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Case 41, part I
CLIN1COPATHOL001C CONFERENCES J Oral
Mexillofac
40565-587,
Surg
1982
Case 41, Part JAMES R. SANNER, DMD,* JOHN JARRETT,
DDS,t
I
AND G. ALLEN BROOKS,
DDS$
inferior area of the lesion. The specimens were forwarded to the Hospital Pathology Service and to the Oral Pathology Department of the Medical University of South Carolina School of Dental Medicine. Histologic examination of the surgical specimens was inconclusive, revealing a paucity of tissue, which was composed primarily of periosteum and new bone formation, and a small strip of cystic capsule. This epithelial
A 70-year-old white man was seen in the admission area of the Columbia Veterans Administration Medical Center in March 1980 for an enlarging mass of the right mandible. The patient was promptly referred by the examining physician to the oral surgery section for treatment and work-up. A careful history revealed that the patient had noticed this lesion six months previously when he experienced increasing difficulty in wearing his complete lower denture. He stated that he had not had drainage from the right mandible or pain in it. The patient was admitted to the oral surgery service, where a thorough history and physical examination were performed. The history was noncontributory for either local or systemic disease. The patient denied having taken any systemic medications. No history of allergies was elicited. The physical examination was also noncontributory. The intraoral examination revealed that the patient was edentulous in both the maxilla and the mandible. A somewhat firm mass of the right mandible, with normal overlying mucosa, was encountered. The buccal and lingual cortices were not palpable. The mass extended from the area of the right second premolar to just left of the midline. At its greatest dimensions the lesion measured 3.5 cm anterior-posteriorly. and 3 cm bucco-lingually (Fig. 1). Both panoramic and occlusal radiographs were obtained. The panoramic radiograph revealed a 3 cm x cm, unilocular, osteolytic lesion, with poorly defined margins and with probable destruction of buccal and lingual cortices (Fig. 2). The occlusal radiograph showed a multiloculated lesion measuring 4 cm anterior-posteriorly, and 3 cm bucco-lingually, with obvious thinning of both cortices and with only faint traces of intrameduallary trabeculation (Fig. 3). Because the results of history and physical examination as well as the chest radiograph, electrocardiogram, and laboratory results were within normal limits, the patient was brought to the oral surgery clinic the following day. After local analgesia was obtained, aspiration of the lesion was performed, yielding 13 ml of serosanguineous fluid. Following aspiration, complete collapse of the lesion occurred (Fig. 4). Surgical exploration of the lesion revealed a cystlike cavity with no ostensible lining except at the inferior border of the mandible, where there was a glistening tissue. Specimens were taken from the lingual flap and from the * Chief. Oral Surgery Section. Veterans Administration Hospital, Columbia, South Carolina. t Professor and Chairman, Department of Oral Pathology. Medical University of South Carolina School of Dental Medicine. $ Staff Periodontist, Veterans Administration Hosoital. Columbia, South Carolina. Address correspondence and reprint requests to Dr. Sanner: Oral Surgery Section, Veterans Administration Hospital, Columbia, South Carolina 29201.
FIGURE 1. Abotv.
Large mass of the right mandible.
FIGURE 2. Crnfe~. Panoramic radiograph, showing the lesion to be osteolytic. with apparently poorly defined margins. FIGURE 3. Below,. Occlusal radiograph showing a multiloculated lesion with thinned buccal and lingual cortices.
0278-2391/82/0900/0585 $00.60 @ American Association 585
of Oral and Maxillofacial Surgeons
CLINICOPATHOLOGIC
CONFERENCES
Because of the inconclusive histologic diagnosis and the relative certainty, based on both clinical and microscopic examination, that the lesion was nonmalignant, it was decided to follow up the patient on a monthly basis. On the first postoperative visit one month later, there was clinical evidence of osteogenesis within both buccal and lingual cortical plates. The occlusal radiograph confirmed that osteogenesis had indeed occurred and that there was no further extension of the lesion. An occlusal film taken two months postoperatively showed further filling in of bone within both cortices (Fig. 6). The patient was thereupon readmitted for further definitive surgical treatment. Discussion:
FIGURE 4.
Collapse of the lesion following aspiration.
cyst featured a small area of islands of proliferating odontogenic epithehum not unlike that seen in many odontogenic cysts, but suggesting the possibility of ameloblastic activity (Fig. 5). However, the lack of solid tumor and the cystic nature of the lesion, combined with the cortical destruction, seemed somewhat inconsistent and confusing.
FIGURE 5.
Photomicrograph
showing ameloblast-like
Dr. Sanner
When the patient was seen initially and the panoramic reviewed, the loss of both buccal and lingual cortices, along with the ill-defined border of the osteolytic lesion. led to the suspicion of malignancy, either primary or metastatic. However, when the occlusal radiograph was examined, with its muhilocular conformation and scant traces of cortical plates remaining, the differential diagnosis was expanded to include the following: cystic ameloblastoma: keratocyst; dentigerous cyst; myxoma; odontogenic fibroma; traumatic bone cyst: central giant cell granuloma; benign fibro-osseous lesion: central hemangioma; and, with much less likelihood, malignancy. After aspiration of the lesion led to its collapse, and surgical exploration revealed a cystlike cavitation devoid of a conspicuous lining, several of the preceding lesions
epithelial islands and cystic lining epithelium (x200).
587
SANNER ET AL
were eliminated from the differential diagnosis because they were solid. They included myxoma, odontgenic fibroma, central giant cell granuloma, and benign fibroosseous lesion. Traumatic bone cyst was considered much less likely because of the extreme expansile tendency seen with this lesion. The central hemangioma was also considered less likely because of the nature of the aspirate obtained. Lesions that were still plausibly included in the diagnosis were cystic ameloblastoma, dentigerous cyst, and keratocyst, because all may demonstrate a multilocular appearance on radiograph, a cystic fluid content, a predisposition for the mandible, and an expansile tendency on a local level. The perplexing aspect of this case was the extreme predisposition of the lesion for cortical osteogenesis. such a short time after aspiration was performed. Purt II of this Clit7ocopcithclltt~i~ pear it7 the October issue.
Cmferet7ce
refill qt-
FIGURE 6. Occlusal radiograph revealing osteogenesis both buccal and lingual cortices.
withir
Mexillofac
40565-587,
Surg
1982
Case 41, Part JAMES R. SANNER, DMD,* JOHN JARRETT,
DDS,t
I
AND G. ALLEN BROOKS,
DDS$
inferior area of the lesion. The specimens were forwarded to the Hospital Pathology Service and to the Oral Pathology Department of the Medical University of South Carolina School of Dental Medicine. Histologic examination of the surgical specimens was inconclusive, revealing a paucity of tissue, which was composed primarily of periosteum and new bone formation, and a small strip of cystic capsule. This epithelial
A 70-year-old white man was seen in the admission area of the Columbia Veterans Administration Medical Center in March 1980 for an enlarging mass of the right mandible. The patient was promptly referred by the examining physician to the oral surgery section for treatment and work-up. A careful history revealed that the patient had noticed this lesion six months previously when he experienced increasing difficulty in wearing his complete lower denture. He stated that he had not had drainage from the right mandible or pain in it. The patient was admitted to the oral surgery service, where a thorough history and physical examination were performed. The history was noncontributory for either local or systemic disease. The patient denied having taken any systemic medications. No history of allergies was elicited. The physical examination was also noncontributory. The intraoral examination revealed that the patient was edentulous in both the maxilla and the mandible. A somewhat firm mass of the right mandible, with normal overlying mucosa, was encountered. The buccal and lingual cortices were not palpable. The mass extended from the area of the right second premolar to just left of the midline. At its greatest dimensions the lesion measured 3.5 cm anterior-posteriorly. and 3 cm bucco-lingually (Fig. 1). Both panoramic and occlusal radiographs were obtained. The panoramic radiograph revealed a 3 cm x cm, unilocular, osteolytic lesion, with poorly defined margins and with probable destruction of buccal and lingual cortices (Fig. 2). The occlusal radiograph showed a multiloculated lesion measuring 4 cm anterior-posteriorly, and 3 cm bucco-lingually, with obvious thinning of both cortices and with only faint traces of intrameduallary trabeculation (Fig. 3). Because the results of history and physical examination as well as the chest radiograph, electrocardiogram, and laboratory results were within normal limits, the patient was brought to the oral surgery clinic the following day. After local analgesia was obtained, aspiration of the lesion was performed, yielding 13 ml of serosanguineous fluid. Following aspiration, complete collapse of the lesion occurred (Fig. 4). Surgical exploration of the lesion revealed a cystlike cavity with no ostensible lining except at the inferior border of the mandible, where there was a glistening tissue. Specimens were taken from the lingual flap and from the * Chief. Oral Surgery Section. Veterans Administration Hospital, Columbia, South Carolina. t Professor and Chairman, Department of Oral Pathology. Medical University of South Carolina School of Dental Medicine. $ Staff Periodontist, Veterans Administration Hosoital. Columbia, South Carolina. Address correspondence and reprint requests to Dr. Sanner: Oral Surgery Section, Veterans Administration Hospital, Columbia, South Carolina 29201.
FIGURE 1. Abotv.
Large mass of the right mandible.
FIGURE 2. Crnfe~. Panoramic radiograph, showing the lesion to be osteolytic. with apparently poorly defined margins. FIGURE 3. Below,. Occlusal radiograph showing a multiloculated lesion with thinned buccal and lingual cortices.
0278-2391/82/0900/0585 $00.60 @ American Association 585
of Oral and Maxillofacial Surgeons
CLINICOPATHOLOGIC
CONFERENCES
Because of the inconclusive histologic diagnosis and the relative certainty, based on both clinical and microscopic examination, that the lesion was nonmalignant, it was decided to follow up the patient on a monthly basis. On the first postoperative visit one month later, there was clinical evidence of osteogenesis within both buccal and lingual cortical plates. The occlusal radiograph confirmed that osteogenesis had indeed occurred and that there was no further extension of the lesion. An occlusal film taken two months postoperatively showed further filling in of bone within both cortices (Fig. 6). The patient was thereupon readmitted for further definitive surgical treatment. Discussion:
FIGURE 4.
Collapse of the lesion following aspiration.
cyst featured a small area of islands of proliferating odontogenic epithehum not unlike that seen in many odontogenic cysts, but suggesting the possibility of ameloblastic activity (Fig. 5). However, the lack of solid tumor and the cystic nature of the lesion, combined with the cortical destruction, seemed somewhat inconsistent and confusing.
FIGURE 5.
Photomicrograph
showing ameloblast-like
Dr. Sanner
When the patient was seen initially and the panoramic reviewed, the loss of both buccal and lingual cortices, along with the ill-defined border of the osteolytic lesion. led to the suspicion of malignancy, either primary or metastatic. However, when the occlusal radiograph was examined, with its muhilocular conformation and scant traces of cortical plates remaining, the differential diagnosis was expanded to include the following: cystic ameloblastoma: keratocyst; dentigerous cyst; myxoma; odontogenic fibroma; traumatic bone cyst: central giant cell granuloma; benign fibro-osseous lesion: central hemangioma; and, with much less likelihood, malignancy. After aspiration of the lesion led to its collapse, and surgical exploration revealed a cystlike cavitation devoid of a conspicuous lining, several of the preceding lesions
epithelial islands and cystic lining epithelium (x200).
587
SANNER ET AL
were eliminated from the differential diagnosis because they were solid. They included myxoma, odontgenic fibroma, central giant cell granuloma, and benign fibroosseous lesion. Traumatic bone cyst was considered much less likely because of the extreme expansile tendency seen with this lesion. The central hemangioma was also considered less likely because of the nature of the aspirate obtained. Lesions that were still plausibly included in the diagnosis were cystic ameloblastoma, dentigerous cyst, and keratocyst, because all may demonstrate a multilocular appearance on radiograph, a cystic fluid content, a predisposition for the mandible, and an expansile tendency on a local level. The perplexing aspect of this case was the extreme predisposition of the lesion for cortical osteogenesis. such a short time after aspiration was performed. Purt II of this Clit7ocopcithclltt~i~ pear it7 the October issue.
Cmferet7ce
refill qt-
FIGURE 6. Occlusal radiograph revealing osteogenesis both buccal and lingual cortices.
withir