in 1951 , eldon j. gardner ( 1909  1989 ) , a college teacher of genetics , first described the syndrome , as a rare autosomal , dominant , inherited disorder with a high degree of penetrance , characterized by a triad of multiple osteomas , colonic polyposis , and mesenchymal tumors of the skin and soft tissues .
it is a variant of the familial adenomatous polyposis syndrome , known to be caused by the mutation in the adenomatous polyposis coli ( apc ) gene located on chromosome 5q21 ( band q21 on chromosome 5 ) .
the incidence of gardner 's syndrome in the general population has been estimated as one in 14,025 live births .
the mandible is the most common location , however , osteomas may occur in the skull , paranasal sinuses , and the long bones .
osteomas precede the clinical and radiographic evidence of colonic polyposis or gardner 's syndrome , therefore , may be insightful markers for the disease . it is also proposed that radiography of the jaws may serve as a valuable tool for the early detection of carriers of gardner 's syndrome .
the epidermoid cyst is the most common cutaneous finding in gardner 's syndrome and is present in multiple forms in 50
 60% of the patients and may occur on the face , extremities , and / or the scalp .
desmoid tumor is benign fibrous proliferation that occurs under the skin predominantly in the abdominal wall .
our patient was a 25-year - old female with a history of multiple swellings in the lower jaw that had developed over a period of 11 years .
an extraoral examination revealed gross facial asymmetry , because of a diffuse swelling on the left side of the mandible measuring about 3 cm  4 cm in size , extending from the parasymphysis to the posterior border of the mandible [ figure 1 ] .
similar swellings , three in number , were present on the inferior aspect on the right side of the mandible .
on palpation , all the swellings were bony hard in consistency , non - tender , and were fixed to the mandible .
a 25-year - old female patient with diffuse bilateral swellings on the lower third of face along the mandibular border .
intraoral examination revealed a diffuse swelling , obliterating the right buccal vestibule , measuring about 2 cm  2 cm in size , and extending from the mesial aspect of tooth 46 to the distal aspect of tooth 48 anteroposteriorly .
on palpation , all the swellings were bony hard in consistency and non - tender .
there were clinically missing teeth 21 and 23 ( no history of extraction revealed ) and over - retained tooth 63 .
patient had a small swelling measuring about 1 cm  1 cm on the scalp , which was fluctuant and cystic in nature ( epidermoid / sebaceous cyst ) .
the patient did not have any symptoms of rectal bleeding , cramping abdominal pain , weight loss , diarrhea or small bowel or colonic obstruction , and was reluctant to get a colonoscopy done to rule out the presence of polyps in the intestine , colon , and rectum .
the clinical and radiographic findings , of osteomas , odontomes , impacted teeth , and sebaceous cyst suggested a diagnosis of gardner 's syndrome .
our patient 's need was aesthetic improvement , for which the osteomas were surgically excised and sent for histopathological examination .
the patient was followed up for one year and has remained asymptomatic , with no relapse of the lesions [ figure 2 ] .
postoperative radiograph after removal of osteomas , impacted teeth , and implant placement , with respect to tooth 21 .
the patient underwent maxillary and mandibular cross - sectional occlusal radiograph , orthopantomograph ( opg ) , and posteroanterior radiograph [ figure 3 ] .
the opg revealed impacted teeth 21 and 23 and homogenous radiopaque masses over the right and left inferior aspect of the mandible , suggestive of osteomas [ figure 4 ] .
also , multiple small , homogeneous radiopaque masses surrounded by a radiolucent halo could be seen throughout the maxilla and mandible , suggestive of complex odontomes .
diffuse sclerotic masses were present throughout the body of the mandible giving it a mottled appearance . impacted teeth 21 and 23 and the complex odontomes in the near vicinity were better visualized in the maxillary cross - sectional occlusal radiograph [ figure 5 ] .
opg demonstrates impacted teeth 21 and 23 , homogenous radiopaque masses over the right and left inferior aspect of the mandible suggestive of osteomas ( large arrows ) .
also multiple small , homogeneous radiopaque masses surrounded by a radiolucent halo could be seen throughout the maxilla and mandible suggestive of complex odontomes ( small arrows).diffuse sclerotic masses are present throughout the body of mandible giving it a mottled appearance maxillary occlusal radiograph shows impacted teeth 21 , 23 ( large arrows ) and odontomes ( small arrows ) in the near vicinity .
the histopathological report revealed the presence of compact lamellar bone with a haversian canal , lacunae , histiocytes , and reversal and resting lines suggestive of osteoma [ figure 6 ] .
photomicrograph shows the presence of compact lamellar bone with haversian canal , lacunae , histiocytes and reversal and resting lines suggestive of osteoma .
it is an autosomal dominant condition with an incidence between 1 in 8300 and 1 in 14,025 live births , affecting both genders equally , with a uniform worldwide distribution .
symptoms are usually present by the end of the second decade of life , but they may present anytime between two months and 70 years . as the clinical and radiological features in the maxillofacial region , such as osteomas , skin cysts , atypical skin pigmentation , and abnormal dental findings or radiographical lesions can precede frequent asymptomatic intestinal polyps for many years , dental practitioners and radiologists should be familiar with the manifestations of this syndrome . unlike most patients with gardner 's syndrome who present with gastrointestinal symptoms such as bloody diarrhea and pain in the abdomen ,
our case showed the classical clinical features associated with the syndrome : multiple osteomas and odontomes , epidermoid cyst , and impacted teeth .
skeletal abnormalities appear in approximately 90% of the patients with gardner 's syndrome , and osteoma is considered to be the most common .
supernumerary teeth , compound odontomes , and / or impacted teeth are seen in 30% of the patients with this disease .
the gastrointestinal manifestations of gardner 's syndrome include colonic adenomatous polyps ( tubular , villous , tubulovillous ) , gastric and small intestinal adenomatous polyps ( 12% of the patients ) , and periampullary carcinomas ( 2% of the patients ) . in our patient
patients may also suffer from congenital hypertrophy of the retinal pigment epithelium , although the finding was absent in our case .
panoramic radiography by the dentist can be useful for early detection of gardner 's syndrome , because the components of this entity , like osteoma , odontoma , supernumerary , and impacted teeth , can be detected . however , panoramic radiography is of limited value in the evaluation , localization , and extension of the tumor mass , considering the superimposition of the bony structures and the two - dimensional image .
therefore , dental professionals should be familiar with the significance of the syndrome as a pre - cancerous condition .
dental management includes removal of the impacted teeth , cysts of the jaw or face , as well as , resection of osteomas for functional or cosmetic reasons .
tooth extraction can be difficult because of generalized increased alveolar bone density and complete absence of periodontal space caused by hypercementosis .
osteomas of the skull , angle of the mandible and its inferior surface are classic bony features , in addition to intestinal ployps , in patients with gardner syndrome
. a practicing dental surgeon should be aware of this entity in which intestinal polyps have 100% chance of malignant transformation .
 gardner 's syndrome is an autosomal dominant disease and is a subtype of familial adenomatous polyposis . 
 it is characterized by adenomatous intestinal polyps , multiple osteomas in the skull , maxillae , mandible , and multiple cutaneous and subcutaneous masses ( epidermoids and desmoid ) . 
 intestinal polyps , if not treated , have 100% chance of becoming malignant . 
 we report a case of a 25-year - old female patient with gardner 's syndrome , with clinical manifestations including impacted supernumerary teeth , odontomes , sebaceous cyst on the scalp , and osteomas . 
 it is important for the general dental practitioners to be aware of the clinical and radiological characteristics of gardner 's syndrome . 
INTRODUCTION
RADIOLOGICAL FEATURES
PATHOLOGICAL FEATURES
DISCUSSION
CONCLUSION