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Brazilian Journal of Oral Sciences
Piracicaba Dental School - UNICAMP
EISSN: 1677-3225
Vol. 4, Num. 13, 2005, pp. 753-756

Brazilian Journal of Oral Sciences, Vol. 4, No. 13, April./June. 2005, pp.753-756

Peripheral ostema of the mandible:Clinical Case

Etienne Romanelli Terra1 Flávia Maria de Moraes Ramos1 Petrus Peraira Gomes2 Luis Augusto Passeri3 Frab Norberto Bóscolo4

1DDS, Oral Radiology, Department of OralDiagnosis, Piracicaba Dental School, State University of Campinas, Brazil. 2DDS, MSc, Oral and Maxillofacial Surgery, Department of Oral Diagnosis, Piracicaba Dental School, State University of Campinas, Brazil. 3DDS, PhD, Oral and Maxillofacial Surgery, Department of Oral Diagnosis, Piracicaba Dental School, State University of Campinas, Brazil. 4DDS, PhD, Oral Radiology, Department of Oral Diagnosis, Piracicaba Dental School, State University of Campinas, Brazil.

Correspondence to: Etienne Romanelli Terra Oral Radiology, Piracicaba Dental School, State University of Campinas, Brazil. Av. Limeira, 901 13414-018 – Piracicaba -SP, Brazil Phone: +55-19-3412-5327 Fax: +55-19-3412-5218 E-mail: etienne_romanelli@ig.com.br

Received for publication: November 26,2004
Accepted: March 16, 2005

Code Number: os05020

Abstract

This reports a case of peripheral osteoma occurring at the mandibular border in a 16-year-old girl. Clinically, a swelling with a hard surface was observed at the inferior border of the right mandibular body, causing facial asymmetry. Radiographic examination revealed radiopacity and a well-circumscribed mass approximately 2 cm in size. The lesion was treated surgically. The histopathological evaluation revealed features compatible with osteoma, such as vital compact and mature medullary bone tissue, showing osteocytes and medullary spaces containing a loose connective tissue with capillaries. There was no evidence of any recurrence.

Key Words: osteoma, peripheral and mandible

Introduction

Osteomas are benign osteogenic lesions characterized by proliferation of either cancellous or compact bone and can be central, peripheral or extraskeletal. They may arise in medullary (endosteal) bone or on the bone surface as a polypoid or sessile mass (periosteal)1-4. Furthermore, the term peripheral osteoma can be used for soft tissue lesions. The most common site is in the skull1,2,5-6. When affecting the facial bones, they are frequently found in the mandible2-3,6-7, the most common locations being the posterior lingual surface5 and the mandible angle area8. Clinically, the peripheral osteoma is usually asymptomatic3,6-7 and can be found during a routine radiographic examination. The lesion has been reported to have a slow growth rate, but it can produce swelling and cause asymmetry1-2. The radiographic appearance is a well-circumscribed radiopaque lesion3-4.

Patients with multiple osteomas should be evaluated with regard to Gardner’s syndrome2-3,5,7,9. These patients may present with symptoms of rectal bleeding, diarrhea, abdominal pain and sebaceous cysts. The triad of colorectal polyposis, skeletal abnormalities, and multiple impacted or supernumerary teeth is consistent with this syndrome3.

Treatment, when necessary, consists of surgical excision2-5,7-9 and its indication is based on the degree of disfigurement, limitation or loss of function2,7. Osteomas rarely recur when treated surgically1,3,5-7.

This study aimed to present an uncommon case of peripheral osteoma in the mandible and discuss it in relation to cases reported in the literature.

Case Report

A 16-year-old white girl was referred to the clinical radiological service of the Piracicaba Dental School-UNICAMP-SP for evaluation of a symptomatic mass in the right posterior portion of the mandible. The patient had noted the mass growing approximately three years earlier and denied any history of previous trauma. Clinically, a hardened nodular lesion could be observed, causing swelling and facial asymmetry at the right inferior border, anterior to the angle of the mandible with approximately 2 cm in size (Fig 1). The patient complained of pain during palpation. Radiographic examination showed a dense, spherical and well-circumscribed radiopaque mass, approximately 2 x 1,5 cm in size at the inferior border of the right side of the mandible (Figs 2 e 3). The main radiological hypotheses were osteoma and exostoses. There was no clinical and radiographical evidence consistent with Gardner´s syndrome. The patient´s family had no history of osteomas and gastrointestinal surgery. The proposed treatment involved surgical excision with the patient under general anesthesia. A submandibular approach was adopted. Following exposure of the lesion (Fig 4), a fissure burr was used to delimit both osteoma and mandibular inferior border and chisels were applied to remove the benign tumor. A round finishing burr was used to shape the area. Closure was done by layers and a dressing applied on top. Microscopically, a vital, compact and mature medullary bone tissue was observed, showing osteocytes and medullary spaces containing a loose connective tissue with capillaries, and histopathological features compatible with osteoma (Fig 5). Up to now (ten months later) no tumoral recurrence has been observed (Fig 6).

Discussion

The etiology of this tumor is unknown3,5-6. Authors have suggested various factors that contribute to the development of the disease, such as trauma, infection and/or inflammation,congenital and hereditary endocrine disorders and external causes. The suggested mechanism that best explains its pathogenesis is a combination of trauma and muscle traction. The former may cause subperiosteal bleeding or edema, and the latter could be related to local elevation of the periosteum. These two probabilities might initiate an osteogenic reaction that could be perpetuated by the continuous muscle traction in the area1,3,7.

Osteoma usually occurs in patients between 15 and 35 years of age1-3,5 and may occur as a central6 or peripheral lesion1-3, as in the present case. Clinically, this lesion appears as a hard, slow growing mass, but it may cause facial asymmetry when its size increases9. The most common site is the skull1,2,57 though it is infrequently seen in jaw bones2,7. This is in contrast to other authors1,3 who state that frontal, ethmoidal, and maxillary sinuses are the most common locations. With regard to facial bones, it is more common in the mandible than in the maxilla, and the lingual surface of the mandible body and the lower border in the angle region are the most common sites7. In the present case, the site of the lesion was at the lower border of the mandible. Although the reports3,67 stated that this lesion is usually asymptomatic, the patient complained of pain. The differential diagnoses include exostoses, which are bony excrescences, odontomas that are benign odontogenic tumors, and osteoblastomas, which are very similar to osteoid osteoma3. The present case presented clinical and radiographic features similar to exostoses, however the diagnoses of osteoma was established after histopathological examination.

The complete surgical removal of the osteoma may be indicated to correct the deformity, or if other problems occur, such as blockage of cavities, compression of nerve terminals or noble tissues10. In asymptomatic patients, whose lesion presents sufficiently slow growth or has stopped growing, follow-up is recommendable11.

Although it is uncommon, a case of recurrence nine years after surgical excision was reported 2. The patient, in this paper, did not show any evidence of recurrence and a clinical and radiographic follow-up protocol was provided.

References
  1. Kaplan I, Calderon S, Buchner A. Peripheral osteoma of the mandible: a study of 10 new cases and analysis of the literature. J Oral Maxillofac Surg 1994; 52: 467-70.
  2. Bosshardt L, Gordon RC, Westerberg M, Morgan A. Recurrent peripheral osteoma of mandible: report of case. J Oral Surg 1971; 29: 446-50.
  3. Sayan NB, Üçok C, Karasu HA, Günham Ö. Peripheral osteoma of the oral and maxillofacial region: a study of 35 new cases. J Oral Maxillofac Surg 2002; 60: 1299-1301.
  4. Weinberg S. Osteoma of the mandibular condyle: report of case. J Oral Surg 1977; 35: 929-32.
  5. Schneider LC, Dolinsky HB, Grodjesk JE. Solitary peripheral osteoma of the jaws: report of case and review of literature. J Oral Surg 1980; 38: 452-5.
  6. Cutilli BJ, Quinn PD. Traumatically induced peripheral osteoma: report of a case. Oral Surg Oral Med Oral Pathol 1992; 73: 667-9.
  7. Swanson KS, Guttu RL, Miller ME. Gigantic Osteoma of the mandible: report of a case. J Oral Maxillofacial Surg 1992; 50: 635-8.
  8. Bessho K, Murakami K, Iizuka T, Ono T. Osteoma in mandibular condyle. Int J Oral Maxillofac Surg 1987; 16: 372-5.
  9. Sant’ana E, Rodrigues CBF, Chinellato LEM. Relato de um caso: osteoma de mandíbula. Rev Assoc Paul Cir Dent 1994; 48: 1239-42.
  10. Jones K, Korzcak P. The diagnostic significance and management of Gardner´s syndrome. Br J Oral Maxillofac Surg 1990; 28: 80-4.
  11. Richardson PE, Arendt DM, Fidler JE, Webber CM. Radiopaque mass in the submandibular region. J Oral Maxillofac Surg 1999; 57: 709-13.

Copyright 2005 - Piracicaba Dental School - UNICAMP São Paulo - Brazil


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