RADIOGRAPHIC

INTERPRETATION OF
TUMORS OF THE
JAWS
DRG SHANTY CHAIRANI

DIFFERENCES BETWEEN
BENIGN LESION AND
MALIGNANT
LESION
Lesion
borders

Benign lesions have well defined borders and

tend to be round or oval because of their
nonaggressive growth.
Malignant lesions exhibit ill-defined borders.
The margin may be very irregular and ragged,
so it is hard to establish the exact limits of the
malignant lesion.
It must be noted that certain benign
processes, such as infections, may produce
lesions with destructive borders

Adjacent cortical bone

Benign lesion tends to displace the adjacent

structure. It has the effect of causing distortion of
the bone, usually the expansion of the cortex. As
the periosteum is elevated it may stimulate the
formation of layers of reactive bone, termed
onion skin because of its radiographic
appearance.
Malignant lesion grow by invasion and destruction
of adjacent structures. The bony cortex will be
destroyed rather than expanded. The lesion may
grow through the bony cortex so rapidly that it
carries portions of the periosteum with it, forming
bone, giving rise to a sunburst appearance.

Radiodensity

Malignant carcinomas are radiolucent lesions. The

presence of new bone formation indicates the
presence of sarcoma rather than carcinoma

Dental involvement

Benign lesios, which are more slowly growing, are

more likely to cause root resorption and
displacement of roots
The rapid growth and spread of malignant lesions
usually causes them to expand around the roots
of teeth, leaving the root intact and teeth in
position. Some may cause root resorption

BENIGN TUMORS OF
THE JAWS

HYPERPLASIAS

Growths of new bone, with normal

architecture, occur on the bones of the
skull and facial skeleton, such as : tori
and exostoses.
Exostoses that frequently occur in well
defined location on the jaw bones are call
tori.
These hyperplastic growths are very
slowly growing and their growth potential
is limited.

TORUS PALATINUS

Clinical features :

Occurs in the central portion of the hard palate.

Any age, but rare in children.
Usually initiated in young adults before age 30
years.
Vary in size and shape

Radiographic features :

The relatively dense radiopaque shadow of a

palatal torus will be superimposed with the apical
areas of the maxillary teeth.
Well defined border

TORUS MANDIBULARIS

Clinical features

Found on the lingual surface of the mandible, above

the mylohyoid line, between the body and the alveolar
process.
Usually bilateral, and most often in premolar region.
Develops in middle aged adults

Radiographic features :

A radiopaque shadow, usually superimposed over the

roots of the premolar and molar teeth
The images of torus mandibularis are not as well
defined from the adjacent normal bone as those of
torus palatinus.

EXOSTOSES

An exophytic nodular growth of dense

cortical bone commonly located on maxillary
or mandibular buccal alveolar bone, usually
in the bicuspid / molar area.
Clinical Features:
Late teen and early adult years
Slowly growing
Multiple rounded or oval mass of dense
bone
Smooth-surfaced

Radiographic Features:

Well-circumscribed, smoothly contoured, and

rounded radiopaque masses.
Some may have poorly defined borders.

ODONTOGENIC TUMOR

AMELOBLASTOMA

A benign and locally aggressive neoplasm

that apparently arises from remnants of the
dental lamina and dental organ (odontogenic
epithelium)
Clinical Features:

Wide age range, mostly between 20-50 years.

Usually it slowly grows as painless swelling of the
affected site
Locally invasion into the surrounding bone.
Capable of causing large facial deformities
80-95% in the mandible (posterior body, ramus
region). In the maxilla mostly in the premolarmolar region.
Incomplete removal can result in recurrence.

Radiographic Features:

Expansile, circumscribed unilocular or

multilocular radiolucent with smooth, welldefined, well-corticated margins
May exhibit a multilocular "soap bubble" or
honey comb appearance
Adjacent teeth are often displaced and
resorbed.
It causes extensive bone expansion.

ADENOMATOID ODONTOGENIC
TUMOR (AOT)

A well-circumscribed lesion derived from

odontogenic epithelium that usually occurs
around the crowns of unerupted anterior teeth of
young patients.
Clinical Features:

Relatively rare.
Occurs during the second decade of life, commonly 14
to 15 years of age
Females affected more often
Usually associated with an impacted tooth
Anterior maxilla is the most common site
Commonly presented in an area of swelling over an
unerupted tooth, usually canine
May be associated with cortical expansion

Radiographic Features:

Well-demarcated unilocular associated

with an unerupted tooth.
The margins is frequently sclerotic.
Some tumors are totally radiolucent; others
show evidence of internal classification.
Radiolucency usually extends apically
beyond the cementoenamel junction
Roots of adjacent teet may be displaced,
but rarely resorbed

CALCIFYING EPITHELIAL
ODONTOGENIC TUMOR
(CEOT)
Also known as Pindborg
Tumor
A locally aggressive tumor appears to arise from
either the reduced enamel epithelium or dental
epithelium.
Clinical Features:

2nd to 10th decade of life with a mean age of 40

Locally invasive with a high recurrence rate
50% associated with impacted teeth
Usually in posterior mandible
Slow growing
Cortical expansion may be present

Radiographic Features:

Well circumscribed unilocular or

multilocular radiolucency
Small lesions may be radiolucent. In
advanced stages irregularly sized
calcifications may be scattered in the
radiolucency.
Often associated with impacted tooth
Cortical bone expansion
It can cause displacement and impaction of
teeth.

ODONTOMA

An usually hamartomatous lesion commonly

found over unerupted teeth, containing
enamel, dentin, pulp,and cementum in either
recognizable tooth shapes (compound) or a
solid gnarled mass (complex).
Clinical Features:
Most in first and second decade
More often maxilla than mandible
Asymptomatic swelling
Failure of tooth eruption

Compound odontoma are usually occur in

the incisor-canine area of the maxilla.
Complex odontoma are usually in the
mandibular first and second molar area.
Pathologic changes of adjacent teeth such
as impaction, malpositioning, diastema,
aplasia and malformation are associated
with 70% of odontoma

COMPOUND ODONTOMA

Radiographic Features:

Usually unilocular
Contains multiple (2 to 30) structures that
resemble miniature teeth

COMPLEX ODONTOMA

Radiographic Features:

Solid unilocular radiopaque mass surrounded by a thin

radiolucent zone
Distinct line of cortication separates lesion from normal bone
Tooth-like structures are absent

AMELOBLASTIC ODONTOMA
(ODONTOAMELOBLASTOMA
An extremely rare odontogenic
)
tumor that

contains an ameloblastomatous
component and odontoma-like elements.
Clinical Features:

Usually in mandible
Usually occur in younger patients in the
second decade of life
Slow growing
Delayed eruption of teeth
Bony expansion

Radiographic Features:

Mixed radiolucent-radiopaque
Calcified structures that may resemble a compound or
complex odontoma, but the radiopaque portion of this
lesion is relatively smaller than in the odontoma
May causes bone expansion, destruction, tooth
displacement and resorption

AMELOBLASTIC FIBROODONTOMA

An expansile growth in young patients

that contains the soft tissue components
of ameloblastic fibroma and the hard
tissue components of complex odontoma
Clinical Features:

First or second decade, mean 10 years

Posterior areas of the mandible primarily
Slow developing swelling of the jaw
Usually no pain

Radiographic Features:

Mixed radiolucent / radiopaque

Well-circumscribed unilocular

AMELOBLASTIC
FIBROMA
A mixed odontogenic tumor arising from both

epithelial and mesenchymal elements of the

tooth germ.
Clinical Features:

First & second decades; mean 14 years

Usually in posterior mandible around 1st molar
Small tumors are often asymptomatic
Large tumors produce swelling; may get quite large &
expand cortex
Slight buccal and lingual cortical expansion may be
present
Often associated with an unerupted tooth.

Radiographic Features:
Unilocular or multilocular radiolucency.
Small lesions are monolocular. Large
lesions are multilocular.
Associated with unerupted tooth or tooth
that failed to develop
Tend to be well-defined & may be sclerotic
It may cause displacement of adjacent
teeth.
Large lesions cause buccal/lingual
expansion.

ODONTOGENIC MYXOMA

Also known as Fibromyxoma

An aggressive intraosseous lesion derived from
embryonic connective tissue associated with
odontogenesis.
Clinical Features:

It can occur at any age but most commonly in the

second and third decades of life, with mean age of
30
Painless and slowly enlarging swelling of the jaw
More often affect the mandible (molar/premolar
region).
Frequently associated with congenitally missing or
unerupted tooth

Radiographic Features:

Typically multilocular (internal septa- strings

of a tennis racket or honeycomb appearance).
Large lesions can have the sun ray
appearance of an osteosarcoma.
Small lesions may be unilocular
Often well-defined.
Adjacent teeth can be displaced but rarely
resorbed.
It causes less bone expansion than in other
benign tumors.

CEMENTOBLASTOMA

A benign, well-circumscribed neoplasm of

cementum-like tissue growing in continuity
with the apical cemental layer of a molar or
premolar.
Clinical Features:

Usually 2nd or third decade, usually before age 25

Mandible in first premolar to molar region
Pain, swelling, and expansion of the cortical plates
Continuous with root, which resorbed
Pulp vitality unrelated

Radiographic Features:

Well defined radiopaque mass attached to the roots of

the associated tooth
Surrounded by radiolucent line
Loss of normal PDL area and root outline
Root resorption of the apical third

NON ODONTOGENIC
TUMORS

OSTEOMA

An exophytic nodular growth of dense cortical

bone on or within the mandible or maxilla in
locations other than those occupied by tori or
exostoses.
Clinical Features:

Any age, most frequently in older than 40 years

Usually on the mandible, most frequenly on the
posterior lingual surface of the ramus and the
inferior border below the molars.
Asymmetry caused by a bony hard swelling on the
jaw
Often associated with Gardner syndrome

Radiographic Features:
Radiopaque mass with well defined borders within a
paranasal sinus or associated with the mandible.
The mandibular lesion may be exophytic, extending
outward into adjacent soft tissue spaces.

GARDNER SYNDROME

A rare autosomal dominant disease

characterized by GI polyps, multiple
osteomas, and soft tissue tumors.
Clinical Features:

Onset early puberty

Congenitally missing teeth, hypercementosis,
odontomas, dentigerous cysts, impacted teeth,
supernumerary teeth, fused or unusually long
roots, and multiple caries.
Osteoma most often develop first within the angle
of the mandible

Radiographic Features:

Usually impacted supernumerary teeth

Osteomas in the mandible or paranasal
sinuses; well delineated or sperical
calcifications

HEMANGIOMA

A proliferation of large (cavernous) or small

(capillary) vascular channels occurring
commonly in children; individual lesions have
variable clinical courses. Rare, benign tumor
that occasionally affects the jaws.
Clinical Features:

It can occur at any age, but more often in

adolescents.
Female predilection
Usually located in skin or mucosal tissue; may
also occur in bone or muscle
Aspiration of the lesion is a important diagnostic
tool.

Radiographic feature :
Multilocular radiolucency (soap bubble or honeycomb
appearance). Large lesions can have the sun ray
appearance of an osteosarcoma.
Root resoption of adjacent teeth is common. Developing
teeth may be larger and erupt earlier.
When the lesion involves the inferior dental canal, the canal
can be enlarged.

OSTEOBLASTOMA

A benign neoplasm of bone that arises from

osteoblasts with similar clinical, radiographic, and
histopathologic features of osteoid osteoma consisting
of well-demarcated, rounded intraosseous swellings,
each with an active cellular central nidus surrounded
by a wide zone of osteoid, with pain upon palpation.
Clinical Features:
Most occur in the 2 nd and 3rd decades of live, with
average age is 17 years
Slight posterior mandibular predilection
More often in males
Painful or tender, diameter 2-12 cm

Radiographic Features:
Well circumscribed round solitary lesion
Expansile
Mixed radiolucent radiopaque lesion not
surrounded by sclerotic bone

OSTEOID OSTEOMA

A benign neoplasm of bone that arises

from osteoblasts.
Clinical Features:

Mostly before age 25

More often in males
Swelling, usually only about 1-2 cm in
diameter
Dull or aching pain (nightly, relieves with
aspirin).
More in long bone and infrequent in jaws

Radiographic Features:

Sclerotic bone surrounding a radiolucent core

Peripheral radiopacity
Well demarcated

MALIGNANT
DISEASE OF THE
JAWS

CARCINOMA

SQUAMOUS CELL
CARCINOMA
The most common
oral malignant tumor which its

origin is from epithelium.

Squamous cell carcinomas of the oral mucosa in their
latter stages invade the underlying bone.
Clinical features :
Predominantly in men older than age 50 years.
Most commonly involves the posterior lateral border
of tongue and lower lip, and less frequently the floor
of the mouth, alveolar mucosa, palate and buccal
mucosa.
Osseus involvement in the jaws is most frequently
seen in the third molar region of the mandible.
Small lesion is asymptomatic, but the larger one
often causes some pain or paresthesia and swelling.

Radiographic features :
Ill-defined moth-eaten radiolucency. Destruction
of alveolar ridge along with a soft tissue mass.
Adjacent teeth: displacement loosened or
resorbed.
Ultimately a pathological fracture may result.

METASTATIC
CARCINOMA
Metastastatic
lesions in the jaws are usually

from primary lesions below the clavicle (breast,

bronchus, kidney, thyroid and prostate) .
Clinical features :

It occurs in adults older than 40 years.

In most cases of metastatic carcinoma to the jaw there
are other skeletal metastases.
Mandible is the most common disease site, usually in
the premolar and molar regions.
Symptoms and signs include pain, swelling,
paraesthesia/anaesthesia. Large lesions can lead to
pathological fractures.

Radiographic features :

Lesion margins are usually well-defined but not

corticated. Then gradually coalesce to form large
ill-defined radiolucensies.
May be single or multiple, and vary in size.
Teeth in the affected region may become loosened
or exfoliate, and root resoprtion is common.

MALIGNANT SALIVARY
GLAND TUMORS

Most malignant tumors of the major and minor

salivary gland arise in the epithelial elements of
these gland.
Clinical features :

Any age, but most occur in midlle age and after.

Often affected females than males.
Generally slow growing and painless
Most common in the mandible, in the posterior
alveolus, the angle and ramus, whereas less than
half that number arise in the maxillary sinus,
palate and posterior ridges of the maxilla.

Radiographic features :

Invasion of the bone by these tumors is not

uncommon.
When they infiltrate bone, they produce a
semicircular radiolucency with ill defined and
ragged borders.

SARCOMA

Malignant lesions arise within the

connective tissues.
Less common than carcinomas.
Usually seen in young people.
Sarcoma generally are seen as rapidly
growing masses that cause irregular
destruction of bone with indistinct
margins.

OSTEOSARCOMA

Also known as Osteogenik Sarcoma

Most common of the malignant neoplasms
derived from bone cells in which the tumor cells
contain high levels of alkaline phosphatase.
Clinical Features:

Between ages of 30 and 40

Affects mandible and maxilla. In the mandible the
lesion is most frequently seen in the body, in the
maxilla lesions are usually in the antrum or alveolar
ridge, but not the palate.
Oral manifestations: Pain and swelling of the involved
bone, loose teeth, paresthesia, bleeding, nasal
obstruction.

Radiographic Features:

Widening of PDL space is early radiographic feature.

Appearance varies from radiolucent, to mixed
radiolucent/radiopaque to radiopaque
There are three main types:
Osteolytic: no neoplastic bone formation: poorly
defined moth-eaten radiolucency, loosening of
associated teeth
Mixed : patches of neoplastic bone formed: poorly
defined radiolucent area with variable internal
radiopacity.
Osteosclerotic : neoplastic bone formation: often
formation of sub-periosteal bone orientated at right
angles to the original cortex, producing the socalled sun-ray appearance, loosening of
associated teeth, distortion of the alveolar ridge.

CHONDROSARCOMA

Uncommon malignant bone neoplasm in the jaws arise from

cartilaginous origin. This tumor arises centrally or
peripherally in the periosteum or other connective tissues
containing cartilage.
Clinical Features:
3rd to 5th decade of life, average age of 45
Most common sites: anterior maxilla, symphysis, coronoid,
and condylar process.
Small area of hyperplasia of the gingiva around a few teeth
to a very large lesion
Aggressive tumor with high rate of recurrence after excision
Pain, swelling, facial asymmetry
Teeth adjacent may be resorbed, loosened or exfoliated
Oral mucosa may have a normal appearance.

Radiographic Features:
Unilocular or multilocular
Poorly defined osteolytic radiolucency with areas of
opacities
Expansile, "moth-eaten", radiolucent area with
indistinct borders
Widening of periodontal membrane and lack of lamina
dura of associated teeth is common

EWINGS SARCOMA

Malignancy of bone derived from mesenchymal

connective tissue of the marrow. Rare in the
facial bones and jaws.
It is a very rapidly growing highly invasive tumor
with early and widespread metastasis.
Clinical features :

90% of patients between the ages of 5 and 30

years.
Local bone pain, localized swelling, fever.
Usually in the mandible
The teeth in the area may become mobile

Radiographic features:

Ill-defined radiolucency.
Expansion of bone with soft tissue mass
adjusted to affected bone.
Periosteal thickenning of cortical erosion.

HEMATOLOGIC NEOPLASM

LEUKEMIA

Malignant neoplasms of haemopoietic

stem cells.
Clinical features :

Acute cases are usually seen in children and

chronic cases in those of 25 to 60 years old.
Signs and symptoms include: bleeding, bone
pain, gingival inflammation, gingival
hyperplasia, loose teeth, ulceration.

Radiographic features : more common in the

acute type

Premature loss of teeth.

Loss of lamina dura.
Periapical radiolucency similar to periodontal disease.
Single layer of periosteal new bone formation on the
inferior border of the mandible.
Multiple punched-out radiolucencies.

IMMUNOLOGIC NEOPLASMS

MALIGNANT LYMPHOMA

Malignant neoplasms of cells of lymphoid origin.

Two major types: Hodgkins Lymphoma and
Non- Hodgkins Lymphoma
Radiographic features :

Generalised osteopenia with loss of the lamina dura

and the inferior dental canal and involvement of the
cortex.
Multilocular, ill-defined bone destruction.
In maxillary sinus lesions, the antral walls can be
destructed and soft tissue mass may be visible. In the
mandible, the lesion can destroy the cortex of the
inferior dental canal.
Root resorption of the adjacent teeth.

MULTIPLE MYELOMA

It is a multifocal cancer of the plasma cells.

Clinical features :

The most common malignancy of bone in

adults. It occurs in adults older than 30 years.
70% involvements of jaws, which the most
frequent sites are the posterior body, angle,
and ramus of the mandible
Symptoms and signs include pain in the teeth
or jaws, swelling, paraesthesia, soft tissue
mass, hemorrhage and tooth mobility. Large
lesions can lead to pathological fractures.

Radiographic features :

Multiple round radiolucencies in the skull and jaws

(more often in the mandible).
Lesion margins are usually well-defined but not
corticated (punched-out)