COM January 2013

Case of the Month Archives

Large Exophytic Vascular Swelling, Area of Teeth #s 17 & 18

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

Dr. Tracy Johnson
Oral & Maxillofacial Surgery, Lakewood, WA

Case Summary and Diagnostic Information

This is a 30-year-old Hispanic male who had had a fast-growing swelling over the six to eight weeks prior to his visit.

Diagnostic Information Available

History of present Illness

This is a 30-year-old Hispanic male who had had a fast-growing swelling over the six to eight weeks prior to his visit (Figure 1). It involved the left posterior mandible in the area of teeth #s 17 & 18 extending to the left retromolar pad area. It was described to be 4 x 4 cm in size and ulcerated. The patient reported that it bled easily but was not painful. There was no evidence of underlying bone involvement.

Figure 1. This photograph was taken at first clinical presentation demonstrating a large, sessile, exophytic, lobular, red and ulcerated swelling of the left posterior mandibular in the area of teeth #s 17 & 18 extending to the retromolar pad area.

Medical History

The patient’s past medical history is unremarkable. The patient is not a smoker.

Clinical and Radiographic Findings

The patient reported a fast-growing, exophytic, red, focally ulcerated and lobular swelling of the posterior mandibular gingiva in the area of teeth #s 17 & 18 and extending to the left retromolar pad area. The lesion was of 6-8 weeks’ duration and was described as 4 x 4cm in size. It was ulcerated, bled easily but was not painful. There was no evidence of bone resorption.

Excisional Biopsy

Treatment

Under local anesthesia, an excisional biopsy was performed. The specimen was removed in one piece (Figure 2).

Figure 2. This photograph is of the gross specimen removed in one piece.

Excisional Biopsy

Histologic examination reveals a multisected piece of soft tissue embedded in five separate blocks labeled A1-A5. All specimens are composed of soft tissue covered by epithelium and supported by a large mass of granulation tissue (Figures 3-5). The surface epithelium shows evidence of ulceration covered by fibrin and neutrophils (Figure 3). The granulation tissue comprises the bulk of the specimen and is loose and vascular and is intensely infiltrated by neutrophils, lymphocytes and plasma cells (Figures 4-5). It contains many blood vessels and shows evidence of endothelial and fibroblast proliferation. Some of the blood vessels are highly dilated and some are very small.

Figure 3. Low power (x40) the H & E histology reveals a large mass of ulcerated granulation tissue composed of proliferating fibroblasts, proliferating endothelial cells and small blood vessels of variable shapes and sizes.

Figure 4. Higher power (x100) the H & E histology reveals an ulcerated and vascular granulation tissue infiltrative by acute and chronic inflammatory cells.

Figure 5. Higher power (x200) the H & E histology of an ulcerated granulation tissue infiltrated by acute and chronic inflammatory cells.

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