RADIOGRAPHIC

INTERPRETATION OF
TUMORS OF THE JAWS

drg. SHANTY CHAIRANI, M.Si.

TUMORS OF THE JAW

1. Benign tumor : a new uncoordinated growth

that generally has the following
characteristics : slowly growing and spread
by direct extension and not by metastases
2. Malignant tumor : an uncontrolled growth of
tissue, which compare to benign neoplasms,
they are more locally invasive, have a
greater degree of cellular anaplasia, and
have the ability to metastasize regionally to
lymph nodes or distantly to other sites
BENIGN TUMORS OF
THE JAWS
Radiographic Features
1. LOCATION
 Many tumors have a specific anatomic
predilection  to establish the differential
diagnosis.
2. PERIPHERY AND SHAPE
 Benign tumors enlarge slowly by formation of
additional internal tissue  the radiographic
borders appear relatively smooth, well defined,
and sometimes corticated.
3. INTERNAL STRUCTURE
 The internal structure may be completely
radiolucent or radiopaque or may be a mixture of
radiolucent and radiopaque tissues.
 If the lesion contains radiopaque elements, these
structures usually represent either residual bone
or a calcified material that is being produced by
the tumor.
4. EFFECTS ON SURROUNDING
STRUCTURES
 A benign tumor exerts pressure on neighboring
structures, resulting in the displacement of teeth
or bony cortices.
 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 and may have a convex or a
lobulated outline
 The internal aspect is homogeneously radiopaque
 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
 Sharply demarcated anteriorly and are less dense
and less well defined as they extend posteriorly
 It’s homogeneously radiopaque
 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 with a
curved border, and rounded radiopaque masses.
 Some may have poorly defined borders.
 Usually homogenous radiopaque
ODONTOGENIC TUMOR
 AMELOBLASTOMA
 Synonyms : Adamantinoma,
adamantoblastoma, adontomes
embryolastiques, and epithelial odontoma
 A slowly growing, locally invasive
epithelial odontogenic tumor of the jaws
with a high rate of recurrence if not
removed adequately, but with virtually no
tendency to metastasize
 AMELOBLASTOMA
 Clinical Features:
 Wide age range, mostly between 20-50 years.
 80-95% in the mandible (posterior body, ramus
region). In the maxilla mostly in the premolar-
molar region.
 Usually it slowly grows as painless swelling of the
affected site, gradually increasing facial
asymmetry
 As the tumor enlarges, palpation may elicit a bony
hard sensation or crepitus as the bone thins.
 Locally invasion into the surrounding bone.
 Incomplete removal can result in recurrence.
 Radiographic Features:
 Develop in the molar-ramus region of the
mandible, may extend to the symphyseal
area. In the maxilla, it occurs in the third
molar area and extend into the maxillary
sinus and nasal floor
 Well defined and frequently delineated by a
curved cortical border
 The internal structure varies from totally
radiolucent to mixed with the presence of
bony septa creating internal compartments
 exhibit a multilocular "soap bubble" or
“honey comb” appearance
 Radiographic Features:
 Effects on Surrounding Structures.
 Extensive root resorption
 Tooth displacement
 Bone expansion and thinning of an adjacent
cortical plate leaving a thin “ eggshell ” of
bone.
 Differential Diagnosis
 Dentigerous cyst  if small and unicystic
 Odontogenic myxoma
 Odontogenic keratocyst
 Central giant cell granuloma
 Ossifying fibroma
 CALCIFYING EPITHELIAL
ODONTOGENIC TUMOR (CEOT)
 Also known as Pindborg Tumor
 A locally invasive epithelial odontogenic
neoplasm, characterised by the presence of
amyloid material that may become calcified.
 Clinical Features:
 2nd to 10th decade of life with a mean age of 40
 Jaw expansion
 Palpation of the swelling reveals a hard tumor.
 Radiographic Features:
 Most develop in the premolar-molar area,
often association with an unerupted or
impacted tooth.
 The border may have a well defined cortex
and some may be irregular and ill defined.
 The internal aspect may appear unilocular
or multilocular with numerous scattered,
radiopaque foci of varying size and
density.
 May displace a developing tooth or prevent
its eruption.
 Cortical bone expansion
 Differential diagnosis
 Dentigerous cysts
 Ameloblastoma
 Adenomatoid odontogenic tumor
 Ameloblastic fibro-odontoma
 Calcifying odontogenic cys
 ADENOMATOID ODONTOGENIC
TUMOR (AOT)
 Synonyms : Adenoameloblastoma and
ameloblastic adenomatoid tumor
 A tumor composed of odontogenic epithelium
in a variety of histoarchitectural patterns,
embedded in a mature connective tissue
stroma and characterized by slow but
progressive growth
 Clinical Features:
 Relatively rare.
 Occurs during the second decade of life, commonly 14
to 15 years of age
 Females affected more often
 The tumor is slow growing and presents as a gradually
enlarging, painless swelling or asymmetry, often
associated with a missing tooth
 Radiographic Features:
 Most occur in the maxilla, especially in the
cuspid region
 A well-defined corticated or sclerotic
border
 Some tumors are totally radiolucent;
others show evidence of internal
classification.
 Radiolucency usually extends apically
beyond the cementoenamel junction
 Adjacent teeth may be displaced, but rarely
resorbed
 May inhibit eruption of an involved tooth.
 ODONTOMA
 Synonyms : Compound odontoma,
compound composite odontoma, complex
odontoma, complex composite odontoma,
odontogenic hamartoma, calcified mixed
odontoma, and cystic odontoma
 A tumor that is radiographically and
histologically characterized by the
production of mature enamel, dentin,
cementum, and pulp tissue
 Two basic types
 Complex : a tumour like malformation
(harmatoma) in which enamel and dentin, and
sometimes cementum, is present
 Compound : a tumour like malformation
(harmatoma) with varying numbers of tooth- like
elements (odontoids)
 Clinical Features:
 Most in first and second decade
 Asymptomatic swelling
 Failure of tooth eruption
Radiographic Features
 The borders of odontomas are well defined and
may be smooth or irregular. These lesions have a
cortical border, and immediately inside and
adjacent to the cortical border is a soft tissue
capsule.
 Interfere with the normal eruption of teeth
 Pathologic changes of adjacent teeth such as
impaction, malpositioning, diastema, aplasia and
malformation are associated with 70% of
odontoma
 COMPOUND ODONTOMA
 Radiographic Features:
 Usually occur in the incisor-canine area of the
maxilla.
 Usually unilocular
 Contains multiple (2 to 30) structures that resemble
miniature teeth
 COMPLEX ODONTOMA
 Radiographic Features:
 Usually in the mandibular first and second molar area
 Solid unilocular radiopaque mass surrounded by a thin
radiolucent zone
 Tooth-like structures are absent
 AMELOBLASTIC FIBROMA
 Synonyms : Soft odontoma, soft mixed
odontoma, mixed odontogenic tumor,
fibroadamantoblastoma, and granular cell
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
 A painless, slow-growing expansion and displacement
of the involved teeth
 Often associated with an unerupted tooth.
 Radiographic Features:
 Usually develop in the premolar-molar area of the
mandible
 The borders are well defined and often corticated
 Usually unilocular (totally radiolucent) but may be
multilocular with indistinct curved septa
 The associated tooth or teeth may be inhibited from
normal eruption or may be displaced in an apical
direction.
 Large lesions cause buccal/lingual expansion with
an intact cortical plate.
 AMELOBLASTIC FIBRO-
ODONTOMA
 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
 Slow developing swelling of the jaw
 Usually no pain
 Radiographic Features:
 Usually occur in the posterior aspect of the
mandible. The epicenter of the lesion is usually
occlusal to a developing tooth or toward the
alveolar crest
 Usually well defined and sometimes corticated
 The internal structure is mixed, with the majority
of the lesion being radiolucent.
 Small lesions may appear as enlarged follicles
with only one or two small discrete radiopacities.
 Larger lesions may have a more extensive
calcified internal structure.
 Most often associated with impacted tooth
 ODONTOGENIC MYXOMA
 Synonyms : Myxoma, myxofibroma, and
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
 Frequently associated with congenitally missing
or unerupted tooth
 High rate of recurrences
 Radiographic Features:
 More common in mandible, in the premolar and
molar areas. In the maxilla usually involve the
alveolar process in the premolar and molar
regions and the zygomatic process.
 May well-defined with corticated margin but most
often is poorly defined, especially in the maxilla.
 Small lesions may be unilocular but typically
multilocular (internal septa- strings of a tennis
racket or honeycomb appearance).
 Adjacent teeth can be displaced but rarely
resorbed.
 It frequently scallops between the roots of
adjacent teeth
 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
 Pain, swelling, and expansion of the cortical plates
 Continuous with root, which resorbed
 Pulp vitality unrelated
 Radiographic Features:
 Often in mandible, in first premolar to molar
region, attached in apex of a tooth root
 Well-defined radiopacity with a cortical border and
then a well-defined radiolucent band just inside
the cortical border
 Mixed radiolucent-radiopaque lesions where the
majority of the internal structure is radiopaque
 External root resorption
 If large enough, this tumor can cause expansion of
the mandible but with an intact outer cortex
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
 Asymmetry caused by a bony hard swelling on the
jaw
 Often associated with Gardner syndrome
 Radiographic Features:
 Usually on the mandible, most frequenly on the
posterior lingual surface of the ramus and the
inferior border below the molars.
 The mandibular lesion may be exophytic,
extending outward into adjacent soft tissue
spaces.
 Radiopaque mass with well defined borders within
a paranasal sinus or associated with the mandible.
 Osteomas composed solely of compact bone are
uniformly radiopaque; those containing
cancellous bone show evidence of internal
trabecular structure
 Large lesions can displace adjacent soft tissues,
such as muscles, and cause dysfunction
 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 :
 Often in mandible, in the posterior body and
ramus and within the inferior alveolar canal. Some
cases, the periphery is well defined and corticated,
and in other cases it may be ill defined and even
simulate the appearance of a malignant tumor
 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.
 The mandibular and mental foramen may 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 2nd and 3rd decades of live, with
average age is 17 years
 More often in males

 Painful or tender, diameter 2-12 cm

 Radiographic Features:
 Often in posterior mandibular, commonly around
the temporomandibular joint
 The borders may be diffuse or may show some
sign of a cortex
 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
 Thickening of the outer cortex by stimulating
periosteal new bone
 formation.
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 so-
called “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
 EWING’S 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: Hodgkin’s Lymphoma and
Non- Hodgkin’s 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)
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