COM October 2004

This is a 60-year-old white male who was referred to Dr. Mark Carlson an Oral and Maxillofacial Surgeon from Tacoma to evaluate a severe and localized bone loss in the upper right posterior maxilla (Fig 1). The referring general dentist noticed severe localized bone loss in the area of tooth #2. A panoramic radiograph revealed a wide area of bone destruction involving the right posterior maxilla and possibly the sinus floor (Fig 1). Tooth # 2 was extracted without complications. The extraction site was described as spongy in consistency. The patient was referred to Dr. Carlson for evaluation and treatment of the bony lesion. At this point the posterior maxilla was asymptomatic but was expansile and measured approximately 2.5 cm transverse by 2.1 cm anteroposterior dimensions. The extraction site of tooth #2 was open but no evidence of an oro-antral fistula. Dr. Carlson performed an incisional biopsy and curettage of the area and submitted the specimen for microscopic examination.

Figure 1. Panoramic view of the presentation in Dec 03 demonstrating destructive radiolucency involving the right posterior second molar tooth, distal bone and the maxillary sinus.

His medical history is significant for hypertension and hypercholesterolemia. The patient has no known drug allergies. Also, the patient had a CAT scan done in June 2003 for symptoms of pneumonia and possible sepsis. He had CT of the head, chest, abdomen, and pelvis, in an attempt to diagnose the etiology of the pneumonia. The radiologist noticed an expansile intermediate-density mass in the right posterior maxilla, causing bony destruction and extending inferiorly into the maxillary sinus, measuring 2.5 X 2.1 cm in greatest dimensions. The radiologist’s interpretation was a possible dentigerous cyst or odontogenic keratocyst, and oral surgery consultation was recommended.

The clinical examination at the dentist’s office showed an area of severe and localized bone loss in the right posterior maxilla simulating localized periodontitis which lead to the extraction of tooth #2. At extraction, the dentist noticed that the bony consistency was soft and spongy combined with extensive bone loss involving the posterior maxilla and the inferior and posterior portions of the maxillary sinus (Fig 1). The Oral Surgeon also noticed bony expansion in addition to the extensive destruction. The bony destruction at that point was measured to be approximately 3 ¼ x 2 ½ cm in greatest dimensions

Figure 1. Panoramic view of the presentation in Dec 03 demonstrating destructive radiolucency involving the right posterior second molar tooth, distal bone and the maxillary sinus.

Histologic examination revealed a solid and benign neoplasm of odontogenic epithelial origin. It is made up of a combination of epithelial islands and cords (Fig 3, 4). The periphery of the islands is lined by columnar or cuboidal and palisaded epithelial cells (Fig 4) and the center of the islands is filled with cuboidal and stellate epithelial cells consistent with stellate reticulum. The epithelial cords are long and are forming a network of two-layers of cuboidal and palisaded epithelial cells. These epithelial islands are suspended on a background of loose and vascular connective tissue.

Figure 3. Low power (x100) histology shows odontogenic epithelial islands and cords. The periphery of the islands is lined by columnar or cuboidal and palisaded epithelial cells and the center of the islands is filled with cuboidal and stellate epithelial cells.

Figure 4. Higher power (x200) histology shows epithelial islands and cords lined by columnar cells, some demonstrating reversed polarization.