Centro Escolar University School Of Dentistry

ODONTOGENIC MYXOMA OF THE MANDIBLE: A SERIES OF CASE REPORTS AND REVIEW OF LITERATURE

A Series of Case Reports Presented to Quirino Memorial Medical Center Dentistry Department

in Partial Fulfillment of the Requirements for the Course Hospital Dentistry 1

by Marrion ules Mendo!a Precious An"elica Mortel #en$ Delos Reyes Mhia Dianne %umbres Ru&ina Ara yne Quinto Pari!ad 'iamiri (horbanipar&ar Hamidre!a Centro Escolar University School Of Dentistry

TABLE OF CONTENTS Page I. ABSTRACT ........... II. 3

INTRODUCTION .. 3 Re&ie) of %iterature**********************+* 3

III.

PATIENT CASE PRESENTATION Case,1 ***************************** *+ Case,***************************** **+ Case,. **********+ ********************+ 4 4 4

IV.

DISCUSSION .. !

V.

CONCLUSION . "#

VI.

APPENDICES .. "

Centro Escolar University School Of Dentistry

I.

ABSTRACT /donto"enic My0oma 1other terms are 2/donto"enic my0oma34 and 2My0ofibroma5 is a tumor of the $a)s )hich apparently arises from the mesenchymal portion of the tooth "erm4 either the dental papilla4 the follicle or the periodontal li"ament+ 6t occurs most frequently in the second or third decades of life4 the a&era"e a"e in the &arious reported series ran"in" from -. 7 .8 years+ Accordin" to Shafer4 there is no particular se0 predilection for occurrence in the mandible+ /ccasional cases occur outside the tooth9bearin" areas4 se&eral cases ha&in" been reported in the condyle or nec: of the condyle+ ;he roent"eno"ram may present a mottled or honeycombed appearance of bone in some cases4 )hile others may appear as a destructi&e4 e0pandin" radioluscency )hich sometimes has a multilocular pattern+ ;he treatment of odonto"enic my0omas is sur"ical e0cision4 follo)ed by cautery+ <0tensi&e lesions may require resection to eradicate the tumor+ Hereby4 presentin" series of case reports re"ardin" sur"ical

mana"ement of odonto"enic my0omas= the first case is a .- year old male patient reported to ha&e a slo) "ro)in"4 painless s)ellin" in the left mandibular re"ion+ ;he second case is a >. year old male patient )ith a complaint of left ma0illary s)ellin"+ ;he third case is a 1? year old male patient )hose complaint is of mild pain and s)ellin" in the ri"ht posterior mandible+ ;he sur"ical

mana"ement that )as chosen in each case is discussed thorou"hly+ Conclusions of each cases su""ested treatment modalities for odonto"enic my0omas and particular inhibition to any recurrences+ II. INTRODUCTION /donto"enic my0omas ha&e been found in patients ran"in" in a"e bet)een 18 and @8 years4 ho)e&er4 they are most commonly dia"nosed in youn" adults 1specifically bet)een -@ and .@ years of a"e5+;he mandible is more li:ely to be affected than thema0illa+ ;he re"ion bet)een the molar and premolar is the site of most common occurrence for multilocular lesions )hile the anterior portion of the mouth fa&ors a smaller4 unilocular &ariety+ Patients afflicted )ith an odonto"enic my0oma "enerally notice a painless4 slo)ly enlar"in" e0pansion of the $a) )ith possible tooth loosenin" or displacement+ As the tumor e0pands4 it frequently infiltrates ad$acent structures+ Ma0illary lesions frequently enter the sinuses )hile mandibular tumors often e0tend into the ramus+ Radio"raphically4

Centro Escolar University School Of Dentistry

odonto"enic my0omas appear most commonly as multilocular radiolucencies )ith ill9 defined borders4 thou"h unilocular cyst9li:e tumors can occur4 especially )hen associated )ith impacted teeth or )hen disco&ered in childhood+ 6deally4 the septa that cause the multilocular feature are thin and strai"ht4 producin" a tennis rac:et or stepladder pattern+ 6n reality4 the ma$ority of the septa &isible in the tumor are cur&ed and coarse4 causin" a Asoap bubbleA or AhoneycombA appearance4 thou"h locatin" one or t)o strai"ht septa can aide in the dia"nosis of this tumor+ Small unilocular lesions ha&e been successfully treated )ith enucleation and curetta"e follo)ed by chemical bone cautery+ Multilocular tumors e0hibit a -@B recurrence rate and4 therefore4 must be treated more a""ressi&ely+ 6n the case of a multilocular my0oma4 resection of the tumor )ith a "enerous portion of surroundin"

>

bone is required+ #ecause of the "elatinous nature of the tumor4 it is crucial for the sur"eon to remo&e the lesion intact so as to further reduce the ris: of recurrence+ ;he purpose of this is to re&ie) the current literature of odonto"enic my0omas and to present three cases that )ere dia"nosed to ha&e the tumor at different locations and treated )ith an emphasis on the different sur"ical mana"ement and reconstruction possibilities+ III. PATIENT CASE PRESENTATION CASE $ : A .- year old male patient reported to the department of /ral medicine and Radiolo"y4 Faculty of dentistry4 amia Milia 6slamia )ith a slo) "ro)in"4 painless s)ellin" in the left mandibular re"ion since - years+ History re&ealed that the patient initially had mobility in mandibular left first and second molar teeth4 follo)in" )hich the patient noticed a small s)ellin" )hich has pro"ressi&ely increased to attain the present si!e+ ;he past medical history )as noncontributory+ <0traoral e0amination re&ealed a painless bony hard s)ellin" on the left side of face in&ol&in" the mandibular body and ramus area+ ;he s)ellin" e0tended superiorly upto the ala9 tra"us line4 inferiorly - cms belo) lo)er border of the mandible4 antero9posteriorly from the symphysis re"ion upto the an"le of the mandible+ ;here )as mar:ed facial asymmetry4 )ith de&iation of the lip to the ri"ht side alon" )ith obliteration of the nasolabial fold+ Sin"le4 mo&eable4 nontender left submandibular lymph node )as also palpable+ 6ntraoral e0amination re&ealed a bony hard s)ellin" e0tendin" from

Centro Escolar University School Of Dentistry

mandibular left central incisor to left retromolar re"ion+ ;here )as bicortical e0pansion+ /n the buccal aspect4 the s)ellin" )as bony hard )ith obliteration of the &estibule+ /n the lin"ual aspect4 there )as an o&erlyin" soft tissue component+ ;he s)ellin" )as firm and yielded on pressure+ 6ndentation mar:s of the cusps of ma0illary teeth on the soft tissue component )ere seen+ Mandibular left second premolar4 first molar4 second molar and third molar teeth sho)ed displacement and mandibular left first and second molar teeth )ere "rade 1 mobile+ Routine haematolo"ical and biochemical laboratory tests )ere )ithin normal limits+

Haemo"lobin

)as

sli"htly

belo)

the

normal

limits

&alue

of

18+@"mB+

/rthopantomo"ram 1/P(5 re&ealed a multilocular radiolucent lesion e0tendin" from mandibular ri"ht central incisor4 lateral incisor and canine tooth upto the si"moid notch on the left side+ Condyle and coronoid process )ere not in&ol&ed+ Destruction of left lo)er border of mandible )as e&ident alon" )ith fine radiatin" bony trabeculae o&er the lo)er border+ ;here )as liftin" of periosteum alon" left an"le of the mandible+ Root resorption )ith mandibular ri"ht central incisor4 lateral incisor4 canine and mandibular left central and lateral incisor teeth )as seen4 and /P( sho)ed tooth floatin" in air appearance+ ;he lesion )as differentially dia"nosed as /donto"enic neoplasm 1Ameloblastoma4 odonto"enic my0oma4 :eratocystic

odonto"enic tumor54 Mali"nancy )ithin odonto"enic neoplasm 1Ameloblastic carcinomaCsarcoma54 central "iant cell "ranuloma and &ascular neoplasm of bone 1Haeman"ioma5+ After the informed consent of the patient4 incisional biopsy )as done and it re&ealed typical features of odonto"enic my0oma4 containin" loosely arran"ed stellate or spindle shaped cells )ithin a my0oid matri0+ H D < stained section sho)s para:eratinised stratified squamous epithelium of &ariable thic:ness+ ;he underlyin" connecti&e tissue )as loose and not hi"hly cellular+ Ender the histopatholo"ic dia"nosis of odonto"enic my0oma4 a lo)er chee: flap )as raised usin" Rou0 lip split incision+ Se"mental mandibulectomy )as done and the tumor mass )as resected alon" )ith it+ ;he resected specimen 1includin" ri"ht canine upto left condyle5 )as sent for histopatholo"ical analysis ;he histopatholo"y of the e0cised tumor mass re&ealed loose my0oid stroma consistin" of loosely arran"ed stellate and spindle9shaped cells4 alon" )ith round cells+ Fe) of the colla"en fibrils )ere seen that tended to intermesh+ Small islands of inacti&e9appearin"

Centro Escolar University School Of Dentistry

odonto"enic rests )ere seen scattered throu"h the my0oid stroma4 histopatholo"y su""esti&e of odonto"enic my0oma+

F%g&'e . : Ma'(e) Fa*%a+ A,-.e/'- 01 /2e +e3/ ,%)e 03 /2e 4a/%e1/

F%g&'e .": S5e++%1g 01 Le3/ ,%)e 03 /2e Ma1)%6&+a' B0)- a1) Ra.&, 'eg%01

Centro Escolar University School Of Dentistry

F%g&'e .3: B01- Ha') S5e++%1g 5%/2 S&+*&, O6+%/e'a/%01 01 /2e B&**a+ A,4e*/

F%g&'e .4: S03/ T%,,&e *0.401e1/ 5%/2 D%,4+a*e.e1/ 03 /ee/2

Centro Escolar University School Of Dentistry

F%g&'e .8: M&+/%+0*&+a' Ra)%0+&,*e1/ Le,%01 5%/2 9F+0a/%1g %1 A%' T00/2: a44ea'a1*e

Centro Escolar University School Of Dentistry

F%g&'e .;: P20/0.%*'0g'a42 ,205%1g +00,e+- a''a1ge) ,/e++a/e a1) ,4%1)+e *e++, %1 .-<0%) ,/'0.a =H > E? #<@

18

F%g&'e .A: P20/0.%*'0g'a42 ,205%1g Ba'%a6+e /2%*(1e,, ,/'a/%3%e) ,C&a.0&, e4%/2e+%&. a1) 101 *e++&+a' &1)e'+-%1g *011e*/%Be /%,,&e

Centro Escolar University School Of Dentistry

11

F%g&'e .D: Seg.e1/a+ Re,e*/%01 03 /2e T&.0' Ma,,

F%g&'e .!: L00,e S/e++a/e? S4%1)+e a1) R0&1) Ce++, %1 a M-<0%) 6a*(g'0&1)? a1) eB%)e1*e 03 I,+a1), 03 O)01/0ge1%* E4%/2e+%&. =H > E? 4#<@

Centro Escolar University School Of Dentistry

CASE $ ":

1-

A >.9year9old male )as referred to our department )ith a complaint of left ma0illary s)ellin" that had been noticed a fe) )ee:s before+ Epon admission4 the patient had already been dia"nosed as ha&in" an /M and had been treated t)ice relati&ely conser&ati&ely in other institution4 usin" curetta"e and peripheral ostectomy alone+ ;he tumour had recurred t)ice and the patient )as then referred to our department+ ;he patient under)ent radio"raphic in&esti"ation4 )hich su""ested a cystic4 IIsoap bubble4JJ li:e lesion in&ol&in" the left ma0illa+ ;he patientJs medical history and re&ie) of systems )ere unremar:able+ /n e0amination of the oral ca&ity4 a mar:ed s)ellin" on the left side of the upper $a) )as noticed+ ;he rest of the patientJs clinical head and nec: e0amination and "eneral e0amination )ere non9 contributory+ Computeri!ed tomo"raphy )as performed )hich sho)ed that the lesion occupied the left ma0illary sinus+ A biopsy )as ta:en and the patholo"ical result concurred )ith the pre&ious dia"nosis of /M+ Esin" a Keber Fer"uson incision4 a left total ma0illectomy )as performed includin" the left orbital floor+ Macroscopically4 the sur"ical specimen measured appro0imately H 0 18 0 F cm+ ;he orbital floor )as reconstructed usin" ;itanium Mesh4 and the ma0illary defect )as primarily reconstructed usin" a temporary obturator that )as fi0ed )ith t)o palatal scre)s on the ri"ht side and suspension !y"omatic )ire on the left side+ ;he final obturator )as fabricated 1 year later+ ;he patient has been follo)ed up for @ years and has remained disease free+

F%g&'e ". : I1/'aEO'a+ E<a.%1a/%01 ReBea+%1g a B&**a+ S5e++%1g

1.

Centro Escolar University School Of Dentistry

F%g&'e ".": Pa10'a.%* Ra)%0g'a42 ,205%1g a .&+/%+0*&+a' 'a)%0+&,*e1/ a'ea %1 /2e +e3/ .a<%++a e</e1)%1g 3'0. /2e )%,/a+ *a1%1e a,4e*/ 6a*( /0 /2e /&6e'0,%/-.

1>

F%g&'e ".3: P'e04e'a/%Be CT ,*a1 %1 a<%a+ B%e5? ,205%1g +e3/ ,%1&, %1Ba,%01 a1) 4a'/%a+ 601- )%,/'a*/%01 =a''05@

Centro Escolar University School Of Dentistry

F%g&'e ".4: T2e G'0,,

Pa/20+0g%*a+ S4e*%.e1

1@

F%g&'e ".8: P20/0g'a42%* B%e5 03 /2e /'a1,%/%01a+ 06/&'a/0' 'e*01,/'&*/%01 /2a/ 5a, 3%<e) 5%/2 /50 4a+a/a+ ,*'e5, a1) a ,&,4e1,%01 F-g0.a/%* 5%'e

Centro Escolar University School Of Dentistry

CASE $ 3: A 1?9year9old male patient )as referred to the Department of /ral Medicine and Radiolo"y for treatment+ Patient "a&e a one9month history of a mild pain and s)ellin" in the ri"ht posterior mandible+ Pain is intermediate and usually seen on mastication+ 6nitially4 the s)ellin" )as small in si!e and sho)ed a "radual increase to its present dimensions+ Clinical e0amination re&ealed a firm4 non9tender s)ellin" e0pandin" the buccal and lin"ual cortices of the mandible4 e0tendin" from ri"ht first premolar re"ion to third molar re"ion4 and it obliterated the buccal &estibule+ ;he s:in o&er the s)ellin" )as normal4 and there )as no history of paresthesia + ;he panoramic radio"raph sho)ed a lar"e )ell9defined4 sclerotic mar"ined4 multilocular radiolucent lesion )ith 2soap bubble3 appearance e0tendin" from the lo)er ri"ht canine to 1 cm distal to the third molar and also sho)ed first molar mesial root resorption+ ;he ri"ht mandibular lateral occlusal radio"raph sho)ed multilocular radiolucent lesion )ith e0pansions of buccal and lin"ual cortices+ Fine needle aspiration )as performed to rule out odonto"enic cysts4 and results )ere ne"ati&e+ #eni"n odonto"enic tumors )ere considered4 and incisional biopsy )as made and a histopatholo"ical e0amination of the tissue sample e0hibited rounded4 stellate4 and spindleshaped mesenchymal cells arran"ed in a loose4 my0oid stroma )ith fe) colla"en fibrils 1Fi"ure @5+ ;hese results )ere su""esti&e of /M+ Se"mental resection of the ri"ht side mandible )as performed under "eneral anesthesia Reconstruction )as done by micro&ascular iliac bone "raftin"4 and fi0ation )as achie&ed )ith titanium plates+ Postoperati&e complications included iliac bone "raft re$ection4 and sequestrated

1F

bone "raft )as remo&ed . months later+ .8 months after the sur"ical procedure4 there )ere no radio"raphic or clinical si"ns of recurrence and patient )as not interested for rehabilitation+

Centro Escolar University School Of Dentistry

F%g&'e 3. : E</'a0'a+ P20/0g'a42? ,205%1g ,5e++%1g %1 /2e R%g2/ S%)e Ma1)%6&+a' 60)-

1G

F%g&'e 3.": I1/'aE O'a+ P20/0g'a42? ,205%1g ,+%g2/ +%1g&a+ *0'/%*a+ e<4a1,%01 %1 /2e '%g2/E ,%)e .a1)%6&+a'

Centro Escolar University School Of Dentistry

1H

F%g&'e 3.3: Pa10'a.%* 'a)%0g'a42 ,205e) a +a'ge 5e++ )e3%1e)? ,*+e'0/%* .a'g%1e)? .&+/%+0*&+a' 'a)%0+&,*e1/ +e,%01 5%/2 9,0a4 6&66+e: a44ea'a1*e %1 '%g2/ ,%)e .a1)%6+e

F%g&'e 3.4: La/e'a+ O**+&,a+ Ra)%0g'a42 03 '%g2/ ,%)e .a1)%6+e ,205%1g e<4a1,%01 03 6&**a+ a1) +%1g&a+ *0'/%*e,

Centro Escolar University School Of Dentistry

1?

F%g&'e 3.8: M%*'0420/0g'a42 ,205%1g .%<e) a'ea 03 3%6'0&, /%,,&e a1) %1*01,4%*&0&, ,/'a1), 03 0)01/0ge1%* e4%/2e+%&. %1 a .-<0%) ,/'0.a =H> E? 4#<@

F%g&'e 3.;: Ra)%0g'a42 03 'e,e*/e) ,eg.e1/ 03 '%g2/ ,%)e .a1)%6+e

Centro Escolar University School Of Dentistry

-8

F%g&'e 3.A: P0,/04e'a/%Be 4a10'a.%* 'a)%0g'a42 ,205%1g 'e*01,/'&*/%01 03 /2e 'e,e*/e) ,%/e 5%/2 .%*'0Ba,*&+a' %+%a* 601e g'a3/%1g a1) 3%<a/%01 5%/2 /%/a1%&. 4+a/e

Centro Escolar University School Of Dentistry

IV.

DISCUSSION /M is re"arded as a locally in&asi&e tumour that does not metastasi!e and e0hibits slo) and asymptomatic e0pansion4 sometimes resultin" in perforation of the cortical borders of the affected bone+ 6n many cases4 these lesions are dia"nosed accidentally by a routine dental chec:up4 and patients are usually in their second or third decade of life in almost F8B of the cases+ Radio"raphically4 the tumour is seen as a unilocular or multilocular radiolucent lesion )ith )ell9defined borders and fine bony trabeculae+ ;he usual radio"raphic description of /Ms is a IIhoneycombJJ4 IIsoap bubbleJJ or IItennis rac:etJJ lesion+ Displacement of teeth is a relati&ely common findin"4 althou"h root resorption is rarely seen+ Histopatholo"ically these beni"n neoplasms )ere classified by the Korld Health /r"ani!ation as beni"n odonto"enic neoplasms of ecto9mesenchymal ori"in consistin" of rounded and an"ular cells embedded in an abundant my0oid stroma )ith fe) colla"en fibrils probably ori"inatin" from either the dental papilla follicle or periodontal li"ament+

-1

;he current recommended therapy depends on the si!e of the lesion and on its nature and beha&iour and can &ary from curetta"e to radical e0cision+ Complete sur"ical remo&al4 usin" curetta"e and peripheral ostectomy alone is not sufficient as the lesion is not encapsulated and because the my0omatous tissue infiltrates ad$acent bone+ ;hese characteristics may e0plain the hi"h rate of recurrence of my0omas )hich ran"es from 18 to ..B )here simple enucleation and curetta"e alone can ha&e recurrence rates of up to -@+ ;he treatment options can include curetta"e )ith peripheral ostectomy4 se"mental resection up to radical resections for the more a""ressi&e lesions reported a @89year follo) up of 18 cases of /Ms4 nine )ere treated by resection and one case )as treated conser&ati&ely by local e0cision+ /nly the conser&ati&ely treated case recurred @ years follo)in" the treatment+ Reconstruction can be"in immediately follo)in" the sur"ical procedure or delayed until an adequate disease free period has past+ 6n our e0perience4 small bony defects 1smaller than @ cm5 can be reconstructed usin" buccal fatpad 1ma0illa54 or usin" corticocancellous iliac crest bone "raft+ %ar"er defects 1more than @ cm5 usually require primary prosthetic reconstruction 1obturator5 follo)ed by a final obturator+ Mandibular lesions can be mana"ed primarily usin" a

Centro Escolar University School Of Dentistry

reconstruction plate follo)ed by an immediate or delayed &asculari!ed fibular free flap4 iliac crest "raft4 costochondral "raft4 or scapular osteocutaneous free flap+ Esually in lar"e /Ms4 a disease free period of se&eral years is ad&ised due to the hi"h recurrence rates of the tumour and the morbidity of the donor site+ 6n this4 a series of three ne) case reports )ith different approaches )ere chosen4 the first presented )ith an asymptomatic slo) "ro)in" s)ellin" in&ol&in" the body of the mandible and ramus+ 6ncisional bipsy )as done it re&ealed typical features of odonto"enic my0oma+ A lo)er chee: flap )as raised usin" Rou0 %ip Split incision= Se"mental Mandibulectomy )as done and the tumor mass )as resected alon" )ith it+ ;he second case reported4 )as a smaller /M that demanded a less a""ressi&e approach4 Computer ;omo"raphy )as performed )hich sho)ed that the lesion occupied the left ma0illary sinus+ Esin" a Keber Fer"uson incision4 a left total ma0illectomy )as needed for total clearance of the lesion+ ;he orbital floor )as reconstructed usin"

--

;itanium Mesh and the ma0illary defect )as primarily reconstructed usin" a temporary obturator+ ;he third and final case displayed a lesion of a 1? year old patient in&ol&in" posterior ri"ht mandible area+ 6t )as in&adin" )ith intermediate pain and more a""ressi&e+ An e0tra oral approach )as chosen due to the si!e and caudal e0pansion of the lesion+ ;he immediate reconstruction of the mandible usin" reconstruction plate made the mandibular morbidity less profound )hen compared )ith its ma0illary lesions4 from the functional point of &ie)+ V. CONCLUSION /donto"enic my0omas are rare beni"n $a) neoplasms4 )ith a "reat deal of contro&ersies re"ardin" the histo"enesis+ ;he neoplasm should be dia"nosed on the basis of radio"raphic ima"in" modalities and histopatholo"ical e0amination+ Appropriate treatment modalities should be instituted and recurrences should be a&oided+ %ocally a""ressi&e /Ms should be treated accordin" to the si!e and beha&iour of the tumour+ Ke belie&e that due to the hi"h recurrence rates of these lesions4 delayed reconstruction is the treatment of choice4 especially in the more locally a""ressi&e tumours+

-.