Diagnostic Imaging of

M a l i g n a n t Tu m o r s i n t h e
Orofacial R egion
Steven R. Singer, DDS*, Adriana G. Creanga, BDS, MS, DABOMR

KEYWORDS
 Malignancy  Diagnosis  Clinical correlations  Radiographic features  Tumors

KEY POINTS
 Malignancies often have serious consequences, including disfigurement and death.
 All radiographs should be examined for signs of malignant lesions.
 Characteristic appearances of malignant lesions include ill-defined borders, asymmetric
appearance, destruction of adjacent bone and cortical borders, and radiolucency with
pieces of trapped bone.
 All bony lesions should be visualized completely and, where possible, in 3 dimensions.
 Histopathologic examination is generally the gold standard for final diagnosis of malignant
lesions.

INTRODUCTION

This article highlights the radiographic features of malignant lesions and presents the
clinical correlations that may aid in the initial diagnosis of orofacial malignancies.
The word “malignant” comes from the Latin malignare, meaning “to act wickedly”
(mal 5 “bad”). Cancer appears when a stimulus triggers abnormal changes to the
chromosomes within cells. The initial stage that can be detected by histopathologic
examination is called dysplasia (abnormality) and there are multiple evolutionary
stages known, such as carcinoma in situ, primary neoplasm, and secondary or met-
astatic neoplasm. Most changes take place at the subcellular level and manifest them-
selves as uncontrolled multiple cell divisions and persistence of old cells while young
cells do not mature and differentiate. The clinically visible aspect is usually a late one,

Financial Disclosures: The investigators of this article have no financial conflicts to disclose.
Department of Diagnostic Sciences, Division of Oral and Maxillofacial Radiology, Rutgers
School of Dental Medicine, 110 Bergen Street, Newark, NJ 07101, USA
* Corresponding author. Rutgers School of Dental Medicine, Room D-860, 110 Bergen Street,
Newark, NJ 07101.
E-mail address: steven.singer@sdm.rutgers.edu

Dent Clin N Am - (2015) -–-

http://dx.doi.org/10.1016/j.cden.2015.08.006 dental.theclinics.com
0011-8532/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
2 Singer & Creanga

illustrated by the cancerous growth, tumor, or mass. It may be at this point that radio-
graphically evident changes also occur.
In contrast to a benign lesion, a malignant tumor is characterized by uncontrolled
growth potential, an aggressive and invasive nature, and the ability to metastasize.
If a tumor arises de novo it is called a primary tumor, and if it originates from a distant
tumor it is referred to as secondary or metastatic. Metastases share the tissues of the
primary tumor, but they occur in a different and, frequently, distant location. Metasta-
ses illustrate the spread of cancer cells, usually traveling through the blood or lymph
vessels, and can invade and develop in any other anatomic region. Often, the first site
of neoplastic invasion is the nearby lymph nodes.
According to the National Cancer Institute, “head and neck cancers, which include
cancers of the oral cavity, larynx, pharynx, salivary glands and nose/nasal passages,
account for 3% of all malignancies in the US.” Cancers of the oral cavity represent
85% of all head and neck cancers,1 the eighth most common malignancy in males
and 15th most common in females. Estimates for 2015 are far from gratifying. The
Oral Cancer Foundation and American Cancer Society estimate in 2015 that 43,000
to 45,000 new cases of oral and oropharyngeal cancers with 8000 to 8650 deaths
(approximately 1 per hour) will occur in the United States.2 An estimated 1 in 92 adults
will be diagnosed with oral or pharyngeal cancer in their lifetime.3
There are multiple and varied risk factors involved in the development of head
and neck cancerous lesions. For example, the use of tobacco and alcohol is
strongly related to oral cancer. According to the American Cancer Society, “3 out
of 4 people with oral cancer have used tobacco, alcohol or both.” It is said that
combining the use of tobacco and alcohol will increase the risk of a malignancy
by 15 times.4
Viruses have been also implicated in the development of oral and oropharyngeal
cancer and, of these, human papillomavirus (HPV) types 16 and 18 are strongly
associated and are thought to cause about half of all oropharyngeal cancer cases.
HPV is a common virus, and in most instances the person’s immune system will
clear the HPV infection. Only 1% of those infected will display a lack of immune
response.2,4,5
Sun exposure is also a risk factor for developing skin cancers, manifesting itself in
the orofacial region as lip cancer. Furthermore, diets that lack vegetables and fruits,
personal history of cancer, betel nut chewing, and other unspecific or minor risk fac-
tors are researched, known, and cited.4 At one time a controversy regarding the rela-
tionship between mouthwash use and increased risk for developing oral cancer arose,
but proved to have no scientific evidence.6
Demographic characteristics have changed over the years. Historically, cancer usu-
ally affected older people and, with respect to oral cancers, mostly male smokers or
heavy drinkers. The newly recognized HPV16 association with oropharyngeal cancer
should eventually shed some light on the more recent reports of changes in age,
gender, and race of persons with oral cancer.
Radiology can be a valuable tool in the detection and diagnosis of malignant dis-
ease, as intraosseous malignancies, in addition to those that start peripherally but later
invade bone, can cause detectable changes in the calcified structures of the teeth and
bone. Many of the changes to bone brought about by malignancies either tend to be
lytic or cause alterations to the normal trabecular pattern. The characteristic irregular
and spike patterns of resorption of the roots of teeth are other changes to calcified
structures that may originate from a malignancy.
Although malignancies represent a small fraction of both the common and un-
common lesions of the jaws, early detection is of constant and significant concern
 Diagnostic Imaging of Malignant Tumors 3

to practicing dentists. Along with regular oral cancer screenings, clinical surveil-
lance for suspicious lesions, routine intraoral dental imaging, and panoramic radio-
graphs often provide the ability to effectively visualize osseous lesions of malignant
disease.
Initial discovery of oral and maxillofacial malignancies may result from complaints of
pathognomonic symptoms, discovery of soft-tissue components of lesions during
intraoral and extraoral examinations, or, rarely, radiographic findings. Most lesions
are discovered late, after invasion of the regional lymph nodes, which may have
become enlarged and sometimes painful. At present there is no specific tool or test
in widespread use by dentists that could aid in oral and maxillofacial cancer screening
and detection, other than meticulous clinical examination of the hard and soft tissues
of the orofacial regions in addition to follow-up of suspected lesions with further
testing, including appropriate radiographic examinations. The final and definitive diag-
nosis is generally the histopathology report, supplemented with clinical and radio-
graphic findings.
The National Institute of Dental and Craniofacial Research describe one method of
clinical examination.3,7 The American Cancer Society and American Dental Associa-
tion recommend that primary care clinicians and dentists initiate periodic examina-
tions of the oral cavity and throat as part of routine cancer-related screenings.2,3,8,9
The high-risk areas for oral cancer are the lateral borders of the tongue, the floor of
the mouth and ventral side of tongue, the soft palate, and the tonsils. These and all
of the other visible structures should be carefully examined during an oral cancer
screening.
Oral cancer screening is an extremely important and sensitive topic, but despite
the attention that cancer receives in both professional and lay publications, most
oral cancers go unnoticed in their initial detectable stages. Dentists are trained to
search for white or red patches, in addition to ulcers, during clinical examinations.
Radiographic signs are also emphasized. This approach should be expanded to
include HPV-related malignancies, which typically do not display discolored patches
and, therefore, may go undetected for longer periods. Nevertheless, early detection,
even if sometimes difficult, is the goal and currently is the main factor that might
provide an improved prognosis. These recommended oral cancer screenings take
place every 3 years for persons older than 20 and annually for those older than
40 years.2,3,8,9
Tables 1–4 show the pertinent details of benign and malignant lesions, and their
differentiation from inflammatory lesions.

Table 1
Frequently used and encountered terms in radiographic analysis

Appearance 2D Radiographs CBCT/MDCT MRI

White Radiopaque High density (bone) High-intensity signal
(fluid, fat)
Contrast agents: enhancement
Black Radiolucent Low density (air, fluid) Low-intensity signal
(cortical bone)
Gray Gray appearance is extremely Soft-tissue density Isointense to muscle
relative to surroundings; can
appear Radiopaque (sinusitis)
or Radiolucent (intraosseous
tumor)
4 Singer & Creanga

Table 2
Radiographic features of malignant tumors

Features Common to All Unique to Some

Location and size Almost anywhere; invade bone from Posterior mandible: sarcomas and
soft tissues in risk areas; various metastases
sizes
Shape and borders Irregular, ill-defined and Well-defined: some SCCs, IMC
noncorticated borders, finger-like
projections, permeative pattern
Internal structure Radiolucent: destructive, Radiopaque: osteosarcomas, breast
and density permeative pattern; remnant and prostate metastases
trabeculae
Effects on Irregular widening of the Root resorption: sarcomas and
surrounding periodontal ligament space with multiple myeloma
structures floating-teeth appearance, Periosteal reaction with sunray/hair-
resorption of cortical outlines, on-end appearance:
invasion of adjacent structures, no osteosarcomas and prostate
periosteal reaction metastases

CLASSIFICATION

Once there is an initial diagnosis, advanced functional and anatomic imaging allows
the cancer to be classified according to TNM staging. T is used to describe the primary
tumor (size, aggressiveness), N addresses involved nearby lymph nodes, and M de-
scribes distant metastases. It is internationally accepted and used, but of importance

Table 3
Radiographic features of benign and malignant tumors to aid in making a differential
diagnosis

Features Benign Malignant

Location Almost anywhere (intraosseous or Almost anywhere, depending on
arising in soft tissue or cartilage) tissue of origin
Shape Regular Irregular
Borders Corticated, well-defined; if inflamed Mostly ill-defined; moth-eaten,
can become poorly defined or permeative/infiltrative; wide
punched-out, noncorticated; transition zone
narrow transition zone
Density Radiolucent, mixed, or radiopaque Mostly radiolucent, with remnant
trabeculae
Size Varying sizes: from very small to Same
extremely large
Internal structure Various degrees of homogeneity and Heterogeneous, usually no
different trabecular patterns: discernible trabecular pattern
“honeycomb,” “soap bubble,” Remnant trabeculation
“tennis racket,” etc
Uni- or multilocular
Effects on Thinning and displacement of roots, Rare displacement, mostly
surrounding cortical plates, sinus floor, interruption with invasion of
structures mandibular canal adjacent structures/spaces
Rarely interruption/effacement
 Diagnostic Imaging of Malignant Tumors 5

Table 4
Radiographic features that differentiate malignancies from inflammatory lesion

Features Inflammation Malignancy

Location Invades bone from adjacent Same
structures (maxillary sinuses,
teeth, soft tissues)
Shape Irregular Same
Borders Ill-defined, permeative, rarely Same
corticated; wide transition zone
Density Depending on stage, varies from Mostly radiolucent; remnant
radiolucent to opaque and also trabeculation may mimic
mixed; sequestrum formation sequestra
Size Any size Any size
Internal structure Altered/resorbed trabecular pattern Same
Effects on Resorptive and/or stimulating new No effect in surrounding trabecular
surrounding bone formation effects on bone
structures adjacent cortices/medullar bone No periosteal reaction (exception
Root resorption osteosarcoma: “sunburst”)
Interruption/perforation of cortices Most frequently no root resorption
Periosteal reaction (“onion skin”) Perforation, pathologic fracture,
invasion present

only when solid tumors are considered or assessed. It is of no use for staging a diffuse
malignancy such as leukemia.
There are other classifications, depending on:
Tissue of Origin
 Carcinomas: epithelial origin
 Sarcomas, mesenchymal
 Hematopoietic malignancies: blood and lymph
 Metastases
Location of Head and Neck Cancers
 Oral
 Lips
 Nasal and nasopharyngeal
 Paranasal sinuses
 Oropharyngeal
 Larynx, thyroid, middle ear, salivary glands
Point of Origin
 Intraosseous/bony
 Soft tissue
1. Carcinomas are malignant tumors of epithelial origin that can arise in either soft
tissue or bone.
a. Squamous cell carcinoma (SCC) arises in the epithelium of the mucous mem-
branes and skin. It is the second most common cancer of the skin after basal
cell carcinoma, and is usually found in areas exposed to sunlight. It seems to
affect males more than females (2:1) and more so in the sixth and seventh
decades.
SCC is also the most common head and neck malignancy and best portrays the
term “oral cancer.” Almost 90% of all head and neck cancers are SCCs. It
6 Singer & Creanga

should be noted that 25% of oral malignancies are HPV-related and may not
provide the typical presentation. SCC is also the most common malignancy of
the oral cavity. When it occurs in the oral cavity, it most frequently involves
the keratinized mucosa of the posterior mandible. SCC lesions can be easily
confused with a benign growth when they are represented by a nontender
soft-tissue mass or a nonhealing ulcer that eventually will cause resorption of
the underlying bone (see Figs. 3–5). In addition to the mucosa, SCC can origi-
nate in other soft tissues, including the salivary glands, tongue (Fig. 1), floor of
the mouth, and tonsillar area (Waldeyer ring).
b. SCC may also originate in bone (Figs. 2–4). It is then referred to as primary intra-
osseous SCC.10–12 Primary intraosseous SCCs are thought to arise from
trapped odontogenic epithelial remnants (rests of Malassez). It is a rare malig-
nancy, more frequently affecting males than females. Primary intraosseous
SCC most commonly arises in the posterior mandible (retromolar pad).
c. Another type of intraosseous epithelial malignancy is central (intraosseous)
mucoepidermoid carcinoma (IMC). The mucoepidermoid carcinoma (MC) is
the most common intraosseous salivary malignancy, and only 2% to 4% of all
MC occur in the jaws, especially posterior mandible areas (mandible/maxilla
ratio 5 3:1 or 4:1).
d. Other sites of origin of intraosseous epithelial malignancies are the epithelial
layers of an originally benign entity, such as an odontogenic cyst13,14 (residual,15
dentigerous) or tumor (keratocystic odontogenic tumor,16 ameloblastoma17).
These lesions are a variant of the intraosseous type, characterized by the malig-
nant transformation of the epithelial lining, most likely as a result of a long-
standing chronic inflammation within the benign tumor or cyst. The terminology
for the ameloblastic type is ameloblastic carcinoma, which can develop de novo
(most frequently) or from malignant transformation of the epithelial layer of a
benign ameloblastoma. This lesion should be differentiated from malignant
ameloblastoma, which is an aggressive form of ameloblastoma, histologically
a well-differentiated, benign tumor that can still cause distant metastases
(lungs).18
e. Malignancies of the paranasal sinuses are rare entities represented by SCC,
adenocarcinoma, or adenoid cystic carcinoma (ACC) developing from the

Fig. 1. Contrast-enhanced MR image of squamous cell carcinoma of the base of the tongue
(A-sagittal slice) with invasion of lymph nodes (B-coronal). Circles indicate region of interest.
(Courtesy of Dr Adrian T. Creanga, Ovidius University, Constanta, Romania.)
 Diagnostic Imaging of Malignant Tumors 7

Fig. 2. Periapical radiographs of squamous cell carcinoma in the anterior maxilla: partially
effaced lamina dura, and bone destruction with remnant trabeculation.

Fig. 3. Axial MDCT in bone windows. Mandibular malignant tumor in the right body, irregular
moth-eaten appearance, permeative pattern, and cortical bone destruction with trabecular
remnants. Circle indicate region of interest. (Courtesy of Dr Adrian T. Creanga, Ovidius Univer-
sity, Constanta, Romania.)
8 Singer & Creanga

Fig. 4. CBCT sagittal slice and reconstructed cephalometric image showing bone destruction
in the anterior maxilla with appearance of “floating teeth.” (Courtesy of Dr Lois Levine,
Wantagh, New York.)

mucosal lining (Schneiderian membrane).19 SCC of the paranasal sinuses rep-

resents only 3% of all head and neck cancers, with the maxillary sinuses being
affected most. SCC of the paranasal sinuses also affects males more, as
opposed to ACC, which affects females twice as often and is more aggressive,
with higher recurrence rates and higher incidence of distant metastases. Adeno-
carcinomas occur more in the ethmoid sinuses and seem to be related to hard-
wood dust exposure. The long-standing, mostly asymptomatic evolution of
these lesions makes them difficult to be discovered in incipient phases. There-
fore they are most frequently found in later stages, when the exact origin is diffi-
cult to establish. In fact, a lesion in the paranasal sinuses could have arisen in
the maxilla (intraosseous, minor salivary gland of palatal mucosa, gingiva) and
then invaded the maxillary sinus, or may have actually originated within the
sinus, in the Schneiderian membrane.
f. Other types of carcinomas seen in the orofacial structures include salivary
adenocarcinomas (polymorphous low grade, acinic cell), ACCs, MCs, and carci-
nomas arising in a benign pleomorphic adenoma (carcinoma ex benign mixed tu-
mor). These lesions can affect any salivary gland, both major and minor, and
therefore can be located almost anywhere. Such carcinomas can be slow-
growing or fast-growing, and can evolve asymptomatically or be associated with
pain and paresthesia. Besides these characteristic salivary malignancies, the sali-
vary glands can be also affected by sarcomas, lymphomas, or metastases.
 Diagnostic Imaging of Malignant Tumors 9

2. Sarcomas are malignancies of mesenchymal origin, originating from, and also

producing, various types of abnormal tissues.20 In comparison with previously
described carcinomas, sarcomas tend to affect younger male patients. Their
most characteristic clinical presentation is painful swelling. The most commonly
found types are as follows.
a. Osteosarcoma21 is an uncommon malignant bone tumor, representing only
20% of all sarcomas. The jaw type represents about 6% to 8% of all osteosar-
comas, and both intraosseous and extraosseous forms occur. The extraoss-
eous types include parosteal and periosteal osteosarcomas. This tumor is
also known as osteogenic sarcoma because of its ability to produce immature
or abnormal bone (osteoid). It usually evolves asymptomatically until it becomes
clinically evident as an intraoral or extraoral swelling that usually extends
beyond the lower border of the mandible. The lesions are typically tender on
palpation, diffuse and immobile, and possibly associated with lip/chin pares-
thesia, with and without trismus (Figs. 5 and 6).
b. Chondrosarcomas22 are only half as common as osteosarcomas. One percent
to 3% of all chondrosarcomas appear in the head and neck area, with the most
common site being the maxilla, followed by mandible, ramus, nasal septum, and
paranasal sinuses.
c. Fibrosarcoma is a malignant tumor of fibroblasts, producing collagen and
elastin. Fibrosarcoma is very common in the extremities, with only 10% of all le-
sions occurring in the head and neck area. These tumors are known to be found
in the nose and sinuses of young adults and children.
d. Ewing sarcoma23 is an extremely rare malignancy of neuroectodermal origin,
more common in long bones (only 1%–2% in the craniofacial area) and affecting
mostly young Caucasian males (approximately 80% are younger than 20 years).
It represents the third most common bone malignancy of childhood, after oste-
osarcomas and chondrosarcomas. The clinical examination reveals local pain
(most frequent symptom) and an associated palpable soft-tissue mass. Radiog-
raphy reveals large poorly defined radiolucencies with adjacent soft-tissue inva-
sion (Fig. 7).
e. Other sarcomas found in the jaws include rhabdomyosarcoma, leiomyosar-
coma, angiosarcoma, and liposarcoma, among others.

Fig. 5. Panoramic radiograph of osteosarcoma of the right mandibular ramus. Radiopaque

entity with sunray appearance of the periosteal reaction. (Courtesy of Dr Frederico Prates,
Porto Alegre, Brazil.)
10 Singer & Creanga

Fig. 6. CBCT coronal, sagittal, and axial slices. Osteogenic osteosarcoma, high-density area,
and periosteal reaction. (Courtesy of Dr Frederico Prates, Porto Alegre, Brazil.)

Fig. 7. Panoramic radiograph showing a large radiolucent lesion in the left mandibular
ramus with pathologic fracture. The final diagnosis was Ewing sarcoma. Circle indicate re-
gion of interest. (Courtesy of Dr Joseph Rinaggio, Rutgers School of Dental Medicine,
Newark, NJ, USA.)
 Diagnostic Imaging of Malignant Tumors 11

3. Hematopoietic malignancies are uncommon in the head and neck area, and
include the following.
a. Multiple myeloma (plasma cell myeloma or plasmacytoma) is a hematopoietic
malignancy originating in the medullar portion of bone. It represents 1% of all
malignancies and 10% of all hematologic neoplasms, affecting jaws in 30%
of cases. Multiple myeloma affects older black males more frequently, and its
characteristic feature is pain in the lumbar spine with or without pathologic
fracture. When occurring in the skull, it produces characteristic radiographic
appearances referred to as “pepper-pot” or “raindrops” skull with multiple,
well-defined, punched-out lesions of varying sizes, involving the skull vault.
b. Non-Hodgkin lymphoma (malignant lymphoma, lymphosarcoma) is diagnosed
annually in approximately 60,000 persons in the United States. Most frequently
it arises in lymph nodes and grows as a nonpainful soft-tissue mass. When
occurring in the oral cavity (posterior hard palate, gingiva, and mandible), it
may arise and develop within bone or soft tissues and is considered an extrano-
dal lesion, most frequently as part of a multifocal disease.
c. Burkitt lymphoma24 is an aggressive B-cell lymphoma that is considered to be a
type of non-Hodgkin lymphoma; it mostly affects children, with 2 known main
subtypes. The African endemic affects the jaws of African young male children
(mean age 8 years), and is strongly related to Epstein-Barr virus and malaria.
The sporadic or American subtype is not seen in jaws, as it mostly affects
abdominal organs. A third subtype is the form associated with human immuno-
deficiency virus.
d. Leukemia is a generic term that represents a vast number of hematopoietic ma-
lignancies (acute or chronic, myelogenous or lymphoblastic, and lymphocytic)
that affect both adults and children. The clinical signs are mostly systemic, rep-
resented by frequent infections, easy bleeding, and bruising and fever. When
occurring in the orofacial area, clinical signs are related to the marked incapacity
to fight bacteria: inflammation (gingivitis/marginal periodontitis) and nonhealing
ulcers. The radiographic signs are minimal (widened periodontal ligament
space) or absent (Figs. 8 and 9).
4. Metastases25–27 are known as secondary malignancies, and represent the spread
of a primary tumor through the bloodstream from a distant site. Metastases often
originate from breast, lung, prostate, colon and rectum, thyroid, or ovaries, and
are most frequently of carcinomatous origin. In fact, metastatic carcinoma is the
most frequent bone cancer, with more than 80% of all cases affecting the
mandible. Their radiographic appearance is extremely variable, from radiolucent,
to mixed, to completely radiopaque (Fig. 10). Most metastases, however, are char-
acterized by a radiolucent appearance (Fig. 11).

Fig. 8. CBCT panoramic reconstruction and 3D reconstruction in a patient with leukemia.

12 Singer & Creanga

Fig. 9. Leukemia. Axial CBCT slices of maxilla and mandible showing widened periodontal
ligament spaces and alveolar bone destruction.

The common clinical appearance indicating the existence of a malignancy is made

up of 1 or more of the following features: mobile, displaced teeth; intraoral white or red
patches; nonhealing ulceration with indurated or rolled borders; affected local or
regional nerve functions, including anesthesia, paresthesia, hypotonia or atonia; ef-
fects of compression or invasion of blood vessels (eg, soft-tissue or bone necrosis,
intraoral bone exposure); and locoregional lymphadenopathy (nonpainful, indurated,
nonmobile nodes).
Patient complaints may include disgeusia, hypogeusia, or ageusia (distorted,
limited, or absent taste), unexplained hemorrhage, epistaxis, foul taste and smell,
lack of normal healing after surgery or trauma, unexplained or rapidly growing swelling
or pain, trouble swallowing, sore throat that will not go away, earache, weight loss,
anesthesia, paresthesia, hypotonia, or atonia. All these are nonspecific findings that
may or may not directly indicate a malignancy, but must be pursued.
Based on patient history, complaint, and clinical findings, radiographs are pre-
scribed. Certainly all lesions with underlying bone, even when the suspicion of malig-
nancy is low, should be imaged (Fig. 12). Often, plain film (periapical or panoramic)
imaging, with a second (occlusal) projection at 90 to the initial view, will allow visual-
ization of changes to bone in the area. An understanding of the common paths of travel
for malignancies may dictate imaging of certain regions, even when the detected

Fig. 10. Cropped panoramic radiograph showing a noncorticated and well-defined radio-
pacity in the anterior mandible (metastasis from breast cancer). Circle indicate region of in-
terest. (Courtesy of Dr Adrian T. Creanga, Ovidius University, Constanta, Romania.)
 Diagnostic Imaging of Malignant Tumors 13

Fig. 11. Vertebral metastasis. Well-defined, punched-out, noncorticated radiolucency. Circle

indicate region of interest. (Courtesy of Dr Adrian T. Creanga, Ovidius University, Constanta,
Romania.)

lesion may not overlie bone. An example of this might be a lesion on the lateral border
of the tongue, which may ultimately invade the bone of the posterior mandible.
All clinical findings should be correlated with radiographic features and vice versa. It
should be noted that a 50% to 60% change in bone demineralization must occur for
the osseous change to be radiographically visible. Therefore, a clinically apparent
lesion may not yet be radiographically evident, even though there is some invasion
of the bone. The final diagnosis is always made by the histopathologic examination.
Although the sequelae of undetected malignancy can be devastating, radiographic
screening for detection of malignancies is seldom productive. Furthermore, it is
certainly not cost effective to provide radiographic screenings for the purpose of
detecting malignancies. Although radiographs are not prescribed for the purpose of
detecting occult malignant lesions, it is imperative to examine all radiographs for signs
of malignancy, regardless of clinical suspicion. Most of the radiographically visible
malignant lesions are incidental findings.

RADIOGRAPHIC DIAGNOSIS

Diagnostic imaging is involved at many and different levels in the detection, evaluation,
and management of malignant lesions.

Fig. 12. Malignant tumor located in the right edentulous maxilla. Ill-defined, noncorticated
radiolucency with interruption of the cortex and associated soft-tissue mass. Circle indicate re-
gion of interest. (Courtesy of Dr Adrian T. Creanga, Ovidius University, Constanta, Romania.)
14 Singer & Creanga

1. Initial diagnosis
2. Accurate staging
3. Establishing the presence of invasion and spread, to better plan surgery and radi-
ation therapy
4. Assessment of bony and lymph node involvement
5. Aid in determining an accurate biopsy site and/or excision, and so forth

Radiographic Examination
Radiographs of the jaws must be examined in a consistent and organized fashion.
Because most lesions tend to be on one side of the jaws or the other, a general check
for asymmetries should be made. Cortical borders are checked for effacement,
expansion, thinning, scalloping, erosion, and other changes. Destruction of cortical
borders indicates more aggressive lesions, whereas evidence of remodeling pro-
cesses favors a diagnosis of less aggressive lesions. The lamina dura of the teeth,
and crestal cortication, are part of the cortical boundaries of the maxilla and mandible,
and should be included in the examination of cortices. Alterations in these structures
include effacement, loss of distinct boundaries, replacement with new remodeled
bone, and widening of the periodontal ligament space. Normal trabecular patterns
demonstrate a response to physiologic stress. Alterations in these patterns indicate
a response to nonphysiologic stressors.

Imaging Protocols
Although malignancies can be detected effectively on routine intraoral imaging (see
Fig. 7), including periapical, bitewing, and occlusal radiographs, follow-up imaging
is generally required. It should be stated that the entire lesion must be visible on the
radiograph, along with a surrounding border of unaffected bone. Visualization of the
third dimension (z axis) is also essential. Although follow-up imaging studies will
almost undoubtedly included advanced imaging, an occlusal radiograph taken at
90 to the initial view can provide knowledge as to the full extent of the lesion, in addi-
tion to effects on adjacent structures.

Imaging Modalities
1. Conventional (intraoral and panoramic radiographs; scintigraphy). Possible find-
ings of radiographic signs of malignancy include:
a. Irregular widening of the periodontal ligament space with “floating-tooth”
appearance mimicking periodontal disease. Displacement or resorption of the
teeth is rare
b. Poorly defined, noncorticated lesions, with a moth-eaten or punched-out
appearance
c. Irregularly shaped, heterogeneous internal structure, radiolucent, radiopaque,
or mixed density area  trabecular remnants.
d. Destruction of cortical borders (floor of the maxillary sinus, nasal fossa, hard
palate, alveolar ridge), enlargement of the mandibular canal and/or mental fora-
men, periosteal reaction
e. Soft-tissue growth/mass (gingiva), invasion of adjacent structures (sinuses,
mandibular canal, and so forth)
f. Overall rapid growth of lesions, accompanied by destruction of adjacent
anatomic structures
2. Advanced imaging, which includes 2 major types:
 Diagnostic Imaging of Malignant Tumors 15

a. Anatomic imaging (or structural), for example, dental computed tomography

(CT) (cone-beam CT [CBCT]), medical CT (Multidetector CT [MDCT]) with or
without contrast, and MRI.
b. Functional imaging records metabolic activity, blood flow, and chemical
composition. Positron emission tomography (PET) or PET-fused MDCT,
single-photon emission CT (SPECT), and functional MRI (fMRI, eg, diffusion
MRI) all offer an advanced 3-dimensional (3D) view and analysis of all maxillofa-
cial structures (bone and soft tissue). These modalities are used to establish an
accurate location and the full extent of a lesion (destruction and invasion of adja-
cent structures) based on metabolic activity. PET is capable of identifying very
early lesions, owing to its ability to detect cellular metabolic activity related to
malignancy. Functional imaging is used for diagnosing, staging, and even
follow-up of different types of cancers. MRI offers the best soft-tissue contrast
and therefore is used to diagnose soft-tissue conditions, such as temporoman-
dibular joint–related conditions, soft-tissue neoplasia, and lymph node or peri-
neural invasion.

Nuclear medicine is a medical specialty that uses internal sources of radiation

(radioactive substances: technetium-99m, gallium-67, iodine-123 and -131, and so
forth) for both diagnosis and treatment of certain conditions. Scintigraphy is a 2-
dimensional (2D) nuclear medicine functional imaging modality. For the diagnostic im-
aging part, external detectors (gamma cameras) capture and record images from the
internally emitted radiation, as opposed to conventional radiographs for which
external x-ray sources are used. The 3D aspect of nuclear medicine is represented
mainly by SPECT imaging, which uses gamma rays and is based on monitoring tissue
biological activity in the area scanned.
Panoramic radiographs are useful for examining a large area of the jaws and adja-
cent structures. Although the resolution of a panoramic radiograph is lower than that of
direct films or digital imaging, it is often adequate for initial identification of potentially
malignant lesions, and is certainly higher than the resolution of advanced imaging mo-
dalities, such as CBCT, MDCT, and MRI.
Where available, CBCT can provide visualization of the third dimension in both mul-
tiplanar projections and oblique views. It is limited by its capacity to image only the
hard tissues, with soft-tissue imaging confined to outlines. An important point is
that, in general, oral and maxillofacial imaging can be confined to visualization of
the lesion in 3 dimensions, as advanced functional and anatomic imaging will be pre-
scribed as part of a workup to determine the staging of the malignancy. Although the
resolution of CBCT is about half of that of panoramic radiographs, it is often adequate
to determine the defining radiographic features of malignant lesions. Furthermore,
CBCT permits multiplanar and oblique reconstructions, allowing the viewer to identify
changes in complex hard-tissue structures including the maxilla, ethmoid and sphe-
noid bones, osteomeatal complex, and temporal bone.
MRI is an imaging technique that relies on the interaction of various components of
the body with a strong magnetic field. The magnetic field creates a temporary realign-
ment of the hydrogen atoms in the structure. Based on molecular structure of the
anatomic component, a different signal will be transmitted to the detector when a
radiofrequency (RF) pulse is applied perpendicular to the magnetic field. It must be
emphasized that this technique does not rely on ionizing radiation.
MRI accurately images both hard and soft tissues; however, it is most useful for
soft-tissue imaging, as it produces images that discriminate between soft-tissue com-
ponents (fat, nerve, and connective tissue), fluid, and tumors.
16 Singer & Creanga

MRI is used in dentistry for imaging of the soft-tissue components of the temporo-
mandibular joint. It is also useful in imaging tumors, as the tumor can often be distin-
guished from the surrounding normal tissues and structures on MR images.
A peculiar feature of MRI is the appearance of calcified structures. Because calci-
fied structures, such as bone and teeth, are low in water content and, therefore, low
in hydrogen atoms, they reflect the RF signal poorly, leaving a dark area on the resul-
tant image. This effect is termed nonenhancing or low signal intensity. Soft-tissue
structures typically have higher water content and, therefore, produce images of vary-
ing shades of gray.
Different scanning protocols are used, based on the anticipated findings. T1-
weighted images are used for demonstration of anatomic structures; characteristically
fat will appear bright (enhancing), whereas water takes on a dark appearance.
When a tumor is known or suspected, T2-weighted images are generally preferred.
In these images water appears bright, whereas fat appears darker. Lesions (both
benign and malignant) tend to have higher water content than normal tissue and, there-
fore, will appear brighter than the surrounding tissues. In addition, benign lesions may
have a cystic component with high water content. Moreover, benign and malignant tu-
mors may cause liquefaction from tissue necrosis, producing an enhancing signal.
Perineural invasion and, thus, tumor spread are best seen on contrast-enhanced T1-
weighted MRI. In this case, MRI is preferred to CT because of reduced metallic artifacts
and better soft-tissue contrast. The same enhanced soft-tissue contrast is extremely
useful in assessing regional lymph node invasion. In these cases, CT will mostly
show indirect signs of nerve invasion, such as enlargement or displacement of
foramina and, in later stages, bone erosion. Contrast-enhanced protocols are preferred
for both modalities because of the inherent ability to assess the vascular component.

Initial Detection of Lesions

Detection of malignancies of the jaws takes several different paths. The most straight-
forward diagnosis can often be made from patients’ complaints that include obvious
clinical signs of malignancies, including paresthesia, dysesthesia, swelling, ulceration,
and bleeding. Detection of suspicious lesions during routine oral cancer screening
also can begin the diagnostic process. Radiographs are indicated when a clinically
suspicious lesion overlies bone.
For radiographic assessment, it is always important to remember that interpretation
of radiographs is mainly a subjective process. The radiographic appearance of
anatomic structures is based on the interactions of x-ray photons with the compo-
nents of the oral cavity and surrounding structures. The energy levels of the photons
are based on the type of x-ray machine and the strings used, and the x-ray detector.
Some notions are clear and straightforward: air appears black, bone appears white,
and soft tissues appear in various shades of gray. Depending on surrounding struc-
tures, fluid or soft tissue may appear opaque. This appearance can be illustrated
with lesions seen developing within the paranasal sinuses, in contrast to the radiolu-
cent appearance it has when located within bone (see Table 1).
Specific radiographic features of malignancies include radiolucent (hypodense) in-
ternal architecture with indistinct borders, projections of the lesion into normal
bone, effacement of medullary bone, and destruction of adjacent cortical borders.
Although most intraosseous lesions do not produce bone, it is not uncommon for
pieces of nonvital bone to be entrapped in the soft tissue of the lesion, yielding a
mixed-density appearance (Fig. 13).
Pathologic fractures are frequently seen as a by-product of the bony destruction.
Once a cortical border has been breached and expansion of the lesion is unchecked
 Diagnostic Imaging of Malignant Tumors 17

Fig. 13. Mandibular malignant tumor-gingival carcinoma with invasion of underlying bone.
Irregularly shaped, ill-defined, noncorticated radiolucency with slight evidence of trabecular
remnants within (right) and wide of area of transition (left). (Courtesy of Dr Adrian T.
Creanga, Ovidius University, Constanta, Romania.)

by adjacent structures, lesions tend to grow as masses with smooth soft-tissue bor-
ders (Fig. 14); this holds especially true when lesions in the posterior maxilla expand
through the sinus floor into the lumen of the maxillary sinus. Effects of malignancies on
adjacent teeth include displacement mimicking premature eruption and root resorp-
tion. The appearance of root resorption caused by malignancy differs from the blunted
appearance generated by inflammation, benign cysts or tumors, and orthodontic
tooth movement. Resorption caused by malignancy gives the root a spiked and irreg-
ular appearance. A pathognomonic feature of malignant lesions is the lack of sur-
rounding reactive bone, giving malignant lesions a punched-out appearance usually
associated with multiple myeloma, but is also seen in other lesions. A typical feature
of sarcomas that have expanded through the periosteum of the primary bone is a
sunray appearance found within a soft-tissue mass (see Figs. 5 and 6).

Fig. 14. Cropped panoramic radiograph showing osteomyelitis with sequestrum formation
close to the inferior border of the left mandible.
18 Singer & Creanga

Radiographic Appearance
When describing and assessing a radiographic image, there are certain features to
follow.
1. Size. Although a characteristic of malignancy is rapid and uncontrolled growth, it
should be remembered that all lesions do start out small. Therefore, the following
radiographic features may also apply to small lesions. If a lesion is suspicious it
should be followed up, regardless of size.
2. Location. Both primary and metastatic tumors may be found anywhere in the maxil-
lofacial region. Tumors can originate in either bone (primary intraosseous tumor) or
soft tissue, secondarily invade bone (gingival carcinoma) or nearby structures,
or travel from distant originating sites (eg, prostate, breast, kidney) through blood
or lymph and metastasize at maxillofacial level. Primary carcinomas are most
frequently seen in the high-risk areas mentioned earlier (eg, floor of the mouth,
tonsils, Waldeyer ring, soft palate, tongue), whereas sarcomas mostly affect the
posterior mandible. Metastases are more common in the posterior regions of
both jaws.
3. Shape and borders. Characteristically, most malignancies have irregular shapes
and poorly defined, noncorticated margins, appearing to blend in with surrounding
normal bone (permeative or infiltrative patterns). When assessing an osteolytic
lesion, a wide zone of transition may indicate an aggressive and infiltrative process.
A narrow zone of transition with well-defined borders favors a benign lesion. Rarely,
if it is slow-growing and invading bone from surrounding soft-tissue structures, a
malignant lesion could exhibit defined and somewhat corticated outlines. Asym-
metrical shapes of lesions, in both 2D and 3D imaging, should be considered
suspicious (see Fig. 12). A significant exception is the IMC, which can exhibit
well-defined sclerotic borders.
4. Density and internal structure/architecture. Most malignancies appear as unilocular
or multilocular radiolucencies, as they tend to cause bone destruction without
inducing reactive bone formation. Sometimes, because of their rapid advance-
ment, malignancies may display remnant sparse trabeculation. Other tumors either
produce abnormal bone (osteogenic sarcomas) or induce abnormal reactive bone
formation (metastatic prostate and breast cancers) so that their appearance, at
least in part, is radiopaque. Rapidly growing lesions may entrap pieces of trabec-
ular bone, yielding a radiolucent appearance with some radiopaque foci, or display
ill-defined, thick, coarse bony septa with an overall multilocular, multicystic appear-
ance, as is sometimes seen in IMC. This tumor also exhibits a mixed radiopaque-
radiolucent appearance.
5. Effects on surrounding structures. Malignant lesions are usually aggressive, rapidly
evolving, and generally destructive and invasive. Owing to their rapid evolution,
roots of teeth are usually unaffected, appearing to be “floating in air” because of
the destruction of the alveolar support and effacement of the lamina dura (see
Figs. 1B, 2, and 8). Sarcomas and multiple myelomas may cause root resorption.
When root resorption is present, it usually follows a “spiked” pattern, as opposed to
the regular horizontal resorption or displacement seen in benign tumors (amelo-
blastoma, Pindborg tumor), inflammatory lesions, or cysts. Destruction of cortical
outlines and invasion of adjacent spaces or structures through the path of least
resistance (eg, maxillary sinus, nasal fossa, carotid space, mandibular canal) is
common. If outer cortical plates are destroyed or interrupted, there is usually no
periosteal reaction. An exception would be sarcomas, whereby unusual patterns
of reactive new bone formation are noted when the lesion has expanded beyond
 Diagnostic Imaging of Malignant Tumors 19

the periosteum of the primary site. Descriptive terms of these bony growth include
“sunray,” “sunburst,” “hair-on-end,” and even “onion skin” if secondarily infected
or inflamed. Another characteristic appearance of the periosteal reaction is the
Codman triangle, seen in aggressive lesions such as Ewing sarcomas or, rarely, os-
teosarcomas. Aggressive lesions have an extremely rapid evolution that will not
allow the periosteal new layers to ossify completely, so only the edges will have
a bony appearance (see Table 2).

Management
If a suspicious lesion is observed clinically it should be radiographed, especially when
there is underlying bone. The first step in imaging small lesions should always be con-
ventional radiographs. In some cases a simple intraoral periapical radiograph would
suffice. If size or location indicates, panoramic radiographs will offer a comprehensive
overview of the entire oral and maxillofacial complex.
Even if the clinical diagnosis is reasonably certain, advanced imaging should be
considered to obtain more information such as exact location, full extent, and lymph
node or perineural invasion. MDCT with contrast, MRI, or PET scans are huge aids in
diagnosis, localization of lesions, planning, staging, surgical excision, radiation, and
chemotherapy. Advanced functional and anatomic imaging is usually performed on
prescription of the oncologist, and may be based on the diagnosis of tissue type
and the genetic typing of the tumor.
The usual course of treatment involves a multidisciplinary approach and is usually
represented by a combination of surgical excision (for tumor removal) with usually
wide clearance margins (1.5–2 cm) with or without radical neck resection (stage
depending), followed by radiation therapy with or without chemotherapy (to destroy
any remaining malignant cell).
Radiographic follow-up of patients with cancer is mandatory: radiographs are
generally indicated every 3 months in the first year, every 6 months in the second
year, and once a year from the third year onward. However, protocols for radiographic
follow-up change based on evidence.
Essential considerations for postradiation therapy are the potential sequelae of
xerostomia, radiation caries, and osteoradionecrosis. In cases of multiple myeloma
and other bone conditions, bisphosphonate medication is administered and, there-
fore, medication-related osteonecrosis of the jaws (MRONJ) is a distinct possibility.28
The risk of MRONJ among patients with cancer depends on the type of drug and dose
administered, and is about 1%. MRONJ is similar clinically and radiographically to
osteoradionecrosis and osteomyelitis. Radiographic features of osteonecrotic condi-
tions include sequestrum formation, a mixed hyperdense and hypodense appearance
of the medullary bone, with a moth-eaten appearance, and erosion of cortical borders
of both the surfaces of the bone and internal structures, such as canals. In the
mandible, the inferior alveolar canal may appear widened, with poorly defined borders.
Diagnosis may often be made from the careful examination of the patient’s dental and
medical history. Osteonecrotic conditions require an initial triggering stimulus, which is
almost always an invasive dental procedure: extraction, endodontic or periodontal
treatment, or other procedures whereby oral bacteria may be introduced into the
bone. Therefore, careful examination and treatment of a patient undergoing either ra-
diation therapy or bisphosphonate medication is essential and should be prioritized.
Teeth with poor prognoses should be extracted and any anticipated invasive proce-
dure should be completed before administration of radiation therapy or bisphospho-
nates. It is also significant that osteonecrotic conditions may mimic metastatic or
primary lesions of malignancies, so biopsy may be indicated (Figs. 15 and 16).
20 Singer & Creanga

Fig. 15. MRONJ with sequestrum formation. Well-defined, noncorticated, mixed-density

lesion located at the level of the inferior border of the mandible. Circle indicate region
of interest. (Courtesy of Dr Adrian T. Creanga, Ovidius University, Constanta, Romania.)

Differential Diagnoses
In general, it is difficult differentiate one malignant tumor from another based solely on
the radiographic appearance. Malignancies have many common radiographic fea-
tures. Furthermore, different stages of development of some tumors may produce
different effects (see Tables 3 and 4).
1. Carcinomas are usually well discernible from other malignancies, especially if there is
a correlating clinical appearance and histologic features. Diagnostic difficulties are
presented by lesions that may have similar radiographic features, such as inflamma-
tion, including apical inflammatory lesions, marginal periodontitis, and osteomyelitis
(see Fig. 10). Even though the radiographic appearance of carcinomas tends to be

Fig. 16. Osteoradionecrosis of left mandible. Circle indicate region of interest. (Courtesy of
Dr Adrian T. Creanga, Ovidius University, Constanta, Romania.)
 Diagnostic Imaging of Malignant Tumors 21

similar to that of inflammatory lesions, involving mostly bone destruction, there is usu-
ally no periosteal reaction in malignant lesions. The remnant trabeculation mentioned
earlier can sometimes mimic the sequestra found in osteomyelitis. If the tumor be-
comes secondarily infected, differentiation would be almost impossible and final diag-
nosis would require a more thorough, advanced imaging modality (CT with contrast,
MRI, PET, nuclear medicine imaging). When originating in bone, malignancy can
sometimes mimic periapical cysts or granulomas. When odontogenic cysts become
infected they tend to lose cortication and become less well defined, a common malig-
nant feature that may easily be misread. Other benign entities should be considered,
especially when assessing a slow-growing, low-grade malignancy such as IMC, ame-
loblastoma, keratocystic odontogenic tumor, or glandular odontogenic cyst.
2. Metastatic disease should be considered first if the existence of the primary tumor
is known. Other entities to consider are primary malignancies and marginal peri-
odontal disease.
3. Regarding sarcomas, entities to consider are other sarcomas, benign fibro-
osseous lesions, and metastases, depending on the internal structure and overall
appearance. Diagnostic features to remember are the characteristic patterns of
the periosteal reaction, especially “sunray” and Codman triangles (see Figs. 3
and 4). Sometimes the result of a histopathologic analysis of a chondrosarcoma
slice may be identical to that of fibrous dysplasia, so a final diagnosis will rely
mostly on the radiographic features.

SUMMARY

Although malignancies in the orofacial structures are rare, early diagnosis and treatment
may have a significant impact on the long-term survival and quality of life of patients.
Along with a thorough medical and surgical history, considerations of habits such as
alcohol and tobacco use, and meticulous clinical examination, radiographs play a valu-
able role in the diagnosis of malignant lesions. All practitioners should be familiar with
radiographic prescribing guidelines and the radiographic characteristics of malignancies
to ensure the earliest diagnosis possible. Also important is that early-stage malignant le-
sions, as viewed on a radiograph, may not yield enough information to yield an exact diag-
nosis. The goal for practitioners should be to identify suspicious lesions and make the
appropriate referrals, so that a diagnosis and treatment can be obtained rapidly.

All long-standing, nonhealing clinically visible lesions overlying bone should be imaged.
Irregular borders, destructive patterns, and invasion of surrounding structures are most sugges-
tive of malignancy.
Radiographic appearance is relative and subjective, and perception depends on surrounding
structures and contrast. Soft tissue appears opaque in the maxillary sinus and lucent when
within bone.
Most frequently, malignancy does not cause a periosteal reaction, a fact that helps to differen-
tiate it from inflammatory lesions.
Risk areas for oropharyngeal cancer are lateral borders of the tongue, the floor of the mouth
and ventral side of tongue, the soft palate, and the tonsils.
Although radiographs are not taken for the sole purpose of cancer screening, all radiographs
acquired are carefully and thoroughly examined.
Cortical bone appears white on radiographic images (conventional or CT) and black on MRI.
The fat content of trabecular bone marrow will make it appear bright on T1-weighted images.
The final and definitive diagnosis is almost always based on the histopathologic examination of
the biopsy specimen, but the “road” to there is always paved with correlations made between
clinical and radiographic findings.
22 Singer & Creanga

REFERENCES

1. Available at: http://www.cancer.gov/researchandfunding/progress/snapshots/

headandneck.
2. Available at: http://www.oralcancerfoundation.org/.
3. Available at: http://www.ada.org/en/member-center/oral-health-topics/cancer-oral.
4. Available at: http://www.cancer.gov/publications/patient-education/WYNTK_oral.
pdf.
5. Tomar S, Graves CA, Altomare D, et al. Human papillomavirus status and gene
expression profiles of oropharyngeal and oral cancers from European American
and African American patients. Head Neck 2015. http://dx.doi.org/10.1002/hed.
24072.
6. Gandini S, Negri E, Boffetta P, et al. Mouthwash and oral cancer risk quantitative
meta-analysis of epidemiologic studies. Ann Agric Environ Med 2012;19(2):
173–80.
7. Available at: http://www.nidcr.nih.gov/oralhealth/Topics/OralCancer/DetectingOral
Cancer.htm#TheExam.
8. Omar E. Current concepts and future of noninvasive procedures for diagnosing
oral squamous cell carcinoma—a systematic review. Head Face Med 2015;
11(1):6.
9. Brocklehurst P, Kujan O, O’Malley LA, et al. Screening programmes for the early
detection and prevention of oral cancer. Cochrane Database Syst Rev
2013;(11):CD004150.
10. Tiwari M. Primary intraosseous carcinoma of the mandible: a case report with
literature review. J Oral Maxillofac Pathol 2011;15(2):205–10.
11. Lugakingira M, Pytynia K, Kolokythas A, et al. Primary intraosseous carcinoma of
the mandible: case report and review of the literature. Oral Maxillofac Surg 2010;
68(10):2623–9.
12. Chan KC, Pharoah M, Lee L, et al. Intraosseous mucoepidermoid carcinoma: a
review of the diagnostic imaging features of four jaw cases. Dentomaxillofac Ra-
diol 2013;42(4):20110162.
13. Jain M, Mittal S, Gupta DK. Primary intraosseous squamous cell carcinoma
arising in odontogenic cysts: an insight in pathogenesis. J Oral Maxillofac Surg
2013;71(1):e7–14.
14. Araújo JP, Kowalski LP, Rodrigues ML, et al. Malignant transformation of an odon-
togenic cyst in a period of 10 years. Case Rep Dent 2014;2014:762969.
15. Muglali M, Sumer AP. Squamous cell carcinoma arising in a residual cyst: a case
report. J Contemp Dent Pract 2008;9(6):115–21.
16. Park HK, Kim TS, Geum DH, et al. Mandibular intraosseous squamous cell carci-
noma lesion associated with odontogenic keratocyst: a case report. J Korean As-
soc Oral Maxillofac Surg 2015;41(2):78–83.
17. Kallianpur S, Jadwani S, Misra B, et al. Ameloblastic carcinoma of the mandible:
report of a case and review. J Oral Maxillofac Pathol 2014;18(Suppl 1):S96–102.
18. Slootweg PJ, Müller H. Malignant ameloblastoma or ameloblastic carcinoma. Oral
Surg Oral Med Oral Pathol 1984;57(2):168–76.
19. Das S, Kirsch CF. Imaging of lumps and bumps in the nose: a review of sinonasal
tumours. Cancer Imaging 2005;5:167–77.
20. Yamaguchi S, Nagasawa H, Suzuki T, et al. Sarcomas of the oral and maxillofacial
region: a review of 32 cases in 25 years. Clin Oral Investig 2004;8(2):52–5.
21. Chittaranjan B, Tejasvi MA, Babu BB, et al. Intramedullary osteosarcoma of the
mandible: a clinicoradiologic perspective. J Clin Imaging Sci 2014;4(Suppl 2):6.
 Diagnostic Imaging of Malignant Tumors 23

22. Pontes HA, Pontes FS, de Abreu MC, et al. Clinicopathological analysis of head
and neck chondrosarcoma: three case reports and literature review. Int J Oral
Maxillofac Surg 2012;41(2):203–10.
23. Rao BH, Rai G, Hassan S, et al. Ewing’s sarcoma of the mandible. Natl J Maxil-
lofac Surg 2011;2(2):184–8.
24. Ugar DA, Bozkaya S, Karaca I, et al. Childhood craniofacial Burkitt’s lymphoma
presenting as maxillary swelling: report of a case and review of literature.
J Dent Child (Chic) 2006;73(1):45–50.
25. Hirshberg A, Shnaiderman-Shapiro A, Kaplan I, et al. Metastatic tumours to the
oral cavity—pathogenesis and analysis of 673 cases. Oral Oncol 2008;44(8):
743–52.
26. Hirshberg A, Buchner A. Metastatic tumours to the oral region. An overview. Eur J
Cancer B Oral Oncol 1995;31B(6):355–60.
27. Varghese G, Singh SP, Sreela LS. A rare case of breast carcinoma metastasis to
mandible and vertebrae. Natl J Maxillofac Surg 2014;5(2):184–7.
28. Ruggiero SL, Dodson TB, Fantasia J, et al, American Association of Oral and
Maxillofacial Surgeons. American Association of Oral and Maxillofacial Surgeons
position paper on medication-related osteonecrosis of the jaw—2014 update.
J Oral Maxillofac Surg 2014;72(10):1938–56.