Case discussion for radiolucent lesion at body and angle of mandible

8/12/2019 Case discussion for radiolucent lesion at body and angle of mandible

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Good Morning


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Case Discussion

Radiolucent Lesion At Right Mandibular body

By:

Dr.Mehul D Jani


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History:

Chief Complaint:

Pain at lower right back teeth region since last 2months.


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History:

H/O/P/I

Pt. was relatively asymptomatic before 2 months. Thanhe noticed a small marble shaped bony hard structure onright side below the mandible 1-1.5 cm away from lower

border of mandible which was tender on palpation.

Lesion slightly increased in size gradually and reachedpresent size.

Pt. reported at CODSRC on 5/7/14 for expert advice andtreatment regarding chief complaint.


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History:

No significant past medicalhistory

Past dental history:

H/O pericoronitis at same sitebefore 2 years and hadconsulted local dentist, who hasprescribed medicines and hisproblem was subside.

No significant family history

Personal history: Diet: veg.

Appetite: not reduces

Bowel: normal

Bladder: normal

Sleep: not disturbed

Allergy: no allergy

Habits: no adverse habits

Marital status: married


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History:

General examinations:

A young 30 years old male patient who is moderately built, well nourished, conscious, co-operative and well oriented to time place and person with normal gait.

No signs of pallor, icterus, cyanosis, koilonychias, edema.

Lymphadenopathy : right submandibular lymph node was enlarged and tender on palpation,

having size of around 1.5 cm diameter which was bony hard in consistency & not fixed to

underlying structure.

Vitals:

B.P:

PULSE:TEMP.:

R.R:

Other structures like head, neck, eye, ears, shoulder, chest, arms, nails appears to be normal.


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History:

Extra oral examinations:

Inspection:

Facial symmetry: bilateral symmetrical

Mouth opening: 45mm (21,31)

Palpation:

TMJ: bilateral symmetrical movement on palpation

Lymph node: right submandibular lymph node was enlarged and tender on palpation, having size of

around 1.5 cm diameter which was bony hard in consistency & not fixed to underlying structure.

No signs of anesthesia /paresthesia on right lip.

Tooth vitality:

46: normal47:noraml

48: delayed response (9)

Percussion:

Tooth were non tender on percussion.


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History:

Intra oral examinations:

Inspection:

Teeth present: 18-28,38-48

No.of teeth : 32

Mucosa, tongue,floor of mouth, vestibule, soft and hard palatal mucosa appears to be

normal.

No appreciable swelling present either buccaly/lingually.

Palpation:

Slight expansion of lingual plate i.r.t 48, extending up to mesial of 2 ndmolar to distal of

third molar.

No signs of anesthesia /paresthesia on tongue.


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History:

Investigations:

I.O.P.A

OCCLUSAL

OPG

CT SCAN

MRI

Routine blood investigations

Chest xray


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History:


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History:


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History:


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History:


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History:


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History:

Provisional diagnosis:

Keretocystic odontogenic tumor???

H


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History:

D/D:

KERETOCYSTIC ODONTOGENIC TUMORUNICYSTIC AMELOBLASTOMA

RADICULAR CYST

AMELOBLASTIC FIBROMA

CEOT

ODONTOGENIC FIBROMA

PRIMARY INTRAOSSEUS CARCINOMA

OSTEOSARCOMAHEMANGIOMA

D ff l D


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Differential Diagnosis:

Keretocystic Odontogenic Tumor Age: peak incidence betweensecond and fourth decades.

Frequency:


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Unicystic Ameloblastoma* Peak age: about 40 years old.

Frequency: Rare, but still the most common odontogenic tumour. Site: Posterior body/angle/ramus of mandible, very occasionally involves the maxilla.

Size: Very variable depending on the age of the lesion, may become very large if

neglected and cause gross facial asymmetry.

Shape: Multilocular, distinct septa dividing the lesion into compartments with large,

apparently discrete areas centrally and with smaller areas on the periphery

Occasionally monolocular in early stages

honeycomb or soap-bubble appearance or multicystic

Outline: Smooth and scalloped

Well defined

Well corticated.

Radiodensity: Radiolucent with internal radiopaque septa.

Effects: Adjacent teeth displaced, loosened, often resorbed

Extensive expansion in all dimensions


Diff i l Di i


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The so-called unicystic ameloblastoma accounts for about 10-15% ofall ameloblastomas.

It usually presents as a monolocular radiolucency associated with

the crown of an unerupted lower third molar, resembling adentigerous cyst, or as a monolocular radiolucency at the apices of

the teeth, resembling a radicular cyst.


Diff i l Di i


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Radicular Cyst* Age: Usually adults, 20-50 year-olds.

Frequency: Most common of all jaw cysts (about 70%).

Site: Apex of any non-vital tooth, particularly upper lateral incisors.

Size: 1.5-3 cm in diameter (if smaller the radiographic distinction between cyst and

granuloma cannot usually be made).

Shape: Round Monolocular.

Outline: Smooth

Well defined

Well corticated if long-standing (unless infected) and

continuous with the lamina dura of the associated tooth.

Radiodensity: Uniformly radiolucent.

Effects: Adjacent teeth displaced, rarely resorbed

Buccal expansion

Displacement of the antrum.


Diff ti l Di i


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Ameloblastic fibroma* Age: Children and adolescents.

Frequency: Rare.

Site: Mandible (usually) or maxilla premolar/ molar region.

Size: Variable.

Shape: Multilocular

Monolocular in the early stages.

Outline: Smooth Well defined

Well corticated.

Radiodensity: Radiolucent with internal radiopaque septa if multilocular.

Effects: Adjacent teeth displaced

Buccal/lingual expansion of the jaw

50% associated with an unerupted tooth.


Diff ti l Di i


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CEOT*

They are often radiolucent in their early stages; then numerous scattered radiopacities

usually become evident within the lesion, often most prominent around the crown ofany associated unerupted tooth.

This appearance is sometimes described as driven snow.

Adjacent teeth can be either displaced and/or resorbed


Diff ti l Di i


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Odontogenic fibroma *

Radiolucent with fine internal radiopaque septa or trabeculae often arranged at right

angles to one another, producing an appearance sometimes described as resembling

the strings of a tennis racketor the letters X and Y.


Diff ti l Di i


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Primary intraosseous carcinoma*

Primary intraosseous carcinoma is an uncommon neoplasm, According to the most

recent edition of the World Health Organization (WHO) classification for histological

typing of odontogenic tumors .

it is defined as a squamous cell carcinoma arising within the jawbone without

connection to the oral mucosa, probably from odontogenic epithelial residues.


Journal of Oral and Maxillofacial Pathology Vol. 15 Issue 2 May - Aug 2011

Diff ti l Di i


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Age: Adults over 50 years old.

Frequency: Rare, but the most common oral malignant tumour.

Site: Mandible, or maxilla if originating in the antrum.

Size: Variable.

Shape: Irregular area of bone destruction often initially saucer-shaped.

Outline: Irregular and moth-eaten

Poorly defined

Not corticated.

Radiodensity: Radiolucent, radiodensity dependent

on degree of destruction.

Effects: Adjacent teeth may be displaced,

loosened and/or resorbed or left floating in space

Destruction of surrounding bone may lead to

pathological fracture.


Diff ti l Di i


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Haemangioma *

Hemangiomas in an intraosseous location, especially of the jaws, are rarely reported

entities.

Age: second decade of life

Site: mostly mandible

Sex predilection : female to male ratio of 2:1.

Patients often experience a firm, painless swelling of the bonewhich may or may notcause facial asymmetry.

Pressure or discomfort, oozing or pulsatile bleedingfrom the gingiva of teeth in the

region of the lesion, a bluish discoloration of the gingiva, mobile teeth, and accelerated

exfoliation of teeth.

In lesions with high vascular pressure, patients often report a sensation of pulsation,

and large lesions extending into adjacent soft tissues may have audible bruits .

Despite the benign nature of the lesion, paresthesia in the region is not uncommon.





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Haemangioma

They can present with a multi-locular soap bubble appearance with irregular, poorly

defined margins.

Definitive diagnosis of an intraosseous hemangioma cannot be made without histologic

examination, but due to the risk of severe hemorrhage, needle aspiration should precede

biopsy of any suspicious lesion. *

The presence of easily aspirated blood with significant volume and brisk hemorrhage from

the puncture site should preclude biopsy.





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Osteosarcoma *

Rare, rapidly destructive malignant tumour of bone. From a radiological viewpoint,

there are three main types:

Osteolytic no neoplastic bone formation

Osteosclerotic neoplastic osteoid and bone formed

Mixed lytic and sclerotic patches of neoplastic bone formed.

Monolocular, ragged area of radiolucency

Poorly defined, moth-eaten outline.

So-called spiking resorption and/or loosening of associated teeth.



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Final diagnosis

(based on clinical and radiological finding)

Keretocystic odontogenic tumor


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Treatment

Surgical enucleation

Extra oral

Submandibularapproach

Swing operation

Intra oral

Extraction of 47,48

Enucleation approachfrom ext. socket

Followed by sterilization of defect with CARNOYS solution


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Extra oral approach

Swing operation:

Modern Applied Science Vol. 2, No. 4


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Mandibular swing approachA Step By Step Approach

Drtbalu's otolaryngology online


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Mandibular osteotomy


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Intraoral procedure


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Mandibular fixation


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Complications:

1. Injury to the marginal mandibular nerve if the dissection is not performed under

subplatysmal plane

2. Injury to Wharton's duct leading to post operative sialadenitis of submandibular gland

3. Injury to lingual artery

4. Injury to lingual nerve

5. Non union / Mal union of mandible

6. Wound infection

7. Osteomyelitis

8. Plate exposure / plate fracture


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Submandibular approach


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Intra oral approach


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Documents

Case discussion for radiolucent lesion at body and angle of mandible