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Imaging Characteristics of Benign, Malignant, and Infectious Jaw

Lesions: A Pictorial Review


Journal Reading

Windy Aprilicia

Preceptor : dr. Dessy Wimelda, Sp.Rad

Department of Radiology, Mayo Clinic in Florida, 4500


San Pablo Rd, Jacksonville, FL 3224. Address correspondence to K. A.
Meyer
OBJECTIF
The purpose of this article is to describe the indications and
appropriate imaging studies for various jaw tumors and tumorlike
lesions, the imaging findings, the differential diagnosis, and appropriate
treatment options.
BENIGN LESIONS
Clinical history
30-year-old woman with a lesion in the left mandible had findings on a
Panorex image that prompted CT for further evaluation.
D, Photograph of gross specimen shows breakthrough of
ameloblastoma on lingual side.

A, Panorex image shows large ly tic lesion (arrows) in


lef t mandible.

B and C, Coronal (B) and axial (C) CT images through


mandible reveal show multilobulated ly tic lesion
(asterisk) in posterior lef t mandible with expansile E, Specimen radiograph shows findings corresponding to D.
remodeling, scalloped borders, and cor tical thinning.
Conclusion
The patient had ameloblastoma, which is a locally invasive, benign
neoplasm arising from enamel-forming cells the odontogenic
epithelium that do not regress during embryonic development .This
lesion typically presents in the third to fifth decades of life.
47-year-old man with ameloblastoma of maxilla.

A, Sagit tal T1-weighted MR image shows B and C, A xial fast spin-echo T2-weighted MR images
heterogeneously low-intensit y lesion (asterisk) in show multiloculated heterogeneously hyperintense
right maxillary sinus largely isointense to skeletal lesion (asterisk) and expansile remodeling of sinus
muscle. walls
Scenario 2
Clinical history
34-year-old man underwent a routine dental examination that included
a Panorex image.
3 4-year-old man with follicular cyst. Panorex image shows
radiolucent, well-defined, ovoid lesion (arrows) adjacent to crown of Drawing shows development odontogenic cysts. 1 =
unerupted right third molar and associated mandibular cortical
thinning follicular cyst, 2 keratocyst, 3 = lateral periodontal
cyst
Conclusion
The diagnosis was follicu- lar cyst, also called dentigerous cyst.Follicular
cysts are slow growing and develop when fluid accumulates between
the follicu- lar epithelium and the crown of a developing or unerupted
tooth.
16-year-old girl with mandibular odontogenic keratocyst.

A, Panorex image shows large lucent lesion with scalloped B, Sagit tal T1-weighted MR image shows expansile lesion
border (arrows). (asterisk) with intermediate signal intensit y in posterior
mandible.
C.Sagit tal contrast-enhanced T1- weighted MR image shows
peripheral rimlike enhancement of lesion around third molar.

Fig. 6—Drawing shows inflammatory odontogenic cysts.


• 1 = apical radicular cyst,
• 2 = lateral radicular cyst,
• 3= residual radicular cyst
D, A xial conventional T2-weighted MR image shows
inhomogeneously hyperintense expansile lesion (asterisk) with areas • 4 = paradental cyst.
of low signal intensit y in lef t posterior mandible.
Scenario 3
Clinical history
A 39-year-old man ar- rived in the emergency department with a 3-day
history of facial cellulitis
Panorex image shows two well-defined small B, A xial CT image through mandible shows one small
sclerotic foci (arrows) in periapical region of well-defined sclerotic focus (arrow ) with subtle
mandibular teeth marginal lucency that correlates with one sclerotic
focus in
Conclusion
The diagnosis was periapical cementoma, which is a periapical lesion in
the premolar or molar region of the mandible. 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.
Scenario 4
Clinical history
52-year-old woman presented with pain after a fall, and cervical spinal
radiographs were obtained.
Fig. 8— 52-year-old woman with
osteochondroma. A and B, Anteroposterior
(A) and oblique (B) collimated radiographs
show exophy tic lesion (arrow ) extending
from mandibular angle with cor tical and
medullary continuit y with 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.
Osteochondroma 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.
Scenario 5
Clinical history
64-year-old woman reported she had been told she had sclerot- ic
mandibular lesions that might represent a metabolic bone problem
6 4-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).
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. With time, the lesions
tend to become more dense. The lesions can be seen in multiple
quadrants in both the maxilla and mandible.
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.
Fig. 10 — 59-year-old man with giant cell tumor
and progressive lef t jaw discomfort and dif
ficult y chewing for 10 years. A xial CT image
through lef t mandibular condyle shows well-
defined ly tic lesion (asterisks) in condyle and
expansile remodeling and cor tical thinning.
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.
Malignant Lesions
Scenario 1
Clinical history
A 50-year-old man pre- sented with a 2-week history of left-sided jaw
pain and a several-month history of left low- er facial numbness and a
tingling sensation in the anterior aspect of the left side of the chin.
C, Coronal CT image near angle of mandible shows
ly tic lesion (asterisk).

A, Panorex image shows loss of superior cortical margin


(white arrow ) and associated subtle ly tic lesion (black
arrow ) in lef t mandibular angle.

B, Bone scans show focus of increased scintigraphic


activit y (arrows) in lef t mandibular angle. D, A xial CT image through mandible shows ly tic
lesion (asterisk).
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 mandible is rare,
presumably because of the paucity of red bone marrow, which is
thought necessary for malignant emboli to become lodged in bone.
When mandibular metastatic lesions occur, they most often are found
distal to the canines, typically involving the ramus of the mandible. This
corresponds to the dis- tribution of red bone marrow in the mandible.
Scenario 2
Clinical history
A 57-year-old man un- dergoing an annual radiographic metastatic
survey reported thoracic back pain.
A and B, Lateral skull radiograph (A) and
collimated
view (B) of mandible from skull radiograph
show multiple punched-out ly tic lesions
(arrows) in 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.
Scenario
Clinical history
77-year-old man had a several-month history of right jaw aching,
which he first noticed after yawning.
A and B, Coronal (A) and axial (B) CT images show large ly tic lesion (arrows) in right
mandibular ramus with expansile cortical remodeling and extraosseous extension. No
internal matrix is present.

C–F, A xial T1-weighted (C), FL AIR (D), contrast-enhanced fat-saturated T1-weighted E), and fast spin-echo T2-weighted (F) MR images show expansile
enhancing intermediate-signal-intensit y lobulated mass (asterisk)
involving right mandibular ramus and right masticator space.
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. 17% of patients
with metastatic melanoma had osseous lesions. Of these patients, 12%
had osseous lesions as the only sign of metastatic disease. .
Infectious Processes
Scenario 1
Clinical history
A 38-year-old man pre- sented with fever, facial swelling, and
tenderness.
A, Clinical photograph at presentation shows inflammatory
changes involving right lower lateral teeth and gingival
discharge (arrow A xial CT images show foci of air in crescentic subfascial
fluid collections, associated inflammatory changes in
subcutaneous and intermuscular 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 cois 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 urse. The clinical presentation
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.
A, Panorex reconstruction of mandibular CT scan shows destruction of E–H, Blood-flow (E), blood-pool (F), and delayed anterior (G)
superior cortex (arrows) of right mandibular body with associated and lateral (H) images from three-phase bone scan show
sclerosis and gas. B–D, A xial (B and C) and collimated coronal (D) CT
images show ly tic destructive changes (asterisk, B) of right mandibular increased radiotracer uptake in right mandibular ramus in all
body with lamellated periosteal reaction (arrows, D). 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.
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