, making them the most common type, followed by dentigerous cysts (37.6%). A similar order has been reported in studies from many countries, such as Saudi Arabia, Turkey, Iran, India, the United Kingdom, Spain, Mexico, Brazil, Canada, and Chile [22–24].
Our findings for odontogenic cysts are in line with the literature regarding the mean age, sex, and site of involvement. Table 5 shows a comparison of our findings with those from other studies from the same region and worldwide.
Table 5.
A comparison of our findings on odontogenic cysts with those from the literature regarding age, sex, and site of involvement
| Study | Age (mean ± SD/peak age range) |
Sex (Male: Female ratio or </>) |
Site (Maxilla: Mandible ratio or </>) |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Radicular cyst | Dentigerous cyst | OKC | Residual cyst | Radicular cyst | Dentigerous cyst | OKC | Residual cyst | Radicular cyst | Dentigerous cyst | OKC | Residual cyst | |
| Our study | 36.97 ± 13.57/41–50 | 25.44 ± 19.88/10 or under | 33.83 ± 15.2/31–40 | 54.5 ± 9.19/41–50 and 61–70 | 1.32:1 | 1.38:1 | 1.3:1 | 2:0 | 1:1 | 0.39:1 | 0.27:1 | 1:1 |
| Almazyad et al. [17] | 34.2 ± 14.8/NA | 26 ± 15.2/NA | 34.6 ± 20.1/NA | 43.2 ± 10.2/NA | 1.21:1 | 1.95:1 | 2.53:1 | 3:1 | 0.84:1 | 0.56:1 | 0.36:1 | 1:1 |
| Kalantari and Samani [25] | 31.44 ± 15.60/NA | 18.05 ± 14.54/NA | 32.35 ± 12.83/NA | NA/NA | 1.22:1 | 0.74:1 | 1.07:1 | NA | Max < Man | Max < Man | Max < Man | NA |
| Ramachandra et al. [24] | 30.92 ± 15.91/NA | 29.78 ± 15.33/NA | 29.55 ± 11.86/NA | NA/NA | 1.81:1 | 1.14:1 | 1.62:1 | NA | 1.89:1 | 0.8:1 | 0.62:1 | NA |
| Ali [1] | 32.8 ± 14.3/NA | 27.4 ± 14.1/NA | 31.6 ± 17.9/NA | 41.3 ± 15.4/NA | 1.38:1 | 1.43:1 | 0.88:1 | 3:1 | 0.98:1 | 0.19:1 | 1:3 | 1:3 |
| Tekkesin et al. [7] | 33.7/NA | 32.80/NA | 40.50/NA | 45.70/NA | 1.23:1 | 1.53:1 | 1.53:1 | 1.72:1 | 1.56:1 | 0.53:1 | 0.61:1 | 1.26:1 |
| Kilinc et al. [26] | 31.4/20–29 | 29.5/20–29 | NA/NA | 48.8/50–59 | 1.4:1 | 2.7:1 | NA | 2:1 | 1.3:1 | 0.49:1 | NA | 0.68:1 |
| Villasis-Sarmiento et al. [27] | NA/30–39 | NA/10–19 | NA/NA | NA/50–59 | 0.81:1 | 1.62:1 | NA | 0.29:1 | 1.3:1 | 0.69:1 | NA | 0.38:1 |
| Avelar et al. [28] | NA/21–30 | NA/11–20 | NA/NA | NA/11–20 | 1.28:1 | 1.74:1 | NA | 0.76:1 | Max < Man | Max < Man | NA | Max < Man |
| Kambalimath et al. [29] | NA/21–30 | NA/11–20 | NA/11–30 | NA/51–60 | M > F | M > F | M > F | M > F | 3.56:1 | 0.37:1 | 0.33:1 | 0.5:1 |
| Sharifian and Khalili [30] | 28.7 ± 12.9/NA | 21.5 ± 14.5/NA | 34.1 ± 16.4/NA | 40 ± 18.0/NA | 1.31:1 | 1.34:1 | 1.46:1 | 1.22:1 | 1.56:1 | 0.83:1 | 0.59:1 | NA |
| Khosravi et al. [31] | 40.55 ± 16/21–30 | 22.06 ± 16.48/11–20 | 31.52 ± 15.13/11–20 | 29.17 ± 13.16/41–50 | 1.19:1 | 1.47:1 | 1.26:1 | 1.77:1 | 1.52:1 | 0.67:1 | 0.5:1 | 0.94:1 |
The striking male predominance for odontogenic cysts can be explained by multiple factors, many of which are related to radicular cysts as this is the most common type. Males exhibit more neglect of oral hygiene, which increases the incidence of pulp necrosis and untreated dental caries. In addition, males often experience more trauma, which also increases the risk of pulp necrosis. Occupational and hormonal factors and their potential role in cyst formation are also under investigation [32, 33]. As the mandibular third molar is the most commonly impacted tooth, this may explain why the mandible is more commonly involved in dentigerous cysts [34].
Table 6 summarizes the data on age, sex, and site from the most recent and/or largest studies for all the other categories.
Table 6.
A comparison of our findings on lesions other than odontogenic cysts with the most recent and/or largest studies
| Study | Mean age (years) | M: F ratio | Site (maxilla: mandible ratio) | |
|---|---|---|---|---|
| Ameloblastoma | Our study | 26.29 | 1:1.3 | 1:6 |
| Lima-Verde-Osterne et al. [35] | 36.3 | 1:1.3 | 1:13.7 | |
| Mascitti et al. [36] | 54.9 | 1.9:1 | 1:3.9 | |
| Almazyad et al. [13] | - | 1.4:1 | 1:4.3 | |
| Adenomatoid odontogenic tumor | Our study | 13 | 1:0 | 1:0 |
| Tamgadge et al. [37] | All < 20 | 1:3 | 1:3 | |
| Siriwardena et al. [38] | 21.02 | 1:1.6 | 2.1:1 | |
| Bansal et al. [39] | 19.8 | 1:1.5 | 2.1:1 | |
| Zafar et al. [40] | 17.7 | 1:1.3 | 2.5:1 | |
| Primary intraosseous carcinoma, NOS | Our study | 48.67 | 2:1 | 1:2 |
| Bodner et al. [41] | 60.2 | 2.2:1 | 0.27:1 | |
| Halboub et al. [42] | 54 | 3.8:1 | Maxilla< Mandible | |
| Cho et al. [43] | 49.7 | 2.3:1 | 1:4 | |
| Odontogenic myxoma | Our study | 25.67 | 0:3 | 3:0 |
| Juengsomjit et al. [44] | 34.6 | 1:2.2 | 1:2.2 | |
| Vasconcelos et al. [45] | 30.7 | 1:1.1 | 1.1:1 | |
| Cemento-ossifying fibroma | Our study | 7 | 1:1 | 2:0 |
| Kaur et al. [46] | 26.6 | 1:1.7 | 1:1.1 | |
| Prabhu et al. [47] | 25.6 | 1:1.2 | 1:1.4 | |
| Neumann et al. [48] | 35 | 1:1.5 | 1:2.5 | |
| Nasopalatine duct cyst | Our study | 35.67 | 5:1 | 6:0 |
| RAMOS PEÑA et al. [49] | 47 | 1:1 | 63:0 | |
| Sofia et al. [50] | 32 | 1.5:1 | 10:0 | |
| Sarangi et al. [51] | 25.5 | 1:1 | 2:0 | |
| Osteomyelitis | Our study | 41.33 | 2:1 | 1:2 |
| Grégoire et al. [52] | 40.5 | 1.3:1 | 1:3.5 | |
| Santos et al. [53] | 55 | 1.1:1 | 1:5.6 | |
| Vardas et al. [54] | Median age 52.7 | 2.9:1 | 9.5:1 | |
| Central giant cell granuloma | Our study | 36.5 | 1:2 | 1:1 |
| Boffano et al. [55] | 41.8 | 1.1:1 | 1:2.3 | |
| Capucha et al. [56] | 30 | 1:1 | 1.3:1 | |
| Lazim et al. [57] | 50 | 1:1.2 | 1:4.2 | |
| Periapical granuloma | Our study | 47.75 | 3:1 | 1:3 |
| Banomyong et al. [58] | 49.5 | 1:2.4 | 10.3:1 | |
| Roi et al. [59] | 43.2 | 1.2:1 | 1.6:1 | |
| Maqtoof and Al-Drobie [60] | 35.8 | 1.3:1 | - | |
| Inflammatory myofibroblastic tumor | Our study | 51 | 0:1 | 1:0 |
| Neronov et al. [61] | 34.8 | 1:1.1 | 1:2.6 |
The second most common category in our cohort was odontogenic tumors, representing 9.4% of the cases. The average age in our study was 27.13 ± 18.03, which is in line with the literature [13]. The most common odontogenic tumor in our cohort was ameloblastoma, a finding that is concordant with the results of several studies from India, Italy, Brazil, Saudi Arabia, and Kuwait [1, 13, 35, 36, 62, 63]. The mean age of the ameloblastoma patients was 26.29 ± 18.29 years, and it occurred more frequently in females (57.1%). The mandible was more frequently involved (85.7%), which is in line with the literature [1, 13, 35, 36, 62, 63]. In multiple studies, including two studies from the same region (Kuwait and Saudi Arabia) [1, 13, 36], ameloblastoma occurred more often in males than females.
Although not entirely understood, the predominance of ameloblastoma in the mandible has been attributed to multiple factors. Ameloblastomas arise from the epithelial remnants (odontogenic epithelium), such as the dental lamina and rests of Malassez, which are more persistent in the mandible. In addition, recent studies have indicated different genetic bases for mandibular and maxillary tumors (BRAF mutations are more common in mandibular tumors while SMO mutations are more commonly seen in maxillary tumors). The bone density differs between the mandible (more cortical bone) and the maxilla (more spongy bone), which allows maxillary tumors to spread more easily into adjacent areas; they are also easier to diagnose and manage when their size is still small, hindering the documentation of the exact incidence of these tumors [64–66].
The most common mesenchymal odontogenic tumor was odontogenic myxoma; this result is in line with what is reported in the literature [12, 13]. The remaining two cases in the mesenchymal odontogenic tumor category were cemento-ossifying fibromas, one occurring in a male and the other in a female, both in the maxilla, although this type has been reported to occur more frequently in the mandible and in a relatively older age group [46]. Odontogenic malignancy is rare, with percentages of less than 5% reported worldwide [13, 36, 63]. However, the percentage among the odontogenic tumors in this study was high (18.75%). All malignant cases fell in the primary intraosseous carcinoma, NOS, category. The criteria for diagnosing primary intraosseous carcinoma include a histopathological confirmation of squamous cell carcinoma, the absence of a connection with the oral mucosa or mucosal ulceration, and the exclusion of metastases from other primaries [3, 67]. These tumors can originate from embryological remnants or from the malignant transformation of an underlying odontogenic cyst or tumor [68]. Interestingly, the percentage in this study was very close to that reported in a study from Ethiopia [69]. Geographic and cultural factors can contribute to the different distribution of malignant odontogenic tumors. Some authors have linked the use of traditional medicines such as the roots and leaves of some plants—which are not effective against maxillofacial lesions—to the increased risk of benign lesions transforming into malignancies [69]. In addition, delayed treatment and undertreatment may contribute to the increased risk of malignant transformation [69–71]. As reflected in our findings, the mandible is more commonly affected by primary intraosseous carcinoma than the maxilla [41].
Non-odontogenic lesions of the jaw constitute another broad category that includes several neoplastic and non-neoplastic lesions. In this study, the most common types in this group were nasopalatine duct cysts and central giant-cell granulomas (with six cases each), followed by suppurative osteomyelitis (three cases) and an intraosseous inflammatory myofibroblastic tumor (IMT) (one case). The last type, which most commonly occurs in the abdominopelvic soft tissues and mainly affects young adults, is extremely rare in the jawbone, with only a few cases reported in the literature, less than 10 of which were reported in the maxilla [72].
Notably, the discrepancy between our findings indicating maxilla predominance and the literature suggesting mandible predominance for certain lesions, such as odontogenic myxoma, cemento-ossifying fibroma, and inflammatory myofibroblastic tumor, can be attributed to the dearth of these cases in our cohort.
Upon analyzing the clinicoradiological impressions in relation to the final histopathological diagnoses, we found some important points to consider in differential diagnosis. Several neoplastic and non-neoplastic lesions can mimic odontogenic cysts, and entities like central giant-cell granulomas, brown tumors, and odontogenic myxomas should also have odontogenic cysts included in their clinical differential diagnoses (Table 3).
The agreement between the clinicoradiological impression and histopathological diagnosis depends on multiple factors such as whether the lesion has distinctive clinical and/or radiological features, whether the sampling was appropriate and representative of the lesional tissue, and the communication between the clinician, radiologist, and pathologist. Odontogenic tumors as a general diagnosis show good agreement. Features such as a mixed radiopaque–radiolucent pattern, multilocular radiolucency, or solid radiopacity as well as the bone changes that can be induced, such as cortical perforation or root resorption, can distinguish tumors from “plain” cysts [73]. On the other hand, lesions that show overlapping radiographic features are more prone to poor agreement, especially inflammatory lesions, cysts, or fibro-osseous lesions. These lesions can be similar in size or location, with well-defined margins, radiolucency, and a unilocular or multilocular appearance, so subtle histological differences such as the presence and type of lining epithelium and inflammation are necessary for diagnosis [74]. Secondary bone changes due to infection such as loss of cortication can mask the true nature of the lesion radiologically [75]. It is worth mentioning that malignancy and osteomyelitis can show overlapping radiological features. Both often have ill-defined borders and show bone destruction. Moreover, they can result in similar symptoms [76]. The communication between the pathologist, clinician, and radiologist is important in fibro-osseous lesions. The diagnosis of fibrous dysplasia can be challenging for histopathologists, as it can mimic other fibro-osseous lesions or even low-grade osteosarcoma [73].
A systematic approach should be followed to reach the correct diagnosis and select the most suitable treatment plan. This approach is multidisciplinary, combining clinical examination, radiological studies, and a definitive histopathological diagnosis [77]. This is necessary for a broad spectrum of lesions including benign cysts as well as benign and malignant neoplasms, many of which show overlapping features. Clinical assessment is the primary method for evaluation, which should include thorough history taking and clinical examination. Information such as age and location can provide important diagnostic clues. A differential diagnosis can be significantly narrowed by imaging studies [78]. However, as shown in Table 4, several lesions share certain radiographic features, and histopathology remains the gold standard for diagnosis. Correct diagnosis can significantly affect the management. For example, OKC and dentigerous cysts can have similar features radiographically. Both can show expansile multilocular radiolucency with displacement of nearby teeth and pressure resorption on the teeth roots. However, OKC requires more aggressive management due to the increased recurrence rate compared with dentigerous cysts in which simple enucleation would suffice [33]. Differentiation between the two should be possible using histopathology.
Our results showed substantial agreement between the clinical impression and the histopathological diagnosis. In addition, several neoplastic and non-neoplastic lesions can mimic odontogenic cysts, and the clinical differential diagnosis of entities like brown tumors, central giant-cell granulomas, odontogenic myxomas, and ossifying fibromas should also include odontogenic cysts.
Among the unusual findings in our study is the limited number of osteomyelitis cases in comparison to primary intraosseous carcinoma, NOS. Ameloblastoma was much more frequently reported than odontoma. Moreover, we reported one case of a maxillary inflammatory myofibroblastic tumor. Interestingly, it showed non-specific aggressive features and the diagnosis was not expected.
Conclusions
The findings of this study indicate that odontogenic cysts were the most prevalent category of intraosseous lesions of the jaw, with radicular cyst being the most common diagnosis overall. In contrast, non-odontogenic mesenchymal tumors were the least common category, represented solely by a single case of inflammatory myofibroblastic tumor. Additionally, adenomatoid odontogenic tumor was rare, occurring in only one case overall.
Supplementary Information
Acknowledgements
Not applicable.
Abbreviations
- WHO
World Health Organization
- OKC
Odontogenic keratocyst
- SPSS
The Statistical Package for Social Science
Authors’ contributions
HO conceptualized the study, reviewed the literature, analyzed the data, and wrote the manuscript. EN contributed in literature review, reading histopathology slides and writing. MAS analyzed the data and reviewed the work. ZMA reviewed the literature and the clinical data. AA read histopathology slides, analyzed the data, and reviewed the work. All authors fulfilled the ICMJE criteria for authorship. All authors read and approved the final manuscript.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
The datasets used during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki, and approved by the Institutional Review Board of Al-Balqa Applied University (Number: 2024/2023/3/20, Date: 27/12/2023), whose protocols are applied by the university teaching hospital (Al-Hussein Salt Hospital). The requirement for informed consent was waived due to the retrospective nature of the study and the use of anonymized patient data.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used during the current study are available from the corresponding author on reasonable request.