Journal Pre-proof

Osteosarcoma of the Jaws: Report of 3 Cases with Emphasis on the

Early Clinical and Radiographic Signs

Scarlet Charmelo-Silva DDS , Allison Buchanan DMD, MS ,

Sajitha Kalathingal BDS, MS , Rafik Abdelsayed DDS, MS

PII: S2212-4403(21)00608-8
DOI: https://doi.org/10.1016/j.oooo.2021.09.001
Reference: OOOO 4717

To appear in: Oral Surg Oral Med Oral Pathol Oral Radiol

Received date: 18 December 2020

Revised date: 23 July 2021
Accepted date: 3 September 2021

Please cite this article as: Scarlet Charmelo-Silva DDS , Allison Buchanan DMD, MS ,
Sajitha Kalathingal BDS, MS , Rafik Abdelsayed DDS, MS , Osteosarcoma of the Jaws: Report
of 3 Cases with Emphasis on the Early Clinical and Radiographic Signs, Oral Surg Oral Med Oral
Pathol Oral Radiol (2021), doi: https://doi.org/10.1016/j.oooo.2021.09.001

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of
record. This version will undergo additional copyediting, typesetting and review before it is published
in its final form, but we are providing this version to give early visibility of the article. Please note that,
during the production process, errors may be discovered which could affect the content, and all legal
disclaimers that apply to the journal pertain.

© 2021 Published by Elsevier Inc.

 Title: Osteosarcoma of the Jaws: Report of 3 Cases with Emphasis on the Early Clinical and

Radiographic Signs

Authors: Scarlet Charmelo-Silva, DDS1

Allison Buchanan DMD, MS 2
Sajitha Kalathingal BDS, MS3
Rafik Abdelsayed DDS, MS4

1. Assistant Professor of Oral Medicine Department of Oral Biology & Diagnostic Sciences,
The Dental College of Georgia at Augusta University
2. Professor of Oral Radiology Department of Oral Biology & Diagnostic Sciences, The
Dental College of Georgia at Augusta University
3. Professor of Oral Radiology Department of Oral Biology & Diagnostic Sciences, The
Dental College of Georgia at Augusta University
4. Professor of Oral Pathology Department of Oral Biology & Diagnostic Sciences, The
Dental College of Georgia at Augusta University

Second author is corresponding author: Allison Buchanan DMD, MS

Address: The Dental College of Georgia at Augusta University
Department of Oral Biology & Diagnostic Sciences
GC 2254
1120 15th Street
Augusta, Georgia
30912-1241

Email: albuchanan1@augusta.edu
Phone: 706-721-2264
Fax: 706-721-4937

Statement of Clinical Relevance

This article reviews the early radiographic signs of osteosarcoma occurring in the interradicular

region. Early diagnosis of osteosarcoma of the jaws is paramount as it significantly improves the

treatment outcome for the patient.

Abstract

Osteosarcoma is the most common primary malignancy of the jaws and is treated by radical

surgical resection. Early detection is crucial since removing the lesion with clean margins

contributes most to outcome. We present three cases of osteosarcoma occurring in the

interradicular region of the mandible, two of which were thought to represent non-malignant
processes upon initial presentation. All three demonstrated early but significant clinical and

radiographic features indicative of the malignant disease process. Radiographically, all of these

cases had in common unilateral periodontal ligament (PDL) space widening, displacement of

teeth, and growth of the crestal bone. Clinically, all three cases presented with a painless

intraoral swelling. Case 1: A 20 year old African American male presented with a swelling and

loose teeth of 1.5 months duration. Histopathological diagnosis of osteoblastic osteosarcoma,

high grade was made. Case 2: A 75 year old Caucasian male presented with a 2 x 2 cm

expansile lesion of two months duration. Histopathological diagnosis

of chondroblastic osteosarcoma was made. Case 3: A 63 year old Caucasian female presented

with a 5-6 mm lesion for at least 1 month duration. Histopathological diagnosis

of chondroblastic osteosarcoma was made. All three cases were treated with wide surgical

resection.

Introduction

Osteosarcoma refers to an osteoid-producing malignancy of mesenchymal origin.1-3 It

accounts for approximately 20% of all bone cancers and has a predilection for the distal femoral

metaphysis, proximal tibia and humeral metaphysis. 2,4,5 Osteosarcoma occurs most frequently

during the second decade of life but there is a smaller peak of incidence after the age of 50.4-6
According to the World Health Organization, there are several variants of osteosarcoma

differentiated by their location, clinical behavior, and cytologic morphology.7 Primary

conventional osteosarcoma, which arises centrally within bone, is the most frequent type.

Osteosarcoma can be subdivided microscopically by cell morphology and type of predominant

matrix production. Of these subtypes osteoblastic, chondroblastic, and fibroblastic variants are

the most common.4 Secondary osteosarcoma arises from pre-existing conditions and has been

associated with Paget’s disease, radiation therapy, fibrous dysplasia, multiple

osteochondromatosis, and chronic osteomyelitis.1,4,8

Osteosarcoma of the craniofacial bones is a rare malignancy accounting for 7% of all

osteosarcomas.2,4,5,8 However, when osteosarcoma occurs in the craniofacial bones, the mandible

and maxilla are the most common sites of occurrence. In the jaws, osteosarcoma accounts for 8%

of all malignancies and is the most common primary malignancy of the jaws.3,9 Osteosarcoma of

the jaws is recognized as a variant of conventional osteosarcoma.2,4 This is because

osteosarcoma of the jaws has a clinical behavior and natural history distinct from osteosarcoma

of the trunk and long bones. 3,10,11 Jaw osteosarcomas usually affect patients 10–20 years older,

are less likely to give rise to distant metastases, and are associated with a better 5-year survival

rate.2,4,6,8,10-15 The mandibular body is most frequently involved, followed by the angle,

symphysis and ascending ramus.16 Maxillary tumors have been reported to show a predilection

for the posterior regions of the alveolar process and the maxillary sinus.5,16,17

Radiographic presentation of osteosarcomas includes osteolytic lesions, osteogenic

lesions, or mixed lytic and sclerotic lesions.3 An important radiographic feature is Garrington’s

sign, which is a symmetric widening of the PDL due to infiltration of tumor cells and is

commonly seen early in the disease process.6,8,9

 The purpose of this article is to: 1) present a series of three cases of osteosarcoma of the

mandible which demonstrated early but significant clinical and radiographic features and 2)

review the relevant literature.

Case Series

Case 1

Clinical presentation

A 20 year old African American male presented with a 1.5 month duration of an intraoral

swelling in the anterior mandible with loosening of his teeth (Figure 1). No pain or paresthesia

were present. The patient’s physician prescribed antibiotics, but the lesion failed to resolve.

Intraoral exam revealed a swelling extending from the mandibular left lateral incisor across the

midline to the mandibular right first premolar (Figure 1). The lesion was indurated, hyperemic

and involved both the buccal and lingual aspects (Figure 1). The mandibular right lateral incisor

was displaced lingually and the mandibular incisors had class I mobility (Figure 1). The

patient’s medical history was positive for asthma.

Radiographic and histopathologic findings

Panoramic and Cone beam computed tomography (CBCT) imaging exams were ordered.

The panoramic radiograph revealed displacement of the mandibular right lateral incisor with

unilateral widening of the periodontal ligament (PDL) space. Unilateral widening of the PDL

space was present on the mandibular right canine as well. The interradicular bone between these

teeth had a patchy sclerotic appearance and growth of the crestal bone was evident. The
periapical bone was radiolucent. Figure 1 demonstrates the panoramic imaging findings. The

CBCT exam revealed a patchy sclerotic bone overgrowth between the mandibular right lateral

incisor and canine (Figure 2). Interestingly, despite some interruption, the adjacent facial plate

appeared relatively normal in contour (Figure 2). A surgical biopsy was performed. The surgical

specimen was decalcified before tissue processing. Formalin-fixed, hematoxylin and stained

decalcified sections revealed a cellular mesenchymal tissue proliferation intermixed with

neoplastic osteoid production (Figure 2A and B). The cellular proliferation is characterized by

pleomorphic polygonal and occasionally spindled cells with round and ovoid hyperchromatic

nuclei, some of which exhibited atypical mitotic figures (Figure 2B). The cellular elements

were intermixed with prominent lacy and diffuse eosinophilic osteoid matrix exhibiting variable

degrees of mineralization. A diagnosis of osteoblastic osteosarcoma, high grade was made. The

patient underwent resection of his mandible from the mandibular right first molar to the

mandibular left first molar.

Case 2

Clinical presentation

A 75 year old Caucasian male presented with a 2 x 2 cm asymptomatic, fixed and expansile

lesion in the left anterior mandible. The patient reported that he noticed a painless mass on his

gum two months prior. The patient sought out care by his dentist. The medical history was
positive for coronary artery disease, hypertension, skin cancer (3 lesions of unknown type), a 57

year history of smoking ½ pack/day, and the use of smokeless tobacco for 30 years.

Radiographic and histopathologic findings

A conventional panoramic radiograph, CBCT, and multidetector computed tomography (MDCT)

imaging were acquired. The panoramic radiograph revealed very similar findings as that of case

1. The lesion presented with hyperdense, osteosclerotic crestal bone overgrowth between the

mandibular left canine and lateral incisor. There was unilateral widening of the PDL space on

these teeth and the left lateral incisor was displaced (Figure 3). In addition to the radiographic

findings from the panoramic radiograph, the CBCT exam revealed that the patchy sclerotic bone

pattern extended beyond the facial plate and that the lesion extended from the mandibular left

canine to the midline (Figure 4). Interestingly, despite the spread of the tumor beyond the facial

plate, in general, the alveolar bone maintained an overall normal contour (Figure 3). In cross

sections, the patchy sclerotic bone pattern displayed a “sunburst” pattern (Figure 3). The MDCT

exam consisted of multidetector helical scanning in the axial projection at 2.5 mm slice thickness

and pitch of 0.52 mm acquired post administration of contrast (Omnipaque 350). Bone and soft

tissue density windows were available. The MDCT imaging confirmed the less aggressive nature

of the histopathological diagnosis (see below) through the absence of lymphadenopathy, the

absence of any notable spread into the mandibular body, and the absence of an adjacent soft

tissue component (Figure 4). The patient’s dentist referred him to ENT for a biopsy. The

surgical specimen was decalcified before tissue processing. Microscopic examination of the

decalcified hematoxylin and eosin stained sections revealed a lobular growth with predominantly

chondroid mesenchymal tissue proliferation as well as osteoid matrix production. The

mesenchymal neoplastic lobular proliferation is characterized by prominent hyaline cartilage-like

matrix supporting numerous mononuclear and multinucleated cellular lacunae, which contained

cells with hyperchromatic and pleomorphic nuclei and atypical mitotic figures. These areas

alternated with diffuse eosinophilic osteoid trabeculae interspersed by cellular mesenchymal

tissue with prominent osteoblasts exhibiting hyperchromatic nuclei (Figure 4). A diagnosis of

chondroblastic osteosarcoma was made. The patient was treated with resection from the left first

molar to the right second premolar.

Case 3

Clinical presentation

A 63 year old Caucasian female presented with a 5-6 mm asymptomatic pink, red and raised

ulcerated firm lesion in the interproximal gingiva between the mandibular left premolars for at

least 1 month. The patient's medical history was essentially unremarkable except for

hyperlipidemia for which she was on medications. She denied smoking or any other use of

substances. Clinically, the lesion was thought to be benign and a differential diagnosis of

pyogenic granuloma versus peripheral giant cell tumor was formed.

Radiographic and histopathologic findings

An intraoral and panoramic radiograph as well as MDCT were acquired. On the conventional 2-

dimensional radiographs, there was unilateral PDL space widening along the mandibular left first

and second premolars (Figure 5). Spacing of the mandibular premolars was present and there

was growth of the crestal bone (Figure 5). Changes in the interradicular bone pattern were
minimal and difficult to appreciate on 2-dimensional imaging. The MDCT exam consisted of

multidetector helical scanning in the axial projection at 2.5 mm slice thickness and pitch of 0.4

mm. Bone and soft tissue density algorithms were available. Contrast was not administered. A

thin bone series was available as well with a slice thickness of 0.7 mm. The MDCT imaging

confirmed that little bone growth was present and only minimal changes in the bony contour at

the level of the ridge crest existed (Figures 5 and 6). Since only minimal bony changes were

visible, the radiographic findings that were characteristic of osteosarcoma were better visualized

on the axial CT images and the custom cross sections created from the thin CT bone series

(Figures 5 and 6). The patient was referred to a local oral surgeon who surgically removed the

gingival nodule and submitted the specimen for histopathological evaluation. Histologic

examination of the formalin-fixed and hematoxylin and eosin-stained sections revealed a

gingival nodule covered by ulcerated squamous epithelium and supported a cellular myxoid

mesenchymal tissue proliferation with chondroid and osteoid matrix production. The cellular

mesenchymal proliferation was non-encapsulated and composed of numerous spindle-shaped,

haphazardly arranged spindled mesenchymal cells with elongated and ovoid hyperchromatic and

pleomorphic nuclei, some of which exhibited mitotic figures. These are embedded in abundant

ground substance, which imparted a myxoid appearance, focally interspersed by chondroid and

osteoid matrix (Figure 6). A diagnosis of chondroblastic osteosarcoma was made. The patient

was treated with segmental resection from the midline to the left molar region and is currently in

the reconstruction phase of treatment.

Discussion
 The reported three cases shared early radiographic and clinical features of osteosarcoma

occurring in an interradicular location without significant involvement of the mandibular body.

Early diagnosis of osteosarcoma is extremely important as it can significantly improve treatment

outcome. While chemotherapy prior to surgery is the treatment of choice for osteosarcomas of

the long bones, this treatment option is controversial for osteosarcomas of the jaws.2,3,11,14,15 This

is perhaps due to their differences in behavior. Osteosarcomas of the jaws, unlike osteosarcomas

of the long bones, have decreased incidence of distant metastasis.8,11,12,14,15 In a study of 214

cases of jaw osteosarcomas, Baumhoer et al reported a 17.6% incidence of metastases.14 In

contrast, osteosarcomas of the peripheral skeleton result in lung metastases in up to 90% of

patients.14 Therefore, osteosarcomas of the jaws, relative to osteosarcomas of the long bones,

have a better prognosis.12 In a study by ElKordy and colleagues only 1 out of 21 cases of

osteosarcomas of the jaws had distant metastases at presentation.12 Consequently, the mainstay

of therapy for osteosarcomas of the jaws is radical resection.2,3,10-12,14 Bertin and colleagues

report an overall survival rate of 77% (at 5 years) after complete resection of local disease.2 The

ability to remove the lesion with clean margins has the biggest effect on outcome for

osteosarcomas of the jaws.3,11,14,15,18 Granowski-LeCornu et al. reported a significant association

between clean margins and improved survival with a 70% increase in survival for every 1 cm

increase in margin width.15 Therefore, it is of utmost importance to be aware of the initial

radiographic and clinical changes that can aid in the detection of osteosarcoma at an earlier stage.

Radiographically, all of these cases had in common unilateral PDL space widening,

displacement of teeth, and growth of the crestal bone. Symmetric widening of the PDL space has

been reported as an early radiographic sign associated with osteosarcoma of the jaws.6,8

Garrington et al. reported that in some cases osteosarcomas can show symmetric widening of the
PDL space before displaying any other prominent radiographic findings.10 The widening of the

PDL space is the result of tumor infiltration.6 In the case of osteosarcoma occurring in an

interradicular location, PDL infiltration is the route of least resistance and therefore it is a

common early radiographic finding. In fact, in a case series reported by Garrington et al, for the

few patients with osteosarcoma of the mandible that did not present with swelling, the most

common presenting symptom was loose teeth and; therefore, they considered this to be an

important initial indicator of osteosarcoma of the mandible.10

Two of our three cases demonstrated a change in the interradicular bone pattern that

presented as sclerotic in nature. Changes in the interradicular bone pattern were not easily

identifiable on two dimensional imaging for case #3. Additionally, although osteophytic bone

production was demonstrated on CT for all three cases, only one of them (case #2) produced the

classic “sunburst” pattern. These findings suggest that tooth displacement and PDL space

widening may precede obvious radiographic changes in bone pattern and emphasizes the

importance of these radiographic findings in the identification of osteosarcoma, occurring in an

interradicular location, in its early stages.

Despite prominent tumor growth in cases 1 and 2 the overall contour of the alveolar bone

was relatively normal, particularly the buccal and lingual portions. This radiographic finding is

indicative of the infiltrative nature of osteosarcoma and is an important radiographic finding

associated with malignancy. A similar finding of malignant tumor infiltration without affecting

the morphology of the alveolar process was reported by Buchanan et al 2015. In this case the

malignancy was non-Hodgkin lymphoma, none the less, this radiographic finding demonstrates

the infiltrative nature of malignant neoplasms.

 Pathologically, 2 of our reported 3 cases are of the chondroblastic osteosarcoma type.

This is consistent with the reported preponderance of the chondroblastic type in craniofacial

osteosarcomas, particularly the mandible and maxilla when contrasted with the long bones.

Chondroblastic osteosarcoma is a subtype, characterized by the prominent production of

chondroid matrix or hyaline cartilage in addition to osteoid or bone matrix.19

On clinical presentation, all three of our cases presented with swelling but no pain. This

is in contrast to osteosarcoma of other bones that commonly presents with pain.10 Indeed

however, the most common clinical sign associated with osteosarcoma of the jaws is

swelling.6,8,11,12,15 In a case series reported by Fernandes and colleagues their incidence of

swelling was 100% in 14 cases of osteosarcoma of the jaws.6 In contrast, only 2 of their 14 cases

presented with pain.6 In another series, Garrington and colleagues reported swelling in 50 out of

54 cases of jaw osteosarcomas while pain was reported for only 23.10 Similarly, Granowski-

LeCornu and colleagues reported swelling in 74.5% and pain in 31.9% of 47 cases of

osteosarcomas of the jaws.15 Therefore, swelling without pain is a common clinical presentation

of osteosarcoma of the jaws.

The growth rate of osteosarcoma is usually rapid.10 Two of our cases reported a 1.5-2

month duration of intraoral swelling and the third case reported that the swelling was present for

at least 1 month. In a case series of 17 jaw osteosarcomas, Ogunlewe et al. reported an average

duration of symptoms of 6.1 months.5 Although the duration of symptoms can vary from 2 to 18

months, a history of intraoral swelling with rapid growth and the absence of pain can be

important clinical indicators of osteosarcoma of the jaws.5

There was a wide age distribution at initial disease presentation in the currently reported

three cases. One of the patients was young (age 20) while the other two patients were ages 75
and 63. The mean age of occurrence for osteosarcomas of the jaws has been reported to range

from 30-43 years.2,3,10-12,14 Nevertheless, and similar to our findings, Garrington et. al reported a

wide age range for osteosarcomas occurring in the mandible (age range 4-64 years) and found

that occurrence was just as likely in the elderly population as in the younger population.10

Paparella and colleagues also found that the occurrence rate of mandibular osteosarcomas was

similar throughout life.3 The fact that osteosarcomas of the mandible can occur over a wide age

range only further emphasizes the importance of the radiographic and clinical findings that aid in

early detection.

We have reported on 3 cases of osteosarcoma occurring in an interradicular location

within the mandible, each of which presented with important early radiographic and clinical

indicators of this disease process. The radiographic findings included unilateral PDL space

widening, displacement of teeth, and growth of the crestal bone. The clinical findings included a

painless intraoral swelling with a history of rapid growth. Since the ability to remove the lesion

with clean margins has the biggest effect on outcome for osteosarcomas of the jaws, early

detection is key for these patients.3,11,14,15,18 The importance of close radiographic inspection

along with clinical correlation cannot be stressed enough in their importance in the detection of

osteosarcoma occurring in an interradicular location.

Credit author statement

Allison Buchanan: Conceptualization, figures, writing-original draft preparation,

supervision; Scarlet Charmelo-Silva: Writing- Original draft preparation, references,
reviewing. Rafik Abdelsayed: figures, writing-original draft preparation, Writing-
Reviewing and Editing, supervision; Sajitha Kalathingal: Writing- Reviewing and
Editing, Validation, Supervision.
Declaration of Competing Interest

None

No financial support was received from any external source or vendor for this project.

References

1. Lindsey BA, Markel JE, Kleinerman ES. Osteosarcoma Overview. Rheumatology and therapy.

2017;4(1):25-43.

2. Bertin H, Gomez-Brouchet A, Rédini F. Osteosarcoma of the jaws: An overview of the

pathophysiological mechanisms. Critical reviews in oncology/hematology. 2020;156:103126.

3. Paparella ML, Olvi LG, Brandizzi D, Keszler A, Santini-Araujo E, Cabrini RL. Osteosarcoma of the

jaw: an analysis of a series of 74 cases. Histopathology. 2013;63(4):551-557.

4. Bennett JH, Thomas G, Evans AW, Speight PM. Osteosarcoma of the jaws: A 30-year

retrospective review. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and

Endodontology. 2000;90(3):323-333.

5. Ogunlewe MO, Ajayi OF, Adeyemo WL, Ladeinde AL, James O. Osteogenic sarcoma of the jaw

bones: A single institution experience over a 21-year period. Oral Surgery, Oral Medicine, Oral

Pathology, Oral Radiology, and Endodontology. 2006;101(1):76-81.

6. Fernandes R, Nikitakis NG, Pazoki A, Ord RA. Osteogenic Sarcoma of the Jaw: A 10-Year

Experience. Journal of Oral and Maxillofacial Surgery. 2007;65(7):1286-1291.

7. WHO Classification of Tumours Editorial Board. WHO Classification of Tumours of Soft Tissue and

Bone. Vol 3. 5th ed. Lyon, France: IARC Press; 2020.

8. Malik F, Gleysteen JP, Agarwal S. Osteosarcoma of the jaw: report of 3 cases (including the rare

epithelioid variant) with review of literature. Oral Surgery, Oral Medicine, Oral Pathology and

Oral Radiology. 2020.

9. Buchanan A, Kalathingal S, Capes J, Kurago Z. Unusual presentation of extranodal diffuse large B-

cell lymphoma in the head and neck: description of a case with emphasis on radiographic

features and review of the literature. In. Vol 44. London2015:20140288.

10. Garrington GE, Scofield HH, Cornyn J, Hooker SP. Osteosarcoma of the jaws. Analysis of 56 cases.

Cancer. 1967;20(3):377-391.

11. Lee RJ, Arshi A, Schwartz HC, Christensen RE. Characteristics and Prognostic Factors of

Osteosarcoma of the Jaws: A Retrospective Cohort Study. JAMA Otolaryngology–Head & Neck

Surgery. 2015;141(5):470-477.

12. ElKordy MA, ElBaradie TS, ElSebai HI, Amin AAE, KhairAlla SM. Osteosarcoma of the jaw:

Challenges in the diagnosis and treatment. Journal of the Egyptian National Cancer Institute.

2018;30(1):7-11.

13. Demicco EG, Deshpande V, Nielsen GP, Kattapuram SV, Rosenberg AE. Well-differentiated

osteosarcoma of the jaw bones: a clinicopathologic study of 15 cases. The American journal of

surgical pathology. 2010;34(11):1647-1655.

14. Baumhoer D, Brunner P, Eppenberger-Castori S, Smida J, Nathrath M, Jundt G. Osteosarcomas

of the jaws differ from their peripheral counterparts and require a distinct treatment approach.

Experiences from the DOESAK Registry. Oral oncology. 2014;50(2):147-153.

15. Granowski-LeCornu M, Chuang S-K, Kaban LB, August M. Osteosarcoma of the jaws: factors

influencing prognosis. Journal of oral and maxillofacial surgery. 2011;69(9):2368-2375.

16. Mardinger O, Givol N, Talmi YP, Taicher S. Osteosarcoma of the jaw. The Chaim Sheba Medical

Center experience. Oral surgery, oral medicine, oral pathology, oral radiology and endodontics.

2001;91(4):445-451.

17. Doval DC, Kumar RV, Kannan V, et al. Osteosarcoma of the jaw bones. British journal of oral and

maxillofacial surgery. 1997;35(5):357-362.

18. Ginat D, Schulte J, Gooi Z, Cipriani N. High-Grade Conventional Osteosarcoma of the Mandible

Associated With P53 Germline Mutation. The journal of craniofacial surgery. 2018;29(3):738-

740.

19. Mamachan P, Dang V, Bharadwaj NS, DeSilva N, Kant P. Chondroblastic osteosarcoma—A case

report and review of literature. Clinical Case Reports. 2020;8(11):2097-2102.

Figure 1. Intraoral photographs and conventional panoramic radiograph.
Figure 2. CBCT and photomicrographs. The CBCT cross sections are through the interradicular
region of the mandibular right lateral incisor and canine. The photomicrographs show cellular
mesenchymal proliferation with prominent eosinophilic osteoid deposition and foci of
calcification (A) and cellular proliferation of highly atypical cells with pleomorphic
hyperchromatic nuclei and abnormal mitosis (B).
Figure 3: Panoramic radiograph and CBCT cross sections. The cross sections are through the
interradicular region of the mandibular left canine and lateral incisor. Note the sunburst pattern
of bone growth.
Figure 4. Top row: MDCT axial slices of soft tissue (a) and bone windows (b-d) with contrast.
Bottom row: photomicrographs (A-B). The MDCT images demonstrate the prominent hard
tissue component of the tumor and lack of an adjacent soft tissue component. MDCT slices a and
b are at the same level. MDCT slices b-d progress inferiorly. Photomicrographs show
mesenchymal proliferation with prominent basophilic cartilaginous matrix as well as bone and
osteoid deposition with foci of calcification (A). Prominent nodular proliferation of hyaline
cartilage-like matrix with uni- and multi-cellular chondrocytic lacunae covered by a cellular cap
(B). A high-resolution version of this slide for use with the Virtual Microscope is available as eSlide:
VM06346
Figure 5: Panoramic radiograph (A), MDCT thin bone series (B), and periapical radiograph (C).
The MDCT cross sections are through the interradicular region of the mandibular left premolars.
Note the minimal growth at the alveolar crest. The infiltration of the PDL space of the first
premolar is visible in the pan, the first cross section of the thin bone series (B), and the periapical
radiograph.
Figure 6: Top row: MDCT axial slices of soft tissue (a) and bone windows (b-d) without
contrast. Bottom Row: Photomicrographs (A-B). The MDCT slices a and b are at the same level.
MDCT slices b-d progress inferiorly. Note the minimal bone changes at the alveolar crest,
infiltration of the PDL space of the mandibular left first premolar, and displacement of the
mandibular left premolars. The photomicrographs show non-encapsulated cellular mesenchymal
proliferation with prominent cartilaginous matrix and eosinophilic osteoid deposits with foci of
calcification (A). Localized areas showing hypercellularity in myxoid stroma with atypical
pleomorphic spindle-shaped cells with elongated hyperchromatic and pleomorphic nuclei and
atypical mitotic figures (B). Atypical mitotic figure (arrow). A high-resolution version of this slide
for use with the Virtual Microscope is available as eSlide: VM06345