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Myxoma of the mandible with unusual radiographic appearance
J Oral Maxillofac
Surg
43.987-990.1985
Myxoma of the Mandible wifh Unusual Radiographic Appearance JORGE A. CHUCHURRU, DDS,* RICARDO LUBERTI, DDS,t JUAN C. CORNICELLI, MD,* AND FRANCISCO V. DOMINGUEZ, DDS§
An unusual radiographic picture of the odontogenie myxoma was reported in 1960 by Large et al.’ in a 3%year-old man who had a left mandibular tumor. It had radiopaque lines with a vertical orientation to the mandible extending from the periosteum into the soft tissues producing a “sunburst” effect suggestive of a malignant bone lesion, possibly an osteogenic sarcoma.’ Eighteen years later Schmidseder et al. ,8 in a report of 1 I cases of myxoma of the jaws collected from 1969 to 1977, described a new case of a large bone-hard tumor in the left horizontal ramus of the mandible in a 34year-old man. Its radiographic appearance. with multiple spicules growing out radially from the lesion into the soft tissues, tended to support a diagnosis of osteogenic malignant bone tumor.” In this case, as in that of Large et al..’ the biopsy yielded a diagnosis of myxofibroma.
Myxoma of bone does not occur outside of the jaws. Most investigators believe the tumor arises from the connective tissue of the dental papilla and have called it an odontogenic myxoma.‘s2 According to the World Health Organization,‘*3 mxyoma of bone is a locally invasive neoplasm consisting of rounded and angular cells lying in an abundant mucoid stroma. In the International Histological Classification of Tumors3 the myxoma of the jaws is placed among the benign odontogenic tumors. From a review of 95 cases of myxoma of the jaws published in the literature and the study of 21 new cases, Barros, et ale4 infer that it is a fairly frequent tumor found most often in females and in the lower jaw. The average age of the patients is 33 years. As myxoma of the jaws involves bone, its radiographic appearance is especially important diagnostically. The tumor presents differently according to its evolution.4 Most often the odontogenic myxoma appears as a well-circumscribed radiolucent area in which there are multilocular compartments. This “soap-bubble” appearance is very similar to that of an ameloblastoma; the differential diagnosis must also include giant-cell granuloma, central hemangioma of bone, fibrous dysplasia, and primordial cyst.= In another instance the compartments of the tumor tend to be angular, separated by straight septa that form square, rectangular or triangular spaces. This radiographic appearance is compared with a “honey comb” or a “tennis racquet.“jJ’ It also may be found as a unilocular cyst-like radiolucency, especially when it occurs pericoronally and involves an impacted toothe The differential diagnosis in such cases must include the dentigerous cyst.
Report of Case In November 1981, a 20-year-old woman was referred to the Department of Stomatology, School of Dentistry of the University of Buenos Aires. Six months before, her lower right second premolar had been extracted, but the postsurgical wound did not heal and, at the same time, an enlargement of the area was observed. Antibiotic therapy failed to improve the situation. Upon the admission to our clinic the patient was in good general health except for the extraoral prominence of the right side of the face (Fig. 1). Intraorally there was a firm, fixed painless swelling of the horizontal ramus of the right mandible extending from the canine to the second molar producing buccal and lingual expansion of the mandible (Fig. 2). There was slight mobility of the second molar. The patient stated that there had been some episodes of paresthesia in the area. The panoramic radiograph (Fig. 3) showed a large radiolucent area of the right side of the mandible extending from the lower right canine to the third molar of the same side without any well-defined margin or sclerotic border. Straight and curved bony trabeculae produced a “honeycomb” pattern. The periapical radiographic examination (Fig. 4) showed a mixed osteolytic and osteogenic lesion. No resorption of the teeth next to the lesion was observed. An occlusal view (Fig. 5) showed multiple spicules of bone extending from both sides of the lesion. espe-
Received from the *Department of Clinical Pathology, tDental radiology. and 80ral Pathology. School of Dentistry, University of Buenos Aires, Argentina and the *Department of Surgery of Head and Neck, Hospital Posadas, Buenos Aires. Address correspondence and reprint requests to Dr. Chuchurru: Catedra de Patologia y Clinica Bucodental II, Facultad de Odontologia Marcel0 T. de Alvear 2142-Piso Y, 1122 Buenos Aires, Argentina.
987
988
FIGURE
MYXOMA OF THE MANDIBLE
1 (lefr, top).
Clinical appearance
FIGURE 2 (right, top). FIGURE 3 (lef, middle). pattern. FIGURE 4 (right, middle). FIGURE 5 (left, bottom). “sunray” effect.
of patient showing asymmetry of the face.
Intraoral view showing a firm, fixed expanding lesion of the right side of the mandible Panoramic radiograph showing large radiolucent area of the right side of the mandible with a “honeycomb” Periapical radiograph shows a mixed osteolytic and osteogenic appearance. Occlusal view showing multiple spicules of bone radiating from both sides of the lesion producing a classic
Microscopic view shows scarce fusiform cells and remains of fibrillar collagen in an abundant mucoid FIGURE 6 (right, bottom). intercellular matrix. An osseous fragment is seen in the lower right corner (H & E, x 250).
CHUCHLJRRU ET AL.
FIGURE 7 (/q?. fop).
989
Surgical specimen.
FIGURE 8 (right. [op).
Postoperative
FIGURE 9 Clc:fi. horrom). FIGURE
IO (/@llr, h~orn).
Postoperative
radiograph taken one and a half years after surgery showing reconstruction intraoral photograph
Postoperative
with rib graft
in place.
facial view showing good facial symmetry.
side, presenting a classic “sun-ray” effect. On gross examination, the biopsy specimens had an irregular appearance with a white, translucent, wet surface from which small filaments of mutinous material protended. When the specimens were cut, the tissue had the same appearance, but there was grittiness, presumably due to the presence of calcified or osseous material. The microscopic examination showed a homogeneous neoplastic tissue with scarce cells and an abundance of intercellular material slightly colored with the hematoxylin stain. The tumor cells were fusiform and stellate. with long and anastomosing cytoplasmic processes and basophilic nuclei. There were no signs of cellular atypia nor was there any indication of mitotic activity. The stroma consisted of small areas of perivascular fibrous tissue and thin lamellar osseous trabeculae (Fig. 6). With PAS technique. the intercellular material, stroma, and some cells were strongly stained. A diagnosis of myxoma was made. The patient was admitted for surgery in January 1982. cially on the buccal
showing prosthesi\
The tumor was resected with a 2 cm-margin through a submandibular incision (Fig. 7). A concomitant reconstruction was made using the anterior arch of the eighth rib. Maxillomandibular fixation was maintained for 60 days. Microscopic examination of the surgical specimen confirmed the diagnosis of myxoma. One and a half years later examination of the patient showed a good esthetic result and no evidence of disease (Figs. 8-10).
Discussion Only two cases 7.8of an odontogenic myxoma of the jaws having the radiographic picture of “sunray” effect have been published previously. Both of them were in the mandible, as was the present case. Contrary to some opinions,8,9 the myxoma of the jaws is not an unusual entity4; however, its diagnosis is not always easy, as it can be confused with
990
MISSILE INJURY
several other conditions such as ameloblastoma, central giant cell granuloma, central hemangioma of bone, fibrous dysplasia, and some types of cyst. The central myxoma of the jaws must be widely resected, because it tends to recur. However, the prognosis is good. The radiographic appearance of the present case and those reported by Large et al.7 and Schmidseder et al.’ could lead to a dangerous misdiagnosis if the lesion is confused with a malignant bone lesion, especially the osteogenic sarcoma, the prognosis and treatment of which are very different. Summary Myxoma of the jaws is a fairly frequent bone tumor classified as a benign odontogenic neoplasm. The radiographic picture varies according to its evolution and, it many cases, diagnosis is not easy. A new case with an unusual radiographic appearance is reported. On occlusal radiographic examination the tumor showed multiple spicules of bone with a classic “sun-ray” effect. Only two similar J Oral Maxillofac 43:990-992.
cases were found in the literature. Oral and maxillofacial surgeons should be aware of this unusual presentation so that a misdiagnosis of malignant bone tumor is not made. References 1. Anderson WAD: Pathology, 5th ed. St. Louis, CV Mosby, 1966 2. Pindborg JJ, Hjorting-Hansen E: Atlas of Diseases of the Jaws. Copenhagen, Munksgaard, 1974 3. World Health Organization: Histological Typing of Odontogenic ‘Ibmours, Jaw Cysts and Allied Lesions. Geneva, WHO International Histological Classification of Tumours, 1971 4. Barros RE, Dominguez FV, Cabrini RL: Myxoma of the jaw. Oral Surg 27:225, 1969 5. Stafne EC, Gibilisco JA: Oral Roentgenographic Diagnosis, 4th ed Philadelphia, Saunders, 1975 6. Wood NK, Goaz PW: Differential Diagnosis of Oral Lesions. Saint Louis, CV Mosby, 1975 7. Large ND, Niebel HH, Fredricks WH: Myxoma of the jaws. Report of two cases. Oral Surg 13:1462. 1960 8. Schmidseder R. Groddeck A, Scheunemann H: Diagnostic and therapeutic problems of myxomas (myxofibromas) of the jaws. J Maxillofac Surg 6:281, 1978 9. Ghosh BC, Huvos AG, Gerald FP, Miller TR: Myxoma of the jaw bones. Cancer 31:237, 1973
Surg
1985
Traumatic Aneurysm of the Facial Artery Caused by Missile Injury H. RAHMAT,
MD,* A. AMIRJAMSHIDI,
Despite the relative lack of protection of the maxillofacial region, traumatic aneurysm and arteriovenous fistula in this region are very rare. Surgical manipulation around the teeth and jaw,’ infections,* blunt trauma to the jaw with or without fracture,2-4 and unknown factors are among the causes of these complications in reported cases. Until now, no arteriographically and/or histologically proven case caused by missile injury has been reported in the literature. Report of Case A 20-year-old soldier was transferred to our hospital from the battlefield on June 10, 1982, ten to 12 hours Received from the *Department of Neurosurgery and the tDepartment of Pathology, Dr. Shariati Hospital, Tehran University, Iran. Address correspondence and reprint requests to Dr. Rahmat: Department of Neurosurgery, Dr. Shariati Hospital, North Kargar Ave., Tehran, Iran.
MD,* AND N. KAMALIAN,
MDt
following missile injury. On admission, he was conscious and obeyed commands readily but was breathing through a tracheostomy tube. He had a wound just above the right corner of his mouth that seemed to be the entrance of the shell fragments that had caused the massive maxillofacial edema and laceration of the tongue. There was no visible exit wound. Plain radiographs, including panoramic views, showed two shell fragments-one within the floor of the mouth and a larger one just medial and below the angle of the left side of the mandible (Fig. 1). During the next two weeks, the soft tissue and pharyngeal edema gradually subsided and the tracheostomy tube was removed. However, the patient began to feel a peculiar sensation under his left jaw. On examination, he had a soft painless swelling beneath and attached to the lower border of the mandible. It was pulsatile, with a palpable thrill over it. A harsh machinery murmur was audible on auscultation. A left carotid angiogram (Fig. 2) showed a large aneurysm that seemed to be arising from the facial artery, with the shell fragment lying on its dome. An enlarged draining vein was also visible in the arterial angiographic phase, suggesting a combined aneurysm and arteriovenous listula.
Surg
43.987-990.1985
Myxoma of the Mandible wifh Unusual Radiographic Appearance JORGE A. CHUCHURRU, DDS,* RICARDO LUBERTI, DDS,t JUAN C. CORNICELLI, MD,* AND FRANCISCO V. DOMINGUEZ, DDS§
An unusual radiographic picture of the odontogenie myxoma was reported in 1960 by Large et al.’ in a 3%year-old man who had a left mandibular tumor. It had radiopaque lines with a vertical orientation to the mandible extending from the periosteum into the soft tissues producing a “sunburst” effect suggestive of a malignant bone lesion, possibly an osteogenic sarcoma.’ Eighteen years later Schmidseder et al. ,8 in a report of 1 I cases of myxoma of the jaws collected from 1969 to 1977, described a new case of a large bone-hard tumor in the left horizontal ramus of the mandible in a 34year-old man. Its radiographic appearance. with multiple spicules growing out radially from the lesion into the soft tissues, tended to support a diagnosis of osteogenic malignant bone tumor.” In this case, as in that of Large et al..’ the biopsy yielded a diagnosis of myxofibroma.
Myxoma of bone does not occur outside of the jaws. Most investigators believe the tumor arises from the connective tissue of the dental papilla and have called it an odontogenic myxoma.‘s2 According to the World Health Organization,‘*3 mxyoma of bone is a locally invasive neoplasm consisting of rounded and angular cells lying in an abundant mucoid stroma. In the International Histological Classification of Tumors3 the myxoma of the jaws is placed among the benign odontogenic tumors. From a review of 95 cases of myxoma of the jaws published in the literature and the study of 21 new cases, Barros, et ale4 infer that it is a fairly frequent tumor found most often in females and in the lower jaw. The average age of the patients is 33 years. As myxoma of the jaws involves bone, its radiographic appearance is especially important diagnostically. The tumor presents differently according to its evolution.4 Most often the odontogenic myxoma appears as a well-circumscribed radiolucent area in which there are multilocular compartments. This “soap-bubble” appearance is very similar to that of an ameloblastoma; the differential diagnosis must also include giant-cell granuloma, central hemangioma of bone, fibrous dysplasia, and primordial cyst.= In another instance the compartments of the tumor tend to be angular, separated by straight septa that form square, rectangular or triangular spaces. This radiographic appearance is compared with a “honey comb” or a “tennis racquet.“jJ’ It also may be found as a unilocular cyst-like radiolucency, especially when it occurs pericoronally and involves an impacted toothe The differential diagnosis in such cases must include the dentigerous cyst.
Report of Case In November 1981, a 20-year-old woman was referred to the Department of Stomatology, School of Dentistry of the University of Buenos Aires. Six months before, her lower right second premolar had been extracted, but the postsurgical wound did not heal and, at the same time, an enlargement of the area was observed. Antibiotic therapy failed to improve the situation. Upon the admission to our clinic the patient was in good general health except for the extraoral prominence of the right side of the face (Fig. 1). Intraorally there was a firm, fixed painless swelling of the horizontal ramus of the right mandible extending from the canine to the second molar producing buccal and lingual expansion of the mandible (Fig. 2). There was slight mobility of the second molar. The patient stated that there had been some episodes of paresthesia in the area. The panoramic radiograph (Fig. 3) showed a large radiolucent area of the right side of the mandible extending from the lower right canine to the third molar of the same side without any well-defined margin or sclerotic border. Straight and curved bony trabeculae produced a “honeycomb” pattern. The periapical radiographic examination (Fig. 4) showed a mixed osteolytic and osteogenic lesion. No resorption of the teeth next to the lesion was observed. An occlusal view (Fig. 5) showed multiple spicules of bone extending from both sides of the lesion. espe-
Received from the *Department of Clinical Pathology, tDental radiology. and 80ral Pathology. School of Dentistry, University of Buenos Aires, Argentina and the *Department of Surgery of Head and Neck, Hospital Posadas, Buenos Aires. Address correspondence and reprint requests to Dr. Chuchurru: Catedra de Patologia y Clinica Bucodental II, Facultad de Odontologia Marcel0 T. de Alvear 2142-Piso Y, 1122 Buenos Aires, Argentina.
987
988
FIGURE
MYXOMA OF THE MANDIBLE
1 (lefr, top).
Clinical appearance
FIGURE 2 (right, top). FIGURE 3 (lef, middle). pattern. FIGURE 4 (right, middle). FIGURE 5 (left, bottom). “sunray” effect.
of patient showing asymmetry of the face.
Intraoral view showing a firm, fixed expanding lesion of the right side of the mandible Panoramic radiograph showing large radiolucent area of the right side of the mandible with a “honeycomb” Periapical radiograph shows a mixed osteolytic and osteogenic appearance. Occlusal view showing multiple spicules of bone radiating from both sides of the lesion producing a classic
Microscopic view shows scarce fusiform cells and remains of fibrillar collagen in an abundant mucoid FIGURE 6 (right, bottom). intercellular matrix. An osseous fragment is seen in the lower right corner (H & E, x 250).
CHUCHLJRRU ET AL.
FIGURE 7 (/q?. fop).
989
Surgical specimen.
FIGURE 8 (right. [op).
Postoperative
FIGURE 9 Clc:fi. horrom). FIGURE
IO (/@llr, h~orn).
Postoperative
radiograph taken one and a half years after surgery showing reconstruction intraoral photograph
Postoperative
with rib graft
in place.
facial view showing good facial symmetry.
side, presenting a classic “sun-ray” effect. On gross examination, the biopsy specimens had an irregular appearance with a white, translucent, wet surface from which small filaments of mutinous material protended. When the specimens were cut, the tissue had the same appearance, but there was grittiness, presumably due to the presence of calcified or osseous material. The microscopic examination showed a homogeneous neoplastic tissue with scarce cells and an abundance of intercellular material slightly colored with the hematoxylin stain. The tumor cells were fusiform and stellate. with long and anastomosing cytoplasmic processes and basophilic nuclei. There were no signs of cellular atypia nor was there any indication of mitotic activity. The stroma consisted of small areas of perivascular fibrous tissue and thin lamellar osseous trabeculae (Fig. 6). With PAS technique. the intercellular material, stroma, and some cells were strongly stained. A diagnosis of myxoma was made. The patient was admitted for surgery in January 1982. cially on the buccal
showing prosthesi\
The tumor was resected with a 2 cm-margin through a submandibular incision (Fig. 7). A concomitant reconstruction was made using the anterior arch of the eighth rib. Maxillomandibular fixation was maintained for 60 days. Microscopic examination of the surgical specimen confirmed the diagnosis of myxoma. One and a half years later examination of the patient showed a good esthetic result and no evidence of disease (Figs. 8-10).
Discussion Only two cases 7.8of an odontogenic myxoma of the jaws having the radiographic picture of “sunray” effect have been published previously. Both of them were in the mandible, as was the present case. Contrary to some opinions,8,9 the myxoma of the jaws is not an unusual entity4; however, its diagnosis is not always easy, as it can be confused with
990
MISSILE INJURY
several other conditions such as ameloblastoma, central giant cell granuloma, central hemangioma of bone, fibrous dysplasia, and some types of cyst. The central myxoma of the jaws must be widely resected, because it tends to recur. However, the prognosis is good. The radiographic appearance of the present case and those reported by Large et al.7 and Schmidseder et al.’ could lead to a dangerous misdiagnosis if the lesion is confused with a malignant bone lesion, especially the osteogenic sarcoma, the prognosis and treatment of which are very different. Summary Myxoma of the jaws is a fairly frequent bone tumor classified as a benign odontogenic neoplasm. The radiographic picture varies according to its evolution and, it many cases, diagnosis is not easy. A new case with an unusual radiographic appearance is reported. On occlusal radiographic examination the tumor showed multiple spicules of bone with a classic “sun-ray” effect. Only two similar J Oral Maxillofac 43:990-992.
cases were found in the literature. Oral and maxillofacial surgeons should be aware of this unusual presentation so that a misdiagnosis of malignant bone tumor is not made. References 1. Anderson WAD: Pathology, 5th ed. St. Louis, CV Mosby, 1966 2. Pindborg JJ, Hjorting-Hansen E: Atlas of Diseases of the Jaws. Copenhagen, Munksgaard, 1974 3. World Health Organization: Histological Typing of Odontogenic ‘Ibmours, Jaw Cysts and Allied Lesions. Geneva, WHO International Histological Classification of Tumours, 1971 4. Barros RE, Dominguez FV, Cabrini RL: Myxoma of the jaw. Oral Surg 27:225, 1969 5. Stafne EC, Gibilisco JA: Oral Roentgenographic Diagnosis, 4th ed Philadelphia, Saunders, 1975 6. Wood NK, Goaz PW: Differential Diagnosis of Oral Lesions. Saint Louis, CV Mosby, 1975 7. Large ND, Niebel HH, Fredricks WH: Myxoma of the jaws. Report of two cases. Oral Surg 13:1462. 1960 8. Schmidseder R. Groddeck A, Scheunemann H: Diagnostic and therapeutic problems of myxomas (myxofibromas) of the jaws. J Maxillofac Surg 6:281, 1978 9. Ghosh BC, Huvos AG, Gerald FP, Miller TR: Myxoma of the jaw bones. Cancer 31:237, 1973
Surg
1985
Traumatic Aneurysm of the Facial Artery Caused by Missile Injury H. RAHMAT,
MD,* A. AMIRJAMSHIDI,
Despite the relative lack of protection of the maxillofacial region, traumatic aneurysm and arteriovenous fistula in this region are very rare. Surgical manipulation around the teeth and jaw,’ infections,* blunt trauma to the jaw with or without fracture,2-4 and unknown factors are among the causes of these complications in reported cases. Until now, no arteriographically and/or histologically proven case caused by missile injury has been reported in the literature. Report of Case A 20-year-old soldier was transferred to our hospital from the battlefield on June 10, 1982, ten to 12 hours Received from the *Department of Neurosurgery and the tDepartment of Pathology, Dr. Shariati Hospital, Tehran University, Iran. Address correspondence and reprint requests to Dr. Rahmat: Department of Neurosurgery, Dr. Shariati Hospital, North Kargar Ave., Tehran, Iran.
MD,* AND N. KAMALIAN,
MDt
following missile injury. On admission, he was conscious and obeyed commands readily but was breathing through a tracheostomy tube. He had a wound just above the right corner of his mouth that seemed to be the entrance of the shell fragments that had caused the massive maxillofacial edema and laceration of the tongue. There was no visible exit wound. Plain radiographs, including panoramic views, showed two shell fragments-one within the floor of the mouth and a larger one just medial and below the angle of the left side of the mandible (Fig. 1). During the next two weeks, the soft tissue and pharyngeal edema gradually subsided and the tracheostomy tube was removed. However, the patient began to feel a peculiar sensation under his left jaw. On examination, he had a soft painless swelling beneath and attached to the lower border of the mandible. It was pulsatile, with a palpable thrill over it. A harsh machinery murmur was audible on auscultation. A left carotid angiogram (Fig. 2) showed a large aneurysm that seemed to be arising from the facial artery, with the shell fragment lying on its dome. An enlarged draining vein was also visible in the arterial angiographic phase, suggesting a combined aneurysm and arteriovenous listula.