Rapidly enlarging painful mandibular swelling with lip numbness

§Chief complaint

Fast-growing painful swelling of the jaw for 6 weeks

§Medical & dental history

• 01No previous radiotherapy or retinoblastoma
• 02No family history of cancer
• 03Recent onset of tooth mobility and paraesthesia

§Clinical examination

• 01Firm, tender, rapidly enlarging swelling of the right mandibular body with overlying skin tethering
• 02Loosening of 45, 46 without periodontal disease
• 03Numbness of the right lower lip
• 04No cervical lymphadenopathy

§ figuresFigures (3)

Verified open-access images only, reproduced for education under their stated licences · no AI-generated or illustrative artwork · Osteosarcoma of the Jaw figures pending faculty review.

§Differential diagnosis

§Final diagnosis

Conventional high-grade osteoblastic osteosarcoma of the right mandible

Symmetrical widening of the periodontal ligament space around teeth in the lesion, sunray periosteal reaction and rapid painful expansion with paraesthesia are the classic triad. Malignancy must be assumed until biopsy proves otherwise.

§Investigations

• 01OPG — sunray spiculation and symmetrical widening of the PDL of 45, 46
• 02CT and MRI — cortical destruction and soft tissue mass with medullary extension
• 03Incisional biopsy under GA
• 04Serum ALP, chest CT and PET-CT for staging

§Treatment plan

• 01Multidisciplinary sarcoma team management
• 02Neoadjuvant chemotherapy where protocol dictates
• 03Radical resection with wide margins as the mainstay
• 04Microvascular reconstruction and prosthetic rehabilitation
• 05Adjuvant chemotherapy based on necrosis rate

§Surgical procedure

• 01Segmental mandibulectomy with 2 cm margins and level I-III neck clearance for access
• 02Free fibula flap reconstruction with a reconstruction plate
• 03Frozen section confirmation of clear margins

§Histopathology report

Pleomorphic malignant spindle cells producing lacy osteoid, high mitotic rate with atypical forms, permeative infiltration of medullary bone. High-grade osteoblastic osteosarcoma; margins clear.

§Follow-up & outcome

• 01Adjuvant chemotherapy completed
• 02Surveillance imaging 3-monthly for 2 years
• 03Disease-free at 24 months; implant rehabilitation started

§Clinical pearls / learning points

• 01Jaw osteosarcoma presents about a decade later than long-bone osteosarcoma and metastasises less often, but local control is difficult.
• 02Symmetrical PDL widening in a single quadrant is a red flag for malignancy.
• 03Margin status is the strongest predictor of survival.

§Related diseases

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