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Case of the Month Archives

COM Dec. 2018 Diagnosis

Large multilocular, expansile radiolucency, anterior mandible

Can you make the correct diagnosis?
This is a 46-year-old female who presented to her dentist with loose anterior teeth and a large swelling in the area of tooth #22 involving the anterior mandible and crossing the midline to area of tooth #27 (Figure 1).

Case of the Month Summary

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The site in the anterior mandible, the age, and the radiographic findings are all consistent with GOC. The gender, however, is not. The histology is also not supportive of GOC.

Glandular odontogenic cyst (GOC) is a developmental cyst of tooth origin characterized by unusual lining epithelium and occasional aggressive behavior. The uniqueness of this cyst lies in its histology. The lining epithelium is stratified squamous in type, but covered by cuboidal or columnar cells (sometimes ciliated) interspersed with microcytic spaces simulating salivary gland ducts, giving rise to the name “glandular.” It is a rare cyst and, though mostly inert, it can sometimes be aggressive in behavior. Because it occurs in association with teeth, it is believed to be of tooth origin. Therefore the name “glandular” is misleading. Glandular odontogenic cyst is more common in adults of an average age of 49, with a slight male predominance. It has, however, been reported in all age ranges, including teenagers. It occurs three times more commonly in the mandible than in the maxilla, especially in the anterior mandible. Radiographically, they tend to present as unilocular and, less commonly, as multilocular radiolucencies. Multilocular GOCs tend to recur more than unilocular ones. These lesions grow to large sizes in the majority of cases and can perforate bone in a manner similar to the behavior of odontogenic keratocyst, a known aggressive cyst of tooth origin. Like OKCs, GOCs can be aggressive in terms of bone destruction and recurrence rate. The recurrence rate ranges between 21-55%. Enucleation and curettage alone carry a high recurrence rate of 25%. Marsupialization has been successfully used.

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The gender, the site, the crossing of the midline and the radiographic findings are consistent with central giant cell granuloma. The patient’s age is within the range of typical CGCG occurrences. The histology, however, is not supportive of CGCG.

Central giant cell granuloma is a non-neoplastic condition that can occasionally behave in a very aggressive and expansile manner, destroying bone and displacing teeth. Over 60% of CGCG cases occur in patients younger than 30 years of age, with twice as many occurrences in females as in males. CGCG is classified into aggressive and non-aggressive types; the aggressive type tends to occur in younger patients and is known to cause disfiguration, especially after surgery. Over 70% of cases occur in the mandible anterior to the first molar tooth. This lesion has also been described in other cranio-facial and small bones such as those of the hands and feet.
The usual treatment for CGCG is surgery, ranging from curettage and en bloc to resection. The latter is used in aggressive and recurring cases. Treatment alternatives to surgery have emerged with successful results, including steroid injections, calcitonin injections, nasal spray, and interferon alfa-2a injections; these are administered 2-3 times per week for several months. The latter is the most expensive alternative treatment.

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The well-demarcated multilocular and expansile radiolucency is a typical radiographic presentation for solid ameloblastoma. The patient’s age fits the age range for this condition. Solid ameloblastoma occurs equally often regardless of gender. The site in the anterior mandible is not consistent with this condition. The histology is that of solid ameloblastoma with predominant follicular histologic subtype.

Solid ameloblastoma is one of the most common benign neoplasms of odontogenic origin. It accounts for 11% of all odontogenic neoplasms. It is a slow-growing, persistent, and locally aggressive neoplasm of odontogenic epithelial origin. It affects a wide age range but is mostly a disease of adults with an average age of 33 and equal sex distribution. Reports from Africa and India show a male predilection; it also has a predilection for occurrence in black patients.

About 85% of ameloblastomas occur in the posterior mandible; most of these occur in the molar-ramus area, and some occur in the anterior mandible but sporadically. About 15% occur in the maxilla, the vast majority of these in the posterior maxilla, in patients around 60 years of age. Solid ameloblastoma is characteristically expansile, radiolucent and multilocular in nature. Solid ameloblastoma, if not treated, can reach very large sizes, causing facial disfigurement. It can loosen, displace and resorb adjacent teeth. With the exception of jaw expansion, it is usually asymptomatic unless infected, in which case it can be mildly painful. Paresthesia and anesthesia are extremely rare, unless the lesion is very large in size. It has a high tendency for recurrence if not treated appropriately with clean margins.

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The multilocular, expansile radiolucency is consistent with radiographic findings of odontogenic myxoma. The age fits the age range of myxoma and the gender is consistent with it. The site is not typical because myxomas have a slight predilection for occurrence in the posterior mandible. They can, however, occur in the anterior mandible and maxilla. The histology is not supportive of odontogenic myxoma.

Odontogenic myxoma occurs in the jaw bones, usually in the tooth-bearing areas of the jaw. It is an uncommon, benign, but locally aggressive neoplasm. Nearly all cases so far have been described in the jaw bones. It is of tooth origin, and is believed to be from the mesenchymal portion of a tooth germ, most likely of the dental papilla. It has the potential for extensive bony destruction and extension into the surrounding structures. Almost 75% of odontogenic myxomas occur in patients around 23-30 years of age with a slight female predilection (1:1.5 male-to-female ratio). It occurs almost equally in the maxilla and mandible with a slight predilection for the posterior mandible. A few cases are described in the ramus and condyle, non-tooth bearing areas. Odontogenic myxoma is slow growing, persistent and destructive. Most cases are expansile and can displace and resorb teeth. In the maxilla, they usually invade the maxillary sinuses and, in rare cases, cross the midline to the opposing sinus. Radiographically, the majority present as expansile and multilocular, though some are unilocular with or without scalloped borders, and rare cases present with a diffuse and mottled appearance which can be mistaken for a malignant neoplasm. It is associated with a high recurrence rate if not treated appropriately.

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