Intended for healthcare professionals

Endgames Spot Diagnosis

Jaw pain

BMJ 2016; 354 doi: (Published 22 September 2016) Cite this as: BMJ 2016;354:i4799
  1. H L Adams, specialty registrar, radiology1,
  2. D C Howlett, consultant radiologist2
  1. 1Brighton and Sussex University Hospitals, Brighton, UK
  2. 2Department of Radiology, East Sussex Healthcare NHS Trust, Eastbourne, UK
  1. Correspondence to: H L Adams h.l.adams{at}

A 67 year old man presented with a 3-4 month history of mild discomfort in his right jaw, which had suddenly worsened. He was unable to open his mouth fully. He had no history of trauma and he was known to have a history of cirrhosis.

What does the plain radiograph show (fig 1)?


Fig 1 Anteroposterior radiograph of facial bones


An aggressive looking bone lesion in the right mandible suggests a pathological fracture.


The radiograph shows a pathological fracture secondary to a lytic, destructive lesion in the right mandible (indicated by the white arrow in fig 2). The lesion is ill defined, lytic, and permeative, resulting in a pathological fracture. Endosteal scalloping (erosion) of the adjacent mandibular cortex can be seen, with destruction medially. A wide zone of transition from abnormal to normal bone can be seen.


Fig 2 Anteroposterior radiograph of facial bones showing pathological fracture (white arrow) in right mandible, secondary to destructive lesion (black arrow), with a large amount of soft tissue swelling (S)

Pathological mandibular fractures are rare and account for up to 2% of mandibular fractures.1 Malignancy is the most common cause; myeloma involves the mandible more commonly than metastatic disease (breast, lung, prostate), whereas primary malignancy (osteosarcoma) is rare. Infection can have a similar appearance. Bisphosphonate induced and radiation induced osteonecrosis can also have an apparently destructive appearance.

Assessment by computed tomography and ultrasound guided biopsy of the right mandible confirmed a destructive lesion and soft tissue mass (fig 3). Histology of the tissue confirmed a metastatic hepatocellular carcinoma. This was a new diagnosis.


Fig 3 Axial section on bony window setting computed tomography, demonstrating a 3 cm expanded and destructive soft tissue mass in right mandible (white arrow)

The frequency of bone metastases from hepatocellular carcinoma varies from 4% to 20% in the literature, with one study reporting a rate as high as 28%.2 Treatment of pathological fractures of the mandible is often difficult as bone is limited or compromised by underlying disease, resulting in problematic fixation.


  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: none.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent: Obtained.


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