M u s c u l o s k e l e t a l I m a g i n g • R ev i ew

Meyer et al.
Jaw Lesions

Musculoskeletal Imaging
Review

Imaging Characteristics of Benign,

FOCUS ON:

Malignant, and Infectious Jaw

Lesions: A Pictorial Review
Kathleen A. Meyer 1 OBJECTIVE. The purpose of this article is to describe the indications and appropriate
Laura W. Bancroft 2 imaging studies for various jaw tumors and tumorlike lesions, the imaging findings, the dif-
Thomas J. Dietrich 3 ferential diagnosis, and appropriate treatment options.
Mark J. Kransdorf 1 CONCLUSION. It is important for radiologists to recognize the indications and appro-
Jeffrey J. Peterson1 priate imaging studies for various jaw lesions. Radiography is typically used for first-line im-
aging. If necessary, it is followed by CT for evaluation of osseous lesions and MRI for char-
Meyer KA, Bancroft LW, Dietrich TJ, Kransdorf acterization of soft-tissue lesions.
MJ, Peterson JJ

Keywords: jaw, jaw lesions, jaw tumors, mandible
DOI:10.2214/AJR.10.7225
Received January 14, 2010; accepted after revision
December 4, 2010.
1Department of Radiology, Mayo Clinic in Florida, 4500
San Pablo Rd, Jacksonville, FL 3224. Address
correspondence to K. A. Meyer
(meyer.kathleen1@mayo.edu).
2 Florida Hospital, University of Central Florida, and
Mayo Clinic College of Medicine, Orlando, FL.
3 University of Louisville, Louisville, KY.
CME
This article is available for CME credit.
See www.arrs.org for more information.
WEB
This is a Web exclusive article.
AJR 2011; 197:W412–W421
0361–803X/11/1973–W412
© American Roentgen Ray Society
P
athologic conditions affecting the
jaw are common yet not frequently
imaged or encountered by radiolo-
gists. It therefore is important for
radiologists to recognize pathologic changes in
the jaw to ensure appropriate, timely patient
care. In cases of infection, the diagnosis typi-
cally is known on the basis of the clinical find-
ings. Imaging studies may be needed, however,
to assess the extent of disease and to aid in treat-
ment planning. Imaging findings may not lead
to a specific diagnosis, but they should narrow
the differential diagnosis and guide further
workup. Often, jaw abnormalities present in a
nonspecific manner, making imaging of utmost
importance in elucidating the cause of the
symptoms. The jaw tumors and tumorlike le-
sions illustrated in this article are ameloblasto-
ma, follicular cyst, periapical cementoma, os-
teochondroma, fibrous dysplasia, giant cell
tumor, osseous metastatic disease, multiple my-
eloma, necrotizing fasciitis, and osteomyelitis.
Benign Lesions
Scenario 1
Clinical history—A 30-year-old woman
with a lesion in the left mandible had find-
ings on a Panorex image that prompted CT
for further evaluation.
Image findings—The Panorex image
showed a large lytic lesion (Fig. 1A) in the
left mandibular body. Coronal and axial CT
images (Figs. 1B and 1C) showed a large
multilobulated lytic lesion in the left posteri-
or mandible with expansile remodeling, scal-
loped borders, and cortical thinning.
Conclusion—The patient had ameloblas-
toma, which is a locally invasive, benign
neoplasm arising from enamel-forming cells
of the odontogenic epithelium that do not
regress during embryonic development [1].
This lesion typically presents in the third to
fifth decades of life [2]. Approximately 75%
occur in the mandible, usually involving the
posterior mandible, often around the third
molar. The other 25% occur in the maxilla.
Ameloblastoma is often associated with
the crown of an unerupted or impacted tooth,
although this patient did not have this find-
ing [2]. It is a slow-growing tumor, allowing
considerable mandibular expansile remodel-
ing [1]. The tumor often has a somewhat bub-
bly appearance and may erode adjacent tooth
roots, although it is considered a benign le-
sion. Malignant transformation is rare, occur-
ring in approximately 1% of cases. There is a
high likelihood of recurrence if the tumor is
not adequately resected.
CT shows a low-attenuating lesion without
matrix mineralization and typically shows
expansile remodeling and cortical thinning.
If extraosseous extension occurs, contrast-
enhanced images show soft-tissue enhance-
ment mixed with low-attenuating regions. At
MRI, ameloblastoma has mixed signal inten-
sity on T1- and T2-weighted images: typically
overall low signal intensity on T1-weighted
images and high signal intensity on T2-
weighted images. Contrast-enhanced imaging
may show enhancing mural nodules and sep-
tations. Figure 2 shows the MRI findings of
maxillary ameloblastoma. The sagittal T1-

W412 AJR:197, September 2011

 Jaw Lesions

A B C
Fig. 1—30-year-old woman with ameloblastoma.
A, Panorex image shows large lytic lesion (arrows) in
left mandible.
B and C, Coronal (B) and axial (C) CT images through
mandible reveal show multilobulated lytic lesion
(asterisk) in posterior left mandible with expansile
remodeling, scalloped borders, and cortical thinning.
D, Photograph of gross specimen shows
breakthrough of ameloblastoma on lingual side.
E, Specimen radiograph shows findings
corresponding to D.

Mandibular locking reconstruction plates

D E
weighted image (Fig. 2A) shows a heteroge-
neously low-intensity lesion involving the
right maxillary sinus that is largely isoin-
tense to skeletal muscle. The axial fast spin-
echo T2-weighted images (Fig. 2B and 2C)
show a multiloculated heterogeneously hy-
perintense lesion and expansile remodeling
of the sinus walls.
Other considerations in this case include
odontogenic keratocyst and dentigerous cyst.
These lesions, however, lack nodular en-
hancement, which can be seen on CT scans
of ameloblastoma. This lesion was resected,
and the jaw was immediately reconstructed
with a locking plate and posterior iliac crest
bone graft. The gross specimen photograph
(Fig. 1D) showed breakthrough of the ame-
loblastoma on the lingual side that correlated
well with the findings on the gross specimen
radiograph (Fig. 1E).
are durable and load bearing. They do not al-
low micromovement between bone margins.
Thus, bone-to-bone contact must be present
for primary bone healing. The screws tra-
verse both cortexes and lock into the plate,
essentially acting as an internal fixator.
Scenario 2
Clinical history—A 34-year-old man un-
derwent a routine dental examination that in-
cluded a Panorex image.
Imaging findings—The Panorex image
(Fig. 3) showed a radiolucent, well-defined,
ovoid lesion adjacent to the crown of the un-

A B C
Fig. 2—47-year-old man with ameloblastoma of maxilla.
A, Sagittal T1-weighted MR image shows heterogeneously low-intensity lesion (asterisk) in right maxillary sinus largely isointense to skeletal muscle.
B and C, Axial fast spin-echo T2-weighted MR images show multiloculated heterogeneously hyperintense lesion (asterisk) and expansile remodeling of sinus walls.

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 Meyer et al.

Fig. 3—34-year-old man with follicular cyst. Panorex image shows radiolucent, Fig. 4—Drawing shows development odontogenic cysts. 1 = follicular cyst, 2 =
well-defined, ovoid lesion (arrows) adjacent to crown of unerupted right third keratocyst, 3 = lateral periodontal cyst.
molar and associated mandibular cortical thinning.

erupted right third molar (tooth 32). Associat- ders and is associated with an impacted tooth the pastelike or cheeselike consistency, kera-
ed mandibular cortical thinning was evident. in the mandibular body and ramus [2]. Sat- tocysts can have areas of high attenuation on
Conclusion—The diagnosis was follicu- ellite lesions, however, often are present and CT scans, areas of low to intermediate signal
lar cyst, also called dentigerous cyst. It is the can coalesce and result in a scalloped-border intensity on T1-weighted MR images, and ar-
most common cause of pericoronal lucen- appearance. These lesions can cause cortical eas of low signal intensity on T2-weighted im-
cy associated with an impacted tooth. Fol- thinning and possibly resorption of the tooth ages. Contrast-enhanced MRI may reveal pe-
licular cysts are slow growing and develop root. Keratocysts contain a cheeselike mate- ripheral rimlike enhancement [4].
when fluid accumulates between the follicu- rial that is found at surgery, easily differenti- Figure 5 illustrates the case of a 16-year-old
lar epithelium and the crown of a developing ating them from follicular cysts. Because of girl with an odontogenic keratocyst associated
or unerupted tooth. The increase in internal
pressure leads to osseous expansion [3]. Fol-
licular cysts typically are asymptomatic and
are found incidentally in the second to fourth
decades of life. Treatment entails removal
of the entire cyst and affected tooth, as was
done in this case. Also in this case, the site
was grafted with hydroxylapatite particle
mix and freeze-dried bone.
There are a few types of odontogenic cysts,
including developmental cysts, inflamma-
tory cysts, and residual cysts. Developmen-
tal odontogenic cysts include follicular cysts,
keratocysts, and lateral periodontal cysts (Fig.
4). Keratocysts typically become evident in
the second through fourth decades of life. Ra- A B
diographically, a keratocyst usually appears
as a unilocular lucent lesion with smooth bor-

Fig. 5—16-year-old girl with mandibular odontogenic

keratocyst.
A, Panorex image shows large lucent lesion with
scalloped border (arrows).
B, Sagittal T1-weighted MR image shows expansile
lesion (asterisk) with intermediate signal intensity in
posterior mandible.
C, Sagittal contrast-enhanced T1- weighted MR
image shows peripheral rimlike enhancement of
lesion around third molar.
D, Axial conventional T2-weighted MR image shows
inhomogeneously hyperintense expansile lesion
(asterisk) with areas of low signal intensity in left
posterior mandible.
C D

W414 AJR:197, September 2011


with the left third molar. The Panorex image
(Fig. 5A) shows the scalloped-border appear-
ance. The lesion has intermediate signal inten-
sity on the T1-weighted images (Fig. 5B) and
peripheral rimlike enhancement on the con-
trast-enhanced image (Fig. 5C). Figure 5D
shows the lesion has inhomogeneously high
signal intensity on a T2-weighted image and
internal areas of lower signal intensity. Treat-
ment is removal of the entire cyst and associat-
ed tooth, but the recurrence rate is high. Lateral
periodontal cysts are typically located between
the tooth roots of vital mandibular canines,
predominantly in men older than 50 years.
The inflammatory odontogenic cysts in-
clude radicular cysts and paradental cysts
(Fig. 6). Radicular cysts are the most common
odontogenic cysts. They typically originate
from a nonvital tooth apex because they re-
sult from pulpal necrosis secondary to dental
caries or trauma [3]. The root apex is within
the cystic lumen; therefore, these cysts do not
distort the roots of adjacent teeth. An odonto-
genic cyst associated with the apex of a tooth
with a crown, thus a diseased tooth, is consis-
tent with a periapical radicular cyst. Paraden-
Fig. 7—39-year-old man
with periapical cementoma.
A, Panorex image shows
two well-defined small
sclerotic foci (arrows)
in periapical region of
mandibular teeth.
B, Axial CT image through
mandible shows one small
well-defined sclerotic focus
(arrow) with subtle marginal
lucency that correlates with
one sclerotic focus in A.
AJR:197, September 2011
Jaw Lesions
Fig. 6—Drawing
shows inflammatory
odontogenic cysts.
1 = apical radicular cyst,
2 = lateral radicular cyst,
3= residual radicular
cyst, 4 = paradental cyst.
tal cysts are located in the distal and buccal
aspects of the radicular regions of an incom-
pletely erupted mandibular third molar. Re-
sidual cysts are odontogenic cysts that remain
after removal of the tooth with which they
were associated. They cannot be radiographi-
cally differentiated from other cysts.
Scenario 3
Clinical history—A 39-year-old man ar-
rived in the emergency department with a
3-day history of facial cellulitis. Panorex im-
aging was performed and followed by CT.
Imaging findings—The Panorex image
(Fig. 7A) incidentally showed two well-defined
small sclerotic foci in the periapical region of
the mandibular teeth on the left side. An axial
CT image (Fig. 7B) through the mandible re-
vealed a single small well-defined sclerotic fo-
cus with subtle marginal lucency that correlat-
ed with one of the sclerotic foci visualized on
the Panorex image.
Conclusion—The diagnosis was periapical
cementoma, which is a periapical lesion in the
premolar or molar region of the mandible [3].
Initially, these lesions are radiolucent and in-
A B
crease in density as cementum is deposited.
The radiolucency surrounding the sclerotic
focus represents the nonmineralized growth
zone [3]. It is important to be aware that peri-
apical cementomas are attached to the root of
the affected tooth and that extraction of the in-
volved tooth is difficult or impossible [3]. The
lesions themselves typically are asymptomat-
ic, and treatment is not required.
Periapical cementomas have a male pre-
dominance [3]. A similar condition with a
female predominance is periapical cemental
dysplasia. Although the descriptions of these
two entities seem to overlap in the literature,
the lesions of periapical cemental dysplasia
are generally described as smaller, occurring
between mandibular canine teeth, and being
seen almost exclusively in women.
Scenario 4
Clinical history—A 52-year-old woman
presented with pain after a fall, and cervical
spinal radiographs were obtained.
Imaging findings—Anteroposterior and
oblique collimated radiographs (Fig. 8)
showed an exophytic lesion extending from
the angle of the left mandible that had cor-
tical and medullary continuity with the
host bone.
Conclusion—The diagnosis was osteo-
chondroma, which is the most common bone
tumor and has cortical and medullary conti-
nuity with the host bone [5]. Osteochondro-
ma is a developmental lesion that typically is
painless. The presence of pain suggests a
complication such as a fracture, bursitis, as-
sociated nerve or blood vessel compression,
or, rarely, malignant transformation. Malig-
nancy should be considered if the lesion con-
tinues to grow or if a cartilaginous cap more
than 2 cm thick is found in a skeletally mature
patient. Malignant transformation occurs in
W415

A B
approximately 1% of solitary osteochondro-
mas and 3–5% of patients with multiple he-
reditary exostosis [5]. Treatment of osteo-
chondroma is specific to each case. Small
asymptomatic osteochondromas can be ob-
served, but larger symptomatic lesions may
have to be resected. The overall recurrence
rate after resection is 2%. Another consider-
ation in this case was chondrosarcoma, but
chondrosarcoma typically undergoes cortical
disruption and has a thick cartilaginous cap.
Scenario 5
Clinical history—A 64-year-old woman
reported she had been told she had sclerot-
ic mandibular lesions that might represent a
metabolic bone problem. A Panorex image
therefore was obtained.
Imaging findings—The Panorex image
(Fig. 9) revealed extensive thickening and
sclerosis of the inferior margin of the man-
dible and multiple sclerotic foci.
Conclusion—The diagnosis was florid ce-
mentoosseous dysplasia, which is generally
confined to the tooth-bearing regions. Af-
fected bone undergoes a change from normal
to an avascular cementum-like lesion. There
are no other associated skeletal abnormali-
ties [6]. The borders are round or lobulated,
and commonly a radiolucent rim is seen sur-
rounding the lesions. With time, the lesions
tend to become more dense [7]. The lesions
can be seen in multiple quadrants in both the
maxilla and mandible [7, 8]. Typically, no
treatment is needed because the lesions are
benign. Patients occasionally undergo treat-
ment for cosmetic reasons.
Another consideration in this case was fi-
brous dysplasia. However, the entities can
be differentiated on the basis of the char-
acter of the mineralization and distribution
within the jaw. The skull and facial bones
W416
Meyer et al.
are involved in approximately 30% of cases
of monostotic fibrous dysplasia and approx-
imately 50% of cases of polyostotic involve-
ment [9]. The monostotic form is usually
asymptomatic, and growth of the lesion sta-
bilizes during puberty. Two thirds of patients
with polyostotic fibrous dysplasia, howev-
er, report symptoms in childhood or ado-
lescence, and the lesions remain active after
puberty. The monostotic form does not prog-
ress to the polyostotic form. Patients with fi-
brous dysplasia may present with craniofa-
cial asymmetry.
Scenario 6
Clinical history—A 59-year-old man with
a history of both acute myelogenous leuke-
mia and chronic lymphocytic leukemia had
a 10-year history of progressive left jaw dis-
comfort and difficulty chewing. CT was per-
formed for further evaluation.
Fig. 9—64-year-old woman with florid
cementoosseous dysplasia. Panorex image shows
extensive thickening and sclerosis of inferior margin
of mandible (asterisks) with multiple sclerotic foci
(arrows).
Fig. 8—52-year-old woman with osteochondroma.
A and B, Anteroposterior (A) and oblique (B)
collimated radiographs show exophytic lesion (arrow)
extending from mandibular angle with cortical and
medullary continuity with host bone.
Imaging findings—An axial CT scan (Fig.
10) showed a well-defined lytic lesion in the
left mandibular condyle with expansile re-
modeling and cortical thinning. The lesion
also had increased radiotracer activity on a
bone scan without evidence of other lesions.
Conclusion—The diagnosis, proved after bi-
opsy, was giant cell tumor. Most giant cell tu-
mors occur in patients 20–50 years old. Five
percent of these tumors are malignant, typically
secondary to radiation of a benign giant cell tu-
mor. Patients may present with pain, local swell-
ing, and limited range of motion of the adjacent
joint. The most common locations of giant cell
tumors, in decreasing order, are the distal femur,
proximal tibia, distal radius, sacrum, and proxi-
mal humerus [10]. A bone scan may show the
doughnut sign, that is, increased activity along
the periphery of the lesion with a central area of
minimal activity. These lesions typically are re-
sected. Local recurrence is common, occurring
in as many as 25% of cases [10]. Other consid-
erations in this case were aneurysmal bone cyst
and metastatic disease. However, the location of
this lesion would be unusual for an aneurysmal
bone cyst because those cysts rarely affect the
articular surface of the bone.
Malignant Lesions
Scenario 1
Clinical history—A 50-year-old man pre-
sented with a 2-week history of left-sided jaw
Fig. 10—59-year-old man with giant cell tumor
and progressive left jaw discomfort and difficulty
chewing for 10 years. Axial CT image through left
mandibular condyle shows well-defined lytic lesion
(asterisks) in condyle and expansile remodeling and
cortical thinning.
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 Jaw Lesions

(or in the appropriate clinical setting, osteo-

myelitis) until proved otherwise. Tumors of
kidney, lung, and breast cancer are the most
common primary lesions to metastasize to
the mandible [1]. Treatment of metastatic dis-
ease of the mandible is often palliative be-
cause the metastasis often is widespread. In
this case, the patient underwent palliative ra-
diation to the mandible.

Scenario 2
A B Clinical history—A 57-year-old man un-
dergoing an annual radiographic metastatic
survey reported thoracic back pain.
Imaging findings—A lateral skull radio-
graph (Fig. 12A) and collimated view of the
mandible (Fig. 12B) from the metastatic sur-
vey showed multiple punched-out lytic le-
sions in the skull and posterior mandible.
Conclusion—The diagnosis was multiple
myeloma, the most common primary bone tu-
mor. Patients usually present with mild tran-
sient bone pain, often worse with activity. Any
bone with red marrow can be affected [12].
In the differentiation of metastatic disease
C D
and multiple myeloma, mandibular involve-
ment strongly favors the latter. Multiple myelo-
Fig. 11—50-year-old man with left-sided jaw pain for 2 weeks and left lower facial numbness and anterior left
chin tingling for several months. Diagnosis was metastatic adenocarcinoma. ma typically is fatal 1–5 years after diagnosis.
A, Panorex image shows loss of superior cortical margin (white arrow) and associated subtle lytic lesion (black Sclerosis may be seen after treatment. If bone
arrow) in left mandibular angle. scintigraphy is performed, the findings may be
B, Bone scans show focus of increased scintigraphic activity (arrows) in left mandibular angle.
C, Coronal CT image near angle of mandible shows lytic lesion (asterisk). normal, or increased (as a result of hyperemia)
D, Axial CT image through mandible shows lytic lesion (asterisk). or decreased (as a result of replacement of mar-
row cells) activity may be found [12]. MRI is
pain and a several-month history of left low- mandible is rare, presumably because of the the most sensitive imaging modality. Multiple
er facial numbness and a tingling sensation paucity of red bone marrow, which is thought myeloma lesions typically have intermediate to
in the anterior aspect of the left side of the necessary for malignant emboli to become low signal intensity compared with bone mar-
chin. After review of a Panorex image, CT lodged in bone. When mandibular metastatic row on T1-weighted images and high signal in-
was ordered for further evaluation. lesions occur, they most often are found distal tensity on T2-weighted and STIR images.
Imaging findings—The Panorex image to the canines, typically involving the ramus Treatment of multiple myeloma varies with
(Fig. 11A) showed loss of the superior cor- of the mandible. This corresponds to the dis- the extent of disease. Patients with diffuse
tical margin in the left mandibular angle. tribution of red bone marrow in the mandible disease can undergo chemotherapy. Radiation
Bone scans of the lesion (Fig. 11B) showed [11]. Jaw swelling is the most common pre- is used for localized disease and pain relief.
increased scintigraphic activity and no other senting sign. However, an important clinical Bisphosphonates, which are osteoclast-inhib-
foci of increased activity. Coronal and axial point is that inferior alveolar nerve anesthesia iting agents, often are prescribed to reduce
CT scans (Figs. 11C and 11D) revealed the should be considered indicative of neoplasia pain and fracture risk.
lytic lesion near the angle of the left mandible.
Conclusion—The patient had a history of
metastatic rectal adenocarcinoma, and biopsy
showed this mandibular lesion was consistent
with metastatic adenocarcinoma. However,
primary osseous tumor also was a consider-
ation in this case. Metastatic disease to the

Fig. 12—57-year-old man with thoracic back pain.

A and B, Lateral skull radiograph (A) and collimated
view (B) of mandible from skull radiograph show
multiple punched-out lytic lesions (arrows) in skull
and posterior mandible.
A B

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 Meyer et al.

Scenario 3
Clinical history—A 77-year-old man had
a several-month history of right jaw aching,
which he first noticed after yawning. CT was
performed to evaluate the symptoms. Be-
cause of the CT findings, MRI was performed
to better characterize the extent of the lesion.
Imaging findings—Coronal (Fig. 13A) and
axial (Fig. 13B) CT images showed a lytic le-
sion in the right mandibular ramus with ex-
pansile remodeling of the cortex, extraosse-
ous extension, and no internal matrix. MRI
(Figs. 13C–13F) showed an expansile, en-
hancing, lobulated mass involving the right
mandibular ramus and right masticator space.
The mass had intermediate signal intensity
and mildly heterogeneous enhancement.
Conclusion—This patient had a remote his-
tory of Clark level III melanoma resected by
wide local excision from the right cheek. Biopsy
confirmed the lesion was metastatic melanoma.
In a study by Patten et al. [13], 17% of patients
with metastatic melanoma had osseous lesions.
Of these patients, 12% had osseous lesions as
the only sign of metastatic disease. Osseous
metastasis was found only in patients with mel-
anoma classified as Clark grade III or higher.
Metastasis of osseous melanoma is predomi-
nantly osteolytic and may consist of associat-
ed soft-tissue masses. Most cases of metastasis
involve the axial skeleton, commonly the spine
[13]. Although not found in this patient, meta-
static lesions of melanoma can have high signal
intensity on T1-weighted MR images, and this
feature is quite specific. Treatment in this case
entailed excision of the right mandibular ramus
and posterior condyle and right parotidectomy.
Infectious Processes
Scenario 1
Clinical history—A 38-year-old man pre-
sented with fever, facial swelling, and ten-
derness. Examination at presentation re-
vealed inflammatory changes involving the
right lower lateral teeth and purulent gingi-
val discharge (Fig. 14A).
Imaging findings—Axial CT images (Figs.
14B–14D) showed foci of air in crescentic
subfascial fluid collections. Associated in-
flammatory changes were appreciated as
stranding in the subcutaneous and intermus-
cular regions and skin thickening.
Conclusion—The diagnosis was necrotiz-
ing fasciitis, a rapidly progressive and often
fatal infection of the fascia. That there are no
natural barriers to the spread of this type of in-
fection allows its rapid spread and fulminant
clinical course. Necrotizing fasciitis is most
commonly caused by a polymicrobial infec-
tion with both aerobic and anaerobic organ-
isms. Approximately 10% of cases are caused
by group A streptococci, the so-called flesh-
eating bacteria [14]. The clinical presentation

A B C

D E F
Fig. 13—77-year-old man with several-month history of jaw aching.
A and B, Coronal (A) and axial (B) CT images show large lytic lesion (arrows) in right mandibular ramus with expansile cortical remodeling and extraosseous extension.
No internal matrix is present.
C–F, Axial T1-weighted (C), FLAIR (D), contrast-enhanced fat-saturated T1-weighted (E), and fast spin-echo T2-weighted (F) MR images show expansile enhancing
intermediate-signal-intensity lobulated mass (asterisk) involving right mandibular ramus and right masticator space.

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 Jaw Lesions

Fig. 14—38-year-old man with fever, facial swelling and tenderness as a result of necrotizing fasciitis.
A, Clinical photograph at presentation shows inflammatory changes involving right lower lateral teeth and
purulent gingival discharge (arrow).
B–D, Axial CT images show foci of air in crescentic subfascial fluid collections, associated inflammatory
changes in subcutaneous and intermuscular regions, and skin thickening.

B C D

is often nonspecific. Extreme pain followed by
anesthesia suggests the diagnosis. Patients also
may have systemic manifestations such as fe-
ver, malaise, and vague, localizing symptoms.
The classic findings are warm overlying skin
and indurated, so-called wooden, skin with
mottled purple patches [14]. However, the skin
may appear normal or resemble skin affected
by cellulitis. Many patients present with acute
renal failure, limiting use of contrast material.
Necrotizing fasciitis has a high mortality
rate of 30–70%, typically as a result of respi-
ratory, kidney, or multiorgan system failure
and sepsis. Radiographically, gas tracking
along the fascial planes in the absence of
penetrating trauma is almost pathognomonic
of necrotizing fasciitis, albeit not a sensitive
imaging finding. MRI is the most sensitive
imaging modality, showing fascial thicken-
ing with abnormal signal intensity and non-
enhancing areas. Fascial thickening almost
always involves both superficial and deep
fascia. In early necrotizing fasciitis, however,
only the superficial fascia may be involved,
as in cellulitis. It is important to understand
that necrotizing fasciitis is a clinical, not a
radiologic, diagnosis. The main indication
for imaging is to aid surgical planning. If
there is clinical concern about necrotizing
fasciitis, surgical treatment should not be de-
layed to perform imaging.
Treatment entails prompt surgical fascioto-
my and débridement with postoperative inten-
sive care. Broad-spectrum antibiotic coverage
should be initiated until the causative organ-
isms are identified. Hyperbaric oxygen therapy
may reduce mortality. In this case, drainage of
the abscess in the right temporal space was fol-
lowed by multiple débridements and removal
of the fascia. The involved teeth were removed,
and wound vacuum-assisted closure was used
to aid in formation of granulation tissue.
Scenario 2
Clinical history—A 73-year-old man with
diabetes presented with persistent right-sid-
ed jaw pain, which he had experienced since
the extraction of two right posterior mandib-
ular teeth (teeth 29 and 30) 6 months earlier.
He had poor healing and repeated visits be-
cause of pain. Mandibular CT was performed
with Panorex reconstruction. After CT, three-
phase bone scintigraphy was performed.
Imaging findings—The Panorex recon-
struction of a mandibular CT scan (Fig.
15A) revealed destruction of the supe-
rior cortex of the right mandibular body
with associated sclerosis. Gas was evident
in the soft tissues immediately superior
to this region. Axial (Figs. 15B and 15C)
and collimated coronal (Fig. 15D) CT im-
ages showed lytic destructive changes in
the right mandibular body with a lamel-
lated periosteal reaction. Changes in the
associated soft tissues, including inflam-
mation and gas, also were found. A three-
phase bone scan (Figs. 15E–15H) showed
increased radiotracer uptake in the right
mandibular ramus in all three phases.
Conclusion—The diagnosis was osteo-
myelitis, which is rare in persons with nor-
mal immune function because they typical-
ly undergo early treatment with antibiotics.
Possible causes of mandibular osteomyelitis
include direct extension of pulpal infection,
acute exacerbation of a periapical lesion,
and a surgical procedure or penetrating
trauma [15]. Associated soft-tissue abnor-
malities (including haziness or obliteration
of the fat planes) help differentiate infection
from neoplasia, which typically sharply dis-
torts fat planes.
The earliest radiographic osseous change
is indistinctness of the cortex, but this
change generally is not evident on radio-
graphs for 1–2 weeks after the onset of in-
fection. Subsequent osseous changes include
permeative osseous destruction and perios-
teal reaction. Sequestra, representing foci of
necrotic bone, are more typically associated
with chronic osteomyelitis and are well vi-
sualized at CT. The sequestra typically con-
tain bacteria and serve as a source of chronic

AJR:197, September 2011 W419

 Meyer et al.

A B C

D E F

Fig. 15—73-year-old man with diabetes and

persistent right-sided jaw pain since extraction of
two right posterior mandibular teeth 6 months earlier.
Diagnosis is osteomyelitis.
A, Panorex reconstruction of mandibular CT scan
shows destruction of superior cortex (arrows) of right
mandibular body with associated sclerosis and gas.
B–D, Axial (B and C) and collimated coronal (D) CT
images show lytic destructive changes (asterisk, B)
of right mandibular body with lamellated periosteal
reaction (arrows, D).
E–H, Blood-flow (E), blood-pool (F), and delayed
anterior (G) and lateral (H) images from three-phase
bone scan show increased radiotracer uptake in right
mandibular ramus in all three phases.
G H

infection. Facial and mandibular radiogra-
phy is relatively insensitive for identification
of acute osteomyelitis. CT is more sensitive,
and contrast-enhanced MRI is much more
sensitive for early disease. T1-weighted MR
images show a confluent region of low signal
intensity, and fluid-sensitive images show in-
creased signal intensity in the bone and soft-
tissue abscess. Fluid-sensitive sequences are
overly sensitive for osteomyelitis, and the
images thus must be interpreted with the T1-
weighted findings. Contrast-enhanced MR
images reveal a rim of enhancement around
the abscess and within the bone. Nuclear
medicine studies used to evaluate for osteo-
myelitis primarily include three-phase bone
scintigraphy and a combined WBC scan.
Three-phase bone scans typically show in-
creased activity in all three phases if the pa-
tient has acute osteomyelitis [16].
Treatment of osteomyelitis depends on the
extent of involved bone; it generally includes
saucerization or resection. Saucerization is
decortication and removal of the involved
underlying bone and surrounding tissues.
Because of the location of osteomyelitis in
this patient, care was taken to preserve the
inferior alveolar nerve. The mandible was re-
constructed, and tobramycin antibiotic beads
were placed and removed in approximately
2–3 days.
Discussion
Pathologic conditions of the jaw are com-
mon, yet they are not frequently imaged or en-
countered by radiologists. It therefore is impor-
tant for radiologists to familiarize themselves
with jaw pathology to ensure appropriate pa-
tient care. There are a few important points

W420 AJR:197, September 2011


to keep in mind. Inferior alveolar nerve an-
esthesia is considered indicative of neopla-
sia until proved otherwise. When presented
with an isolated mandibular lesion, one must
maintain a high index of suspicion to diag-
nose metastatic disease. Finally, necrotizing
fasciitis is a clinical not a radiologic diagno-
sis, and the main indication for imaging is
to aid in surgical planning. Fascial thicken-
ing almost always involves both superficial
and deep fascia. In early necrotizing fasci-
itis, however, only the superficial fascia may
be involved, as in cellulitis.
Conclusion
Proper characterization of jaw abnormali-
ties is essential to ensure appropriate patient
care and reduce morbidity. Imaging plays a
key role in the characterization of a variety
of jaw lesions, and radiologists must be fa-
miliar with these imaging findings.
References
1. Dunfee BL, Sakai O, Pistey R, Gohel A. Radio-
logic and pathologic characteristics of benign and
malignant lesions of the mandible. RadioGraph-
F O R YO U R I N F O R M AT I O N
This article is available for CME credit. See www.arrs.org for more information.
AJR:197, September 2011
Jaw Lesions
ics 2006; 26:1751–1768
2. Scholl RJ, Kellett HM, Neumann DP, Lurie AG.
Cysts and cystic lesions of the mandible: clinical
and radiologic-histopathologic review. Radio-
Graphics 1999; 19:1107–1124
3. Palser F, Visser H. Pocket atlas of dental radiol-
ogy. New York, NY: Thieme, 2007:238–301
4. Bernaerts A, Vanhoenacker FM, Hintjens J, et al.
Tumor and tumor-like conditions of the jaw: radio-
lucent lesions. (review) JBR-BTR 2006; 89:81–90
5. Murphey MD, Choi JJ, Kransdorf MJ, et al. Imaging
of osteochondroma: variants and complications with
radiologic-pathologic correlation. RadioGraphics
2000; 20:1407–1434
6. Jerjes W, Banu B, Swinson B, Hopper C. Florid
cemento-osseous dysplasia in a young Indian
woman: a case report. Br Dent J 2005; 198:477–
478
7. Singer SR, Mupparapu M, Rinaggio J. Florid ce-
mento-osseous dysplasia and chronic diffuse os-
teomyelitis. J Am Dent Assoc 2005; 136:927–931
8. Bernaerts A, Vanhoenacker FM, Hintjens J, et al.
Tumor and tumor-like conditions of the jaw:
mixed and radiopaque lesions. (review) JBR-BTR
2006; 89:91–99
9. Kumar R, Madewell JE, Lindell MM, Swischuk
LE. Fibrous lesions of bones. RadioGraphics
1990; 10:237–256
10. Murphey MD, Nomikos GC, Flemming DJ, et al.
Imaging of giant cell tumor and giant cell repara-
tive granuloma of bone: radiologic-pathologic
correlation. RadioGraphics 2001; 21:1283–1309
11. Schwartz ML, Baredes S, Mignogna FV. Meta-
static disease to the mandible. Laryngoscope
1988; 98:270–273
12. Weissleder R, Wittenberg J, Harisinghani M,
Chen J. Primer of diagnostic imaging, 4th ed.
Philadelphia, PA: Mosby, 2007:441–442
13. Patten RM, Shuman WP, Teefey S. Metastases
from malignant melanoma to the axial skeleton: a
CT study of frequency and appearance. AJR 1990;
155:109–112
14. Fugitt JB, Puckett ML, Quigley MM, Kerr SM.
Necrotizing fasciitis. RadioGraphics 2004; 24:
1472–1476
15. Taori KB, et al. CT evaluation of mandibular os-
teomyelitis. Indian J Radiol Imaging 2005 15:
4:447–451
16. Love C, Din AS, Tomas MB, Kalapparambath
TP, Palestro CJ. Radionuclide bone imaging: an
illustrative review. RadioGraphics 2003; 23:341–
358
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