COM January 2012

Case of the Month Archives

January 2012: Well-Demarcated, Locally Destructive Radiolucency, Right Posterior Mandible

Dolphine Oda, BDS, MSc
doda@u.washington.edu

Contributed by: Dr. Thomas Maring
Oral & Maxillofacial Surgery, Seattle, WA

Case Summary and Diagnostic Information

This is a 39-year-old Asian female who presented with an expansile and well-demarcated radiolucency involving teeth #s 30 & 32.

Diagnostic Information Available

History of present Illness

This is a 39-year-old Asian female who presented with an expansile and well-demarcated radiolucency involving teeth #s 30 & 32 (Figure 1). The panoramic radiograph demonstrates a large and well-defined unilocular radiolucency with a second more radiolucent destruction in the area apical to tooth #30 indicating perforation of the lingual, buccal or both plates. Tooth #30 was non-vital and both teeth #s 30 & 31 show evidence of root resorption. The past medical history is negative for any significant disease or risk factors.

Figure 1. This is a panoramic radiograph taken at first clinical presentation. Note the large, well-defined unilocular radiolucency involving area of teeth #s 30-32. Also note the more radiolucent small round lesion apical to tooth #30 indicating bone perforation.

Medical History

The patient’s past medical history is negative for any significant disease or risk factors.

Clinical and Radiographic Findings

The patient reported progressive swelling of the right posterior mandible of unknown duration. Tooth # 30 was not vital. The swelling had perforated the lingual plate. There were no other radiolucencies in the jaw bone.

Figure 1. This is a panoramic radiograph taken at first clinical presentation. Note the large, well-defined unilocular radiolucency involving area of teeth #s 30-32. Also note the more radiolucent small round lesion apical to tooth #30 indicating bone perforation.

Excisional Biopsy

Treatment

Under local anesthesia, a full-thickness flap around the area was raised and the area was thoroughly curetted. The area was sutured and the specimen submitted for microscopic evaluation.

Excisional Biopsy

Histologic examination reveals multiple pieces of hard and soft tissue composed of a fibro-osseous lesion associated with a small cystic structure. The bulk of the specimen is made up of a benign fibro-osseous lesion which is made up of fibrous connective tissue stroma surrounding small bony trabeculae and globules of cementum-like material. The connective tissue stroma is made up of spindle-shaped fibroblasts, some arranged in a haphazard manner while others are arranged in short bundles. The connective tissue stroma surrounds shows no evidence of atypia and the bony trabeculae are mature and are of variable shapes and sizes. The connective tissue stroma also surrounds globules of cementum-like calcified material. Some of the bony trabeculae have osteoblastic rimming. The connective tissue stroma is vascular. Inflammatory cells are absent. The cystic structure comprises a small portion of the specimen and is made up of fibrous and granulation tissue lined by proliferative and non-keratinized stratified squamous epithelium. The granulation tissue wall is infiltrated by many lymphocytes, plasma cells and neutrophils. The latter are arranged in clusters some present within the lining epithelium.

Figure 2. Low power (x100) H & E histology illustrates a benign fibro-osseous lesion with cellular connective tissue stroma and hard tissue consisting of bone and cementum-like globules.

Figure 3. Higher power (x200) H & E histology illustrates a benign fibro-osseous lesion with cellular connective tissue stroma and hard tissue consisting of bone and cementum-like globules.

Figure 4. Higher power (x200) H & E histology illustrates a cystic structure lined by non-keratinized stratified squamous epithelium and connective tissue wall heavily infiltrated with plasma cells, lymphocytes and neutrophils.

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