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Cases from the clinic of the Cairo dental school
CASES FROM THE CLINIC OF THE CAIRO DENTAL
SCHOOL
N. SALAMA, B.CH.T). (CAIRO), L.D.S. (EKG.) ,* ASD AZIZ HILMY, B.CH.D.(CAIRO),
T
L.~.S.(ENG.),*
CAIRO. EOYPT
HE following are some of the cases seen in our clinic in Cairo, Egypt, with the type of treatment used by us for such tumors.
Case 1. A Case of an Extensive Fibromyxoma of the Left Maxilla and Palate An adult 45-year-old Egyptian man reported with an extensive solid vascular, very firm growth with smooth normal-colored surface, and short, broad pedicle, growing from the alveolar process region of the left premolar and molar and encroaching on the whole palatal aspect of the maxilla. It was protruding outward slightly, but to a great extent was located palatally. It had started eleven years previously and gradually increased in size. No bony expansion could be felt, an indication of its peripheral origin. It was quite painless. No enlargement of the lymph nodes was present. Both hard and soft palates were unaffected, but owing to the huge bulk of the growth it caused some difficulty The bone of the left maxilla and palate was in swallowing and mastication. unaffected with the exception of a slight outward protrusion localized to the alveolar process from which the neoplasm was originating. The patient’s general health was quite good. The blood count was normal and Wassermann reaction wa,s negative. The neoplasm seemed to be originating from the mucoperiosteum. The left antral cavity was clear. Premolars and molars were missing, and therefore the occlusal aspect of the tumor was partly eroded by traumatic occlusion of opponent teeth. Its consistency was hard and slippery to the touch, with no tendency to bleeding (Fig. 1).
Radiographic
Appearances.-The occlusal views of the left maxilla revealed a localized erosion of the bone of the alveolar process ext.ending from the left first premolar to the third molar and tuberosity l’egions, with some trabeculation seen in the eroded areas (Fig. 2). The bone of the hard palate was unaffected (Fig. 3). The appearances suggested a slow-growing tumor most probably of the mixed cell type.
Microscopic Appearances.-Examination of a section of tissue revealed a normal epithelial covering with a matrix chiefly made Up of collagenous fibrous tissue and fibroblasts. A great part of the structure showed myxomatous tissue with its typical triangular and stellate cells. Impregnat,ion with inflammatory cells could also be seen (Fig. 4). Operation.-Under general anesthesia the growth was chiseled out completely with the alveolar process carrying the canine and first premolar. The external facial wound and the region of the alveolus healed normally and rapidly (Fig. 5). t *Assistant tWe are specimen.
Professor, Dental School, Cairo, Egypt. F.R.C.S.(Eng.) obliged t.o Dr. A. Abu-Zekry.
966
for
his
operation
and
for
the
CASES
FROM
CLINIC
OF CAIRO
DENTAL
967
SCHOOL
Case2. A Caseof Endosteal (Central) Fibromyxoma of the Right Maxilla A 32-year-old Egyptian man reported with a solid, vascular, sessile growth occupying the right maxilla and protruding externally and internally. It had It occupied the region from the upper right canine up to the right tuberositg.
Fig.
l.-Photograph
of patient
Fig.
2.
with an extensive flbromyxoma showing the neoplasm in situ.
of the
left
Fig.
3.
maxilla
and
palate,
Fig. 2.-A case of extensive Abromyxoma of the left maxilla and palate. Occlusal radiograph of the left maxilla showing the presence of localized erosion of the bone of the alveolar process. Some trabeculation is seen in the eroded area. Bone of the hard palate is unaffected. Fig. 3.-A case of extensive flbromyxoma of the left maxilla and palate. Occlusal radiograph of the left maxilla, showing the presence of localized erosion of the bone of tile alveolar process. Bone of the hard palate is unaffected.
had a smooth surface with normal color of the gingiva. The first and second molars were removed a year previously with the growth, but it had recurred. It had started three years previously and had been gradually increasing in
968
N.
SSLAMA
AND
AZIZ
HII,MY
size. The growth, being of endosteal origin, had obliterated the antral cavity and expanded the bone in all directions. Its occlusal surface was partly eroded due to traumatic occlusion of the opponent teeth. The patient’s general health
Fig.
4.-Photomicrograph
Fig.
5.-Photograph
of
of specimen both outer
tumor
of the mvxomatous
left
maxilla structures.
and
palate,
showing
(flbromyxoma of the left maxilla), showing and inner extensions with teeth in situ.
fibrous
its occlusal
and
view,
was quite good. The blood count was normal and the Wassermann reaction was negative. The neoplasm was quite firm to the touch with no tendency to bleed. Both cheek and palate were free (Fig. 6).
CASES
FROM
CIJNIC
OF
CAIRO
DENTAI,
969
SCIIOOI,
Radiographic Appearances.-X-ray examination revealed a growth seen arising from the right alveolar ridge and projecting into the right antrum which appeared opaque (Fig. 7). The alveolar bone was completely destroyed by it.
Fig.
6.
Fig. B.-Photograph the neoplasm in situ. Fig. 7.-Radiograph of the right maxilla.
Fig. bone bone
Fig. with Fig. with
Fig. of patient of skull
with showing
endost&l opacity
flbromyxoma in the
right
8.
8.-Occlusal radiograph of the right maxilla, flne reticulation with honeycomb picture. 9.-Occlusal radiograph of the right maxilla, fine reticulation with honeycomb picture.
7.
of the antrum
Fig.
right with
maxilla, definite
showing expansion
9.
showing
destruction
of
the
alveolar
showing
destruction
of
the
alveolar
970
N.
Marked expansion of honeycombed picture dense sclerosis in the gested a slow-growing
SALAM-
AND
AZIZ
HIIJlY
it. was also seen. Inside the growth, fine reticulation with was detected (Fig. 8). Its margins were clear-cut with healthy bone posteriorly (Fig. !I). The appearances sugendosteal or central growth.
Microscopic Appearances.-Examination revealed normal epithelial covering with a matrix chiefly made up of collagenons fibrous tissue and fibroblasts. A great part of the structure showed mpxomatous degeneration with its typical stellate cells. Round cell infilt,ration was also present (Fig. 10). Operation.--Under general anesthesia the whole right maxilla was surgically removed en masse? and the cavity left to heal. After the lapse of about three months, a mechanical artificial restoration was fitted to close the l)erforation into the sinus and nose.
Fig.
I O.-Photomicrograph with
of endosteal flbromyxoma of the right myxomatous clepenwittion with inflammiltory
maxilla, showing infiltration.
fibrous
tissue
Case 3. A Case of Complex Composite Odontome Occupying the Molar Regions of the Right Side of the Mandible A 30-year-old Egyptian man reported with a septic cavity at the lower right molar region causing pain, tenderness, and swelling. On probing this cavity, hard, irregular, calcified tissue could be felt. This cavity had been present for a very long time, causing acute exacerbations now and then. All the lower molars were missing with no history of previous extractions. The The body of the lower jaw was exremaining dentition was quite normal. panded buccolingually at both the rnolar and angle regions. Acute lymphadThere was neuralgic ehitis was present due to the associated pyogenic infection. pain at the right side of the head with slight inability to open the mouth.
CARES FROM
CIJNIC
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SCHOOI~
971
Radiographic Appearances-X-ray examination revealed the presence of a fairly huge mass of irregularly calcified tissues occupying completely the right molar region and the angle of the jaw, with thin fungating edges and and at its lower rarefied areas at its occlusal and distal aspects. Anteriorly Fig. 11.
Fig. 12. Fi Il.-Extraoral radiograph of the rjght side of the mandible, showing complex composite o%ontome in situ. Anteriorly and at its lower border a molarlike tooth is seen embedded and fitting in the odontome with its roots curved posteriorly. Fig. lZ.-Extraoral radiograph of the right side of the mandible after complete removal of the odontome.
border a molarlike tooth was seen embedded and fitting into the odontome with its roots curved posteriorly. The occlusal depression coincided with the perforated cavity in the soft tissues. The odontome extended posteriorly beyond the right angle and occupied partly the ascending ramus with bone
972
N.
SALAMA AND AzIz HILMY
covering it o~~lusally. A line of demarcation could be seen around it. The inferior border of the lower jaw was thinned out with slight periosteal deposition of bone externally (Kg. 11). Operation.-After the disappearance of the acute inflammation, regional anesthesia was used to remove the odont,ome. Owing to its irregular fungating edges that were interlocked in the thinned-out bone, the removal was very difficult. Utmost care had to be taken to avoid fracture of the mandible. Deep below the odontome anteriorly a fully calcified first molar was present which was removed easily and assembled in its depressions on the excised odontome. A huge bone cavity was left for daily dressings (F’ig. 12).
Description of the Odontome.-After
bleaching and complete dehydration, the odontome with the tooth articulated in its position weighed 11.715 Gm. its dimensions were as follows: anteroposteriorly, 43 mm. ; vertically, 22 mm. ; buccolingually 21 mm. On examination, it appeared as an irregularly shaped mass with deep excavations both occlusally and distally. I:oth the inner surface and its inferior border were smooth. Anteriorly and at its lower border, there was a deep depression into which the occlusal surface of the first molar had been accurately fitted. Both roots of this molar were curved backward. The whole mass seemed clinically to be formed of enamel, dentinc, and ccmentum irregularly mixed (Fig. 13).
Fig.
i3.--Cornglex
cornymite
odontome,
anteroposterior
view
Case 4. A Case of an Extensive Endosteal (Central) Osteoclastoma (Giant Cell Tumor) of the Left Side of the lkudible A 60-year-old Egyptian woman reported with an extensive solid vascular growth, occupying completely the left half of the mandible. It started about a year previously and rapidly increased in size until it had attained the present size in a relatively short period. The growth was of endosteal or central origin, and had expanded the mandible externally and internally, resulting in great deformity of facial contour. The neoplasm was dark red in color, had an irregular lohulated surface with fluctuations which could be elicited at certain areas due to the presence of blood cysts and osteoclastic erosion of the bone. The patient’s general health was poor. She had advanced oral sepsis. The teeth in relation to the growth were very loose and were removed. Blood cell Wassermann reaction was negative. Blood count was within normal limits.
CASES
Fig.
FROM
CLINIC
OF CAIRO
DENTAL
SCHOOL
Fig.
14.
Fig. 14.-Photograph of patient with an extensive facial contour due to its external expansion of bone. Fig. 15.-Intraoral view of extensive osteoclastoma ing the neoplasm in situ.
osteoclastoma, of the left
Fig. I&-Extraoral radiograph of the left side of the mandible, left body and its ramus with definite line of demarcation between healthy bone. Inferiorly the margin of the bme almost intact, but the bone is markedly rarefled.
15.
showing
deformity
side of the mandible,
showing expansion visible trabeculation near the alveolar
of show-
of the and border,
974
N.
SAIAMA
ANLI
AZIZ
HIL,MV
calcium was normal. No other involvement in the bones of t,he limbs could be found. Such growths are very common in young subjects, yet this case ill ustrates that they can occur as well late in life (Figs. 14 and 15).
Fig.
Fig.
li.-Occlusal
radiograph of the left side of the mandible. showing erosion of bone of body and thin trabeculntion.
18.-Photomicrograph ous multinucleated
cells
of an osteoclastoma lying in a cellular
expansion
of the left side of the mandible matrix with delicate connective
with
mas: 3ive
showing nun ,ertissue stroma.
Radiographic Appearances.-Examination revealed expansion of t,he 1eft body of the mandible by an ost,eolytic growth in the horizontal ramus wit1 1 a definit,e line of demarcation between visible trabecnlation and the healt ;hy bone. Inferiorly the margin of the bone was almost intact, but near the alveolar border the bone was markedly rarefied (Figs. 16 and 17).
CASES FROM
CLINIC
OF CAIRO DENTAL
SCHOOL
975
Microscopic Appearances.-Pathologic examination revealed normal epithelium. The matrix was very cellular with delicate connective tissue stroma Some bone containing fairly numerous large cells with multiple nuclei. Infiltration with inflammatory spicules could be seen scattered here and there. plasma cells could also be seen (Fig. 18). Treatment,-Under general anesthesia, the left half of the mandible completely excised and the part subjected to deep x-ray therapy.
was
Case 5. A Case of Osteoma in a Child A 13-year-old Egyptian female child reported with a very solid growth of hard consistency, protruding buccally and occupying the regions of the left maxilla. It had a sessile base palatally, with a narrowed pedunculated area Its surface was firm and smooth, normal in co!or, with some indentabuccally. tions due to traumatic bite of* the lower teebh. The upper left premolars were displaced slightly, but the left first molar was pushed backward and prevented the eruption of the second molar. It had started about eighteen months previously and was slowly growing and increasing in size. There was no bony expansion of the left maxilla, an indication of its peripheral origin. There was no history of specific illness and the child was apparently in good health. The remaining dentition was normal with no other abnormality in the oral mucosa. The blood count was normal and the Wassermann reaction was negative. No enlargement of the lymph nodes or metastasis could be seen anywhere in the body. The growth was chiefly composed of osseous tissue, and chiseling was resorted to while taking a biopsy.
Fig. 19.--Occlusal radiograph of the left maxilla, showing oma, triangular in shape with smooth deflned outline.
the presence of a pedunculated osteAdjacent teeth appear displaced.
Radiographic Appearances.-The x-ray revealed the presence of a pedunculated osseous mass of tissue protruding externally from the alveolar crest of the left maxilla, triangular in shape with smooth defined outline. It had displaced the adjacent teeth (Fig. 19). The appearance was that of an osteoma.
976
S.
SALAMA
AND
AZIZ
HILMY
Microscopic Appearances.-A section was cut from the specimen after its complete excision through the central part of the growt,h. It was removed with its buccal pedicle intact. It was surprising to find that the whole outer mass of the growth was lined wit,h normal epithelium and the whole structure below was pure osseous tissue (Fig. 20). The pedicle appeared to be made up of a fibrocellular structure with no bony tissue in it and to be lined with epithelium in continuity with that of the large mass, and contained fairly large numbers of multinucleated cells (giant, cells). Therefore the histologic appear(This tumor may be classified as ances revealed an osteonaa with osteoclnsia. a fibro-osteoma.-Ed.)
Fig. 20.-An enlarged photomicrograph of the whole section taken from a patient with combined osteoma of the left maxilla, showing the osseous structure of the whole mass of the growth together with its pedicle which is in continuity with it and appeared as an osteoclastoma.
Case 6. A Case of an Infected Cystic Ameloblastoma Affecting the Whole Right Side of the Mandible and Ascending Ramus A 2%year-old Egyptian girl reported with an extensive swelling of long duration of the right lower jaw, together with the right side of the face (Fig. 21). The swelling had appeared about eight years previously and slowly inThe swelling was acutely creased in size, expanding the bone in all directions. The patient was in a infected and there was profuse suppuration intraorally. Most of the teeth at the very toxic condition with a rise in her temperature. region involved were missing ; the few remaining were very loose. The condition at first was thought to be an acute suppurative osteomyelitis of the right side of the mandible and ascending ramus, but on further examination there appeared to be a huge cystic mass arising from her lower jaw (Fig. 22). Most of the oral extension of the growth was fluctuant and aspirated fluid came out purulent in color, containing only blood and pus cells. Besides this oral condition, the patient did not complain of any systemic illness. No blood changes
CASES FROM
CLINIC
OF CAIRO DENTAL
977
SCHOOL
could be detected with the exception of mild leucocytosis. Wassermann reaction was negative. The pressure of the expanded growth had displaced the upper right molars inward and had mechanically interfered with occlusion.
Fig. 21.-Photograph Fig. 22.-Photograph
Fig. 21. of patient of patient
Fig. 23.-Extraoral multiple cystic areas with right third molar is seen to shadows the tooth did
Fig. 22. with facial swelling due to expansion showing neoplasm in situ.
radiograph of thinned bony pushed up in not appear in
of growth.
the right side of the mandible and ramus, showing septa and expanded right body and ramus. Thek&e; the sigmoid notch with its crown downward. print, but was quite visible in its x-ray.)
Radiographic Appeaxasces.-The x-ray revealed tha,t the right lower jaw was rarefied and contained multiple cysts extending into the ascending ramus. The lower right third molar was displaced and pushed upward and seen at the region of the sigmoid notch with its crown downward. The condition denoted a cystic adamantinoma (Fig. 23).
Microscopic Examination.-Examination o-f a section revealed normal epithelial covering with a fibro-osseous stroma inside of which columns of odontogenie epithelium could be seen, toget,her with multiple small and large cystic areas lined by columnar epithelium. Diagnosis:
Cystic ameloblastoma
(Fig. 24).
Treatment and Operation.-Local multiple incisions and efficient drainage cleared up the acute infection. The whole right side of the lower jaw and its ascending ramus were completely excised under general anesthesia.
Fig.
P4.-Photomicrograph ascending
of infected ramus, showing
multilocular cyst typical structures
of the right side of the of cystic ameloblastoma.
mandible
and
Case 7. A Case of Cystic Ameloblastoma of the Right Body of the Mandible A 37-year-old Egyptian man reported with an unsight,ly chronic facial swelling of the right body of the mandible (Fig. 25). It had started two years previously and gradually increased in size. On examination, a fluctuant endosteal growth could be felt occupying the region of the right side of the mandible where the teeth were missing. The neoplasm had expanded the body of the The jaw had been completely resorbed lower jaw both outward and inward. at certain areas buccally. The mass had an irregular occlusal surface due to pressure from opponent teeth. aspirated fluid came out yellowish in color, The patient’s general health was but no crystals of cholesterin were found. good. Blood count was normal and Wassermann reaction was negative. The No lymph node enlargement or metasremaining dentition was quite normal. tasis was present.
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Radiographic Appearance&--The ties (Fig.
Fig.
26), separated by thinned-out
25.-Photograph
Fig.
of patient
26.
with
DENTAL
SCHOOL
979
x-rays revealed multilocular cystic cavibony septa affecting the body of the
adanmntinoma of the right out3 facial expansion.
body
Fig.
of the mandible,
showing
27.
Fig. 26.-Extraoral radiograph of the right side of the mandible. showing multilocular cystic cavities separated by thinned-out bony septa The alveolar ridge is thinned out. Remnants of irregular bone could be seen in the cystic areas. Fig. 27.--Occlusal radiograph of the right side of the mandible, showing cystic expansion of bone externally.
right’lower outwardly areas.
jaw with thinned-out alveolar ridge. The expansion was seen mostly (Fig. 27). Remnants of irregular bone could be seen in the cystic
980
N. SALAMA
AND AZIZ HII,MT
Microscopic Appearances.-Examination revealed the typical structures of a cystic adamantinoma. A normal epithelial covering was seen with delicate fibrous matrix below it, into which cystic ameloblastomatous tissue was growing, lined with columnar cells (Fig. 28). Fibrous and bony septa could be seen intermingled between these cystic areas, Operation.-Under general anesthesia the whole out,er wall of t,he swelling was removed with the mucoperiosteum. All cavities were caonnected and thoroughly scraped. The part was subjected later on to deel) x-ray therapy to avoid recurrence.”
Fig. 28.-Photomicrograph normal epithelial covericg with tissue m&S growing.
of adamantinoma of the right side of the mandible. showing connective tissue stroma irto which cystic ameloblastomatous
Case 8. A Case of Extensive Squamous Cell Carcinoma of the Left Body of the Mandible and Ascending Ramus, Originally a Cystic Ameloblastoma A 30-year-old Egyptian man reported suffering from an extensive chronic unsightly swelling of the left side of the face and left side of the mandible with multiple infected sinuses and deep ulcers of the left side of the face, condyle, and submaxillary regions. The condition was of a very rapid nature. It had started only five months previously, but there was a continuous swelling for the last few years, with complete inability to open the mouth. The patient was highly emaciated and debilitated due to malnutrition and toxic infection. The clinical appearances suggested a rapidly infiltrating malignant growth with secondary infection. Enlarged lymph nodes were found in the neck. The *We ILl‘e obliged the specimens.
to Dr. -4. Abu-Zekry,
F.Ii.C.S.(Eng.)
for the
operation and the g&Y of
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FROM
CLINIC
OF CAIRO
DENTAL
981
SCHOOL
teet h in the region involved were partially exfoliated, but some were stil 11present and very 10~)se and embedded in an infected, ulcerated mass of tisr me. Orally, the gingival sulcus, floor of the mouth, and cheek were involved by the lestructive process. The left cheek was perforated due to rapid progress of th ulceration . Blood examination revealed mild leucocytosis. Wassermann reac ion was
Fig. 29.-Exter lsive squamous cell a< :ystic amel oblastoma, showing
Fig.
30.-Radiograph
carcinoma the facial
of the left appearance
of the left side of the mandible of the left body with cystic cavities
body and ramus and the multiple
which dischar
and ramus, showing extensive in the ascending ramus.
Was ging
wiginally eiinuses.
bone
erosion
982
N.
SALAMA
ANI
AZIZ
HILMY
negative. There was facial edema with orbital cellulitis CJn the left. The patient was in the general hospital, and penicillin therapy, which controlled the sepsis, was administered. The tissues of the left, side of the face and neck were all hard and indurated (Fig. 29).
Radiographic Appearances.-Two extraoral radiographs were taken. The second one revealed extensive bone erosion of the left body with cystic cavities clearly seen in the remaining portion of the left body and the whole of t.he ascending ramus. Definite expansion of body and ramus could be seen. The picture was that of a typical cystic ameloblastoma (Fig. 30). Microscopic Appearances.-Two sections were examined, one taken from the edges of perforation of the cheek and the other from the mass of soft tissues at,tached to an extracted tooth. Both revealed an actively growing squamous cell carcinoma with few keratinizing cell nests with deep round cell infiltration (Fig. 31).
Fig.
31.-Photomicrograph showing carcinoma with keratinized cell
typical structures of nests and inflammatory
an
actively infiltration
growing squamous with plasma cells.
cell
Case 9. A Case of an Extensive Squamous Cell Carcinoma of Lips, Gingivae, and Floor of Mouth A 50-year-old Egyptian man presented an extensive ulceration of the lower lip, both corners of the upper lip, gingivae, and floor of the mouth. The infiltration of the growth had involved nearly completely the entire lower jaw, destroying both soft and hard structures. The lower lip had collapsed downward and presented a huge area of ulceration with an extremely irregular floor
CARES
Fig. Fig.
FROM
CLINIC
OF CAIRO
DENTAL
SCHOOL
epithelioma
of lips,
Fig.
32.
32.-Photograph
of patient
with
extensive
983
33. gingiva.
an<1 floor
of
mouth. Fig. 33.-Radiograph of the body and a great
Fig.
34.-Photomicrograph
of right body of mandible, part of the ascending ramus
of extensive
s~~u~~~,u~~cell
showing complete by squamous cell
erosion of carcinoma.
carcinoma
lips
of the
and
the
floor
boric
of the
984
N. SALAMA
ASI)
,\ZI% FLIIXB
which had hard everted edges. The lesion started one year previously and very rapidly attained its present size. The floor of the ulceration had many bleeding, eroded areas with saliva drippling from the mouth. Hard, shotty nodes could be felt subment,all; and in both submaxillary regions, which were believed consistent with acute lymphadenitis due to secondary sept,ic infection. The patient was highly febrile, cachertic, and very emaciated. Blood count was within normal limits with definite leucocytosis. Wassermann reaction was negat,ive. Most of t,he teeth of the lower jaw, particularly the right side, had been shed as a result of destruction of their surrounding structures by the invading neoplasm. The bone of both bodies of the lower jaw, particularly the right side, (1’ (rrowth and had been completely eroded was secondarily involved by the invadin, r, The tremendous size of on the right side, resulting in a pathologic fracture. the growth intraorall>- had mechanically impeded to a great extent, the use of food ; hence nourishment was greatly impaired (Fig. 32).
Radiographic Appearances.-Examination of the x-ray revealed complete erosion of the right body of the lower jaw and a great part of its ascending ramus. The shadow of the neoplasm affecting t,he soft tissues could also be clearly seen (Fig. 33). Microscopic Appearances.--Examination revealed the structures rapidly growing squamous cell carcinoma with columns of growing and few kerat,inizing cell nests. This was a fairly rapidly growing The Gssue was deeply impregnated with inflammator~~ plasma eells
of a fairI> cpithelium carcinoma. (Fig. 34).
SCHOOL
N. SALAMA, B.CH.T). (CAIRO), L.D.S. (EKG.) ,* ASD AZIZ HILMY, B.CH.D.(CAIRO),
T
L.~.S.(ENG.),*
CAIRO. EOYPT
HE following are some of the cases seen in our clinic in Cairo, Egypt, with the type of treatment used by us for such tumors.
Case 1. A Case of an Extensive Fibromyxoma of the Left Maxilla and Palate An adult 45-year-old Egyptian man reported with an extensive solid vascular, very firm growth with smooth normal-colored surface, and short, broad pedicle, growing from the alveolar process region of the left premolar and molar and encroaching on the whole palatal aspect of the maxilla. It was protruding outward slightly, but to a great extent was located palatally. It had started eleven years previously and gradually increased in size. No bony expansion could be felt, an indication of its peripheral origin. It was quite painless. No enlargement of the lymph nodes was present. Both hard and soft palates were unaffected, but owing to the huge bulk of the growth it caused some difficulty The bone of the left maxilla and palate was in swallowing and mastication. unaffected with the exception of a slight outward protrusion localized to the alveolar process from which the neoplasm was originating. The patient’s general health was quite good. The blood count was normal and Wassermann reaction wa,s negative. The neoplasm seemed to be originating from the mucoperiosteum. The left antral cavity was clear. Premolars and molars were missing, and therefore the occlusal aspect of the tumor was partly eroded by traumatic occlusion of opponent teeth. Its consistency was hard and slippery to the touch, with no tendency to bleeding (Fig. 1).
Radiographic
Appearances.-The occlusal views of the left maxilla revealed a localized erosion of the bone of the alveolar process ext.ending from the left first premolar to the third molar and tuberosity l’egions, with some trabeculation seen in the eroded areas (Fig. 2). The bone of the hard palate was unaffected (Fig. 3). The appearances suggested a slow-growing tumor most probably of the mixed cell type.
Microscopic Appearances.-Examination of a section of tissue revealed a normal epithelial covering with a matrix chiefly made Up of collagenous fibrous tissue and fibroblasts. A great part of the structure showed myxomatous tissue with its typical triangular and stellate cells. Impregnat,ion with inflammatory cells could also be seen (Fig. 4). Operation.-Under general anesthesia the growth was chiseled out completely with the alveolar process carrying the canine and first premolar. The external facial wound and the region of the alveolus healed normally and rapidly (Fig. 5). t *Assistant tWe are specimen.
Professor, Dental School, Cairo, Egypt. F.R.C.S.(Eng.) obliged t.o Dr. A. Abu-Zekry.
966
for
his
operation
and
for
the
CASES
FROM
CLINIC
OF CAIRO
DENTAL
967
SCHOOL
Case2. A Caseof Endosteal (Central) Fibromyxoma of the Right Maxilla A 32-year-old Egyptian man reported with a solid, vascular, sessile growth occupying the right maxilla and protruding externally and internally. It had It occupied the region from the upper right canine up to the right tuberositg.
Fig.
l.-Photograph
of patient
Fig.
2.
with an extensive flbromyxoma showing the neoplasm in situ.
of the
left
Fig.
3.
maxilla
and
palate,
Fig. 2.-A case of extensive Abromyxoma of the left maxilla and palate. Occlusal radiograph of the left maxilla showing the presence of localized erosion of the bone of the alveolar process. Some trabeculation is seen in the eroded area. Bone of the hard palate is unaffected. Fig. 3.-A case of extensive flbromyxoma of the left maxilla and palate. Occlusal radiograph of the left maxilla, showing the presence of localized erosion of the bone of tile alveolar process. Bone of the hard palate is unaffected.
had a smooth surface with normal color of the gingiva. The first and second molars were removed a year previously with the growth, but it had recurred. It had started three years previously and had been gradually increasing in
968
N.
SSLAMA
AND
AZIZ
HII,MY
size. The growth, being of endosteal origin, had obliterated the antral cavity and expanded the bone in all directions. Its occlusal surface was partly eroded due to traumatic occlusion of the opponent teeth. The patient’s general health
Fig.
4.-Photomicrograph
Fig.
5.-Photograph
of
of specimen both outer
tumor
of the mvxomatous
left
maxilla structures.
and
palate,
showing
(flbromyxoma of the left maxilla), showing and inner extensions with teeth in situ.
fibrous
its occlusal
and
view,
was quite good. The blood count was normal and the Wassermann reaction was negative. The neoplasm was quite firm to the touch with no tendency to bleed. Both cheek and palate were free (Fig. 6).
CASES
FROM
CIJNIC
OF
CAIRO
DENTAI,
969
SCIIOOI,
Radiographic Appearances.-X-ray examination revealed a growth seen arising from the right alveolar ridge and projecting into the right antrum which appeared opaque (Fig. 7). The alveolar bone was completely destroyed by it.
Fig.
6.
Fig. B.-Photograph the neoplasm in situ. Fig. 7.-Radiograph of the right maxilla.
Fig. bone bone
Fig. with Fig. with
Fig. of patient of skull
with showing
endost&l opacity
flbromyxoma in the
right
8.
8.-Occlusal radiograph of the right maxilla, flne reticulation with honeycomb picture. 9.-Occlusal radiograph of the right maxilla, fine reticulation with honeycomb picture.
7.
of the antrum
Fig.
right with
maxilla, definite
showing expansion
9.
showing
destruction
of
the
alveolar
showing
destruction
of
the
alveolar
970
N.
Marked expansion of honeycombed picture dense sclerosis in the gested a slow-growing
SALAM-
AND
AZIZ
HIIJlY
it. was also seen. Inside the growth, fine reticulation with was detected (Fig. 8). Its margins were clear-cut with healthy bone posteriorly (Fig. !I). The appearances sugendosteal or central growth.
Microscopic Appearances.-Examination revealed normal epithelial covering with a matrix chiefly made up of collagenons fibrous tissue and fibroblasts. A great part of the structure showed mpxomatous degeneration with its typical stellate cells. Round cell infilt,ration was also present (Fig. 10). Operation.--Under general anesthesia the whole right maxilla was surgically removed en masse? and the cavity left to heal. After the lapse of about three months, a mechanical artificial restoration was fitted to close the l)erforation into the sinus and nose.
Fig.
I O.-Photomicrograph with
of endosteal flbromyxoma of the right myxomatous clepenwittion with inflammiltory
maxilla, showing infiltration.
fibrous
tissue
Case 3. A Case of Complex Composite Odontome Occupying the Molar Regions of the Right Side of the Mandible A 30-year-old Egyptian man reported with a septic cavity at the lower right molar region causing pain, tenderness, and swelling. On probing this cavity, hard, irregular, calcified tissue could be felt. This cavity had been present for a very long time, causing acute exacerbations now and then. All the lower molars were missing with no history of previous extractions. The The body of the lower jaw was exremaining dentition was quite normal. panded buccolingually at both the rnolar and angle regions. Acute lymphadThere was neuralgic ehitis was present due to the associated pyogenic infection. pain at the right side of the head with slight inability to open the mouth.
CARES FROM
CIJNIC
OF CAIRO DESTAI,
SCHOOI~
971
Radiographic Appearances-X-ray examination revealed the presence of a fairly huge mass of irregularly calcified tissues occupying completely the right molar region and the angle of the jaw, with thin fungating edges and and at its lower rarefied areas at its occlusal and distal aspects. Anteriorly Fig. 11.
Fig. 12. Fi Il.-Extraoral radiograph of the rjght side of the mandible, showing complex composite o%ontome in situ. Anteriorly and at its lower border a molarlike tooth is seen embedded and fitting in the odontome with its roots curved posteriorly. Fig. lZ.-Extraoral radiograph of the right side of the mandible after complete removal of the odontome.
border a molarlike tooth was seen embedded and fitting into the odontome with its roots curved posteriorly. The occlusal depression coincided with the perforated cavity in the soft tissues. The odontome extended posteriorly beyond the right angle and occupied partly the ascending ramus with bone
972
N.
SALAMA AND AzIz HILMY
covering it o~~lusally. A line of demarcation could be seen around it. The inferior border of the lower jaw was thinned out with slight periosteal deposition of bone externally (Kg. 11). Operation.-After the disappearance of the acute inflammation, regional anesthesia was used to remove the odont,ome. Owing to its irregular fungating edges that were interlocked in the thinned-out bone, the removal was very difficult. Utmost care had to be taken to avoid fracture of the mandible. Deep below the odontome anteriorly a fully calcified first molar was present which was removed easily and assembled in its depressions on the excised odontome. A huge bone cavity was left for daily dressings (F’ig. 12).
Description of the Odontome.-After
bleaching and complete dehydration, the odontome with the tooth articulated in its position weighed 11.715 Gm. its dimensions were as follows: anteroposteriorly, 43 mm. ; vertically, 22 mm. ; buccolingually 21 mm. On examination, it appeared as an irregularly shaped mass with deep excavations both occlusally and distally. I:oth the inner surface and its inferior border were smooth. Anteriorly and at its lower border, there was a deep depression into which the occlusal surface of the first molar had been accurately fitted. Both roots of this molar were curved backward. The whole mass seemed clinically to be formed of enamel, dentinc, and ccmentum irregularly mixed (Fig. 13).
Fig.
i3.--Cornglex
cornymite
odontome,
anteroposterior
view
Case 4. A Case of an Extensive Endosteal (Central) Osteoclastoma (Giant Cell Tumor) of the Left Side of the lkudible A 60-year-old Egyptian woman reported with an extensive solid vascular growth, occupying completely the left half of the mandible. It started about a year previously and rapidly increased in size until it had attained the present size in a relatively short period. The growth was of endosteal or central origin, and had expanded the mandible externally and internally, resulting in great deformity of facial contour. The neoplasm was dark red in color, had an irregular lohulated surface with fluctuations which could be elicited at certain areas due to the presence of blood cysts and osteoclastic erosion of the bone. The patient’s general health was poor. She had advanced oral sepsis. The teeth in relation to the growth were very loose and were removed. Blood cell Wassermann reaction was negative. Blood count was within normal limits.
CASES
Fig.
FROM
CLINIC
OF CAIRO
DENTAL
SCHOOL
Fig.
14.
Fig. 14.-Photograph of patient with an extensive facial contour due to its external expansion of bone. Fig. 15.-Intraoral view of extensive osteoclastoma ing the neoplasm in situ.
osteoclastoma, of the left
Fig. I&-Extraoral radiograph of the left side of the mandible, left body and its ramus with definite line of demarcation between healthy bone. Inferiorly the margin of the bme almost intact, but the bone is markedly rarefled.
15.
showing
deformity
side of the mandible,
showing expansion visible trabeculation near the alveolar
of show-
of the and border,
974
N.
SAIAMA
ANLI
AZIZ
HIL,MV
calcium was normal. No other involvement in the bones of t,he limbs could be found. Such growths are very common in young subjects, yet this case ill ustrates that they can occur as well late in life (Figs. 14 and 15).
Fig.
Fig.
li.-Occlusal
radiograph of the left side of the mandible. showing erosion of bone of body and thin trabeculntion.
18.-Photomicrograph ous multinucleated
cells
of an osteoclastoma lying in a cellular
expansion
of the left side of the mandible matrix with delicate connective
with
mas: 3ive
showing nun ,ertissue stroma.
Radiographic Appearances.-Examination revealed expansion of t,he 1eft body of the mandible by an ost,eolytic growth in the horizontal ramus wit1 1 a definit,e line of demarcation between visible trabecnlation and the healt ;hy bone. Inferiorly the margin of the bone was almost intact, but near the alveolar border the bone was markedly rarefied (Figs. 16 and 17).
CASES FROM
CLINIC
OF CAIRO DENTAL
SCHOOL
975
Microscopic Appearances.-Pathologic examination revealed normal epithelium. The matrix was very cellular with delicate connective tissue stroma Some bone containing fairly numerous large cells with multiple nuclei. Infiltration with inflammatory spicules could be seen scattered here and there. plasma cells could also be seen (Fig. 18). Treatment,-Under general anesthesia, the left half of the mandible completely excised and the part subjected to deep x-ray therapy.
was
Case 5. A Case of Osteoma in a Child A 13-year-old Egyptian female child reported with a very solid growth of hard consistency, protruding buccally and occupying the regions of the left maxilla. It had a sessile base palatally, with a narrowed pedunculated area Its surface was firm and smooth, normal in co!or, with some indentabuccally. tions due to traumatic bite of* the lower teebh. The upper left premolars were displaced slightly, but the left first molar was pushed backward and prevented the eruption of the second molar. It had started about eighteen months previously and was slowly growing and increasing in size. There was no bony expansion of the left maxilla, an indication of its peripheral origin. There was no history of specific illness and the child was apparently in good health. The remaining dentition was normal with no other abnormality in the oral mucosa. The blood count was normal and the Wassermann reaction was negative. No enlargement of the lymph nodes or metastasis could be seen anywhere in the body. The growth was chiefly composed of osseous tissue, and chiseling was resorted to while taking a biopsy.
Fig. 19.--Occlusal radiograph of the left maxilla, showing oma, triangular in shape with smooth deflned outline.
the presence of a pedunculated osteAdjacent teeth appear displaced.
Radiographic Appearances.-The x-ray revealed the presence of a pedunculated osseous mass of tissue protruding externally from the alveolar crest of the left maxilla, triangular in shape with smooth defined outline. It had displaced the adjacent teeth (Fig. 19). The appearance was that of an osteoma.
976
S.
SALAMA
AND
AZIZ
HILMY
Microscopic Appearances.-A section was cut from the specimen after its complete excision through the central part of the growt,h. It was removed with its buccal pedicle intact. It was surprising to find that the whole outer mass of the growth was lined wit,h normal epithelium and the whole structure below was pure osseous tissue (Fig. 20). The pedicle appeared to be made up of a fibrocellular structure with no bony tissue in it and to be lined with epithelium in continuity with that of the large mass, and contained fairly large numbers of multinucleated cells (giant, cells). Therefore the histologic appear(This tumor may be classified as ances revealed an osteonaa with osteoclnsia. a fibro-osteoma.-Ed.)
Fig. 20.-An enlarged photomicrograph of the whole section taken from a patient with combined osteoma of the left maxilla, showing the osseous structure of the whole mass of the growth together with its pedicle which is in continuity with it and appeared as an osteoclastoma.
Case 6. A Case of an Infected Cystic Ameloblastoma Affecting the Whole Right Side of the Mandible and Ascending Ramus A 2%year-old Egyptian girl reported with an extensive swelling of long duration of the right lower jaw, together with the right side of the face (Fig. 21). The swelling had appeared about eight years previously and slowly inThe swelling was acutely creased in size, expanding the bone in all directions. The patient was in a infected and there was profuse suppuration intraorally. Most of the teeth at the very toxic condition with a rise in her temperature. region involved were missing ; the few remaining were very loose. The condition at first was thought to be an acute suppurative osteomyelitis of the right side of the mandible and ascending ramus, but on further examination there appeared to be a huge cystic mass arising from her lower jaw (Fig. 22). Most of the oral extension of the growth was fluctuant and aspirated fluid came out purulent in color, containing only blood and pus cells. Besides this oral condition, the patient did not complain of any systemic illness. No blood changes
CASES FROM
CLINIC
OF CAIRO DENTAL
977
SCHOOL
could be detected with the exception of mild leucocytosis. Wassermann reaction was negative. The pressure of the expanded growth had displaced the upper right molars inward and had mechanically interfered with occlusion.
Fig. 21.-Photograph Fig. 22.-Photograph
Fig. 21. of patient of patient
Fig. 23.-Extraoral multiple cystic areas with right third molar is seen to shadows the tooth did
Fig. 22. with facial swelling due to expansion showing neoplasm in situ.
radiograph of thinned bony pushed up in not appear in
of growth.
the right side of the mandible and ramus, showing septa and expanded right body and ramus. Thek&e; the sigmoid notch with its crown downward. print, but was quite visible in its x-ray.)
Radiographic Appeaxasces.-The x-ray revealed tha,t the right lower jaw was rarefied and contained multiple cysts extending into the ascending ramus. The lower right third molar was displaced and pushed upward and seen at the region of the sigmoid notch with its crown downward. The condition denoted a cystic adamantinoma (Fig. 23).
Microscopic Examination.-Examination o-f a section revealed normal epithelial covering with a fibro-osseous stroma inside of which columns of odontogenie epithelium could be seen, toget,her with multiple small and large cystic areas lined by columnar epithelium. Diagnosis:
Cystic ameloblastoma
(Fig. 24).
Treatment and Operation.-Local multiple incisions and efficient drainage cleared up the acute infection. The whole right side of the lower jaw and its ascending ramus were completely excised under general anesthesia.
Fig.
P4.-Photomicrograph ascending
of infected ramus, showing
multilocular cyst typical structures
of the right side of the of cystic ameloblastoma.
mandible
and
Case 7. A Case of Cystic Ameloblastoma of the Right Body of the Mandible A 37-year-old Egyptian man reported with an unsight,ly chronic facial swelling of the right body of the mandible (Fig. 25). It had started two years previously and gradually increased in size. On examination, a fluctuant endosteal growth could be felt occupying the region of the right side of the mandible where the teeth were missing. The neoplasm had expanded the body of the The jaw had been completely resorbed lower jaw both outward and inward. at certain areas buccally. The mass had an irregular occlusal surface due to pressure from opponent teeth. aspirated fluid came out yellowish in color, The patient’s general health was but no crystals of cholesterin were found. good. Blood count was normal and Wassermann reaction was negative. The No lymph node enlargement or metasremaining dentition was quite normal. tasis was present.
CASES
FROM
CLINIC
OF CATRO
Radiographic Appearance&--The ties (Fig.
Fig.
26), separated by thinned-out
25.-Photograph
Fig.
of patient
26.
with
DENTAL
SCHOOL
979
x-rays revealed multilocular cystic cavibony septa affecting the body of the
adanmntinoma of the right out3 facial expansion.
body
Fig.
of the mandible,
showing
27.
Fig. 26.-Extraoral radiograph of the right side of the mandible. showing multilocular cystic cavities separated by thinned-out bony septa The alveolar ridge is thinned out. Remnants of irregular bone could be seen in the cystic areas. Fig. 27.--Occlusal radiograph of the right side of the mandible, showing cystic expansion of bone externally.
right’lower outwardly areas.
jaw with thinned-out alveolar ridge. The expansion was seen mostly (Fig. 27). Remnants of irregular bone could be seen in the cystic
980
N. SALAMA
AND AZIZ HII,MT
Microscopic Appearances.-Examination revealed the typical structures of a cystic adamantinoma. A normal epithelial covering was seen with delicate fibrous matrix below it, into which cystic ameloblastomatous tissue was growing, lined with columnar cells (Fig. 28). Fibrous and bony septa could be seen intermingled between these cystic areas, Operation.-Under general anesthesia the whole out,er wall of t,he swelling was removed with the mucoperiosteum. All cavities were caonnected and thoroughly scraped. The part was subjected later on to deel) x-ray therapy to avoid recurrence.”
Fig. 28.-Photomicrograph normal epithelial covericg with tissue m&S growing.
of adamantinoma of the right side of the mandible. showing connective tissue stroma irto which cystic ameloblastomatous
Case 8. A Case of Extensive Squamous Cell Carcinoma of the Left Body of the Mandible and Ascending Ramus, Originally a Cystic Ameloblastoma A 30-year-old Egyptian man reported suffering from an extensive chronic unsightly swelling of the left side of the face and left side of the mandible with multiple infected sinuses and deep ulcers of the left side of the face, condyle, and submaxillary regions. The condition was of a very rapid nature. It had started only five months previously, but there was a continuous swelling for the last few years, with complete inability to open the mouth. The patient was highly emaciated and debilitated due to malnutrition and toxic infection. The clinical appearances suggested a rapidly infiltrating malignant growth with secondary infection. Enlarged lymph nodes were found in the neck. The *We ILl‘e obliged the specimens.
to Dr. -4. Abu-Zekry,
F.Ii.C.S.(Eng.)
for the
operation and the g&Y of
CASES
FROM
CLINIC
OF CAIRO
DENTAL
981
SCHOOL
teet h in the region involved were partially exfoliated, but some were stil 11present and very 10~)se and embedded in an infected, ulcerated mass of tisr me. Orally, the gingival sulcus, floor of the mouth, and cheek were involved by the lestructive process. The left cheek was perforated due to rapid progress of th ulceration . Blood examination revealed mild leucocytosis. Wassermann reac ion was
Fig. 29.-Exter lsive squamous cell a< :ystic amel oblastoma, showing
Fig.
30.-Radiograph
carcinoma the facial
of the left appearance
of the left side of the mandible of the left body with cystic cavities
body and ramus and the multiple
which dischar
and ramus, showing extensive in the ascending ramus.
Was ging
wiginally eiinuses.
bone
erosion
982
N.
SALAMA
ANI
AZIZ
HILMY
negative. There was facial edema with orbital cellulitis CJn the left. The patient was in the general hospital, and penicillin therapy, which controlled the sepsis, was administered. The tissues of the left, side of the face and neck were all hard and indurated (Fig. 29).
Radiographic Appearances.-Two extraoral radiographs were taken. The second one revealed extensive bone erosion of the left body with cystic cavities clearly seen in the remaining portion of the left body and the whole of t.he ascending ramus. Definite expansion of body and ramus could be seen. The picture was that of a typical cystic ameloblastoma (Fig. 30). Microscopic Appearances.-Two sections were examined, one taken from the edges of perforation of the cheek and the other from the mass of soft tissues at,tached to an extracted tooth. Both revealed an actively growing squamous cell carcinoma with few keratinizing cell nests with deep round cell infiltration (Fig. 31).
Fig.
31.-Photomicrograph showing carcinoma with keratinized cell
typical structures of nests and inflammatory
an
actively infiltration
growing squamous with plasma cells.
cell
Case 9. A Case of an Extensive Squamous Cell Carcinoma of Lips, Gingivae, and Floor of Mouth A 50-year-old Egyptian man presented an extensive ulceration of the lower lip, both corners of the upper lip, gingivae, and floor of the mouth. The infiltration of the growth had involved nearly completely the entire lower jaw, destroying both soft and hard structures. The lower lip had collapsed downward and presented a huge area of ulceration with an extremely irregular floor
CARES
Fig. Fig.
FROM
CLINIC
OF CAIRO
DENTAL
SCHOOL
epithelioma
of lips,
Fig.
32.
32.-Photograph
of patient
with
extensive
983
33. gingiva.
an<1 floor
of
mouth. Fig. 33.-Radiograph of the body and a great
Fig.
34.-Photomicrograph
of right body of mandible, part of the ascending ramus
of extensive
s~~u~~~,u~~cell
showing complete by squamous cell
erosion of carcinoma.
carcinoma
lips
of the
and
the
floor
boric
of the
984
N. SALAMA
ASI)
,\ZI% FLIIXB
which had hard everted edges. The lesion started one year previously and very rapidly attained its present size. The floor of the ulceration had many bleeding, eroded areas with saliva drippling from the mouth. Hard, shotty nodes could be felt subment,all; and in both submaxillary regions, which were believed consistent with acute lymphadenitis due to secondary sept,ic infection. The patient was highly febrile, cachertic, and very emaciated. Blood count was within normal limits with definite leucocytosis. Wassermann reaction was negat,ive. Most of t,he teeth of the lower jaw, particularly the right side, had been shed as a result of destruction of their surrounding structures by the invading neoplasm. The bone of both bodies of the lower jaw, particularly the right side, (1’ (rrowth and had been completely eroded was secondarily involved by the invadin, r, The tremendous size of on the right side, resulting in a pathologic fracture. the growth intraorall>- had mechanically impeded to a great extent, the use of food ; hence nourishment was greatly impaired (Fig. 32).
Radiographic Appearances.-Examination of the x-ray revealed complete erosion of the right body of the lower jaw and a great part of its ascending ramus. The shadow of the neoplasm affecting t,he soft tissues could also be clearly seen (Fig. 33). Microscopic Appearances.--Examination revealed the structures rapidly growing squamous cell carcinoma with columns of growing and few kerat,inizing cell nests. This was a fairly rapidly growing The Gssue was deeply impregnated with inflammator~~ plasma eells
of a fairI> cpithelium carcinoma. (Fig. 34).