GROUP 4 - Module 2

Group Members:
● Abayari, Omar Wilfred S.
● Alnajjar, Zaid
● Garcia, Duane Matthew
● Herrera, Erica Mae O.
● Ibañez, Izza Mae L.
● Inocencio, Alex Miguel P.
● Mercado, Mary Ylizabette F.
● Purugganan, Jasper Angelo B.
● Ruiz, Princess Angelique B.

LESSON 3: BENIGN TUMORS OF THE JAW

Jaw tumors and cysts are relatively rare growths or lesions that develop in the jawbone or the soft tissues
in the mouth and face. Jaw tumors and cysts sometimes referred to as odontogenic or nonodontogenic,
depending on their origin can vary greatly in size and severity. These growths are usually noncancerous
(benign), but they can be aggressive and expand, displace or destroy the surrounding bone, tissue and
teeth.

Treatment options for jaw tumors and cysts vary, depending on the type of growth or lesion you have, the
stage of growth, and your symptoms. Mouth, jaw and face (oral and maxillofacial) surgeons can treat your
jaw tumor or cyst usually by surgery, or in some cases, by medical therapy or a combination of surgery
and medical therapy.

Examples of benign tumors of the jaw:

1. Ameloblastoma - Usually non-cancerous (benign) tumor. It develops most often in the jaw near
the molars. The most common type is aggressive, forming large tumors and growing into the
jawbone.

Clinically: Often show a painless, slow-growing swelling or mass in the jaw or facial region. In
advanced cases, it can lead to facial asymmetry or deformity.

Radiographically: Frequently present as multilocular, "soap-bubble" or "honeycomb"

radiolucencies in the affected area. Occasionally, unilocular radiolucencies are seen, particularly
in smaller or early-stage lesions.

Histologically: Characterized by islands or nests of epithelial cells resembling ameloblasts,

which are surrounded by a fibrous stroma. These cells show palisading columnar basal cells with
reverse polarization and stellate reticulum-like cells in the center, typical of the follicular or
plexiform patterns.

2. Central giant cell granuloma - Benign lesions that grow from bone cells. They most often occur
in the front portion of the lower jaw.
 Clinically: It may present as a painless swelling or expansion of the affected area, with
occasional discomfort or loosening of adjacent teeth. In some cases, the overlying mucosa
appears normal, but there can be ulceration if the lesion is large.

Radiographically: Radiographically, CGCG typically appears as a well-defined, multilocular or

unilocular radiolucency, often with thinning or perforation of cortical bone. It may cause root
resorption or tooth displacement.

Histologically: The lesion is characterized by multinucleated giant cells scattered within a

background of spindle-shaped mononuclear cells. Hemorrhage, hemosiderin deposits, and areas
of osteoid formation may also be present. The overall appearance resembles other giant cell
lesions, necessitating careful diagnosis.

3. Dentigerous cyst - This is the most common form of cyst that affects the jaws. Most often these
cysts will occur around wisdom teeth that are not fully erupted, but they can also involve other
teeth.

Clinically:
● Appearance: Usually asymptomatic, but may present as a painless swelling. In rare
cases, it can cause facial asymmetry or tooth displacement.
● Location: Most often associated with impacted third molars or canines.

Radiographically: A well-defined, unilocular radiolucency surrounding the crown of an

unerupted tooth. The cyst appears attached at the cementoenamel junction (CEJ), and it may
cause root resorption of adjacent teeth.

Histologically: The cyst wall is lined by a thin layer of non-keratinized stratified squamous
epithelium. The connective tissue wall may show chronic inflammation, and the epithelial lining
can sometimes show hyp
erplasia.

4. Odontogenic keratocyst - Also referred to as a keratocystic odontogenic tumor because of its

tumorlike tendency to recur after surgical treatment. Although this cyst is typically slow growing,
it can still be destructive to the jaw and teeth if left untreated.

Clinically: It presents as a painless swelling, though it can sometimes cause significant bone
expansion.

Radiographically: It often appears as a well-defined, unilocular or multilocular radiolucent area.

It may cause cortical bone thinning and root resorption in adjacent teeth.
 Histologically: The OKC is lined by a parakeratinized stratified squamous epithelium, typically
5-8 cell layers thick. The epithelial lining is corrugated and flat, with a prominent basal layer of
palisaded, hyperchromatic cells. The cyst wall is thin, often without inflammation, and may
contain daughter cysts or islands of epithelium.

5. Odontogenic myxoma - This is a rare, slow-growing, benign tumor that occurs most often in the
lower jaw. The tumor can be large and aggressively invade the jaw and surrounding tissue and
displace teeth.

Clinically: Odontogenic myxoma often presents as a painless, slow-growing mass, leading to

facial asymmetry or displacement of teeth in the affected area. The overlying mucosa usually
appears normal unless ulceration occurs from trauma or secondary infection.

Radiographically: It is typically seen as a multilocular radiolucent lesion with a "honeycomb" or

"soap bubble" appearance. Margins may be well-defined or diffuse, and the lesion can cause root
resorption or tooth displacement.

Histologically: Histologically, odontogenic myxoma consists of a myxoid or mucoid stroma with

spindle-shaped or stellate cells embedded in a loose, gelatinous matrix. The tissue may show
delicate, randomly arranged collagen fibers with minimal vascularization.

6. Odontoma - The most common benign tumor of the jaw, has no symptoms but may interfere with
tooth development and eruption.

Clinically: Odontomas often present as painless, slow-growing masses in the jaw, sometimes
causing delayed eruption of permanent teeth. They are usually found incidentally during routine
dental exams.

Radiographically: Odontomas appear as radiopaque (dense, white) lesions with well-defined

borders, often surrounded by a radiolucent halo. There are two types: compound odontomas,
which show tooth-like structures, and complex odontomas, appearing as a disorganized mass of
dental tissues.

Histologically: Consist of a mix of enamel, dentin, cementum, and pulp tissue. Compound
odontomas display organized tooth-like formations, while complex odontomas present irregular,
disorganized dental tissue.
Other Types of Cysts and Tumors:
● Adenomatoid odontogenic tumor - This is a rare tumor of epithelial origin comprising 3% of all
the odontogenic tumors. It is a benign, painless, noninvasive, and slow-growing lesion, with a
relative frequency of 2.2-13% and often misdiagnosed as an odontogenic cyst on clinical
examination.
● Calcifying epithelial odontogenic tumor - A calcifying epithelial odontogenic tumor (CEOT) is
a locally invasive epithelial neoplasm characterized by the development of intraepithelial
structures, probably of an amyloid-like nature, which may become calcified and liberated as the
cells break down.
● Glandular odontogenic cyst - Defined as a rare odontogenic cyst that can develop in the
maxillofacial region with aggressive behavior. It tends to develop into enormous proportions with
high recurrence rates. The mandibular anterior area is the common site of occurrence of GOC,
and it appears as an asymptomatic slow-growing swelling.
● Squamous odontogenic tumor - The squamous odontogenic tumor (SOT) is a rare, benign,
locally infiltrative neoplasm of the jaws that appears to originate from the rests of Malassez,
gingival surface epithelium or from remnants of the dental lamina.
● Calcifying odontogenic cyst - It is a rare developmental odontogenic cyst with notable presence
of histopathological features which include a cystic lining demonstrating characteristic “Ghost”
epithelial cells with a propensity to calcify.
● Cementoblastoma - is a rare odontogenic tumor characterized by the formation of a mass of
cementum or cementum-like tissue attached to the roots of a tooth. Cementoblastoma are
distinctive but relatively uncommon tumors.
● Aneurysmal bone cyst - This is a pseudo-cystic lesion lacking an epithelial lining. It is a rapidly
growing and destructive bone lesion characterized by replacement of the normal bone with
fibro-osseous tissue containing blood-filled sinusoidal / cavernous spaces
● Ossifying fibroma - a rare non cancerous tumor made of bone tissue that forms within
connective tissue. These slow-growing tumors most commonly affect bones in your face,
especially the jawbones
● Osteoblastoma - Benign osteoblastoma is an osteoid and bone-forming benign tumor that most
frequently occurs in young adults and primarily involves the vertebral column, long bones, small
bones of the extremities and facial bones, including the jaw.
● Central fibroma - Central odontogenic fibroma (COF) is an extremely rare benign tumor that
accounts for 0.1% of all odontogenic tumors. It appears as an asymptomatic expansion of the
cortical plate of the mandible or maxilla.

Surgical removal is the main treatment for many types of jaw tumors and cysts. Depending on the
location and extent of your tumor or cyst, you may also need to have teeth removed or receive
reconstruction of your jawbone.

Tumor or cyst type Treatment

Dentigerous cysts - Extraction of associated tooth followed by

removal of the cyst
 Odontomas - Surgical removal

Ameloblastoma - Usually surgically removed

- Jaw reconstruction surgery
- Radiation therapy if surgery isn't an
option

Ameloblastic carcinoma - Surgical removal

- Radiation therapy
- Cryotherapy
- Chemotherapy

Central giant cell granulomas - Almost always cured with surgical

removal

Squamous cell carcinoma - Surgical removal

- Chemotherapy
- Radiation therapy

Osteosarcoma - Surgical removal

- Chemotherapy
- Radiation therapy

TREATMENT OPTIONS
Treatment options for jaw tumors and cysts vary, depending on the type of growth or lesion you have, the
stage of growth, and symptoms.

Mouth, jaw and face (oral and maxillofacial) surgeons can treat your jaw tumor or cyst usually by surgery,
or in some cases, by medical therapy or a combination of surgery and medical therapy.

CASE REPORT
“Multidisciplinary management of an advanced mandibular ameloblastoma: Etiopathogenesis,
surgical management and prosthetic rehabilitation”

The ameloblastoma is a benign but locally aggressive epithelial odontogenic neoplasm. Although rare, the
ameloblastoma is the most common odontogenic tumor associated with the maxillofacial complex which
possesses a significant propensity for local recurrence in the setting of conservative treatment.

CASE OVERVIEW
A patient was referred for management of an extensive ameloblastoma associated with the left mandible.
Management consisted of a bilateral composite mandibular resection and reconstruction via free tissue
transfer utilizing an osteocutaneous fibular free flap.

Histopathologic analysis confirmed the diagnosis of a conventional ameloblastoma. Delayed oral

rehabilitation employing virtual surgical planning to facilitate the placement of endosseous implants with
immediate loading of a fixed acrylic prosthesis was accomplished in the post-operative period without
any evidence of recurrence.
CASE PRESENTATION
Patient Information:
● Age: 31 year old
● Gender: Male

Chief Complaint
The patient endorsed a four-year history of an indolent left mandibular mass which had recently
demonstrated accelerated and painful growth with intermittent episodes of intraoral bleeding.

SYMPTOMS
Clinically, it may be manifested by a wide range of symptoms including:
● Expansion of the involved osseous structures
● Tooth mobility
● Pain
● Trismus
● Neurosensory disturbances

HISTOLOGICAL FEATURES
It includes a presence of a lesion which is:
● Well-defined
● Corticated
● And either homogeneously radiolucent or multilocular with the presence of multiple curvilinear
septations
● Considerable expansion of adjacent osseous cortices
● Potential extension of the lesion into the adjacent soft tissues

Pre-operative right lateral (A), frontal (B) and left lateral (C) clinical photographs
selective axial bone window (D), three-dimensional reconstruction (E) and axial soft tissue window (F)
non-contrast enhanced computed tomographic images demonstrating the presence of an expansile and
multicystic mass associated with the left mandibular and ramus body.

CLINICAL FINDINGS
● A firm mass associated with the left mandible which was not tender to palpation.
● There was no palpable cervical lymphadenopathy and the temporomandibular joint range of
motion was within functional limits.
● Cranial nerves II to XII were grossly intact in a bilateral fashion. The left mandibular second
premolar and second molar were mobile but not sensitive to percussion.

RADIOGRAPHIC FINDINGS
● CT imaging demonstrated the presence of expansile and multilocular mass with both solid and
cystic regions associated with the left mandibular.
● The mass had effaced the oropharyngeal airway but there was no imminent concern for airway
embarrassment.

HISTOPATHOLOGY
● Presence of a completely excised conventional ameloblastoma which was characterized by a
multitude of histologic patterns, including the follicular, plexiform and acanthomatous variants.
● Representative high-power (20X) hematoxylin and eosin stained photomicrograph of the
resection specimen demonstrating features consistent with a conventional follicular
ameloblastoma

DIAGNOSIS
A community-acquired panoramic radiograph demonstrated the presence of a well-defined, corticated,
expansile and multilocular entity occupying the entirety of the left mandibular body and inferior segment
of the left mandibular ramus.

An incisional biopsy was rendered prior to his referral which revealed the presence of a conventional
ameloblastoma.
 ● Incisional Biopsy is the removal of a portion or sample from the edge of the lesion with some
normal tissue for identification of the lesion.

TREATMENT PLAN
Upon discussion with the patient, the decision was made to proceed with a segmental mandibular
resection and immediate mandibular reconstruction with free tissue transfer.

Due to COVID-19, unfortunately the preoperative course of this patient was complicated by
symptomatic deterioration due to inability to access the elective operating room. During this period, there
was considerable growth of the already substantial tumor as well as severe localized secondary infections.
This then required multiple courses of antibiotic therapy as well as intraoral incision and drainage
procedure to temporize the patient as he awaited operative scheduling.

TREATMENT PROGRESS
ANESTHESIA- The use of sedation or general anesthesia to prevent pain and discomfort during dental
procedure by numbing a specific area.
● After reaching the operating room, induction of general anesthesia was done.
● Oral endotracheal intubation was converted to a tracheostomy which facilitated the subsequent
extraction of the right mandibular canine tooth.

EXCISION - The removal of a growth, tissue, organ, or bone with a cutting instrument like a scalpel or
laser.
● Then, excision of the left submandibular cutaneous sinus tract and composite resection of the left
and right mandible was made. Careful attention was paid to the buccal, marginal and zygomatic
branches of the left facial nerve which were circumferentially dissected off the superficial aspect
of the tumor.

RESECTION - Surgery to remove tissue or part or all of an organ.

● Resection margins were fashioned in the positions of the right mandibular canine and a region
inferior to the left condylar neck allowing for the extirpation of the mass after the application of
maxillomandibular fixation with Erich arch bars.

RECONSTRUCTION - Surgery that is done to reshape or rebuild (reconstruct) a part of the body
changed by previous surgery.
● A reconstruction plate was then contoured in a free-hand fashion and affixed to the left
mandibular condylar neck and body of the right mandible for the inset of the harvested right
fibular free-flap into a three-segment defect. Maxillomandibular fixation was subsequently
released and the premorbid occlusion was noted to be maintained.
● The skin paddle associated with the fibular flap was used to reconstruct the large mucosal defect
within the oral cavity.
 INTRAOPERATIVE CLINICAL PHOTOGRAPHS and PHOTOMICROGRAPH

Clinical photographs demonstrating the initial tumor dissection (A), tumor resection with the associated
soft and hard tissue defects (B), inset of the right fibular free flap (C) and resected tumor specimen (D)
The procedure was completed in an uneventful fashion and the post-operative course in hospital was
uncomplicated.

POST OPERATIVE CLINICAL and INTRAORAL PHOTOGRAPHS with PANORAMIC

RADIOGRAPH

Post-operative right lateral (A), frontal (B), left lateral (C) and intraoral clinical photographs
demonstrating healed transcervical incisions (D & E), adequate facial symmetry and continuity of the soft
tissues within the oral cavity. Panoramic imaging (F) reveals an absence of disease recurrence and the
presence of a fibular free flap with associated hardware and osseous union between the native mandible
and individual fibular segments.

Two-years after primary reconstruction, there was no radiographic or clinical evidence of recurrence and
the decision was made to proceed with oral rehabilitation.\

As the patient expressed keen interest in aesthetic and functional rehabilitation in as short a period as
possible, virtual surgical planning was employed to design a guided approach for endosseous implant
placement and immediate loading of a fixed prosthesis.
 ● ANESTHESIA
○ Procedure was carried out under deep intravenous procedural sedation.

● PROCEDURE
○ Endosseous implants were then placed with the aid of a surgical guide in the edentulous
left first molar and first premolar as well as left and right lateral incisor regions, engaging
the superior and inferior cortices of the fibular graft. Immediate insertion of the
provisional fixed acrylic prosthesis was then achieved with the use of an occlusal index to
ensure the virtually planned occlusion would be obtained.

INTRAOPERATIVE CLINICAL PHOTOGRAPHS FOLLOWING PLACEMENT OF

IMPLANTS with PANORAMIC RADIOGRAPH

Virtual surgical planning images (A) Clinical photographs following the placement of implants within the
grafted mandible (B) and insertion of the interim prosthesis with the occlusal index (C). Post-operative
open-mouth (D) and closed-mouth (E). Panoramic image demonstrating the interval appearance of four
endosseous implants within the grafted mandible (F).

DISCUSSION
The initial curative management of gnathic ameloblastomas may be achieved via either conservative or
radical surgical approaches. Conservative procedures include enucleation, curettage, peripheral
ostectomy, cryotherapy and chemical cauterization. Radical treatment is best characterized by either
marginal or segmental resection with either early, delayed or a complete absence of hard and soft tissue
reconstruction.
While careful consideration is often given to both the reconstruction of the hard and soft tissues, a
secondary goal of functional restoration includes neurosensory recovery. Large defects involving the
inferior alveolar nerve following mandibular resection, repair with autogenous graft harvest from either
the greater auricular or sural nerves can be achieved with excellent success.

The use of virtual surgical planning (VSP) has revolutionized planning for reconstructive surgery. It has
reduced operative times and enhanced surgical results through increased predictability and accuracy.
Dental rehabilitation is an integral phase of the reconstructive process. One of the primary goals of
mandibular reconstruction is to provide the osseous architecture to facilitate endosseous implant
placement. The survival of endosseous implants within composite free flaps is critical in achieving the
requisite support for dental prostheses to enhance mastication, speech and facial aesthetics.
LESSON 4: MALIGNANT LESIONS

Malignant Tumors of the Oral Cavity

Oral cavity malignancies can originate from a range of tissues, including the salivary glands, musculature,
and blood vessels, or may present as metastatic lesions from distant primary tumors. However, the most
prevalent form of oral cancer is squamous cell carcinoma (epidermoid carcinoma), which primarily arises
from the epithelial lining of the oral mucosa. These carcinomas are often initially detected by dentists
during comprehensive oral examinations, underscoring the critical role of routine dental check-ups in
early cancer diagnosis and intervention.

Most common type of oral cancer:

Squamous cell carcinoma accounts for over 90% of oral cavity cancers. The oral cavity and oropharynx
are typically lined with squamous cells, which are flat, scale-like epithelial cells observable under a
microscope. Squamous cell carcinoma arises when genetic mutations cause these normally healthy cells
to become abnormal, leading to uncontrolled growth and malignancy.

Clinically: It presents as a firm, scaly, or crusted lesion that may ulcerate or bleed.

Radiographically: It can appear as a poorly defined, destructive mass, particularly in areas where it
affects deeper tissues, such as the lungs or bones.

Histologically: Is characterized by atypical squamous cells with enlarged, irregular nuclei, and evidence
of keratinization, including keratin pearls. It often shows invasion into surrounding tissues and an
inflammatory response.

Less common type of oral cancer:

1. Verrucous carcinoma: About 5 percent of all oral cavity tumors are verrucous carcinoma, a very
slow-growing cancer of squamous cells. This type of oral cancer rarely spreads to other parts of
the body, but it may invade nearby tissue.

Clinically: It presents as a slow-growing, exophytic, warty lesion with a rough surface, often seen
on mucosal surfaces such as the oral cavity or skin.

Radiographically: In radiographs may show bone destruction or invasion if it extends deeper,

particularly in oral lesions.

Histologically: Verrucous carcinoma displays broad, well-differentiated epithelial projections

with minimal cytologic atypia. The tumor invades the underlying tissue with pushing rather than
infiltrating borders, and there is an absence of the typical keratin pearls seen in more aggressive
carcinomas.

2. Minor salivary gland carcinomas: This disease includes several types of oral cancer that may
develop on the minor salivary glands, which are located throughout the lining of the mouth and
 throat. These include adenoid cystic carcinoma, mucoepidermoid carcinoma and polymorphous
low-grade adenocarcinoma.

Clinically: Clinical photos may show a localized swelling or ulceration.

Radiographically: Radiographs are generally non-specific but may reveal bone involvement if
the tumor invades surrounding structures.

Histologically: Histologically, the tumor can show infiltrative growth with varied cellular
patterns, such as ductal or cribriform structures, depending on the subtype (e.g., adenoid cystic
carcinoma or mucoepidermoid carcinoma). Perineural invasion is a common feature in some
types, particularly adenoid cystic carcinoma.

3. Lymphoma: Oral cancers that develop in lymph tissue, which is part of the immune system, are
known as lymphomas. The tonsils and base of the tongue both contain lymphoid tissue.

Clinically: Clinically, it may present as painless, enlarged lymph nodes, often in the neck,
armpits, or groin.

Radiographically: Radiographs can show masses or enlarged lymph nodes, particularly in the
chest or abdomen.

Histologically: Is characterized by abnormal lymphocytes, with specific features depending on

the subtype, such as Reed-Sternberg cells in Hodgkin lymphoma or various lymphocytic
infiltrates in non-Hodgkin lymphoma.

4. Mucosal melanoma: Mucosal melanoma is a rare disease that forms in the moist membranes
lining the inside of the body rather than in the skin.

Clinically: It often presents as an irregular, pigmented lesion or ulceration in mucosal areas such
as the oral cavity, nasal cavity, or genital tract.

Radiographically: Radiographs may reveal localized or diffuse lesions, sometimes with bone
involvement.

Histologically: Typically shows nests of atypical melanocytes in the mucosal epithelium and
underlying stroma, with variable pigmentation and often marked by a high mitotic rate and
infiltrative growth pattern.
Possible pre-cancerous conditions:
Benign oral cavity tumors: Various non-cancerous tumors and tumor-like conditions can develop in the
oral cavity and oropharynx (posterior throat region). Although these lesions are benign, they may
occasionally undergo malignant transformation. As a precautionary measure, benign tumors are
frequently excised surgically to mitigate the risk of future cancer development. The types of benign oral
lesions include:
● Eosinophilic granuloma
● Fibroma
● Granular cell tumor
● Keratoacanthoma
● Leiomyoma
● Osteochondroma
● Lipoma
● Schwannoma
● Neurofibroma
● Papilloma
● Condyloma acuminatum
● Verruciform xanthoma
● Pyogenic granuloma
● Rhabdomyoma
● Odontogenic tumors (lesions that begin in tooth-forming tissues)

Clinical staging refers to assessing the extent of the disease before undertaking treatment and has two
purposes:
1. Selection of the best treatment
2. Meaningful comparison of the end results reported from different sources

Staging of clinical lesions is crucial for several types of oral malignancies, including squamous cell
carcinomas (epidermoid carcinomas) and oral lymphomas. The staging process varies based on the
specific type of malignancy and may involve a range of diagnostic procedures, such as radiography, blood
tests, and, in some cases, surgical exploration of other body regions to assess the potential spread of the
tumor (metastasis).

Treatment Modalities for Malignancies

The treatment for any given case depends on several factors, including the
1. Histopathologic diagnosis
2. Location of the tumor
3. Presence and degree of metastasis
4. The radiosensitivity or chemosensitivity of the tumor
5. The age and general physical condition of the patient
6. Experience of the treating clinicians,
7. and the wishes of the patient.
When regional lymph node involvement is suspected, radiation therapy may be administered either pre- or
post-operatively to target residual malignant cells in adjacent tissues.

In cases of systemic metastasis, or when dealing with particularly chemosensitive tumors, such as
lymphomas, chemotherapy may be employed as a primary treatment, either in isolation or in combination
with surgery and radiation.

Modern treatment of malignancies frequently takes place in specialized institutions, where

multidisciplinary teams collaborate to determine optimal therapeutic approaches. These multidisciplinary
teams, or "tumor boards," typically comprise a surgeon, a medical oncologist, and a radiation oncologist.
In the management of head and neck cancers, additional experts often include a general dentist,
maxillofacial prosthodontist, nutritionist, speech pathologist, and, when necessary, a sociologist or
psychiatrist to address psychosocial aspects of care.

● Radiotherapy
○ Radiotherapy for the treatment of malignant neoplasms is based on the fact that tumor
cells in stages of active growth are more susceptible to ionizing radiation compared with
adult tissue. The faster the cells are multiplying or the more undifferentiated the tumor
cells, the more likely it is that radiation will be effective.
○ Radiation prevents the cells from multiplying by interfering with their nuclear material.
Normal host cells are also affected by radiation and must be protected as much as
possible during treatment
○ Fractionation of the delivery of radiation means that instead of giving the maximal
amount of radiation a person can withstand at one time, smaller increments of radiation
(i.e., fractions) are given over several weeks, which allows the healthier normal tissues
time to recover between doses.
● Chemotherapy
○ Chemicals that act by interfering with rapidly growing tumor cells are used for treating
many types of malignancies. As with radiation, the chemicals are not totally selective but
affect normal cells to some extent.
○ Given intravenously
○ To reduce the toxicity of a single agent given in large quantities, multiple-agent therapy is
frequently administered.
● Surgery
○ The surgical procedures for excision of oral malignancies vary with the type and extent of
the lesion. Small epidermoid carcinomas that are in accessible locations and are not
associated with palpable lymph nodes can be excised
○ Malignancies of the oral cavity that have suspected or proven lymph node involvement
are candidates for composite resection in which the lesion, surrounding tissues, and
lymph nodes of the neck are totally removed.
CASE REPORT

“A Rare Case of Malignant Melanoma of the Mandible: CT and MRI Findings”

CASE OVERVIEW
Malignant melanoma of the oral cavity is extremely rare. It is a malignant tumor of melanocytes or their
precursor cells and is often mistaken for a benign pigmented condition. The prognosis for this condition is
generally poor. Oral malignant melanoma is an aggressive neoplasm that accounts for less than 0.5% of
all melanomas, most commonly affecting the palate and maxillary gingiva, while the mandible, tongue,
buccal mucosa, and lips are less frequently involved. Although a few reports have described imaging
findings of malignant melanoma in the oral cavity, detailed computed tomography (CT) and magnetic
resonance imaging (MRI) findings for mandibular gingival melanoma remain limited. Here, we present a
rare case of malignant melanoma of the mandible along with its associated CT and MRI findings.

CASE PRESENTATION
The patient, a 51-year-old man, had a swelling on the right side of his mandible that had been growing
over 6 months. Upon examination, the tumor was described as a soft tissue mass measuring 4.0 by 5.5cm,
with varying appearances from gray to black and soft to firm. Characteristics of the tumor included being
easily bleeded, lobulated, and having a rubbery consistency. The patient had no significant past medical
history or family history.

PATIENT’S INFORMATION
● Age: 51 year old
● Gender: Male

CHIEF COMPLAINT
● A patient presented with a swelling on the right side of the mandible that had developed over 6
months.

PAST MEDICAL HISTORY

● He had no significant past medical or family history.

CLINICAL FINDINGS
● During clinical examination, the tumor presented as a soft tissue mass measuring 4.0 × 5.5 cm. Its
appearance ranged from gray to black, with varying textures from soft to firm. The tumor was
easily prone to bleeding, had a lobulated structure, and exhibited a rubbery consistency.

RADIOGRAPHIC FINDINGS
● Panoramic imaging revealed bone destruction in the right mandibular molar area. Axial CT scan
displayed an expansile mass in the right mandible with buccal and lingual extension, showing
heterogeneous enhancement. Sagittal CT scan indicated irregular alveolar bone destruction in the
right mandibular molar region. MRI findings included a homogeneous expansile mass with
intermediate-signal intensity on T1-weighted images and high T1-weighted signal intensity in
part of the melanoma. T1-weighted, contrast-enhanced MRI exhibited an enhancing mass.
T2-weighted MRI demonstrated the tumor with low to intermediate signal intensity and
 high-signal intensity. Soft tissue algorithm contrast-enhanced CT and MR images revealed
lymphadenopathy.

HISTOPATHOLOGY:
● Tumor cells had spindle shape
● Atypical nuclei with distinct nucleoli

DIAGNOSIS
● Immunohistochemical studies revealed positivity for S-100 and Melan A. The conclusive
histopathological diagnosis was malignant melanoma.

TREATMENT:
● A segmental mandibulectomy with radical neck dissection was performed under general
anesthesia

PANORAMIC IMAGING

SHORT TI INVERSION RECOVERY (STIR) IMAGES

AXIAL MR IMAGING APPEARANCE

DISCUSSION
Malignant melanoma of the mandibular gingiva is extremely rare. McLean et al. reviewed 22 cases of
primary sinonasal melanoma and 8 oral cavity melanomas, with a mean patient age of 67.5 years, 60% of
whom were male. Smith et al. identified 46 cases of oral melanomas, with 68.8% located in the maxillary
mucosa and 16% in the mandibular mucosa. Imaging findings vary: panoramic radiographs typically
reveal bone loss or ill-defined radiolucencies, while CT scans show bone destruction, soft tissue
expansion, and lymph node involvement. MRI findings often show high signal intensity on T1-weighted
images due to melanin and hemorrhage, which enhances tumor visibility. In this article, a case of a
51-year-old male with malignant melanoma of the mandibular gingiva is presented, and it is noted that
melanoma tends to enhance well on contrast imaging due to its rich vascular network.
References:
● Types of oral cancer: most common type. (n.d.). City of Hope.

https://www.cancercenter.com/cancer-types/oral-cancer/types

● A Rare Case of Malignant Melanoma of the Mandible: CT and MRI Findings. (2017). Chinese

Journal of Dental Research/˜the œChinese Journal of Dental Research, 20(2), 111–114.

https://doi.org/10.3290/j.cjdr.a38276

● Hupp, J. R., Ellis, E., III, & Tucker, M. R. (2019). Contemporary oral and maxillofacial surgery.

STOMATOLOGY EDU JOURNAL, 6(4), 277.

https://doi.org/10.25241/stomaeduj.2019.6(4).bookreview.1