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An unusual case of “simple bone cyst” of the mandible
Int. J. Oral Surg. 1978: 7:32-35 (Key words: bone cyst, sL,nple; cyst, sh~lple; surgery, ort~l)
An unusual case of "simple bone cyst" of the mandible ANDERS HEIMDAflL
Department of Oral Surgery, Dental School, Huddinge, Sweden
AnST~CT -- Reviews of the literature show that simple bone cysts of the laws no lovtger can be considered rare. The clinical and radiographic appearances are mostly rather typical, but in some cases there are great variations. In this article an unusual case with both facial asymmetry and bilateral occurrence is described. The differential diagnosis between simple bone cysts, tumors, odontogenic cysts and vascular abnormalities is sometimes hard to establish. In those cases aspiration biopsy can be of great help.
(Received ]or publication 28 October 1976, accepted 5 lanual3, 1977)
Since the first reported case of simple bone cyst ( I C D - D A 526.21) of the mandible7, more than 200 cases have been reported in the literature. Excellent reviews of the literature-~,6, t0 have been made, including some recent reviewsqs, tL F r o m these reviews it is easy to select the "typical case". This is a m a n or a woman between 15 and 20 years old without symptoms in the jaws. During routine radiography a rather large cystic lesion is found in the mandible. It has no sclerotic lining like an odontogenic cyst. There is a scalloping appearance between the roots of the adjacent teeth but there is no evidence that it originates from any of them. Clinically all teeth appear to be vital. A surgical intervention has to be done to confirm the diagnosis "simple bone cyst". During surgery an empty cavity or a cavity filled with sanguinoserous liquid is
found. There is no soft tissue lining of the cavity. The histopathologic findings reveal no signs of tumor, cysts or inflammation. The postoperative healing is uneventful and completed in 1-3 yem's. Aside from this "typical ease", great variation may be seen both in the age of the patients and the clinical appearance of the cyst. This variation has been very well described in several articIes~,4,5,R. In many (24 %)~ of the reported cases a slight swelling of the affected jaw has been noticed. In a few cases the expansion has produced a disfiguration of the face~0,18. Seven cases of bilateral lesions in the mandible have been reported l, 8, 5, s, 12,a4. The following case has both striking facial asymmetry and bilateral lesions in the mandible, and may therefore be of interest to describe.
M A N D I B U L A R SIMPLE BONE CYST
Fig. 1. The simple bone cyst caused considerable facial disfiguration.
Case report A young man, 16 years of age, was referred to the Department of Oral Surgery, Dental School, Huddinge, because of facial swelling of the right mandible (Fig. 1). H e was free from other symptoms and there were no signs
33
of inflammation. T h e swelling had been present for several years and he denied t r a u m a to the jaws. All his teeth were vital a n d i n excellent condition. On the o r t h o p a n t o m o g r a m two cystic lesions were visible. In t h e corpus of the right mandible a lesion 7 • 3 cm w i t h a scalloping appearance between the roots of the adjacent teeth caused a considerable expansion of the cortex (Figs. 2, 3). In the region of the canine and the premolars of the left m a n d [ b t e a cyst-like radioluceney 2.5 • 2.5 cm was found. None of the teeth had deep caries or evidence of apical inflammation. Aspiration biopsy from the lesions was m a d e and sanguinoserous liquid was aspirated f r o m both sides. In this liquid histiocyte-like resorption cells and some erythrocytes were found. There were no signs of epithelial cells or malignancy. Laboratory findings, including calcium and phosphorus of serum and urine, were normal. A preliminary diagnosis of bilateral "simple bone cysts" was made. TREATMENT Surgery was performed to. confirm the diagnosis. In general anesthesia buccal m u c o periosteal flaps were raised and the lesions were fenestrated. O n both sides sanguinoserous liquid was found. T h e r e were n o signs of cystlining or soft tissue. In the cyst of the right mandible the neurovascular b u n d l e h u n g free from the roots of the teeth (Fig. 4). Curettage
Fig. 2. Orthopantomographic radiogram shows the bilateral lesions.
34
HEIMDAHL
Fig. 3. There was a large expansion of the mandible in buccollngual direction.
Fig. 4. Inside the cyst the neurovascular bundle (arrow) hangs free from the roots of the teeth.
was performed. The he,fling was normal and 3 months after the operation radiographic evidence of bone healing was noticed.
ever, surgical intervention is necessary to make the proper diagnosis. The lesion ahnost invariably heals in 1-3 years after surgery. It not known whether the single bone cyst can regress spontaneously, but there are cases reported with spontaneous resolution 12.
Discussion T h e etiology of the simple bone cysts is obscure, and several theories exist. The oldest and most widely held theorya is that it is the failure to heal of a traumatically induced infrabony hemorrhage which leaves a more or less empty cavity. BEASLEYt, in his article on 30 cases, gives an interesting discussion on the different theories. The relationship between giant cell tumors, simple bone cysts and "Stafne's bone cavities" has been discussed 1~ Investigations of the intracystic pressure and intracystic osmotic tension have also been madel~. Regardless of the etiology one of the problems of simple bone cysts is the differential diagnosis from other cysts, tumors and vascular abnormalities. Aspiration biopsy is a good aid for establishing a correct preliminary diagnosis. Sometimes the bone is hard to perforate, and a needle made for bone m a r r o w aspiration from the sternum is therefore helpful. In most cases, how-
References l. BEASISEY,J. D., IiI: Traumatic cysts of the jaws. Report of 30 cases. J. AnL Dent. Assoc. 1976: 92: 145-152. 2. GARDNER,A. F., STOJ_J~Ea, S. M. & S'nalO, J. M.: A study os the traumatic bone cyst of the jaws. J. Can. Dent. Assoc. 1962: 28: 151-166. 3. GRASSO, A. M., DEMKEn, D. & FINNnGAN, J.: Traumatic cyst of the mandible: Report of a case. J. Oral Surg. 1969: 27: 341-344. 4. HANSON,L. S., SAPOSm, J. & SPROAT,R. C.: Traumatic bone cysts of the jaws. Oral Surg. 1974: 37: 899-910. 5. HEUBNER, G. R. & r['LrRLINGTON, E. G.: So-called traumatic (hemorrhagic) bone cysts of the jaws. Oral Surg. 1971: 31: 354-365. 6. Hown, G. L.: "Hemorrhagic cysts" of the mandible. Br. J. Oral Surg. 1965: 3: 55-91. 7. L~JcAs, C. D.: Do all cysts of the j~w originate from the dental system? (Discussion: BLr.~, T.). J. A m . Dent. Assoc. 1929: 16: 647-661.
M A N D I B U L A R S I M P L E B O N E CYST 8. MORRIS, C. R., STEED, D. L. & JAconY, J. J.: Traumatic bone cysts. J. Oral Surg. 1.970: 28: 188-195. 9. PoMtvmR, G.: Z u r Kenntnis der progressiren H:imaton- und Phlegmasiever~inderungen der RShrenknochen auf G r u n d tier mikroskopischen Befande im neuen Knozystenfalle H. v. Haberers. Arch. Orthop. Unfallchir. 1920: 17: 17-69. 10. RUSHTON, M. A.: Solitary bone cysts in the mandible. Br. Dent. J. 1946: 81: 37-49. I1. Smve•rNK, N. P. J. B.: The simple bone cyst. Vrije, A m s t e r d a m 1974.
Address:
Anders Heimdahl Dept. of Oral Surgery School of Dentistry (Karolinska Institutet) Fack S-141 04 Huddinge Sweden
35
12. SZERLIP, L.: Traumatic b o n e cysts: Resolution without surgery. Oral Surg. 1966: 21: 201-204. 13. T~OMA, K. H.: The treatment of extravasation cysts with the use of Gelfoam. Oral Surg. 1954: 8: 950-954. 14. TI-:O~A, K. H.: Oral surgery, 4th ed. C. V. Mosby, St. Louis 1963, p. 897. :15. TOLLEX, P. A.: Radioactive isotope and other investigations in a case of h a e m o r rhagic cyst of the mandible. Br. I. Oral Surg. 1964: 2: 86-93.
An unusual case of "simple bone cyst" of the mandible ANDERS HEIMDAflL
Department of Oral Surgery, Dental School, Huddinge, Sweden
AnST~CT -- Reviews of the literature show that simple bone cysts of the laws no lovtger can be considered rare. The clinical and radiographic appearances are mostly rather typical, but in some cases there are great variations. In this article an unusual case with both facial asymmetry and bilateral occurrence is described. The differential diagnosis between simple bone cysts, tumors, odontogenic cysts and vascular abnormalities is sometimes hard to establish. In those cases aspiration biopsy can be of great help.
(Received ]or publication 28 October 1976, accepted 5 lanual3, 1977)
Since the first reported case of simple bone cyst ( I C D - D A 526.21) of the mandible7, more than 200 cases have been reported in the literature. Excellent reviews of the literature-~,6, t0 have been made, including some recent reviewsqs, tL F r o m these reviews it is easy to select the "typical case". This is a m a n or a woman between 15 and 20 years old without symptoms in the jaws. During routine radiography a rather large cystic lesion is found in the mandible. It has no sclerotic lining like an odontogenic cyst. There is a scalloping appearance between the roots of the adjacent teeth but there is no evidence that it originates from any of them. Clinically all teeth appear to be vital. A surgical intervention has to be done to confirm the diagnosis "simple bone cyst". During surgery an empty cavity or a cavity filled with sanguinoserous liquid is
found. There is no soft tissue lining of the cavity. The histopathologic findings reveal no signs of tumor, cysts or inflammation. The postoperative healing is uneventful and completed in 1-3 yem's. Aside from this "typical ease", great variation may be seen both in the age of the patients and the clinical appearance of the cyst. This variation has been very well described in several articIes~,4,5,R. In many (24 %)~ of the reported cases a slight swelling of the affected jaw has been noticed. In a few cases the expansion has produced a disfiguration of the face~0,18. Seven cases of bilateral lesions in the mandible have been reported l, 8, 5, s, 12,a4. The following case has both striking facial asymmetry and bilateral lesions in the mandible, and may therefore be of interest to describe.
M A N D I B U L A R SIMPLE BONE CYST
Fig. 1. The simple bone cyst caused considerable facial disfiguration.
Case report A young man, 16 years of age, was referred to the Department of Oral Surgery, Dental School, Huddinge, because of facial swelling of the right mandible (Fig. 1). H e was free from other symptoms and there were no signs
33
of inflammation. T h e swelling had been present for several years and he denied t r a u m a to the jaws. All his teeth were vital a n d i n excellent condition. On the o r t h o p a n t o m o g r a m two cystic lesions were visible. In t h e corpus of the right mandible a lesion 7 • 3 cm w i t h a scalloping appearance between the roots of the adjacent teeth caused a considerable expansion of the cortex (Figs. 2, 3). In the region of the canine and the premolars of the left m a n d [ b t e a cyst-like radioluceney 2.5 • 2.5 cm was found. None of the teeth had deep caries or evidence of apical inflammation. Aspiration biopsy from the lesions was m a d e and sanguinoserous liquid was aspirated f r o m both sides. In this liquid histiocyte-like resorption cells and some erythrocytes were found. There were no signs of epithelial cells or malignancy. Laboratory findings, including calcium and phosphorus of serum and urine, were normal. A preliminary diagnosis of bilateral "simple bone cysts" was made. TREATMENT Surgery was performed to. confirm the diagnosis. In general anesthesia buccal m u c o periosteal flaps were raised and the lesions were fenestrated. O n both sides sanguinoserous liquid was found. T h e r e were n o signs of cystlining or soft tissue. In the cyst of the right mandible the neurovascular b u n d l e h u n g free from the roots of the teeth (Fig. 4). Curettage
Fig. 2. Orthopantomographic radiogram shows the bilateral lesions.
34
HEIMDAHL
Fig. 3. There was a large expansion of the mandible in buccollngual direction.
Fig. 4. Inside the cyst the neurovascular bundle (arrow) hangs free from the roots of the teeth.
was performed. The he,fling was normal and 3 months after the operation radiographic evidence of bone healing was noticed.
ever, surgical intervention is necessary to make the proper diagnosis. The lesion ahnost invariably heals in 1-3 years after surgery. It not known whether the single bone cyst can regress spontaneously, but there are cases reported with spontaneous resolution 12.
Discussion T h e etiology of the simple bone cysts is obscure, and several theories exist. The oldest and most widely held theorya is that it is the failure to heal of a traumatically induced infrabony hemorrhage which leaves a more or less empty cavity. BEASLEYt, in his article on 30 cases, gives an interesting discussion on the different theories. The relationship between giant cell tumors, simple bone cysts and "Stafne's bone cavities" has been discussed 1~ Investigations of the intracystic pressure and intracystic osmotic tension have also been madel~. Regardless of the etiology one of the problems of simple bone cysts is the differential diagnosis from other cysts, tumors and vascular abnormalities. Aspiration biopsy is a good aid for establishing a correct preliminary diagnosis. Sometimes the bone is hard to perforate, and a needle made for bone m a r r o w aspiration from the sternum is therefore helpful. In most cases, how-
References l. BEASISEY,J. D., IiI: Traumatic cysts of the jaws. Report of 30 cases. J. AnL Dent. Assoc. 1976: 92: 145-152. 2. GARDNER,A. F., STOJ_J~Ea, S. M. & S'nalO, J. M.: A study os the traumatic bone cyst of the jaws. J. Can. Dent. Assoc. 1962: 28: 151-166. 3. GRASSO, A. M., DEMKEn, D. & FINNnGAN, J.: Traumatic cyst of the mandible: Report of a case. J. Oral Surg. 1969: 27: 341-344. 4. HANSON,L. S., SAPOSm, J. & SPROAT,R. C.: Traumatic bone cysts of the jaws. Oral Surg. 1974: 37: 899-910. 5. HEUBNER, G. R. & r['LrRLINGTON, E. G.: So-called traumatic (hemorrhagic) bone cysts of the jaws. Oral Surg. 1971: 31: 354-365. 6. Hown, G. L.: "Hemorrhagic cysts" of the mandible. Br. J. Oral Surg. 1965: 3: 55-91. 7. L~JcAs, C. D.: Do all cysts of the j~w originate from the dental system? (Discussion: BLr.~, T.). J. A m . Dent. Assoc. 1929: 16: 647-661.
M A N D I B U L A R S I M P L E B O N E CYST 8. MORRIS, C. R., STEED, D. L. & JAconY, J. J.: Traumatic bone cysts. J. Oral Surg. 1.970: 28: 188-195. 9. PoMtvmR, G.: Z u r Kenntnis der progressiren H:imaton- und Phlegmasiever~inderungen der RShrenknochen auf G r u n d tier mikroskopischen Befande im neuen Knozystenfalle H. v. Haberers. Arch. Orthop. Unfallchir. 1920: 17: 17-69. 10. RUSHTON, M. A.: Solitary bone cysts in the mandible. Br. Dent. J. 1946: 81: 37-49. I1. Smve•rNK, N. P. J. B.: The simple bone cyst. Vrije, A m s t e r d a m 1974.
Address:
Anders Heimdahl Dept. of Oral Surgery School of Dentistry (Karolinska Institutet) Fack S-141 04 Huddinge Sweden
35
12. SZERLIP, L.: Traumatic b o n e cysts: Resolution without surgery. Oral Surg. 1966: 21: 201-204. 13. T~OMA, K. H.: The treatment of extravasation cysts with the use of Gelfoam. Oral Surg. 1954: 8: 950-954. 14. TI-:O~A, K. H.: Oral surgery, 4th ed. C. V. Mosby, St. Louis 1963, p. 897. :15. TOLLEX, P. A.: Radioactive isotope and other investigations in a case of h a e m o r rhagic cyst of the mandible. Br. I. Oral Surg. 1964: 2: 86-93.