# Malignant Diseases of the Jaws • Malignant lesions in the jaws share common imaging features: • **Destructive & Invasive/infiltrative (lytic and ill-defined)** • Malignancies that can affect the jaws are divided into four categories: • **Carcinomas** (lesions of epithelial origin) • **Sarcomas** (lesions of mesenchymal origin) • Malignancies of the **hematopoietic system** (lymphoma, leukemia, myeloma) • **Metastatic lesions** from distant sites Malignant lesions in the jaws share common imaging features: - Destructive & invasive/infiltrative (lytic and ill-defined) Malignancies that can affect the jaws are divided into four categories: 1. **Carcinomas** — lesions of epithelial origin 2. **Sarcomas** — lesions of mesenchymal origin 3. Malignancies of the **hematopoietic system** — lymphoma, leukemia, myeloma 4. **Metastatic lesions** from distant sites D E FIG. 23-1 Diagrammatic representation of radiologic features of oral malignancy. **A**, Ill-defined invasive borders followed by bone destruction. **B**, Destruction of the cortical boundary (floor of maxillary antrum) with an adjacent soft tissue mass (*arrows*). **C**, Tumor invasion along the periodontal membrane space causing irregular thickening of this space. **D**, Multifocal lesions located at root apices and in the papilla of a developing tooth destroying the crypt cortex and displacing the developing tooth in an occlusal direction (*arrow*). **E**, Four types of effects on cortical bone and periosteal reaction, from top to the bottom: cortical bone destruction without periosteal reaction, laminated periosteal reaction with destruction of the cortical bone and the new periosteal bone, destruction of cortical bone with periosteal reaction at the periphery forming Codman’s triangles, and a spiculated or sunray type of periosteal reaction. **F**, Bone destruction around existing teeth, producing an appearance of teeth floating in space.     *FIG. 23-1 Diagrammatic representation of radiologic features of oral malignancy.* - **A** — Ill-defined invasive borders followed by bone destruction. - **B** — Destruction of the cortical boundary (floor of maxillary antrum) with an adjacent soft tissue mass (*arrows*). - **C** — Tumor invasion along the periodontal membrane space causing irregular thickening of this space. - **D** — Multifocal lesions located at root apices and in the papilla of a developing tooth destroying the crypt cortex and displacing the developing tooth in an occlusal direction (*arrow*). - **E** — Four types of effects on cortical bone and periosteal reaction, from top to the bottom: cortical bone destruction without periosteal reaction, laminated periosteal reaction with destruction of the cortical bone and the new periosteal bone, destruction of cortical bone with periosteal reaction at the periphery forming Codman's triangles, and a spiculated or sunray type of periosteal reaction. - **F** — Bone destruction around existing teeth, producing an appearance of teeth floating in space. A labelled schematic diagram showing two teeth embedded in alveolar bone with an ill-defined, invasive border and destruction of the underlying trabecular structure. A schematic line drawing illustrating multifocal lesions located at root apices and in the papilla of a developing tooth. The diagram shows these lesions destroying the crypt cortex and displacing the developing tooth in an occlusal direction, as indicated by the white arrow. This diagram illustrates four types of effects on cortical bone and periosteal reaction, arranged vertically. From top to bottom, it depicts: cortical bone destruction without periosteal reaction; laminated periosteal reaction with destruction of the cortical bone and new periosteal bone; destruction of cortical bone with periosteal reaction at the periphery forming Codman's triangles; and a spiculated or sunray type of periosteal reaction. A schematic line drawing illustrating the radiologic sign of 'teeth floating in space.' It depicts a row of teeth with their roots fully exposed due to severe alveolar bone destruction, appearing suspended above a detached lower cortical plate. # Carcinomas * **Squamous Cell Carcinoma (SCC)** * **SCC of the Oral Mucosa** * The **most common** malignant tumour of the head and neck, originating from surface epithelium * **Primary Intraosseous SCC** * Arises within the jawbones and has no original connection with the surface epithelium of the oral mucosa (rare) * **SCC Originating in a Cyst** * The lining squamous epithelium of a **cyst** gives rise to the malignant neoplasm (rare) * Radiographic Features on Dental Imaging (PA, OPG & CBCT) * Ill-defined hypodensity “Moth eaten” * Destruction of adjacent cortical structures such as cortical plates, lamina dura and antral floors * Irregular PDL space widening of affected teeth. If extensive, the teeth appear “floating” * Irregular MC widening   #### Squamous Cell Carcinoma (SCC) - **SCC of the oral mucosa** — the **most common** malignant tumour of the head and neck, originating from surface epithelium - **Primary intraosseous SCC** — arises within the jawbones and has no original connection with the surface epithelium of the oral mucosa (rare) - **SCC originating in a cyst** — the lining squamous epithelium of a **cyst** gives rise to the malignant neoplasm (rare) #### Radiographic Features on Dental Imaging (PA, OPG & CBCT) - Ill-defined hypodensity — "moth eaten" - Destruction of adjacent cortical structures such as cortical plates, lamina dura and antral floors - Irregular PDL space widening of affected teeth; if extensive, the teeth appear "floating" - Irregular MC widening > [!note] Lecturer — Jaw Malignancy Overview > Jaw malignancies are uncommon but tend to be aggressive. Early detection is important because it significantly affects prognosis. > [!note] Lecturer — Clinical Features > Oral mucosal squamous cell carcinoma may present with several clinical features. > > - Ulceration > - A non-healing socket > - Pain > - Paresthesia > - Unexplained tooth mobility - ==Irregular widening or loss of the mandibular canal== - ==Soft tissue involvement== Radiograph: A cropped dental image (likely a periapical or panoramic view) showing an ill-defined hypodensity with a "moth-eaten" appearance, illustrating the destruction of adjacent cortical structures and irregular widening of the periodontal ligament space. Radiograph: This is an Orthopantomogram (OPG) or panoramic dental radiograph displaying the maxilla and mandible. It illustrates extensive pathology in the right posterior mandibular region, characterized by a large, ill-defined radiolucent area with a "moth-eaten" appearance and destruction of the cortical bone, consistent with the features of squamous cell carcinoma described on the slide. **FIG. 23-4** This primary intraosseous carcinoma in the left mandible exhibits no internal structure, a poorly defined periphery, and thinning of the overlying mandibular bone. **FIG. 23-5** Carcinoma arising in a preexisting dentigerous cyst related to the mandibular left third molar shows absence of a cyst cortex, invasion into adjacent bone, and ill-defined borders.   *FIG. 23-4* This primary intraosseous carcinoma in the left mandible exhibits no internal structure, a poorly defined periphery, and thinning of the overlying mandibular bone. *FIG. 23-5* Carcinoma arising in a preexisting dentigerous cyst related to the mandibular left third molar shows absence of a cyst cortex, invasion into adjacent bone, and ill-defined borders. Radiograph: A lateral jaw radiograph showing a large, ill-defined radiolucent area in the posterior mandible with no internal structure and thinning of the overlying bone. Radiograph: A dental X-ray of the posterior mandible showing an impacted third molar surrounded by a large, ill-defined radiolucent area that lacks a distinct cyst cortex and appears to invade the adjacent bone. Other *Rare* Carcinomas of the Jaws • **Central** Mucoepidermoid Carcinoma • Mucoepidermoid carcinoma is usually salivary gland malignancy. Central type is ***rare*** • Likely originates from pluripotential odontogenic epithelium or from a cyst lining. • Histologically indistinguishable from its soft tissue counterpart. • Radiographically, **unilocular or multilocular expansile** mass often well defined and well corticated (ddx. Ameloblastoma) • Teeth remain largely unaffected by this disease, although adjacent lamina dura may be lost. • Malignant Ameloblastoma, etc.   #### Central Mucoepidermoid Carcinoma - Mucoepidermoid carcinoma is usually a salivary gland malignancy; the central type is *rare* - Likely originates from pluripotential odontogenic epithelium or from a cyst lining - Histologically indistinguishable from its soft tissue counterpart - Radiographically, a **unilocular or multilocular expansile** mass, often well defined and well corticated (ddx: ameloblastoma) - Teeth remain largely unaffected by this disease, although adjacent lamina dura may be lost #### Other Rare Carcinomas - Malignant ameloblastoma, etc. > [!note] Lecturer — Diagnostic Difficulty > Central mucoepidermoid carcinoma can closely resemble a benign multilocular lesion such as ameloblastoma. > This similarity makes diagnosis difficult despite the lesion’s malignant behavior. Radiograph showing a multilocular radiolucency in the posterior mandible, characterized by a soap-bubble appearance. The lesion is located adjacent to molars with large restorations and extends inferiorly toward the lower border of the jaw. Radiograph: A cross-sectional dental imaging scan showing a multilocular radiolucency in the mandible. The lesion appears as a dark, expansile area with internal septations that displaces the inferior alveolar canal and erodes the superior crest of the alveolar process. Further Imaging Required * **MSCT** with IV contrast * **MRI** with Gad (soft tissue details, perineural spread & nodal metastasis, etc) * **PET/CT** for cancer staging * *Ultrasound* $\rightarrow$ *used for guided biopsy (lymph nodes in the neck)* - **MSCT** with IV contrast - **MRI** with Gad (soft tissue details, perineural spread & nodal metastasis, etc) - **PET/CT** for cancer staging - *Ultrasound* → used for guided biopsy (lymph nodes in the neck) > [!note] Lecturer — Further Assessment > Aggressive bony features on primary imaging require urgent referral to an oral and maxillofacial surgeon. > > - CT assesses bulk bony destruction, dental involvement, nodal involvement, contrast enhancement, biopsy, and staging; contrast helps define malignant tumor margins when they are difficult to identify without it. > - MRI provides superior assessment of marrow and soft tissue involvement, tumor size, deep-space and muscle invasion, perineural spread, and nodal metastasis. It is sensitive to early marrow invasion and soft tissue changes that may precede cortical damage and was described as the principal imaging method for staging. > - PET/CT evaluates distant metastasis, while bone scans can assess bone metastasis; PET/CT has higher sensitivity and specificity for bone metastasis than bone scans. > - Ultrasound is useful for assessing cervical lymph nodes and detecting nodal metastasis, as well as guiding biopsy.     Coronal computed tomography (CT) scan of the paranasal sinuses, displaying the maxillary sinuses, ethmoid air cells, and nasal cavity. This is a coronal computed tomography (CT) scan of the paranasal sinuses. The image displays the bony structures and air-filled cavities, including the maxillary, ethmoid, and frontal sinuses, as well as the nasal cavity. This axial CT scan of the facial bones demonstrates a large, heterogeneous soft-tissue mass occupying the left maxillary sinus. The lesion appears to cause expansion and erosion of the surrounding bony walls, including the medial wall and orbital floor. The image shows the cover of a textbook titled 'Atlas of Oral and Maxillofacial Radiology' by Bernard Koong, published by Wiley Blackwell. The design features a stylized, reddish-orange anatomical profile illustration of a human head against a teal background.    A grayscale sagittal CBCT (cone-beam computed tomography) scan of the anterior mandible. The image displays a cross-section of three teeth and their roots embedded in the alveolar bone, revealing significant vertical bone loss around the root surfaces. A grayscale cross-sectional medical image, likely a CT scan or radiograph, showing a vertical segment of bone containing a large, dark, ovoid radiolucent area within its structure. The bright white outer rim indicates cortical bone, while the central cavity suggests a lesion or anatomical void surrounded by soft tissue. The image is the front cover of a textbook titled 'Atlas of Oral and Maxillofacial Radiology' by Bernard Koong, published by Wiley Blackwell. It features a stylized graphic combining a lateral profile of a human skull with anatomical details like teeth and red muscular structures against a teal background. Sarcomas • **Osteosarcoma** • Osteoid is produced by the malignant stroma ie. Osteoblastic tumour • **Chondrosarcoma** • Sarcoma of cartilaginous origin • **Ewing’s Sarcoma** • Arise in the medullary bone and spread to the endosteal and periosteal surfaces • Fibrosarcoma, etc.   - **Osteosarcoma** - Osteoid is produced by the malignant stroma, i.e. osteoblastic tumour - **Chondrosarcoma** - Sarcoma of cartilaginous origin - **Ewing's Sarcoma** - Arise in the medullary bone and spread to the endosteal and periosteal surfaces - Fibrosarcoma, etc. > [!note] Lecturer — Sarcoma Overview > Sarcomas arise from connective tissues and are mesenchymal in origin. They tend to occur in younger patients than carcinomas. > > - Compared with carcinomas, sarcomas are destructive lesions that may also produce new bone formation. > - Carcinomas are more predominantly destructive and lytic, whereas sarcomas may show mixed-density appearances because of new bone production. Axial CT scan of the head showing a soft tissue mass in the left maxillary sinus and masticator space, indicated by white arrows. The lesion appears to cause expansion and erosion of the surrounding bony walls. This is a radiograph of a resected segment of the jaw, likely the mandible. It shows several teeth embedded in the bone, along with a prominent periosteal reaction where new bone formation appears as vertical striations (often described as a 'sunburst' pattern) extending from the surface of the jaw. Osteosarcoma of the Jaws • **Primary osteosarcoma:** typically occurs in young patients with 75% taking place before the age of 20 • **Secondary osteosarcoma:** occurs in the elderly, secondary to malignant degeneration of benign bone diseases eg. Paget disease, osteochondroma, etc • **Radiographic features:** • Expansile & destructive mass with ill-defined borders • Destruction of cortex • Internal “Cloud-like” opacities cotton balls • **Sunburst & spiculated periosteal reaction** • Enlarged neurovascular canals • MRI is used for local staging by assessing intraosseous tumour extension and soft tissue involvement. • Bone scans for distant sites   - **Primary osteosarcoma:** typically occurs in young patients, with 75% taking place before the age of 20 - **Secondary osteosarcoma:** occurs in the elderly, secondary to malignant degeneration of benign bone diseases, e.g. Paget disease, osteochondroma, etc #### Radiographic Features - Expansile & destructive mass with ill-defined borders - Destruction of cortex - Internal "cloud-like" opacities — cotton balls - **Sunburst & spiculated periosteal reaction** - Enlarged neurovascular canals #### Additional Imaging - MRI is used for local staging by assessing intraosseous tumour extension and soft tissue involvement. - Bone scans for distant sites - ==Mixed density caused by new bone formation== - ==Irregular periodontal ligament space widening== - ==Loss or destruction of the lamina dura== - ==Loss of the mandibular canal== > [!note] Lecturer — Osteosarcoma vs SCC > Osteosarcoma may show increased density because of new bone formation, whereas SCC more typically produces lucency or decreased density. Both can show invasive cortical destruction, irregular periodontal ligament widening, and loss of the lamina dura or mandibular canal. - ==MRI can detect early marrow invasion and soft tissue changes before cortical damage is visible on CT== - ==CT helps assess bony destruction, dental involvement, biopsy, and staging-related information== - ==PET CT has higher sensitivity and specificity than bone scans for bone metastasis== > [!note] Lecturer — Chondrosarcoma Imaging > Chondrosarcoma of the temporomandibular joint was described as extremely rare and involves cartilaginous tissue rather than only bone. Unlike osteosarcoma, it is predominantly lytic and may show ring-and-arc or popcorn calcification, with calcification around the borders of lytic lesions. Coronal CT scan of the facial bones showing a large, expansile mass in the left maxilla and zygoma region. The lesion contains dense, irregular internal opacities consistent with tumor bone formation (cloud-like/cotton-wool appearance) and causes significant destruction and expansion of the surrounding bony structures. Radiograph of a mandible showing an expansile, destructive mass with ill-defined borders and internal 'cloud-like' opacities. A prominent sunburst periosteal reaction is visible along the inferior border. B C  *B* *C* A cropped panoramic radiograph showing the posterior mandible with a region of increased bone density and irregularity in the first molar area. Two black arrows point to specific teeth where the periodontal ligament spaces appear widened. Chondrosarcoma - left condyle   Chondrosarcoma — left condyle Radiograph: Coronal CT scan of the mandible and temporomandibular joints showing a large, expansile lesion involving the left condyle with cortical thinning and internal calcifications. Axial CT scan of the facial skeleton demonstrating a large, expansile soft-tissue mass involving the left condyle and ramus of the mandible. The lesion is indicated by white arrows and shows areas of internal calcification or ossification, causing significant expansion and distortion of the normal bony architecture. A B FIG. 23-12 **A** and **B**, Coronal CT images with bone algorithm demonstrating Ewing’s sarcoma involving the left mandibular condyle; note the irregular margins, destruction of the medial cortex of the condyle, and a small pathologic fracture (arrow).  *A* *B* *FIG. 23-12 A and B, Coronal CT images with bone algorithm demonstrating Ewing's sarcoma involving the left mandibular condyle; note the irregular margins, destruction of the medial cortex of the condyle, and a small pathologic fracture (arrow).* > [!note] Lecturer — Ewing Sarcoma > Ewing's sarcoma was described as the second most common malignant primary bone tumor of childhood after osteosarcoma. It is closely related to Askin tumor and neuroepithelioma, which are collectively referred to as the Ewing sarcoma family of tumors. > > - Imaging may show predominantly lytic lesions, ill-defined margins, and variable periosteal reactions. > - Misdiagnosis is common because it can mimic osteomyelitis and other malignant non-sarcoma tumors. - ==Fibrosarcoma of the jaws was described as very rare== - ==Hematopoietic malignancies arise from blood-forming tissues and may present differently from other solid tumors.== Radiograph: A pair of coronal CT images with bone algorithm (labeled A and B) demonstrating the mandibular rami and condyles. Image A shows a black arrow pointing to an irregularity, destruction, and pathologic fracture of the left mandibular condyle. 2 LEFT  *2* *LEFT* Radiograph: A panoramic dental X-ray displaying the maxilla and mandible, showing significant destruction of the right maxillary sinus boundaries, zygomatic process, hard palate, and alveolar process consistent with a fibrosarcoma. High-grade Fibrosarcoma of the MD With Mets Fig. 7. Scintigraphy exhibiting metastases in articulations.     High-grade Fibrosarcoma of the MD with Mets *Fig. 7. Scintigraphy exhibiting metastases in articulations.* Radiograph: A close-up dental X-ray showing a row of teeth with radiopaque restorations (fillings) in the crowns. The image highlights the roots and surrounding alveolar bone, illustrating a mild radiolucent lesion involving the area of the right mandibular second premolar. Clinical photo: An intraoral view showing the upper and lower dental arches fitted with orthodontic braces (metal brackets and archwires). The teeth are retracted by lips, revealing the appliance on both the maxillary and mandibular teeth. Radiograph: A panoramic dental X-ray (orthopantomogram) showing the upper and lower jaws with teeth. The image displays a radiolucent area in the anterior mandible, consistent with the caption's description of an undefined lesion extending across the midline. The image displays two whole-body bone scintigraphy scans, labeled 'ANT' (anterior) and 'POST' (posterior), showing the skeletal structure with areas of increased radiotracer uptake. These hot spots are visible in the skull, ribs, pelvis, and notably at the distal ends of the long bones in the legs (ankles/feet), indicating metastatic activity. # Hematopoietic Malignancies • Multiple Myeloma • Most common adult primary malignant bone cancer • Classic radiographic feature: multiple ‘punched-out’ lytic lesions • Lymphoma • **Non-Hodgkin** (most lymphomas involving the jaws) >>>> Hodgkin • Lytic, destructive & invasive/infiltrative • Leukemia • ALL (most common leukemia in children), AML, CLL, CML - **Multiple Myeloma** - Most common adult primary malignant bone cancer - Classic radiographic feature: multiple 'punched-out' lytic lesions - **Lymphoma** - Non-Hodgkin (most lymphomas involving the jaws) >>>> Hodgkin - Lytic, destructive & invasive/infiltrative - **Leukemia** - ALL (most common leukemia in children), AML, CLL, CML Atlas of Oral and Maxillofacial Radiology BERNARD KOONG WILEY Blackwell    *Atlas of Oral and Maxillofacial Radiology — Bernard Koong — Wiley Blackwell* Radiograph: A composite image showing a panoramic dental radiograph at the top and two cross-sectional CT slices below, illustrating the position of an impacted tooth relative to the maxillary sinus. A panoramic dental radiograph (orthopantomogram) showing the maxilla and mandible, including the full dentition with multiple restorations and impacted third molars. The temporomandibular joints are visible at the far left and right edges of the image. The image displays a medical illustration of a human head in profile, featuring a sagittal cutaway view that reveals the underlying skeletal and soft tissue structures of the oral and maxillofacial region.   Radiograph: An axial cross-sectional computed tomography (CT) scan of the maxilla, displaying the dental arch and surrounding bone structure. A prominent hyperdense object is visible in the right anterior region, consistent with a metallic restoration or artifact. A dental radiograph (X-ray) showing the posterior teeth in a quadrant. Visible structures include upper and lower molars with distinct roots, as well as a bright white metallic restoration or crown on one of the lower teeth. Metastatic Lesions in the Jaws • Metastatic tumours represent the establishment of new malignant disease from a distant malignant tumour • Common primary sites include the breast, kidney, lung, prostate, thyroid, stomach • Radiographic Features: • **Sclerotic (breast & prostate mets) or** • **Lytic (renal & thyroid mets)** • Multiple foci • Most are ill-defined  - Metastatic tumours represent the establishment of new malignant disease from a distant malignant tumour. - Common primary sites include the breast, kidney, lung, prostate, thyroid, stomach. #### Radiographic Features - Sclerotic (breast & prostate mets) or lytic (renal & thyroid mets) - Multiple foci - Most are ill-defined - ==Multiple destructive areas may be present.== - ==Periosteal changes may occur.== - ==Normal trabecular pattern may be lost.== - ==Cortical destruction may occur.== - ==The mandibular canal may be destroyed or lost.== - ==Teeth may be displaced.== - ==Follicular spaces around unerupted teeth may be destroyed.== - ==Sclerotic metastases may resemble bone islands, but periosteal change is not expected with bone islands.== - ==Bone islands involving the condyles are rare.== - ==Multiple sclerotic lesions in unusual locations should prompt assessment of other skeletal regions.== - ==Metastasis should be considered particularly when there is a history of breast or prostate cancer.== - ==The mandibular body is the most common site of involvement.== - ==Multiple lesions involving the condyles, rami, and cervical spine are suspicious for malignancy.== > [!note] Lecturer — Metastatic Spread > Metastatic lesions usually arise from a distant primary tumor through the blood vessels. > > - Jaw metastases commonly arise from tumors located anatomically inferior to the clavicle. > - Paresthesia is an important clinical feature because of nerve involvement. > - Metastatic lesions may involve multiple regions because they travel through the body. A composite panel of five radiographic images (labeled A-E) displaying metastatic lesions in the jaws. The collection includes periapical and panoramic X-rays showing ill-defined areas of bone destruction, as well as axial CT scans revealing soft tissue masses and bony involvement.      A coronal CT scan of the upper cervical spine, displaying the dens (odontoid process) of the axis vertebra situated between the lateral masses of the atlas. Radiograph: A cross-sectional CT scan showing the mandible, with multiple hyperdense circular objects (likely dental implants or root canal fillings) visible in the upper region and a distinct elongated structure in the lower right. A grayscale medical scan, likely a CT image, showing a cross-section of bone and soft tissue. The image features a distinct curved bony structure on the right side with a measurement scale bar adjacent to it. Radiograph: A grayscale medical image showing a bony structure, likely a section of the skull or facial bones, with visible cortical and trabecular patterns. A book cover graphic featuring the title 'Atlas of Oral and Maxillofacial Radiology' by Bernard Koenig, published by Wiley Blackwell. The design includes a lateral view illustration of human skull anatomy with visible soft tissue structures against a blue background.  A panoramic dental radiograph (OPG) displaying the maxilla and mandible. The image reveals a mixed dentition stage with developing permanent tooth buds visible within the jawbones, alongside erupted primary teeth.  Radiograph: A panoramic dental X-ray showing the maxilla and mandible with a full set of teeth. Several posterior teeth exhibit high-density radiopaque restorations (crowns or fillings), and some roots appear elongated, possibly indicating dental implants.  A panoramic radiograph (orthopantomogram) displaying the maxilla and mandible. The image reveals severe alveolar bone loss, with the height of the remaining bone in both jaws reduced to approximately the level of the mandibular canal. ## Case: Rare carcinomas of the jaws ### Question **Scenario:** Examples of rare carcinomas of the jaws, including primary intraosseous carcinoma and carcinoma arising from a dentigerous cyst. **What's shown:** Images showing decreased density with irregular margins. One lesion is slightly more well-defined, while the other has no visible margins and shows loss of the mandibular canal. **Consider:** Identify the imaging features of these rare carcinomas. ### Answer **Observations:** - Decreased density with irregular margins. - One lesion is slightly more well-defined (intraosseous type). - The other lesion has no visible margins and loss of the mandibular canal. **Reasoning:** Primary intraosseous carcinoma and carcinoma arising from a dentigerous cyst are rare but share typical malignant imaging features. The lack of visible margins and the loss of anatomical boundaries, such as the mandibular canal, are key indicators of their aggressive, malignant behavior. **Takeaway:** Rare carcinomas of the jaws exhibit typical malignant features such as ill-defined margins and the destruction of anatomical structures like the mandibular canal. ## Case: SCC involving the left maxilla ### Question **Scenario:** A CT scan of a patient with squamous cell carcinoma (SCC) involving the left maxilla. **What's shown:** A large soft tissue mass with extensive destruction of the left maxilla and floating teeth. The margins are ill-defined and highly erosive, with soft tissue present where normal fat should be. **Consider:** Identify the malignant features of this SCC. ### Answer **Observations:** - Large soft tissue mass. - Extensive destruction of the left maxilla. - Floating teeth. - Ill-defined and highly erosive margins. - Soft tissue replacing normal fat spaces. **Reasoning:** The lesion demonstrates classic malignant features, including ill-defined margins, extensive bony destruction, floating teeth, and soft tissue extension that replaces normal anatomical fat. **Takeaway:** SCC of the maxilla can present with extensive bony destruction, floating teeth, and a soft tissue mass replacing normal fat spaces. ## Case: SCC of a non-healing mandibular socket ### Question **Scenario:** A case of SCC involving a non-healing left mandibular socket. **What's shown:** A lesion with surrounding sclerosis making it appear more well-defined, but with invasive, ill-defined margins anteriorly and inferiorly. There is destruction of the lamina dura of a premolar and the cortical borders of the mandibular canal, along with irregular PDL space widening. **Consider:** Identify the aggressive features of this SCC despite the surrounding sclerosis. ### Answer **Observations:** - Surrounding sclerosis. - Invasive and ill-defined margins anteriorly and inferiorly. - Destruction of the lamina dura of a premolar. - Destruction of the cortical borders of the mandibular canal. - Irregular PDL space widening. **Reasoning:** Although surrounding sclerosis can make a lesion appear more well-defined, the anterior and inferior margins remain invasive and ill-defined. The destruction of the lamina dura, mandibular canal borders, and irregular PDL widening are critical red flags for malignancy. **Takeaway:** Surrounding sclerosis can mask the ill-defined margins of an SCC, but localized cortical destruction and irregular PDL widening remain critical indicators of malignancy. ## Case: Osteosarcoma with sun-ray periosteal change ### Question **Scenario:** Examples of osteosarcomas of the jaws. **What's shown:** Expansile mixed-density lesions, with one demonstrating a sun-ray periosteal reaction. **Consider:** Identify the characteristic imaging features of osteosarcoma. ## Case: Rare carcinomas of the jaws ### Question **Scenario:** Examples of rare carcinomas of the jaws, including primary intraosseous carcinoma and carcinoma arising from a dentigerous cyst. **What's shown:** Images showing decreased density with irregular margins. One lesion is slightly more well-defined, while the other has no visible margins and shows loss of the mandibular canal. **Consider:** Identify the imaging features of these rare carcinomas.   ### Answer **Observations:** - Decreased density with irregular margins. - One lesion is slightly more well-defined (intraosseous type). - The other lesion has no visible margins and loss of the mandibular canal. **Reasoning:** Primary intraosseous carcinoma and carcinoma arising from a dentigerous cyst are rare but share typical malignant imaging features. The lack of visible margins and the loss of anatomical boundaries, such as the mandibular canal, are key indicators of their aggressive, malignant behavior. **Takeaway:** Rare carcinomas of the jaws exhibit typical malignant features such as ill-defined margins and the destruction of anatomical structures like the mandibular canal. ## Case: SCC involving the left maxilla ### Question **Scenario:** A CT scan of a patient with squamous cell carcinoma (SCC) involving the left maxilla. **What's shown:** A large soft tissue mass with extensive destruction of the left maxilla and floating teeth. The margins are ill-defined and highly erosive, with soft tissue present where normal fat should be. **Consider:** Identify the malignant features of this SCC.  ### Answer **Observations:** - Large soft tissue mass. - Extensive destruction of the left maxilla. - Floating teeth. - Ill-defined and highly erosive margins. - Soft tissue replacing normal fat spaces. **Reasoning:** The lesion demonstrates classic malignant features, including ill-defined margins, extensive bony destruction, floating teeth, and soft tissue extension that replaces normal anatomical fat. **Takeaway:** SCC of the maxilla can present with extensive bony destruction, floating teeth, and a soft tissue mass replacing normal fat spaces. ## Case: SCC of a non-healing mandibular socket ### Question **Scenario:** A case of SCC involving a non-healing left mandibular socket. **What's shown:** A lesion with surrounding sclerosis making it appear more well-defined, but with invasive, ill-defined margins anteriorly and inferiorly. There is destruction of the lamina dura of a premolar and the cortical borders of the mandibular canal, along with irregular PDL space widening. **Consider:** Identify the aggressive features of this SCC despite the surrounding sclerosis.  ### Answer **Observations:** - Surrounding sclerosis. - Invasive and ill-defined margins anteriorly and inferiorly. - Destruction of the lamina dura of a premolar. - Destruction of the cortical borders of the mandibular canal. - Irregular PDL space widening. **Reasoning:** Although surrounding sclerosis can make a lesion appear more well-defined, the anterior and inferior margins remain invasive and ill-defined. The destruction of the lamina dura, mandibular canal borders, and irregular PDL widening are critical red flags for malignancy. **Takeaway:** Surrounding sclerosis can mask the ill-defined margins of an SCC, but localized cortical destruction and irregular PDL widening remain critical indicators of malignancy. ## Case: Osteosarcoma with sun-ray periosteal change ### Question **Scenario:** Examples of osteosarcomas of the jaws. **What's shown:** Expansile mixed-density lesions, with one demonstrating a sun-ray periosteal reaction. **Consider:** Identify the characteristic imaging features of osteosarcoma.  Case: Rare carcinomas of the jaws FIG. 23-4 This primary intraosseous carcinoma in the left mandible exhibits no internal structure, a poorly defined periphery, and thinning of the overlying mandibular bone. Radiograph: A lateral jaw radiograph showing a large, ill-defined radiolucent area in the posterior mandible with no internal structure and thinning of the overlying bone. FIG. 23-5 Carcinoma arising in a preexisting dentigerous cyst related to the mandibular left third molar shows absence of a cyst cortex, invasion into adjacent bone, and ill-defined borders. Radiograph: A dental X-ray of the posterior mandible showing an impacted third molar surrounded by a large, ill-defined radiolucent area that lacks a distinct cyst cortex and appears to invade the adjacent bone. This axial CT scan of the facial bones demonstrates a large, heterogeneous soft-tissue mass occupying the left maxillary sinus. The lesion appears to cause expansion and erosion of the surrounding bony walls, including the medial wall and orbital floor. A grayscale cross-sectional medical image, likely a CT scan or radiograph, showing a vertical segment of bone containing a large, dark, ovoid radiolucent area within its structure. The bright white outer rim indicates cortical bone, while the central cavity suggests a lesion or anatomical void surrounded by soft tissue. FIG. 23-10 Cropped panoramic image of an osteosarcoma occupying the body of the right mandible. Note the widened ligament spaces (arrows) and that the density of the mandible in the first molar region is greater than normal due to abnormal bone formation from the tumor. A cropped panoramic radiograph showing the posterior mandible with a region of increased bone density and irregularity in the first molar area. Two black arrows point to specific teeth where the periodontal ligament spaces appear widened. ### Answer **Observations:** - Expansile mixed-density lesions. - Sun-ray periosteal change. **Reasoning:** Osteosarcomas are characterized by new bone formation giving a mixed, cloud-like density, expansile and destructive behavior with ill-defined borders, and classic periosteal reactions like the sun-ray or sunburst pattern. **Takeaway:** Osteosarcomas of the jaws present as expansile mixed-density lesions with classic periosteal reactions such as a sun-ray or sunburst pattern. ## Case: Subtle osteosarcoma on OPG ### Question **Scenario:** An osteosarcoma lesion that appears subtle on an OPG. **What's shown:** A non-healing socket with destruction of adjacent cortical structures (lamina dura), irregular PDL space widening, increased density (rather than decreased density), and loss of the mandibular canal. **Consider:** Identify the red flags for osteosarcoma in this subtle presentation. ### Answer **Observations:** - Non-healing socket. - Destruction of adjacent cortical structures and lamina dura. - Irregular PDL space widening. - Increased density. - Loss of the mandibular canal. **Reasoning:** While the lesion is subtle on the OPG, the combination of a non-healing socket, cortical destruction, irregular PDL widening, and specifically increased density (unlike the lucency seen in SCC) along with loss of the mandibular canal points to osteosarcoma. **Takeaway:** Osteosarcoma can present subtly on an OPG, but increased density combined with cortical destruction, irregular PDL widening, and loss of the mandibular canal are key diagnostic red flags. ## Case: Chondrosarcoma of the TMJ ### Question **Scenario:** A rare case of chondrosarcoma involving the temporomandibular joint (TMJ). **What's shown:** Predominantly lytic lesions with rings and arcs calcification or popcorn calcification around the borders. **Consider:** Identify the distinguishing calcification patterns of chondrosarcoma. ### Answer **Observations:** - Predominantly lytic lesions. - Rings and arcs calcification. - Popcorn calcification around the borders. **Reasoning:** Unlike osteosarcomas which show new bone formation, chondrosarcomas involve cartilaginous tissue and are predominantly lytic. The presence of rings and arcs or popcorn calcifications around the borders is characteristic of cartilaginous tumors. **Takeaway:** Chondrosarcomas of the TMJ are predominantly lytic and characteristically display rings and arcs or popcorn calcifications. ## Case: High-grade fibrosarcoma in a pediatric patient ### Question **Scenario:** A 16-year-old girl with ortho braces presenting with jaw swelling and a high-grade fibrosarcoma of the mandible. **What's shown:** Initial PA showing a lytic lesion with ill-defined margins in the 4, 5 region. A follow-up OPG two months later shows extensive, rapid progression of the lesion. **Consider:** Evaluate the progression and outcome of this high-grade malignancy. ### Answer **Observations:** - Lytic lesion with ill-defined margins in the 4, 5 region on initial PA. - Extensive and rapid progression on OPG two months later. **Reasoning:** The rapid and extensive progression over just two months aligns with the high-grade, aggressive nature of fibrosarcoma. **Outcome:** The patient received a total mandibulectomy. A bone scan a year later showed extensive metastasis throughout the body. Despite radiation and chemotherapy, the patient did not survive. **Takeaway:** High-grade fibrosarcomas of the jaw are extremely aggressive, rapidly progressive, and carry a poor prognosis with a high risk of extensive metastasis and mortality. ## Case: Lymphoma of the right maxilla ### Answer **Observations:** - Expansile mixed-density lesions. - Sun-ray periosteal change. **Reasoning:** Osteosarcomas are characterized by new bone formation giving a mixed, cloud-like density, expansile and destructive behavior with ill-defined borders, and classic periosteal reactions like the sun-ray or sunburst pattern. **Takeaway:** Osteosarcomas of the jaws present as expansile mixed-density lesions with classic periosteal reactions such as a sun-ray or sunburst pattern. ## Case: Subtle osteosarcoma on OPG ### Question **Scenario:** An osteosarcoma lesion that appears subtle on an OPG. **What's shown:** A non-healing socket with destruction of adjacent cortical structures (lamina dura), irregular PDL space widening, increased density (rather than decreased density), and loss of the mandibular canal. **Consider:** Identify the red flags for osteosarcoma in this subtle presentation. ### Answer **Observations:** - Non-healing socket. - Destruction of adjacent cortical structures and lamina dura. - Irregular PDL space widening. - Increased density. - Loss of the mandibular canal. **Reasoning:** While the lesion is subtle on the OPG, the combination of a non-healing socket, cortical destruction, irregular PDL widening, and specifically increased density (unlike the lucency seen in SCC) along with loss of the mandibular canal points to osteosarcoma. **Takeaway:** Osteosarcoma can present subtly on an OPG, but increased density combined with cortical destruction, irregular PDL widening, and loss of the mandibular canal are key diagnostic red flags. ## Case: Chondrosarcoma of the TMJ ### Question **Scenario:** A rare case of chondrosarcoma involving the temporomandibular joint (TMJ). **What's shown:** Predominantly lytic lesions with rings and arcs calcification or popcorn calcification around the borders. **Consider:** Identify the distinguishing calcification patterns of chondrosarcoma.   ### Answer **Observations:** - Predominantly lytic lesions. - Rings and arcs calcification. - Popcorn calcification around the borders. **Reasoning:** Unlike osteosarcomas which show new bone formation, chondrosarcomas involve cartilaginous tissue and are predominantly lytic. The presence of rings and arcs or popcorn calcifications around the borders is characteristic of cartilaginous tumors. **Takeaway:** Chondrosarcomas of the TMJ are predominantly lytic and characteristically display rings and arcs or popcorn calcifications. ## Case: High-grade fibrosarcoma in a pediatric patient ### Question **Scenario:** A 16-year-old girl with ortho braces presenting with jaw swelling and a high-grade fibrosarcoma of the mandible. **What's shown:** Initial PA showing a lytic lesion with ill-defined margins in the 4, 5 region. A follow-up OPG two months later shows extensive, rapid progression of the lesion. **Consider:** Evaluate the progression and outcome of this high-grade malignancy.    ### Answer **Observations:** - Lytic lesion with ill-defined margins in the 4, 5 region on initial PA. - Extensive and rapid progression on OPG two months later. **Reasoning:** The rapid and extensive progression over just two months aligns with the high-grade, aggressive nature of fibrosarcoma. **Outcome:** The patient received a total mandibulectomy. A bone scan a year later showed extensive metastasis throughout the body. Despite radiation and chemotherapy, the patient did not survive. **Takeaway:** High-grade fibrosarcomas of the jaw are extremely aggressive, rapidly progressive, and carry a poor prognosis with a high risk of extensive metastasis and mortality. ## Case: Lymphoma of the right maxilla Case: Osteosarcoma with sun-ray periosteal change > Answer C Axial CT scan of the facial skeleton demonstrating a large, expansile soft-tissue mass involving the left condyle and ramus of the mandible. The lesion is indicated by white arrows and shows areas of internal calcification or ossification, causing significant expansion and distortion of the normal bony architecture. B Radiograph: Coronal CT scan of the mandible and temporomandibular joints showing a large, expansile lesion involving the left condyle with cortical thinning and internal calcifications. Fig. 2. Clinical appearance of intraosseous fibrosarcoma (august, 01, 2001) with extensive swelling from region of the right mandibular lateral incisor to the right mandibular second premolar. The image displays two whole-body bone scintigraphy scans, labeled 'ANT' (anterior) and 'POST' (posterior), showing the skeletal structure with areas of increased radiotracer uptake. These hot spots are visible in the skull, ribs, pelvis, and notably at the distal ends of the long bones in the legs (ankles/feet), indicating metastatic activity. Fig. 3. Subsequent orthopantomography examination (august, 01, 2001). The radiograph showed a radiolucency undefined lesion extending from region of the left mandibular central incisor to the right mandibular first molar. Radiograph: A panoramic dental X-ray (orthopantomogram) showing the upper and lower jaws with teeth. The image displays a radiolucent area in the anterior mandible, consistent with the caption's description of an undefined lesion extending across the midline. Fig. 7. Scintigraphy exhibiting metastases in arti- culations. Clinical photo: An intraoral view showing the upper and lower dental arches fitted with orthodontic braces (metal brackets and archwires). The teeth are retracted by lips, revealing the appliance on both the maxillary and mandibular teeth. ### Question **Scenario:** A case of lymphoma involving the right maxilla. **What's shown:** An initial non-diagnostic OPG. A cropped OPG shows unusual PDL space widening of the right maxillary teeth. A subsequent CT shows irregular PDL space widening, destruction of the lamina dura, buccal cortex, and sinus floor. **Consider:** Differentiate the imaging features of lymphoma from other malignancies like SCC. ### Answer **Observations:** - Unusual PDL space widening. - Destruction of the lamina dura. - Destruction of the buccal cortex and sinus floor. **Reasoning:** The imaging features of lymphoma, including irregular PDL widening and destruction of cortical structures like the lamina dura and sinus floor, are very similar to SCC, making it difficult to distinguish between the two based on imaging alone. **Takeaway:** Lymphoma of the jaw can mimic SCC on imaging, presenting with irregular PDL widening and destruction of cortical structures like the lamina dura and sinus floor. ## Case: Leukemia in a mixed dentition patient ### Question **Scenario:** A young patient with mixed dentition presenting with leukemia involving the left mandible. **What's shown:** A lytic and invasive lesion with lamina dura destruction and loss of follicular space borders of unerupted teeth (38). The lucency is subtle due to the naturally low bone density in children. **Consider:** Identify the subtle signs of leukemia in a pediatric jaw radiograph. ### Answer **Observations:** - Lytic and invasive lesion. - Lamina dura destruction. - Destruction and loss of follicular space borders of unerupted teeth. - Subtle lucency. **Reasoning:** In children, bone density is naturally low, making lucency subtle. Therefore, destructive changes such as PDL space widening, lamina dura destruction, loss of cortical structures, and displacement or follicular space destruction of unerupted teeth are more reliable indicators of leukemia. **Takeaway:** In pediatric patients, leukemia may present with subtle lucency; clinicians should instead look for destructive changes like lamina dura loss, cortical destruction, and disruption of unerupted tooth follicular spaces. ## Case: Sclerotic metastasis with periosteal changes ### Question **Scenario:** A case of sclerotic metastasis in the jaws. **What's shown:** Sclerotic lesions that resemble bone islands but are located in unusual spots like the condyles, accompanied by periosteal changes. **Consider:** Differentiate sclerotic metastases from benign bone islands. ### Answer **Observations:** - Sclerotic lesions resembling bone islands. - Located in unusual areas like the condyles. - Visible periosteal changes. **Reasoning:** Sclerotic metastases (often from breast or prostate primary tumors) can look like bone islands. However, bone islands in the condyles are rare, and the presence of periosteal changes is a red flag that indicates malignancy rather than a benign bone island. **Takeaway:** Sclerotic metastases can mimic bone islands, but their presence in unusual locations like the condyles and the presence of periosteal changes are key indicators of malignancy. ## Case: Incidental suspected leukemia in a young patient ### Question **Scenario:** An incidental finding on an OPG taken for treatment planning in a young patient. **What's shown:** Altered trabecular pattern of the left mandible, lytic change of the inferior border, destruction of the mandibular canal, hyperdensity with displacement of tooth 38, loss of follicular space, and loss of lamina dura and mandibular canal around tooth 37. **Consider:** Identify the malignant features and likely diagnosis based on the patient's age. ### Question **Scenario:** A case of lymphoma involving the right maxilla. **What's shown:** An initial non-diagnostic OPG. A cropped OPG shows unusual PDL space widening of the right maxillary teeth. A subsequent CT shows irregular PDL space widening, destruction of the lamina dura, buccal cortex, and sinus floor. **Consider:** Differentiate the imaging features of lymphoma from other malignancies like SCC.   ### Answer **Observations:** - Unusual PDL space widening. - Destruction of the lamina dura. - Destruction of the buccal cortex and sinus floor. **Reasoning:** The imaging features of lymphoma, including irregular PDL widening and destruction of cortical structures like the lamina dura and sinus floor, are very similar to SCC, making it difficult to distinguish between the two based on imaging alone. **Takeaway:** Lymphoma of the jaw can mimic SCC on imaging, presenting with irregular PDL widening and destruction of cortical structures like the lamina dura and sinus floor. ## Case: Leukemia in a mixed dentition patient ### Question **Scenario:** A young patient with mixed dentition presenting with leukemia involving the left mandible. **What's shown:** A lytic and invasive lesion with lamina dura destruction and loss of follicular space borders of unerupted teeth (38). The lucency is subtle due to the naturally low bone density in children. **Consider:** Identify the subtle signs of leukemia in a pediatric jaw radiograph.  ### Answer **Observations:** - Lytic and invasive lesion. - Lamina dura destruction. - Destruction and loss of follicular space borders of unerupted teeth. - Subtle lucency. **Reasoning:** In children, bone density is naturally low, making lucency subtle. Therefore, destructive changes such as PDL space widening, lamina dura destruction, loss of cortical structures, and displacement or follicular space destruction of unerupted teeth are more reliable indicators of leukemia. **Takeaway:** In pediatric patients, leukemia may present with subtle lucency; clinicians should instead look for destructive changes like lamina dura loss, cortical destruction, and disruption of unerupted tooth follicular spaces. ## Case: Sclerotic metastasis with periosteal changes ### Question **Scenario:** A case of sclerotic metastasis in the jaws. **What's shown:** Sclerotic lesions that resemble bone islands but are located in unusual spots like the condyles, accompanied by periosteal changes. **Consider:** Differentiate sclerotic metastases from benign bone islands.  ### Answer **Observations:** - Sclerotic lesions resembling bone islands. - Located in unusual areas like the condyles. - Visible periosteal changes. **Reasoning:** Sclerotic metastases (often from breast or prostate primary tumors) can look like bone islands. However, bone islands in the condyles are rare, and the presence of periosteal changes is a red flag that indicates malignancy rather than a benign bone island. **Takeaway:** Sclerotic metastases can mimic bone islands, but their presence in unusual locations like the condyles and the presence of periosteal changes are key indicators of malignancy. ## Case: Incidental suspected leukemia in a young patient ### Question **Scenario:** An incidental finding on an OPG taken for treatment planning in a young patient. **What's shown:** Altered trabecular pattern of the left mandible, lytic change of the inferior border, destruction of the mandibular canal, hyperdensity with displacement of tooth 38, loss of follicular space, and loss of lamina dura and mandibular canal around tooth 37. **Consider:** Identify the malignant features and likely diagnosis based on the patient's age.  Case: Lymphoma of the right maxilla > Question Radiograph: A composite image showing a panoramic dental radiograph at the top and two cross-sectional CT slices below, illustrating the position of an impacted tooth relative to the maxillary sinus. A panoramic dental radiograph (orthopantomogram) showing the maxilla and mandible, including the full dentition with multiple restorations and impacted third molars. The temporomandibular joints are visible at the far left and right edges of the image. A dental radiograph (X-ray) showing the posterior teeth in a quadrant. Visible structures include upper and lower molars with distinct roots, as well as a bright white metallic restoration or crown on one of the lower teeth. Radiograph: A cross-sectional CT scan showing the mandible, with multiple hyperdense circular objects (likely dental implants or root canal fillings) visible in the upper region and a distinct elongated structure in the lower right. A panoramic dental radiograph (OPG) displaying the maxilla and mandible. The image reveals a mixed dentition stage with developing permanent tooth buds visible within the jawbones, alongside erupted primary teeth. ### Answer **Observations:** - Altered trabecular pattern. - Lytic change of the inferior border. - Destruction of the mandibular canal. - Hyperdensity displacing tooth 38. - Loss of follicular space. - Loss of lamina dura around tooth 37. **Reasoning:** The diffuse loss of cortical structures, trabecular pattern, and mandibular canal borders are typical of malignancy. Given the young age of the patient, these aggressive, destructive features are most likely indicative of leukemia rather than an infection or other solid tumor. **Takeaway:** Diffuse loss of cortical and canal borders with altered trabecular patterns in a young patient is highly suspicious for leukemia and requires urgent referral. ## Case: Suspected SCC involving the alveolar crest ### Question **Scenario:** A case presenting with localized malignant features in the mandible. **What's shown:** Irregular widening of the PDL space of tooth 36, loss of lamina dura, and loss of visibility of the left mandibular canal. **Consider:** Determine the likely origin and type of this localized malignancy. ### Answer **Observations:** - Irregular PDL space widening of tooth 36. - Loss of lamina dura. - Loss of the left mandibular canal. **Reasoning:** The localized nature of the lesion, likely originating from the alveolar crest or gingiva, combined with irregular PDL widening and loss of the mandibular canal, is highly suspicious for a localized malignancy such as SCC. **Takeaway:** Localized irregular PDL widening and loss of the mandibular canal originating from the alveolar crest are highly suspicious for SCC and require urgent referral. ## Case: Multiple myeloma ### Question **Scenario:** An OPG showing classic features of multiple myeloma. **What's shown:** Multiple punched-out lytic lesions distributed throughout the jaws. **Consider:** Identify the classic radiographic presentation of multiple myeloma. ### Answer **Observations:** - Multiple punched-out lytic lesions. **Reasoning:** The presence of multiple, distinct punched-out lytic lesions is the classic and highly characteristic imaging appearance of multiple myeloma in the jaws. **Takeaway:** Multiple punched-out lytic lesions on a jaw radiograph are a classic and highly characteristic sign of multiple myeloma. ### Answer **Observations:** - Altered trabecular pattern. - Lytic change of the inferior border. - Destruction of the mandibular canal. - Hyperdensity displacing tooth 38. - Loss of follicular space. - Loss of lamina dura around tooth 37. **Reasoning:** The diffuse loss of cortical structures, trabecular pattern, and mandibular canal borders are typical of malignancy. Given the young age of the patient, these aggressive, destructive features are most likely indicative of leukemia rather than an infection or other solid tumor. **Takeaway:** Diffuse loss of cortical and canal borders with altered trabecular patterns in a young patient is highly suspicious for leukemia and requires urgent referral. ## Case: Suspected SCC involving the alveolar crest ### Question **Scenario:** A case presenting with localized malignant features in the mandible. **What's shown:** Irregular widening of the PDL space of tooth 36, loss of lamina dura, and loss of visibility of the left mandibular canal. **Consider:** Determine the likely origin and type of this localized malignancy.  ### Answer **Observations:** - Irregular PDL space widening of tooth 36. - Loss of lamina dura. - Loss of the left mandibular canal. **Reasoning:** The localized nature of the lesion, likely originating from the alveolar crest or gingiva, combined with irregular PDL widening and loss of the mandibular canal, is highly suspicious for a localized malignancy such as SCC. **Takeaway:** Localized irregular PDL widening and loss of the mandibular canal originating from the alveolar crest are highly suspicious for SCC and require urgent referral. ## Case: Multiple myeloma ### Question **Scenario:** An OPG showing classic features of multiple myeloma. **What's shown:** Multiple punched-out lytic lesions distributed throughout the jaws. **Consider:** Identify the classic radiographic presentation of multiple myeloma.  ### Answer **Observations:** - Multiple punched-out lytic lesions. **Reasoning:** The presence of multiple, distinct punched-out lytic lesions is the classic and highly characteristic imaging appearance of multiple myeloma in the jaws. **Takeaway:** Multiple punched-out lytic lesions on a jaw radiograph are a classic and highly characteristic sign of multiple myeloma. Case: Incidental suspected leukemia in a young patient > Answer Radiograph: A panoramic dental X-ray showing the maxilla and mandible with a full set of teeth. Several posterior teeth exhibit high-density radiopaque restorations (crowns or fillings), and some roots appear elongated, possibly indicating dental implants. A panoramic radiograph (orthopantomogram) displaying the maxilla and mandible. The image reveals severe alveolar bone loss, with the height of the remaining bone in both jaws reduced to approximately the level of the mandibular canal. [^1]: Original PDF page 1: [[L6 - Imaging for Jaw Malignancies.pdf#page=1|L6 - Imaging for Jaw Malignancies, p.1]] [^2]: Original PDF page 2: [[L6 - Imaging for Jaw Malignancies.pdf#page=2|L6 - Imaging for Jaw Malignancies, p.2]] [^3]: Original PDF page 3: [[L6 - Imaging for Jaw Malignancies.pdf#page=3|L6 - Imaging for Jaw Malignancies, p.3]] [^4]: Original PDF page 4: [[L6 - Imaging for Jaw Malignancies.pdf#page=4|L6 - Imaging for Jaw Malignancies, p.4]] [^5]: Original PDF page 5: [[L6 - Imaging for Jaw Malignancies.pdf#page=5|L6 - Imaging for Jaw Malignancies, p.5]] [^6]: Original PDF page 6: [[L6 - Imaging for Jaw Malignancies.pdf#page=6|L6 - Imaging for Jaw Malignancies, p.6]] [^7]: Original PDF page 7: [[L6 - Imaging for Jaw Malignancies.pdf#page=7|L6 - Imaging for Jaw Malignancies, p.7]] [^8]: Original PDF page 8: [[L6 - Imaging for Jaw Malignancies.pdf#page=8|L6 - Imaging for Jaw Malignancies, p.8]] [^9]: Original PDF page 9: [[L6 - Imaging for Jaw Malignancies.pdf#page=9|L6 - Imaging for Jaw Malignancies, p.9]] [^10]: Original PDF page 10: [[L6 - Imaging for Jaw Malignancies.pdf#page=10|L6 - Imaging for Jaw Malignancies, p.10]] [^11]: Original PDF page 11: [[L6 - Imaging for Jaw Malignancies.pdf#page=11|L6 - Imaging for Jaw Malignancies, p.11]] [^12]: Original PDF page 12: [[L6 - Imaging for Jaw Malignancies.pdf#page=12|L6 - Imaging for Jaw Malignancies, p.12]] [^13]: Original PDF page 13: [[L6 - Imaging for Jaw Malignancies.pdf#page=13|L6 - Imaging for Jaw Malignancies, p.13]] [^14]: Original PDF page 14: [[L6 - Imaging for Jaw Malignancies.pdf#page=14|L6 - Imaging for Jaw Malignancies, p.14]] [^15]: Original PDF page 15: [[L6 - Imaging for Jaw Malignancies.pdf#page=15|L6 - Imaging for Jaw Malignancies, p.15]] [^16]: Original PDF page 16: [[L6 - Imaging for Jaw Malignancies.pdf#page=16|L6 - Imaging for Jaw Malignancies, p.16]] [^17]: Original PDF page 17: [[L6 - Imaging for Jaw Malignancies.pdf#page=17|L6 - Imaging for Jaw Malignancies, p.17]] [^18]: Original PDF page 18: [[L6 - Imaging for Jaw Malignancies.pdf#page=18|L6 - Imaging for Jaw Malignancies, p.18]] [^19]: Original PDF page 19: [[L6 - Imaging for Jaw Malignancies.pdf#page=19|L6 - Imaging for Jaw Malignancies, p.19]] [^20]: Original PDF page 20: [[L6 - Imaging for Jaw Malignancies.pdf#page=20|L6 - Imaging for Jaw Malignancies, p.20]] [^21]: Original PDF page 21: [[L6 - Imaging for Jaw Malignancies.pdf#page=21|L6 - Imaging for Jaw Malignancies, p.21]] [^22]: Original PDF page 22: [[L6 - Imaging for Jaw Malignancies.pdf#page=22|L6 - Imaging for Jaw Malignancies, p.22]] [^23]: Original PDF page 23: [[L6 - Imaging for Jaw Malignancies.pdf#page=23|L6 - Imaging for Jaw Malignancies, p.23]] [^24]: Original PDF page 24: [[L6 - Imaging for Jaw Malignancies.pdf#page=24|L6 - Imaging for Jaw Malignancies, p.24]] [^25]: Original PDF page 25: [[L6 - Imaging for Jaw Malignancies.pdf#page=25|L6 - Imaging for Jaw Malignancies, p.25]] [^26]: Original PDF page 26: [[L6 - Imaging for Jaw Malignancies.pdf#page=26|L6 - Imaging for Jaw Malignancies, p.26]] [^27]: Original PDF page 27: [[L6 - Imaging for Jaw Malignancies.pdf#page=27|L6 - Imaging for Jaw Malignancies, p.27]]