- Email: [email protected]
A stereosialographic study of developmental mandibular bone defects (Stafne's idiopathic bone cavities)
OrighTalReports
Int. J. Oral Surg. 1975: 4:51-54 bone cavities; bone dejects; nlandible, developmental dejects; radiography; sialography) ( K e y words:
A stereosialographic study of developmental mandibular bone defects (Stafne's idiopathic bone cavities) VALLE J. OIKARINEN, JUHANI WOLF AND MAILA JULKU
Departments of Oral Surgery and Dental Roentgenology, Institute oJ Dentistry, University o/Helslnki, Helsinki, Finland
ABSTRACT-- The purpose of the study was to investigate with the aid of stereosialography and orthopantomography, the connection between developmental mandibular bone defects and the submandibular salivary gland. In sialographies on seven patients, there were two cases in which the contrast medium was found, with certainty, to fill the lobe of the submandibular salivary gland in the area of the bone defect. In four cases the contrast medium ended in the immediate vicinity of the defect, in one case no conclusive result was obtained. The results of the study suggest that the developmental mandibular bone defect and the lobe of the submandibular salivary gland being in close contact with the lingual surface of the mandible have a probable etiologic causal connection, at least in a number of cases.
(Received/or publication 9 November, accepted 20 November 1974)
The bone cavity in flue region of the mandibular angle, beneath the mandibular canal, is a defect-like change of the mandibular bone structure occurring mainly in middle-aged or old men, with an incidence of one per thousand population, t4 Certain recent observations suggest that this might really be a developing bone defeet, growing slowly with age~4, e~. S T A F N E ~0 was the first to assume that there is a common background factor, but to date no such factor has been ascertained. Since the bone defect is located on the lingual surface of the mandibIe, close to the mandibular angle, the participation of the submandibu-
lar salivary gland in the formation of the bone defect has been considered one of the most probable causes. Verification on this point has been sought by means o f sialography 19, and indications in this direction have also been provided by surgical procedures used in treating the defectt,4,n,L~, la, On the other hand, negative surgical findings in relation to the salivary gland tissue have been equally frequent 2, z, ~, 0,10,is, x~,~1. The purpose of the present study was to analyze, with the aid of stereosialography and orthopantomography, the relationship between the submandibular gland a n d the developmental mandibuIar bone defect.
52
OIKARINEN, WOLF AND JULKU
Table 1. Stereosialographic findings of submandibular salivary glands in cases of developmental mandibular bone defects
Case
Location of defect in mandible
Relation of submandibular salivary glands to mandibular bone defect
Age in years
Sex
1
45
M
L
+
2 3 4 5 6 7
48 50 52 59 61 66
M M M M M M
R R R L L R
++++ +-k-++ ++ + + + ++ ++ +
+ + + + Contrast medium + + + Contrast medium defect. + + Contrast medium + Contrast medium dibular surface.
in the ducts of the defect area. in the ducts that extend to (are situated at) the very margin of the in the ducts in the neighborhood of the defect. in the ducts in the direction of, but not very close to, the inner man-
Material and methods The study was carried out at the I-Ielsinki University Institute of Dentistry. The series consisted of seven patients whose orthopantomograms revealed a developmental mandibular bone defect. These patients underwent sialography of the submandibular salivary gland on the side of the defect, with "Dionosil| aqueous" (Glaxo) as the contrast medium. These stereo-orthopantomograms were examined separately by two persons familiar with stereoradiography. Their interpretations agreed.
Results In the sialograms of two of the six patients of t h e series (Table 1), contrast medium could b e seen in the lobes of the submandibular gland, parts of which were situated inside the m a n d i b u l a r cavities (Fig. 1). In four cases, contrast m e d i u m was seen in isolated branches of the duct of the glandular lobe, terminating right at the margin of the b o n e cavity. In these cases the contrast m e d i u m failed to enter the very smallest ductules. In one case, separate fine
branches filled with contrast medium were discernible at the bone defect, but in the stereoradiegram it could be seen that they were not situated in the immediate neighborhood of the lingual aspect of the bone.
Discussion A n y verifiable information we have of the developmental bone defects seen in radiograms is based primarily on observations made on skulls,S, I1 and on certain operative findings. KAYit, in his anthropologic study of dry mandibles, found seven idiopathic bone cavities. In these defects the surface of the floor structure varied f r o m rough and markedly corrugated to smooth with minor irregularities and pitting. Th e edge of the compact bone depression was either punched-out or shelving and the shape of the defect roughly circular or ovoid. Corresponding sporadic clinical observations have also been made in connection with operations r-', and they agreed with the radiographic findings. Unanimity ends here, for no findings suggestive of a uniform eti-
M A N D I B U L A R BONE D E F E C T
A
53
S
Fig. 1. Sialograms of submandibular salivary glands in cases of developmental bone defect, taken with the aid of the stereo-orthopantomographic method of radiography. A, the duct and its main branches are very well filled with contrast medium. The first major b r a n c h makes a sharp turn towards the bone defect on the lingual mandibular surface and breaks into fine branches that spread over the defect area to its buccal cortical wall. B, the first m a j o r branch leaves t h e submandibular main duct before its curve. A t first it runs parallei to the main duct, b u t at t h e lower border of the mandible it turns sharply upward and breaks up into a firte tree of ducts. The foremost of these finer branches runs towards the lingual surface of the mandible, while t h e terminal branches extend to the area of the bone defect.
ology h a v e b e e n discovered i n c o n n e c t i o n with surgery. I n a n u m b e r o.f cases the b o n e cavities h a v e b e e n emptya, ~, lo, 11,1 ~,as;
o t h e r s h a v e c o n t a i n e d l y m p h a t i c tissue% ~1 or m u s c l e 14. T h e p r e s e n t siaIographic study, however, u n d e n i a b l y suggests t h a t these
54
OIKARINEN, WOLF AND /ULKU
bone changes, at least in a number of cases, are connected with the lobes of the submandibular salivary gland. At the same time, none of our sialog~ms completely excluded the involvement of the submandibuIar salivary gland in these defects. A similar observation was reported by S~.whRI)z9 from his sialographic study e,f two patients. Also some observations made in conneetion with operations suggest a relationship between the submandibuIar salivary gland and these defects 1, 4, ~,~, 7, 9,10,z3. Age-dependent or, more especially, hypertrophic changes m a y be responsible for the mandibular bone defects developing and increasing in size after middle age. '~ A conclusion that can be drawn on the basis of our present stereosialographic study is that the developmental mandibular bone defect and a lobe, usually the upper lobe, of the submandibular salivary gland tangential to the lingual surface of the mandible have a probable etiologic relationship.
References I. AMARAL,W. L & IACOnS,D. S.: Aberrant sativary gland defect in the mandible. Oral Surg. 1961: 14: 748-752. 2. BERGENHOLTZ, A. & PgassoN, G.: Idiopathic bone cavities. Oral" Surg. 1963: 16: 703-710. 3. BERNSTEIN, I-I. F., LAM, 17.. C. & POMIJE, F. W.: Static bone cavities of the mandible. I. Oral Surg. 1958: 16: 46-52. 4. CHour,~s, N. C, & ToTo, P. D.: Etiology of static bone defects of the mandible. Y. Oral Surg. 1960: 18: 16-20. 5. ESCHLER, l.: t~ber rSntgenologische "zysteniihnliche" Aufhellungen im Winkel und im horizontalen Ast des Unterkiefers. Zahnaerztl. Welt Reform 1959: 60: 703706. 6. FORDYCB, G. L.: The probable nature of so-called latent haemorrhagic cysts of the mandible. Br. Dent. J. 1956: 10: 40--42. 7. GLANS, M. & Rtro, J.: Statiske knoglekaviteter i underkaeben. Tandlaegebladet 1962: 66: 241-246.
8. I-IARVEY,W. • NOBLE, H. W.: Defects on the lingual surface of the mandible near the angle. Br. I. Oral Surg. 1968: 6: 7583. 9. HAYES, FI.: Aberrant submaxillary gland tissue presenting as a cyst of the jaw. Oral Surg. 1961: 14: 313-316. 10. IAcons, M. H.: Traumatic hone cysts. Oral Surg. 1955: 8: 940-949. 11. KAY, L. W.: Some anthropologle investigations of interest to oral surgeons, lnt. J. Oral Surg. 1974: 3: 363-379. 12. KILLEY, H. C. & KAY, L. W.: Benign cystic lesions of the jaws. 2nd ed. E. & S. Livingstone, Edinburgh and London 1972, p. 109-112. 13. Klaga,AaxmK, T. L: Stafne's idiopathic bone cavity with complications in diagnosis. Dent. Mad. 1967: 84: 191-193. 14. OIKaRItqEtq, V. J. & JULKU, M.: An orthopantomographic study of developmental mandibular bone defects (Stafne's idiopathic bone cavities). Int. J. Oral Svrg. 1974: 3: 71-76. 15. OLECrI, E. & AROaA, B. K.: Lingual mandibular bone cavity. Oral Surg. 1961: 14: 1360-1366. 16. PETERSON, W.: Cyctic cavity in the mandible, g. Oral Surg. 1944: 2: 182-187. 1% PIr,rDBoRo, J. L & HJ~RTING-HANSEN, E.: Atlas of diseases of the laws. Munksgaard, Copenhagen 1974, p. 170-171. 18. RowE, N. L.: 1962. Cited by KILL~Y & KAy 1972. 19. S~WAI~D, G. R.: Salivary gland inciusions in the mandible, Br. Dent. J. 1960: 108: 321-325. 20. S~:xrmL E. C.: Bone cavities situated near the angle of the mandible. J. Am. dent. Assoc. 1942: 29: 1969-1972. 21. THOr~_A,K. H.: Case report of a so-called latent bone cyst, Oral Surg, 1955: 8: 963966. 22. TOLMAN,D. E. & STAFNE,E. C.: Developmental bone defects of the mandible. Oral Surg. 1967: 24: 488-490.
Address: Fabianinkatu 24 SF--O0100 Helsinki 10 Finland
Int. J. Oral Surg. 1975: 4:51-54 bone cavities; bone dejects; nlandible, developmental dejects; radiography; sialography) ( K e y words:
A stereosialographic study of developmental mandibular bone defects (Stafne's idiopathic bone cavities) VALLE J. OIKARINEN, JUHANI WOLF AND MAILA JULKU
Departments of Oral Surgery and Dental Roentgenology, Institute oJ Dentistry, University o/Helslnki, Helsinki, Finland
ABSTRACT-- The purpose of the study was to investigate with the aid of stereosialography and orthopantomography, the connection between developmental mandibular bone defects and the submandibular salivary gland. In sialographies on seven patients, there were two cases in which the contrast medium was found, with certainty, to fill the lobe of the submandibular salivary gland in the area of the bone defect. In four cases the contrast medium ended in the immediate vicinity of the defect, in one case no conclusive result was obtained. The results of the study suggest that the developmental mandibular bone defect and the lobe of the submandibular salivary gland being in close contact with the lingual surface of the mandible have a probable etiologic causal connection, at least in a number of cases.
(Received/or publication 9 November, accepted 20 November 1974)
The bone cavity in flue region of the mandibular angle, beneath the mandibular canal, is a defect-like change of the mandibular bone structure occurring mainly in middle-aged or old men, with an incidence of one per thousand population, t4 Certain recent observations suggest that this might really be a developing bone defeet, growing slowly with age~4, e~. S T A F N E ~0 was the first to assume that there is a common background factor, but to date no such factor has been ascertained. Since the bone defect is located on the lingual surface of the mandibIe, close to the mandibular angle, the participation of the submandibu-
lar salivary gland in the formation of the bone defect has been considered one of the most probable causes. Verification on this point has been sought by means o f sialography 19, and indications in this direction have also been provided by surgical procedures used in treating the defectt,4,n,L~, la, On the other hand, negative surgical findings in relation to the salivary gland tissue have been equally frequent 2, z, ~, 0,10,is, x~,~1. The purpose of the present study was to analyze, with the aid of stereosialography and orthopantomography, the relationship between the submandibular gland a n d the developmental mandibuIar bone defect.
52
OIKARINEN, WOLF AND JULKU
Table 1. Stereosialographic findings of submandibular salivary glands in cases of developmental mandibular bone defects
Case
Location of defect in mandible
Relation of submandibular salivary glands to mandibular bone defect
Age in years
Sex
1
45
M
L
+
2 3 4 5 6 7
48 50 52 59 61 66
M M M M M M
R R R L L R
++++ +-k-++ ++ + + + ++ ++ +
+ + + + Contrast medium + + + Contrast medium defect. + + Contrast medium + Contrast medium dibular surface.
in the ducts of the defect area. in the ducts that extend to (are situated at) the very margin of the in the ducts in the neighborhood of the defect. in the ducts in the direction of, but not very close to, the inner man-
Material and methods The study was carried out at the I-Ielsinki University Institute of Dentistry. The series consisted of seven patients whose orthopantomograms revealed a developmental mandibular bone defect. These patients underwent sialography of the submandibular salivary gland on the side of the defect, with "Dionosil| aqueous" (Glaxo) as the contrast medium. These stereo-orthopantomograms were examined separately by two persons familiar with stereoradiography. Their interpretations agreed.
Results In the sialograms of two of the six patients of t h e series (Table 1), contrast medium could b e seen in the lobes of the submandibular gland, parts of which were situated inside the m a n d i b u l a r cavities (Fig. 1). In four cases, contrast m e d i u m was seen in isolated branches of the duct of the glandular lobe, terminating right at the margin of the b o n e cavity. In these cases the contrast m e d i u m failed to enter the very smallest ductules. In one case, separate fine
branches filled with contrast medium were discernible at the bone defect, but in the stereoradiegram it could be seen that they were not situated in the immediate neighborhood of the lingual aspect of the bone.
Discussion A n y verifiable information we have of the developmental bone defects seen in radiograms is based primarily on observations made on skulls,S, I1 and on certain operative findings. KAYit, in his anthropologic study of dry mandibles, found seven idiopathic bone cavities. In these defects the surface of the floor structure varied f r o m rough and markedly corrugated to smooth with minor irregularities and pitting. Th e edge of the compact bone depression was either punched-out or shelving and the shape of the defect roughly circular or ovoid. Corresponding sporadic clinical observations have also been made in connection with operations r-', and they agreed with the radiographic findings. Unanimity ends here, for no findings suggestive of a uniform eti-
M A N D I B U L A R BONE D E F E C T
A
53
S
Fig. 1. Sialograms of submandibular salivary glands in cases of developmental bone defect, taken with the aid of the stereo-orthopantomographic method of radiography. A, the duct and its main branches are very well filled with contrast medium. The first major b r a n c h makes a sharp turn towards the bone defect on the lingual mandibular surface and breaks into fine branches that spread over the defect area to its buccal cortical wall. B, the first m a j o r branch leaves t h e submandibular main duct before its curve. A t first it runs parallei to the main duct, b u t at t h e lower border of the mandible it turns sharply upward and breaks up into a firte tree of ducts. The foremost of these finer branches runs towards the lingual surface of the mandible, while t h e terminal branches extend to the area of the bone defect.
ology h a v e b e e n discovered i n c o n n e c t i o n with surgery. I n a n u m b e r o.f cases the b o n e cavities h a v e b e e n emptya, ~, lo, 11,1 ~,as;
o t h e r s h a v e c o n t a i n e d l y m p h a t i c tissue% ~1 or m u s c l e 14. T h e p r e s e n t siaIographic study, however, u n d e n i a b l y suggests t h a t these
54
OIKARINEN, WOLF AND /ULKU
bone changes, at least in a number of cases, are connected with the lobes of the submandibular salivary gland. At the same time, none of our sialog~ms completely excluded the involvement of the submandibuIar salivary gland in these defects. A similar observation was reported by S~.whRI)z9 from his sialographic study e,f two patients. Also some observations made in conneetion with operations suggest a relationship between the submandibuIar salivary gland and these defects 1, 4, ~,~, 7, 9,10,z3. Age-dependent or, more especially, hypertrophic changes m a y be responsible for the mandibular bone defects developing and increasing in size after middle age. '~ A conclusion that can be drawn on the basis of our present stereosialographic study is that the developmental mandibular bone defect and a lobe, usually the upper lobe, of the submandibular salivary gland tangential to the lingual surface of the mandible have a probable etiologic relationship.
References I. AMARAL,W. L & IACOnS,D. S.: Aberrant sativary gland defect in the mandible. Oral Surg. 1961: 14: 748-752. 2. BERGENHOLTZ, A. & PgassoN, G.: Idiopathic bone cavities. Oral" Surg. 1963: 16: 703-710. 3. BERNSTEIN, I-I. F., LAM, 17.. C. & POMIJE, F. W.: Static bone cavities of the mandible. I. Oral Surg. 1958: 16: 46-52. 4. CHour,~s, N. C, & ToTo, P. D.: Etiology of static bone defects of the mandible. Y. Oral Surg. 1960: 18: 16-20. 5. ESCHLER, l.: t~ber rSntgenologische "zysteniihnliche" Aufhellungen im Winkel und im horizontalen Ast des Unterkiefers. Zahnaerztl. Welt Reform 1959: 60: 703706. 6. FORDYCB, G. L.: The probable nature of so-called latent haemorrhagic cysts of the mandible. Br. Dent. J. 1956: 10: 40--42. 7. GLANS, M. & Rtro, J.: Statiske knoglekaviteter i underkaeben. Tandlaegebladet 1962: 66: 241-246.
8. I-IARVEY,W. • NOBLE, H. W.: Defects on the lingual surface of the mandible near the angle. Br. I. Oral Surg. 1968: 6: 7583. 9. HAYES, FI.: Aberrant submaxillary gland tissue presenting as a cyst of the jaw. Oral Surg. 1961: 14: 313-316. 10. IAcons, M. H.: Traumatic hone cysts. Oral Surg. 1955: 8: 940-949. 11. KAY, L. W.: Some anthropologle investigations of interest to oral surgeons, lnt. J. Oral Surg. 1974: 3: 363-379. 12. KILLEY, H. C. & KAY, L. W.: Benign cystic lesions of the jaws. 2nd ed. E. & S. Livingstone, Edinburgh and London 1972, p. 109-112. 13. Klaga,AaxmK, T. L: Stafne's idiopathic bone cavity with complications in diagnosis. Dent. Mad. 1967: 84: 191-193. 14. OIKaRItqEtq, V. J. & JULKU, M.: An orthopantomographic study of developmental mandibular bone defects (Stafne's idiopathic bone cavities). Int. J. Oral Svrg. 1974: 3: 71-76. 15. OLECrI, E. & AROaA, B. K.: Lingual mandibular bone cavity. Oral Surg. 1961: 14: 1360-1366. 16. PETERSON, W.: Cyctic cavity in the mandible, g. Oral Surg. 1944: 2: 182-187. 1% PIr,rDBoRo, J. L & HJ~RTING-HANSEN, E.: Atlas of diseases of the laws. Munksgaard, Copenhagen 1974, p. 170-171. 18. RowE, N. L.: 1962. Cited by KILL~Y & KAy 1972. 19. S~WAI~D, G. R.: Salivary gland inciusions in the mandible, Br. Dent. J. 1960: 108: 321-325. 20. S~:xrmL E. C.: Bone cavities situated near the angle of the mandible. J. Am. dent. Assoc. 1942: 29: 1969-1972. 21. THOr~_A,K. H.: Case report of a so-called latent bone cyst, Oral Surg, 1955: 8: 963966. 22. TOLMAN,D. E. & STAFNE,E. C.: Developmental bone defects of the mandible. Oral Surg. 1967: 24: 488-490.
Address: Fabianinkatu 24 SF--O0100 Helsinki 10 Finland