TUMORS OF THE MANDIBLE

PART I: GENERALITIES AND PRINCIPLES

REYNALDO O. JOSON, M.D.

TABLE OF CONTENTS
Introduction ......................... 1
Objectives ........................... 1
Recommended Preparation .............. 2
I. Anatomy ........................ 3
II. Functions ..................... 4
III. Origin of Mandibular Tumors .... 4
IV. Pathology of Mandibular Tumors . 5
V. Functional Classification ...... 9
VI. Clinical Evaluation ............10
A. Physical Examination
B. Radiography
C. Biopsy
VII. Treatment ......................13
VIII. Operative Procedures ...........14
A. Extirpative
B. Reconstructive
IX. To Whom To Refer ...............16
References ...........................17
Post-test ............................19
Answers to Post-test .................24
Recommended Follow-up ................26
About the Author .....................26
Primary intended
medicine.

users -

Students of

Estimated study time - One hour.

REYNALDO O. JOSON, M.D.
April, 1992

INTRODUCTION
A
series of
self-instructional
programs has been designed to cover all
aspects in the management of patients
with mandibular tumors. This program is
the first part in the series.
It
discusses
the
generalities
and
principles related to diagnosis
and
treatment of mandibular tumors.
The
basic information given here provides
the
necessary
background
for
the
subsequent parts in the series.
OBJECTIVES
Upon completion of this program,
the user should be able to:
1. Identify the different parts of
the mandible.
2. Enumerate the functions of the
mandible.
3. List
the
elements
in
the
mandible which can be sources of tumor
formation.
4. Diagram a functional classification of mandibular tumors.
5. Compare the relative frequencies
between:
5.1 Benign and malignant mandibular tumors.
5.2 Benign odontogenic and nonodontogenic tumors.
5.3 Malignant odontogenic and
non-odontogenic tumors.
6. Name two diseases under each
category:
1

6.1
6.2

Benign odontogenic tumors.

Benign
non-odontogenic
tumors.
6.3 Malignant
non-odontogenic
tumors.
7. Identify two physical examination findings that will lead to the
suspicion of mandibular tumors.
8. List the two types of radiographic procedures that can be done to
study the mandible.
9. Interpret the more common radiographic findings of the mandible.
10. Name the indication for a biopsy
of mandibular tumors.
11. Choose the
proper treatment,
whether operative or non-operative, for
a particular patient with a mandibular
tumor.
12. Indicate
to
whom to
refer
patients with mandibular tumors needing
operative treatment.
13. Choose the proper extirpative
procedure for a particular mandibular
tumor.
14. List the two goals of a reconstructive procedure on the mandible.
15. Enumerate
the two types
of
materials
that
can
be
used
to
reconstruct a mandibular defect.

RECOMMENDED PREPARATION
A basic knowledge of anatomy and
pathology is necessary for the user to
obtain
maximum
benefit
from
this
program.
2

I. ANATOMY OF THE MANDIBLE

A knowledge of the anatomy of the
mandible is needed in the following
situations:
1. During
communication
among
physicians
2. In making a physical diagnosis
3. In
making
a
radiologic
diagnosis
4. In making an intraoperative
diagnosis
5. During treatment
The parts of
illustrated below:

the

mandible

are

II. FUNCTIONS OF THE MANDIBLE

A knowledge of the functions of the
mandible
is needed during
surgical
treatment,
particularly
in
the
reconstructive
part.
The
mandible
contributes to the contour of the face
and
it
has
important
masticatory
functions.
Hence, the aims of
any
reconstructive procedure on the mandible
should be restoration and maintenance of
these two functions.

III. ORIGIN OF MANDIBULAR TUMORS

There are three elements in the
mandible that can be sources or origins
of
mandibular tumors.
These
three
elements are the following:
1. The bone itself
2. The tooth
3. The
soft tissue intimately
adherent to the mandible, in particular,
the gingival mucosa
Tumors arising from the teeth
called odontogenic tumors.

are

Tumors arising from the bone itself

are called non-odontogenic mandibular
tumors or simply, non-odontogenic tumors.
Tumors arising from the gingival
mucosa are called gingival tumors of the
mandible.
Strictly speaking, gingival
tumors are also non-odontogenic tumors.
4

However,
in medical parlance,
nonodontogenic
tumors refer to
tumors
arising from the mandibular bone itself.

IV. PATHOLOGY OF MANDIBULAR TUMORS

Mandibular tumors are
generally
classified into odontogenic and nonodontogenic tumors. Under each category
are myriads of pathologies. Tables 1 to
3
contain some classifications
and
enumerations of the different mandibular
tumors.
The more common benign odontogenic
tumors are the radicular cysts, the
dentigerous
cysts,
and
the
ameloblastomas.
The
more
common
benign
nonodontogenic tumors are exostosis
or
osteoma and ossifying fibroma.
The more common
odontogenic tumors are
chondrosarcoma.

malignant
nonosteosarcoma and

Table 1. Cysts of the Mandible

---------------------------------------Epithelial Cysts
I. Odontogenic
A. Developmental
1. Gingival cysts of infants
(dental lamina cyst, Epstein's pearls,
Bohn's nodules)
2. Gingival cysts of adults
3. Lateral periodontal cyst
4. Dentigerous
(follicular)
cyst
5. Odontogenic
keratocyst:
nevoid basal cell carcinoma syndrome
6. Calcifying odontogenic cyst
B. Inflammatory
1. Radicular cyst
2. Residual cyst
3. Inflammatory
lateral
periodontal cyst
4. Paradental cyst
II. Non-odontogenic (fissural)
A. Nasopalatine
duct
(incisive
canal) cyst
B. Median
palatine and
median
mandibular cysts
C. Nasolabial (naso-alveolar) cyst
Non-epithelial cyst
I. Traumatic
bone cyst (simple,
unicameral, solitary, hemorrhagic bone
cyst)
II. Aneurysmal bone cyst
---------------------------------------Source: Modified after Shear M: Cysts of
the
Oral Regions,
2nd ed. Boston:
Wright-PSG, 1983, p.3.

Table

2. Classification of Odontogenic
Tumors
---------------------------------------Epithelial Odontogenic Tumors
Minimal
inductive
change
in
connective tissue
1. Ameloblastoma
2. Adenomatoid
odontogenic
tumor
3. Calcifying
epithelial
odontogenic tumor
Marked
inductive
change
in
connective tissue
1. Ameloblastic fibroma
2. Ameloblastic fibrosarcoma
3. Complex odontoma
4. Compound odontoma
Mesodermal Odontogenic Tumors
1. Myxoma
2. Odontogenic fibroma
3. Cementoma
a. Periapical
cemental
dysplasia
b. Benign cementoblastoma
c. Cementifying fibroma
d. Familial
multiple
(gigantiform) cementomas
---------------------------------------Source:
Based on classification
of
Pindborg and Clausen; modified by Gorlin
RJ, Goldman HM (eds): Thoma's
Oral
Pathology, 6th ed. St. Louis: The C.V.
Mosby Co., 1970.

Table 3. Non-odontogenic Tumors

---------------------------------------Benign Bone-forming Tumors
Osteoma
Ossifying fibroma
Osteoblastoma
Osteoid osteoma
Malignant Bone-forming Tumors
Osteosarcoma
Malignant Cartilaginous Tumors
Chondrosarcoma
Tumors of Fibrous Connective
Origin
Desmoplastic fibroma
Fibrosarcoma

Tissue

Tumors
of
Histiocytic
Fibrohistiocytic Origin
Malignant fibrous histiocytoma
Histiocytosis X

and

Giant Cell and Fibro-osseous Lesions

Central giant cell granuloma
Aneurysmal bone cyst
Cherubism
Fibrous dysplasia
Tumors and Tumor-like Conditions
of
Blood Vessels Arising in the Skeletal
System
Hemangioma of bone
Miscellaneous
Ewing's sarcoma
Primary
salivary
gland
within bone
Primary lymphoma of bone
Burkitt's lymphoma
8

tumors

V.

FUNCTIONAL
CLASSIFICATIONS
MANDIBULAR TUMORS

OF

Mandibular tumors can be classified

into
whether
they are
benign
or
malignant.
Between the two,
benign
tumors are more common.
Benign mandibular tumors can be
odontogenic or non-odontogenic. Between
the two, odontogenic tumors are more
common.
Benign mandibular tumors may be
congenital, developmental,
traumatic,
inflammatory, endocrinologic, metabolic,
and neoplastic in etiology.
Malignant mandibular tumors
can
also be odontogenic or non-odontogenic.
Between the two, non-odontogenic tumors
are more common.
Malignant non-odontogenic
tumors
can
be primary or secondary.
The
primary tumors include the osteosarcomas
and the chondrosarcomas. The secondary
tumors include those due to metastasis
from a distant source and those due to
an invasion from a nearby cancer, such
as an oral cancer.

Table 4. Functional Classification of

Mandibular Tumors
---------------------------------------Benign
Odontogenic
Non-odontogenic
Malignant
Odontogenic
Non-odontogenic
Primary
Secondary

VI. CLINICAL EVALUATION

The
mandibular
following:

clinical
evaluation
tumors relies mainly on

of
the

1. Physical examination
2. Radiography
3. Biopsy

A. PHYSICAL EXAMINATION
The physical examination is the
first examination that will suggest that
a tumor on the face is mandibular in
origin.
A physician seeing a tumor in the
lower jaw area should right away think
of a possible mandibular tumor.
Upon
palpation, if the consistency is bony
hard, the said physician should all the
more suspect a mandibular tumor.
10

B. RADIOGRAPHY
To confirm the mandibular origin of
the tumor, radiography should be done.
There are two types of radiography that
can be done on the mandible. One is the
panorex
or panoramic view of
the
mandible.
The
other
is
the
anteroposterior
and
lateral-oblique
views of the mandible. Each type of
radiography is as good as the other with
all its inherent limitations.
Beside confirming the mandibular
origin of the tumor through the presence
of
some
abnormal changes
in
the
mandible, the radiograph can also give
suggestions as to the possible type of
tumor
based
on
the
radiographic
findings.
The tumor on X-rays may be radioopaque or radiolucent. Some tumors are
characteristically radio-opaque
while
some are radiolucent.
The tumor may be a unilocular or
multilocular radiolucency. It may be a
unilocular radiolucency located at the
apex of a tooth, in which case, a
radicular cyst is suspected. It may be
a radiolucency at the crown of
an
impacted
tooth, in which
case,
a
dentigerous cyst is suspected. It may
be a multilocular radiolucency
with
soap-bubble
appearance
without
any
definite relation to the teeth, in which
case, an ameloblastoma is suspected.

11

The radiograph may show reparative

changes suggestive of an inflammatory
lesion.
It
may
show
sequestrum
suggestive of osteomyelitis.
The
radiograph may show
lytic
changes suggestive of a malignancy.
It
may show sun-burst appearance suggestive
of osteosarcoma.
Lastly, the radiograph may show
findings suggestive of an
endocrine
abnormality such as hyperparathyroidism.
In short, based on the radiographic
findings, a more specific diagnosis of
the mandibular tumor may be attempted.
C. BIOPSY
If after the radiography a more
definitive diagnosis is needed before a
decision on the treatment will be made,
a section biopsy of the mandibular tumor
can be done. This procedure entails
getting a sample of the tumor and then
examining it under the microscope.

12

VII. TREATMENT OF MANDIBULAR TUMORS

After clinical evaluation comes the
treatment.
Treatment is either operative or
non-operative.
Majority
of
the
mandibular tumors will need an operative
treatment. Only a few will need a nonoperative treatment. Examples of the
latter are mandibular tumors secondary
to an endocrine abnormality such as
hyperparathyroidism, in which case
the
treatment
is directed
towards
the
parathyroid
abnormality.
Another
example is exostosis or osteoma,which
may be left alone unless it is big and
causing a cosmetic problem.
The
type of treatment
to
be
instituted, whether operative or nonoperative, will depend on a lot of
factors.
Some of these factors are
listed below:
1. Diagnosis of the mandibular
tumor, especially in terms of whether it
is a surgical disease or not.
2. Problems being caused by
the mandibular tumor such as
pain,
facial
deformity,
and
masticatory
dysfunction, in which case an operative
treatment may be a remedy.
3. Resectability of the tumor.
4. Consent of the patient.
5. Concomitant
medical
conditions that may contraindicate the
performance of an operation.
13

VIII. OPERATIVE PROCEDURES

The essential operative procedure
for mandibular tumor is removal of the
tumor.
A reconstructive procedure may
be done if indicated.
A. EXTIRPATIVE
Extirpation or removal of the tumor
may be in the following forms:
1.
2.
3.
4.

Currettage
Excision
Marginal mandibulectomy
Segmental mandibulectomy

The form of tumor extirpation that

will be done is determined mainly by the
diagnosis and the extent of the tumor.
For an osteomyelitis not involving the
full-thickness
of the
mandible,
a
currettage is done. For radicular and
dentigerous cysts and exostosis,
an
excision is done. For a tumor involving
the full-thickness of the mandible, a
segmental mandibulectomy has to be done.
A marginal mandibulectomy is done for
tumors involving the alveolar processes
and
the
superior portion
of
the
mandible.
A marginal
mandibulectomy
will leave the inferior portion of the
mandible with no loss in the continuity
of the bone.

14

For malignant tumors and benign

tumors with a track record of having
recurrences
after
currettage
and
excision, a wide excision is done.
A
wide
excision
has at
least
onecentimeter
margin
of
normal
bone
included in the resection. Marginal and
segmental
mandibulectomies are
wide
excisional procedures.
B. RECONSTRUCTIVE
Among
the different
forms
of
extirpative procedures of
mandibular
tumor, only the segmental mandibulectomy
will
end up with a break in
the
continuity of the mandible. Thus, after
a
segmental
mandibulectomy,
a
reconstructive procedure is always a
consideration.
The defect in the continuity of the
mandible can be bridged by a bone graft,
prosthesis, or a combination of both. A
bone graft can be an autograft or an
allograft, the former coming from the
patient himself and the latter coming
from another person. The bone graft can
be cancellous or cortical. It can be a
free
graft, a pedicled
myo-osseous
graft, or a graft with microvascular
reconstruction.
The common sources of
bone grafts are the ribs, the iliac
bones, and the clavicles.
Prostheses can come in the form of
a Kirchner wire, a metallic plate, or a
metallic tray.

15

After reconstructing the mandibular

defect, a dental prosthesis is usually
needed.
The
aims
of
a
mandibular
reconstruction are to restore and to
maintain the facial contour and the
masticatory functions. These objectives
are
best
achieved by
a
combined
mandibular reconstruction and a dental
prosthesis.

IX. TO WHOM TO REFER

All
patients
with
mandibular
tumors, needing definitive management
and
operative treatment, should
be
referred
to
surgeons
with
subspecialization
in head and
neck
surgery.
The dental prosthesis may be
fitted by an orthodontist.

16

REFERENCES
1. Browne GA: Odontogenic
tumors and
tumors of the bone. In McQuarrie DG,
Adams GL, Shons AR, Browne GA (eds):
Head
and
Neck
Cancer.
Clinical
Decisions and Management
Principles.
Chicago: Year Book Medical Publishers,
Inc. 1986, p. 334-346.
2. Ellis
E
III:
Management
of
odontogenic
cysts and
tumors.
In
Thawley
SE,
Panje
WR
(eds):
Comprehensive Management of Head and
Neck
Tumors.
Philadelphia:
W.B.
Saunders, Co. 1987, p. 1446-1483.
3. Gorlin RJ: Odontogenic tumors.
In
Gorlin RJ, Goldman HM (eds): Thoma's
Oral Pathology, 6th ed. St. Louis: The
C.V. Mosby Co., 1970.
4. Greer RO Jr, Rohrer MD, Young SK:
Clinical evaluation and pathology. Nonodontogenic tumors.
In Thawley
SE,
Panje WR (eds): Comprehensive Management
of Head and Neck Tumors.
Philadelphia:
W.B. Saunders, Co. 1987, p. 1510-1559.
5. Lawson W, Loscalzo LJ, Baek S, Biller
HF, Krespi YP: Experience with immediate
and delayed mandibular reconstruction.
Laryngoscope 1982, 92:5-10.
6. Lore JM Jr: An Atlas of Head and Neck
Surgery, 3rd ed. Philadelphia:
W.B.
Saunders, Co. 1988, p. 562-601.
17

7. McDaniel RK: Clinical evaluation and

pathology.
Odontogenic cysts and tumors.
In Thawley SE, Panje WR (eds):
Comprehensive Management of Head and
Neck Tumors.
Philadelphia: W.B.Saunders, Co. 1987, p. 1446-1483.
8. Pindborg JJ, Clausen F: Classification of odontogenic tumors; suggestion.
Acta Odont Scand
1958, 16:293.
9. Scott RF, Ellis E III:
Surgical
treatment of non-odontogenic tumors. In
Thawley
SE,
Panje
WR
(eds):
Comprehensive Management of Head and
Neck
Tumors.
Philadelphia:
W.B.
Saunders Co. 1987, p. 1559-1577.
10. Shear M: Cysts of the Oral Regions,
2nd ed. Boston: Wright-PSG, 1983, p.3.

18

TUMORS OF THE MANDIBLE

PART I: GENERALITIES AND PRINCIPLES

POST-TEST
DIRECTION: Identify the different
of the mandible by filling in the
in the blanks provided.

19

parts
names

DIRECTION: Below is a skeletal diagram

of a functional classification of the
pathology of mandibular tumors
with
clues provided at each level. Fill in
the appropriate names in the blanks
provided.
Clues
Cancer or not

Mandibular Tumors
8.........l 9...........
l
Origin of tumor 10.......l 12.........
11.......l 13.........
Types of cancer
l
based on origin
l
14........
l
15........
DIRECTION:
Match
the
radiographic
findings on the mandible in Column A
with the interpretations in Column B.
Place the appropriate letter in the
blanks provided.
Column A
---16. Sunburst
appearance
---17. Unilocular
radiolucency
at apex of
tooth
---18. Soap-bubble
appearance
---19. Lytic
changes
---20. Radiolucency
at crown of
an impacted
tooth
---21. Reparative
changes
---22. Sequestrum
20

Column B
A. Malignant tumor
B. Ameloblastoma
C. Dentigerous
cyst
D. Radicular cyst
E. Osteosarcoma
F. Inflammatory
lesion
G. Osteomyelitis

DIRECTION: Match the type of treatment

needed
for a particular
mandibular
tumor. Place the appropriate letter in
the blanks provided.
___23.
___24.
___25.
___26.
___27.
___28.
___29.

Ameloblastoma
A. Operative
Small osteoma
B. Non-operative
Huge osteoma
Radicular cyst
Dentigerous cyst
Osteosarcoma
Chondrosarcoma

DIRECTION: Match the proper extirpative

procedure for a particular mandibular
tumor.
___30.
___31.
___32.
___33.

Osteomyelitis
Radicular cyst
Dentigerous cyst
Gingival cancer
(1 cm.)
___34. Osteosarcoma
___35. Chondrosarcoma
___36. Huge ameloblastoma

A. Currettage
B. Excision
C. Marginal
mandibulectomy
D. Segmental
mandibulectomy

DIRECTION:
Compare
the
relative
frequency of the following mandibular
tumors. Place the appropriate letter in
the blanks provided using the key below:
A
B

if
if

___37. A.
B.
___38. A.
B.
___39. A.
B.

A is more common
B is more common
Benign tumors
Malignant tumors
Benign odontogenic tumors
Benign non-odontogenic tumors
Malignant odontogenic tumors
Malignant
non-odontogenic
tumors
21

DIRECTION:
answers.

Supply

the

40-41. Enumerate the two

the mandible.
40.
41.

appropriate
functions

of

42-44. List the elements in the mandible

which can be sources of tumor
formation.
42.
43.
44.
45-50. Name
two diseases under each
category.
Benign odontogenic tumors
45.
46.
Benign non-odontogenic tumors
47.
48.
Malignant non-odontogenic tumors
49.
50.
51-52. Identify two physical examination
findings that will lead
to a
suspicion of mandibular tumor.
51.
52.
53-54. List two
that can
mandible.
53.
54.

radiographic procedures
be done to study the

22

55.

Name the indication for a biopsy

of a mandibular tumor.
55.

56.

Indicate to whom should patients

with mandibular tumors
needing
operative treatment be referred.
56.

57-58. List the two goals of a reconstructive

procedure
on
the
mandible.
57.
58.
59-60. Enumerate
the
materials that
to
reconstruct
defect.
59.
60.

23

two
can
a

types
of
be
used
mandibular

TUMORS OF THE MANDIBLE

PART I: GENERALITIES AND PRINCIPLES
ANSWERS TO POST-TEST
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.

Condyloid process
Coronoid process
Ascending ramus
Alveolar processes or ridges
Mentum
Body
Angle of the mandible
Benign
Malignant
Odontogenic or non-odontogenic
Non-odontogenic or odontogenic
Odontogenic
Non-odontogenic
Primary
Secondary
E
D
B
A
C
F
G
A
B
A
A
A
A
A
A

24

31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.

B
B
C
D
D
D
A
A
B
Facial contour
Masticatory function
Bone
Tooth
Soft tissue (gingiva)
Dentigerous or radicular cyst
Ameloblastoma
Osteoma
Ossifying fibroma
Osteosarcoma
Chondrosarcoma
Inspection - tumor at lower jaw
area
Palpation - bony consistency of
the tumor
Panorex view
Anteroposterior
and
lateraloblique views
Need
for a more
definitive
diagnosis prior to a decision
on the treatment
Surgeons with a subspecialty in
head and neck surgery
Restoration of facial contour
Restoration
of
masticatory
function
Bone graft
Prosthesis

25

RECOMMENDED FOLLOW-UP
After
completing
this
selfinstructional
program, the user
is
advised to discuss this program with his
teachers as well as his peers.
He is
also strongly advised to proceed to Part
II, which presents illustrative cases.
If he
is interested and if he is a
surgeon or a surgeon-to-be,
he
can
proceed
to
Part III, which is on
surgical decision-making.

ABOUT THE AUTHOR

DR. REYNALDO O. JOSON is currently
an assistant professor at the University
of the Philippines College of Medicine.
He is a staff member of the Division of
Head and Neck, Breast, Esophagus, and
Soft Tissue Surgery of the Department of
Surgery
at the
Philippine
General
Hospital.

COPYRIGHT, 1992

26