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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
Differential Diagnosis:
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.
Differential Diagnosis:
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.
Differential Diagnosis:
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.
Differential Diagnosis:
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
Differential Diagnosis:
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.
Differential Diagnosis:
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.
Differential Diagnosis:
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.
Differential Diagnosis:
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.
Differential Diagnosis:
Journal of Oral and Maxillofacial Pathology Vol. 15 Issue 2 May - Aug 2011
Differential Diagnosis:
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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.
Differential Diagnosis:
Journal of Oral and Maxillofacial Pathology Vol. 15 Issue 2 May - Aug 2011
Differential Diagnosis:
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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.
Differential Diagnosis:
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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 swing approachA Step By Step Approach
Drtbalu's otolaryngology online
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Mandibular swing approachA Step By Step Approach
Drtbalu's otolaryngology online
Mandibular osteotomy
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Mandibular swing approachA Step By Step Approach
Drtbalu's otolaryngology online
Intraoral procedure
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Mandibular swing approachA Step By Step Approach
Drtbalu's otolaryngology online
Mandibular fixation
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Mandibular swing approachA Step By Step Approach
Drtbalu's otolaryngology online
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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