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OLIGOSYMPTOMATIC FORM OF MELKERSSON-ROSENTHAL SYNDROME: A CASE REPORT
OOOO Volume 129, Number 1 retromandibular region. Orthopantomography and cone beam computerized tomography revealed a mixed multiloculated osteolytic lesion in the right mandibular angle and ramus with expansion into cortical bone. A segmental mandibular resection with safety margins was done, and autologous vascular iliac crest graft was fixed with a plate for osteosynthesis. Clinical-radiographic control at 1 year showed preserved mandibular mobility, bone neoformation, and absence of recurrence. The absence of capsule facilitates the tumor infiltration and explains its high recurrence. For odontogenic myxomas of <3 cm, conservative surgical treatment is proposed, while for larger odontogenic myxomas, surgical resection with safety margins of at least 1 cm and immediate functional reconstruction are required.
AGGRESSIVE IDIOPATHIC BILATERAL CENTRAL GIANT CELL GRANULOMA OF THE JAW: A CASE REPORT. RODRIGO ANDRES GUTIERREZ DIAZ, LUIS MARTIN CASTRO HERRERA, e NIGA FELIPE IGNACIO FUENTES ZU and, JUAN PABLO AITKEN SAAVEDRA Central giant cell granuloma (GCCG) is a benign osteolytic proliferation with diverse clinical and radiologic behavior patterns, characterized by the presence of multinucleated giant cells in a vascular stroma. A 25-year-old man presented with bilateral swelling in the posterior mandibular region of 2-month duration with painful symptomatology. Intraoral exam showed bilateral expansion of the vestibular cortical bones in the mandibular retromolar region. Panoramic radiograph and computed tomography revealed extensive bilateral multilocular mandibular areas causing bilateral expansion of the vestibular cortical bones. The histopathologic examination showed benign fibroblasts matrix with variable number of giant cells and hemorrhagic content. Immunohistochemistry for CD-68 glycoprotein showed positive immunoreactivity. Biochemical examination showed no signs of hyperparathyroidism. Diagnosis of CGCG is a complex task, even more so when the clinical presentation is unusual. Currently, it is known that the occurrence of multiple lesions of CGCG is associated with different systemic diseases.
ORAL LEIOMYOMA: UNUSUAL CLINICAL MANIFESTATION OF A RARE LESION. ROGERIO JARDIM CALDAS, BRUNO AUGUSTO BENEVENUTO DE ANDRADE, MARIO JOSE e ROMANACH, FLAVIA CRISTINA ROSAS DE CARVALHO, DANIELLE CASTEX CONDE, HELITON SPINDOLA ANTUNES and, PAULO SERGIO DA SILVA SANTOS Oral leiomyoma is a benign smooth muscle neoplasm of rare incidence, described as an asymptomatic nodule. We report a case of solid leiomyoma with a distinctive clinical manifestation in the anterior tongue. A 46-year-old woman complained of pain in her tongue with impairment of chewing and speaking for 2 months. Clinically, she presented with a depression covered by a pink-colored smooth mucosa, also surrounded by whitish prominent borders. The lesion was firm measuring 7 mm. Incisional biopsy was performed. Histologic examination revealed a noncapsulated proliferation of spindle cells with pale, eosinophilic, and vacuolated cytoplasm containing elongated cigar-shaped nuclei, which were organized in sweeping fascicles intermingled with muscle tissue, blood vessels, and inflammatory infiltrate. No evidence of cellular atypia was found. Tumor cells were strongly marked with muscle-
ABSTRACTS
e31
specific actin antibody, but negative for S-100 protein. The final diagnosis was leiomyoma. After 3 months of complete excision, no pain or signs of recurrence were noted.
SOLITARY INFANTILE MYOFIBROMA OF THE MANDIBLE IN A 2-YEAR-OLD CHILD: DIAGNOSIS AND TREATMENT OF A RARE LESION. VICTOR MONTALLI, FABRICIO PASSADOR, ROGERIO JORGE, ANTONIO AUGUSTO CAMPANHA, ALBINA ALTEMANI, PAULO DE CAMARGO MORAES and, VERA CAVALCANTI DE ARAUJO A 2-year-old male patient came to our service with the complaint of swelling located in the left side of the lower jaw. There was a history of trauma 3 months prior to the lesion formation. The swelling was initially noticed as a small nodule, which increased in size gradually. On palpation, the swelling was well localized, firm, nonmobile, 3 £ 3 cm in diameter, nontender, fixed to the underlying bone, and nonadherent to the superficial skin. No submandibular lymphadenopathy was noted. Computed tomography scan of the jaws with a 3-dimensional reconstruction image showed the presence of a soft tissue lesion with bone erosion of the inferior aspect of the left side of the body of the mandible. Histologically, a typical biphasic cellular arrangement was noted. Immunohistochemical markers have been useful for the definitive diagnosis of this uncommon neoplasm. The clinical, radiologic, histologic and immunohistochemical aspects corroborate the diagnosis of infantile myofibroma.
SURGICAL CONSERVATIVE TREATMENT OF AMELOBLASTIC FIBRODENTINOMA. GUSTAVO LUIZ ALKMIN PAIVA, PABLO e MORANDO, AGUSTIN VARGAS, FERNANDO SIMOES ALAN ROGER DOS SANTOS SILVA, GUSTAVO GROTHE MACHADO and, ANDRE CAROLI ROCHA Although controversial, the World Health Organization has recently categorized ameloblastic fibrodentinoma (AFD) as part of the spectrum of odontomas, pointing out that it may be a “developing odontoma.” The aim of this presentation is to report the case of a 9-year-old girl with a painless swelling in the posterior right mandible. Intraoral examination revealed a firm and slightly tender swelling on palpation. Panoramic radiograph showed a massive well-defined radiolucency affecting the mandibular body and ascending ramus presenting the so-called "soap bubble pattern" and root resorption. The diagnosis of AFD was provided by incisional biopsy. Primary treatment was performed by an intraoral approach and conservative surgical excision. After 9 months of treatment and follow-up, a discreet radiolucency with sclerotic borders was detected near the condylar neck and managed by another conservative surgery via retromandibular approach. No recurrence was noticed after a 3 years of follow-up.
OLIGOSYMPTOMATIC FORM OF MELKERSSON-ROSENTHAL SYNDROME: A CASE REPORT. JULIANA PORTES DE OLIVEIRA, e NEZ THAYLLA NU AMIN DICK, DANIELLE CASTEX CONDE, ELIANE PEDRA DIAS, KARIN GON¸CALVES CUNHA, ARLEY SILVA JUNIOR and, ADRIANNA MILAGRES The Melkersson-Rosenthal syndrome is characterized by the presence of the classic triad: orofacial granulomatosis, facial
ABSTRACTS
e32
paralysis, and fissured tongue. However, all 3 symptoms appear only in 8% to 25% of the cases. Cases with only 2 symptoms are considered oligosymptomatic forms. The orofacial granulomatosis is an idiopathic disorder and represents the most common symptom of the syndrome. We report the case of an 81-year-old man with a complaint of painless swelling on the lower lip of 3 months’ duration. During the clinical exam, a fissured tongue was noticed and there was no history of facial paralysis. An incisional biopsy was performed and a noncaseating granulomatous inflammation was observed histopathologically. No foreign material was present and special stains for fungal and bacteria were negative, confirming the diagnosis of granulomatous cheilitis. The patient was treated with systemic corticosteroid and there is a complete remission of the labial edema after 10 months of follow-up.
INTRAOSSEOUS MUCOEPIDERMOID CARCINOMA IN A YOUNG PATIENT: A CASE REPORT. CYNTIA HELENA PEREIRA DE CARVALHO, GEORGE BORJA DE FREITAS, ARTHUR BARBOSA DE FRANCA, ¸ ADILIS STEPPLE DA FONTE NETO, ATEFANNY TORRES DOS SANTOS, BARBARA e VANESSA DE BRITO MONTEIRO and, GEORGE JOAO FERREIRA DO NASCIMENTO Intraosseous mucoepidermoid carcinomas are rare, making up only 2% to 3% of all mucoepidermoid carcinomas reported. These tumors are common in the fourth and fifth decades of life and their occurrence in the first 2 decades is highly unusual. This work reports an uncommon case of intraosseous mucoepidermoid carcinoma arising in the mandible of a 16-year-old boy that exhibited a rapid and asymptomatic growth of the lingual cortex with negative aspiration puncture. Panoramic radiographic and computed tomography revealed a multilocular, radiolucent, hypodense lesion extending from the body to the angle of the right mandible associated with unerupted teeth numbers 47 and 48. After incisional biopsy, microscopic analysis showed salivary gland epithelial malignant proliferation presenting variable amounts of intermediate, epidermoid, and mucous cells building cystic cavities filled with a periodic acid-Schiff (PAS) and Alcian blue positive amorphous material compatible with mucin. Patient was referred for oncologic treatment and has been followed for 1 year with no recurrence.
ORAL PROLIFERATIVE VERRUCOUS LEUKOPLAKIA: A LONG-TERM CLINICAL, CYTOPATHOLOGIC, AND HISTOPATHOe NEZ LOGIC FOLLOW-UP. THAYLLA NU AMIN DICK, ELOA BORGES LUNA, JULIANA PORTES DE OLIVEIRA, ARLEY SILVA JUNIOR, ADRIANNA MILAGRES, ELIANE PEDRA DIAS and, KARIN SOARES CUNHA Proliferative verrucous leukoplakia (PVL) is an aggressive form of leukoplakia, which affects multiple oral sites, with high probability of recurrence and a high rate of malignant transformation. Clinically it may present as a homogeneous white plaque or leukoeritroplakia, with an exophytic or verrucous surface. We report a case with 8 years of follow-up of an 85-year-old woman with white plaques on the left buccal mucosa, inferior alveolar mucosa, floor of the mouth, and lateral border of the tongue. Combined cytopathologic and histopathologic examination was performed over 6 years, showing initially mild dysplasia and keratosis, which progressed to moderate and severe dysplasia. After 6 years of follow-up evaluation, an upper alveolar mucosa lesion
OOOO January 2020 was diagnosed as an in situ carcinoma. The patient was referred for treatment, and a surgical resection was performed. The patient is currently being monitored and evaluated with periodic cytopathologic exams.
PERIPHERAL DESMOPLASTIC AMELOBLASTOMA IN THE MANDIBLE. DARCY FERNANDES, HEITOR ALBERGONI DA SILVEIRA, CAMILA DE OLIVEIRA BARBEIRO, MARIEL RUIVO BIANCARDI, LUCAS RIBEIRO TEIXEIRA, ANDREIA BUFALINO and, JORGE ESQUICHE LEON The peripheral ameloblastoma, desmoplastic histologic type, is a rare, benign tumor among the odontogenic tumors. Both the mandible and maxilla can be affected; it is characterized by slow growth, and usually is asymptomatic. A 58-year-old male patient was referred presenting with a painless nodule in the gingiva. Intraoral examination revealed an extraosseous submucosal nodule with 10 £ 10 mm located at the mucus-gingival junction on the right side of the mandible. An excisional biopsy was performed. Microscopy showed a desmoplastic stroma that compressed the tumor epithelial cells within islands and a myxoid stroma surrounding the tumoral nests. Cytokeratin AE1, cytokeratin AE3, and p63 were positive, Ki-67 was low (<2%), and p53 was negative by immunohistochemistry. The clinicopathologic features sustained the diagnosis of peripheral ameloblastoma, desmoplastic histologic type. The patient did not present with recurrence after 8 months of follow-up. This report contributes to a better understanding of the origin and behavior of this condition.
ORAL MANIFESTATIONS OF CHRONIC GRAFT-VERSUS-HOST DISEASE: REPORT OF 2 CASES. CONSTANZA MARIN MARQUEZ, RENE MARTINEZ FLORES and, SVEN NIKLANDER EBENSPERGER Chronic graft-versus-host disease (GVHD) is a major late complication in patients treated by allogeneic hematopoietic stem cell transplantation. It is defined as a multisystem alloimmune and autoimmunelike disorder characterized by immune dysregulation, immune deficiency, impaired end-organ function, and decreased survival. Chronic GVHD resembles both clinically and histologically, many autoimmune disorders and other immunologic diseases. The oral cavity is the second most commonly involved organ system, behind skin involvement and can present as mucosal erythema, lichenoid lesions, ulcerated mucosa, and leukoplakia lesions that may be considered a potential risk factor for the development of oral cancer. We report the clinical features of 2 cases, occurring in a 41-year-old man and a 60-yearold woman. Both patients had a favorable outcome treated with topical or systemic corticosteroids and, in 1 of the cases, with the cyclosporine adjustment.
BOTRYOID ODONTOGENIC CYST IN THE MAXILLA. KARINE DUARTE DA SILVA, JULIO CESAR TANOS DE LACERDA, MARIA CASSIA FERREIRA DE AGUIAR, RICARDO ALVES MESQUITA and, PATRICIA CARLOS CALDEIRA A 53-year-old woman presented an asymptomatic lesion in the anterior maxilla, causing a discrete bone expansion and
AGGRESSIVE IDIOPATHIC BILATERAL CENTRAL GIANT CELL GRANULOMA OF THE JAW: A CASE REPORT. RODRIGO ANDRES GUTIERREZ DIAZ, LUIS MARTIN CASTRO HERRERA, e NIGA FELIPE IGNACIO FUENTES ZU and, JUAN PABLO AITKEN SAAVEDRA Central giant cell granuloma (GCCG) is a benign osteolytic proliferation with diverse clinical and radiologic behavior patterns, characterized by the presence of multinucleated giant cells in a vascular stroma. A 25-year-old man presented with bilateral swelling in the posterior mandibular region of 2-month duration with painful symptomatology. Intraoral exam showed bilateral expansion of the vestibular cortical bones in the mandibular retromolar region. Panoramic radiograph and computed tomography revealed extensive bilateral multilocular mandibular areas causing bilateral expansion of the vestibular cortical bones. The histopathologic examination showed benign fibroblasts matrix with variable number of giant cells and hemorrhagic content. Immunohistochemistry for CD-68 glycoprotein showed positive immunoreactivity. Biochemical examination showed no signs of hyperparathyroidism. Diagnosis of CGCG is a complex task, even more so when the clinical presentation is unusual. Currently, it is known that the occurrence of multiple lesions of CGCG is associated with different systemic diseases.
ORAL LEIOMYOMA: UNUSUAL CLINICAL MANIFESTATION OF A RARE LESION. ROGERIO JARDIM CALDAS, BRUNO AUGUSTO BENEVENUTO DE ANDRADE, MARIO JOSE e ROMANACH, FLAVIA CRISTINA ROSAS DE CARVALHO, DANIELLE CASTEX CONDE, HELITON SPINDOLA ANTUNES and, PAULO SERGIO DA SILVA SANTOS Oral leiomyoma is a benign smooth muscle neoplasm of rare incidence, described as an asymptomatic nodule. We report a case of solid leiomyoma with a distinctive clinical manifestation in the anterior tongue. A 46-year-old woman complained of pain in her tongue with impairment of chewing and speaking for 2 months. Clinically, she presented with a depression covered by a pink-colored smooth mucosa, also surrounded by whitish prominent borders. The lesion was firm measuring 7 mm. Incisional biopsy was performed. Histologic examination revealed a noncapsulated proliferation of spindle cells with pale, eosinophilic, and vacuolated cytoplasm containing elongated cigar-shaped nuclei, which were organized in sweeping fascicles intermingled with muscle tissue, blood vessels, and inflammatory infiltrate. No evidence of cellular atypia was found. Tumor cells were strongly marked with muscle-
ABSTRACTS
e31
specific actin antibody, but negative for S-100 protein. The final diagnosis was leiomyoma. After 3 months of complete excision, no pain or signs of recurrence were noted.
SOLITARY INFANTILE MYOFIBROMA OF THE MANDIBLE IN A 2-YEAR-OLD CHILD: DIAGNOSIS AND TREATMENT OF A RARE LESION. VICTOR MONTALLI, FABRICIO PASSADOR, ROGERIO JORGE, ANTONIO AUGUSTO CAMPANHA, ALBINA ALTEMANI, PAULO DE CAMARGO MORAES and, VERA CAVALCANTI DE ARAUJO A 2-year-old male patient came to our service with the complaint of swelling located in the left side of the lower jaw. There was a history of trauma 3 months prior to the lesion formation. The swelling was initially noticed as a small nodule, which increased in size gradually. On palpation, the swelling was well localized, firm, nonmobile, 3 £ 3 cm in diameter, nontender, fixed to the underlying bone, and nonadherent to the superficial skin. No submandibular lymphadenopathy was noted. Computed tomography scan of the jaws with a 3-dimensional reconstruction image showed the presence of a soft tissue lesion with bone erosion of the inferior aspect of the left side of the body of the mandible. Histologically, a typical biphasic cellular arrangement was noted. Immunohistochemical markers have been useful for the definitive diagnosis of this uncommon neoplasm. The clinical, radiologic, histologic and immunohistochemical aspects corroborate the diagnosis of infantile myofibroma.
SURGICAL CONSERVATIVE TREATMENT OF AMELOBLASTIC FIBRODENTINOMA. GUSTAVO LUIZ ALKMIN PAIVA, PABLO e MORANDO, AGUSTIN VARGAS, FERNANDO SIMOES ALAN ROGER DOS SANTOS SILVA, GUSTAVO GROTHE MACHADO and, ANDRE CAROLI ROCHA Although controversial, the World Health Organization has recently categorized ameloblastic fibrodentinoma (AFD) as part of the spectrum of odontomas, pointing out that it may be a “developing odontoma.” The aim of this presentation is to report the case of a 9-year-old girl with a painless swelling in the posterior right mandible. Intraoral examination revealed a firm and slightly tender swelling on palpation. Panoramic radiograph showed a massive well-defined radiolucency affecting the mandibular body and ascending ramus presenting the so-called "soap bubble pattern" and root resorption. The diagnosis of AFD was provided by incisional biopsy. Primary treatment was performed by an intraoral approach and conservative surgical excision. After 9 months of treatment and follow-up, a discreet radiolucency with sclerotic borders was detected near the condylar neck and managed by another conservative surgery via retromandibular approach. No recurrence was noticed after a 3 years of follow-up.
OLIGOSYMPTOMATIC FORM OF MELKERSSON-ROSENTHAL SYNDROME: A CASE REPORT. JULIANA PORTES DE OLIVEIRA, e NEZ THAYLLA NU AMIN DICK, DANIELLE CASTEX CONDE, ELIANE PEDRA DIAS, KARIN GON¸CALVES CUNHA, ARLEY SILVA JUNIOR and, ADRIANNA MILAGRES The Melkersson-Rosenthal syndrome is characterized by the presence of the classic triad: orofacial granulomatosis, facial
ABSTRACTS
e32
paralysis, and fissured tongue. However, all 3 symptoms appear only in 8% to 25% of the cases. Cases with only 2 symptoms are considered oligosymptomatic forms. The orofacial granulomatosis is an idiopathic disorder and represents the most common symptom of the syndrome. We report the case of an 81-year-old man with a complaint of painless swelling on the lower lip of 3 months’ duration. During the clinical exam, a fissured tongue was noticed and there was no history of facial paralysis. An incisional biopsy was performed and a noncaseating granulomatous inflammation was observed histopathologically. No foreign material was present and special stains for fungal and bacteria were negative, confirming the diagnosis of granulomatous cheilitis. The patient was treated with systemic corticosteroid and there is a complete remission of the labial edema after 10 months of follow-up.
INTRAOSSEOUS MUCOEPIDERMOID CARCINOMA IN A YOUNG PATIENT: A CASE REPORT. CYNTIA HELENA PEREIRA DE CARVALHO, GEORGE BORJA DE FREITAS, ARTHUR BARBOSA DE FRANCA, ¸ ADILIS STEPPLE DA FONTE NETO, ATEFANNY TORRES DOS SANTOS, BARBARA e VANESSA DE BRITO MONTEIRO and, GEORGE JOAO FERREIRA DO NASCIMENTO Intraosseous mucoepidermoid carcinomas are rare, making up only 2% to 3% of all mucoepidermoid carcinomas reported. These tumors are common in the fourth and fifth decades of life and their occurrence in the first 2 decades is highly unusual. This work reports an uncommon case of intraosseous mucoepidermoid carcinoma arising in the mandible of a 16-year-old boy that exhibited a rapid and asymptomatic growth of the lingual cortex with negative aspiration puncture. Panoramic radiographic and computed tomography revealed a multilocular, radiolucent, hypodense lesion extending from the body to the angle of the right mandible associated with unerupted teeth numbers 47 and 48. After incisional biopsy, microscopic analysis showed salivary gland epithelial malignant proliferation presenting variable amounts of intermediate, epidermoid, and mucous cells building cystic cavities filled with a periodic acid-Schiff (PAS) and Alcian blue positive amorphous material compatible with mucin. Patient was referred for oncologic treatment and has been followed for 1 year with no recurrence.
ORAL PROLIFERATIVE VERRUCOUS LEUKOPLAKIA: A LONG-TERM CLINICAL, CYTOPATHOLOGIC, AND HISTOPATHOe NEZ LOGIC FOLLOW-UP. THAYLLA NU AMIN DICK, ELOA BORGES LUNA, JULIANA PORTES DE OLIVEIRA, ARLEY SILVA JUNIOR, ADRIANNA MILAGRES, ELIANE PEDRA DIAS and, KARIN SOARES CUNHA Proliferative verrucous leukoplakia (PVL) is an aggressive form of leukoplakia, which affects multiple oral sites, with high probability of recurrence and a high rate of malignant transformation. Clinically it may present as a homogeneous white plaque or leukoeritroplakia, with an exophytic or verrucous surface. We report a case with 8 years of follow-up of an 85-year-old woman with white plaques on the left buccal mucosa, inferior alveolar mucosa, floor of the mouth, and lateral border of the tongue. Combined cytopathologic and histopathologic examination was performed over 6 years, showing initially mild dysplasia and keratosis, which progressed to moderate and severe dysplasia. After 6 years of follow-up evaluation, an upper alveolar mucosa lesion
OOOO January 2020 was diagnosed as an in situ carcinoma. The patient was referred for treatment, and a surgical resection was performed. The patient is currently being monitored and evaluated with periodic cytopathologic exams.
PERIPHERAL DESMOPLASTIC AMELOBLASTOMA IN THE MANDIBLE. DARCY FERNANDES, HEITOR ALBERGONI DA SILVEIRA, CAMILA DE OLIVEIRA BARBEIRO, MARIEL RUIVO BIANCARDI, LUCAS RIBEIRO TEIXEIRA, ANDREIA BUFALINO and, JORGE ESQUICHE LEON The peripheral ameloblastoma, desmoplastic histologic type, is a rare, benign tumor among the odontogenic tumors. Both the mandible and maxilla can be affected; it is characterized by slow growth, and usually is asymptomatic. A 58-year-old male patient was referred presenting with a painless nodule in the gingiva. Intraoral examination revealed an extraosseous submucosal nodule with 10 £ 10 mm located at the mucus-gingival junction on the right side of the mandible. An excisional biopsy was performed. Microscopy showed a desmoplastic stroma that compressed the tumor epithelial cells within islands and a myxoid stroma surrounding the tumoral nests. Cytokeratin AE1, cytokeratin AE3, and p63 were positive, Ki-67 was low (<2%), and p53 was negative by immunohistochemistry. The clinicopathologic features sustained the diagnosis of peripheral ameloblastoma, desmoplastic histologic type. The patient did not present with recurrence after 8 months of follow-up. This report contributes to a better understanding of the origin and behavior of this condition.
ORAL MANIFESTATIONS OF CHRONIC GRAFT-VERSUS-HOST DISEASE: REPORT OF 2 CASES. CONSTANZA MARIN MARQUEZ, RENE MARTINEZ FLORES and, SVEN NIKLANDER EBENSPERGER Chronic graft-versus-host disease (GVHD) is a major late complication in patients treated by allogeneic hematopoietic stem cell transplantation. It is defined as a multisystem alloimmune and autoimmunelike disorder characterized by immune dysregulation, immune deficiency, impaired end-organ function, and decreased survival. Chronic GVHD resembles both clinically and histologically, many autoimmune disorders and other immunologic diseases. The oral cavity is the second most commonly involved organ system, behind skin involvement and can present as mucosal erythema, lichenoid lesions, ulcerated mucosa, and leukoplakia lesions that may be considered a potential risk factor for the development of oral cancer. We report the clinical features of 2 cases, occurring in a 41-year-old man and a 60-yearold woman. Both patients had a favorable outcome treated with topical or systemic corticosteroids and, in 1 of the cases, with the cyclosporine adjustment.
BOTRYOID ODONTOGENIC CYST IN THE MAXILLA. KARINE DUARTE DA SILVA, JULIO CESAR TANOS DE LACERDA, MARIA CASSIA FERREIRA DE AGUIAR, RICARDO ALVES MESQUITA and, PATRICIA CARLOS CALDEIRA A 53-year-old woman presented an asymptomatic lesion in the anterior maxilla, causing a discrete bone expansion and