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Case #78

History: A 6-year-old boy presented to the oral surgeon after being referred by his pediatric dentist for an unusual finding over the right mandible in a panoramic radiograph. The patient was asymptomatic, and his past medical history was unremarkable.

The extra- and intraoral exams were within normal limits.

The pediatric dentist sent a copy of the panoramic radiograph to the oral surgeon. The panoramic image and a cropped image of the right mandible are shown below. Click to enlarge.

1\What is the most likely initial diagnosis?

A\ Hypercementosis

B\Myxoma

C\Idiopathic bone sclerosis

D\Osteoma

E/Cementoblastoma

F\None of the above

The oral surgeon consulted with an oral and maxillofacial radiologist, who provided an interpretation report to the surgeon. The following is from the report:

There is a radiopaque lesion, nonhomogeneous, surrounded by a radiolucent area and a radiopaque line. The lesion is well-defined. Significant displacement of teeth #27 and #28 is observed. There is root resorption of teeth and .

2\Based on the radiology findings, what is the LEAST likely diagnosis?

A\Cementoblastoma

B\Complex odontoma

C\Compound odontoma

D\Idiopathic bone sclerosis

In the report, the radiologist included three differential diagnoses, including odontoma.

3\Based on the images and radiology findings, what is the most likely diagnosis?

A\Complex odontoma

B\Compound odontoma

C\Fibro-odontoma

D\None of the above

4\The radiologist advised the dentist to order additional imaging to better evaluate the lesion. Which of the following was probably NOT recommended by the radiologist?

A\ Mandibular occlusal radiograph

B\ Computed tomography (CT)

C\ Periapical radiograph

D\Ultrasound

E\Cone-beam (CBCT)

5\What is the next best step?

A\ Incisional biopsy

B\Excisional biopsy

C\Prescription of antibiotics

D\Surgical excision of the lesion

E\None of the above

A few days later, the oral surgeon surgically resected the lesion. The specimen was submitted for histopathology analysis, which confirmed the diagnosis.

Diagnosis: Complex odontoma

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CASE #77

History: A 6-year-old boy presented to the pediatric dentist for an evaluation of a “mass” over the dorsal aspect of the tongue. His parents stated that the lesion was initially small but changed in size significantly over the last five months. The patient had no history of trauma, and his medical history was unremarkable.

Intraoral exam: Within normal limits.

Extraoral exam: The patient had an exophytic, painless mass over the dorsum of the tongue and located at the midline. The lesion was about 1 cm in size and bled easily.

Intraoral image and photo taken by the parents are shown below. Click to enlarge.

1\Which of the following should be included in the differential diagnosis?

A\Vascular lesion

B\Pyogenic granuloma

C\Fibroma

D\All of the above

E\None of the above

2\Which of the following is the most likely diagnosis?

A\Vascular lesion

B\Pyogenic granuloma

C\Fibroma

D\None of the above

3\What is the most likely next step?

A\Incisional biopsy

B\Swab and cytology

C\ Excisional biopsy

D\None of the above

The pediatric dentist referred the patient to an oral surgeon, who evaluated the patient and performed an excisional biopsy. The following is from the histopathology report:

The microscopic examination reveals sections composed of highly vascular proliferation that resembles granulation tissue. Numerous small and large channels are formed and filled with red blood cells and lined by a flat endothelial cell.

4\Based on the histopathology findings, what is the diagnosis?

A\Fibroma

B\Peripheral giant cell granuloma

C\Peripheral ossifying fibroma

D\Leiomyoma

E\Pyogenic granuloma

Diagnosis: Pyogenic granuloma

With the final unusual diagnosis of pyogenic granuloma, the oral surgeon provided the parents with information and recommended a follow-up appointment in six months. The patient returned to the oral surgeon’s office for follow-up. Excellent healing was noted without recurrence.

Follow-up image is shown below. Click to enlarge.

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Discussion

Pyogenic granuloma is an inflammatory hyperplasia. Pyogenic granuloma is an incorrect term, because the lesion is unrelated to infection and, based on histology, does not show the presence of granulomas. Pyogenic granuloma is considered to be a reactive tumor-like lesion that arises in response to different stimuli, such as chronic, low-grade local irritation or trauma. Hormonal factors also have been associated with the presence of this condition. Approximately one-third of the lesions occur after trauma, so a history of trauma before development of the lesion is not unusual, especially for extragingival pyogenic granulomas. Poor oral hygiene may be a precipitating factor in some cases.

Clinically, a pyogenic granuloma is a smooth or lobulated exophytic lesion that presents sometimes as small, red erythematous papules on a pedunculated or sessile base, which is usually hemorrhagic and compressible. The size varies from a few millimeters to several centimeters. Pyogenic granulomas typically grow fast, and they reach the full size within weeks or months. It is very unusual for the lesion to cause bone changes. The lesion is usually asymptomatic, and the surface is ulcerable and friable. From the histopathology examination, pyogenic granulomas show a highly vascular proliferation that resembles granulation tissue. Numerous small and large channels are formed and filled with red blood cells and lined by a flat endothelial cell.

The differential diagnosis includes peripheral giant cell granuloma, peripheral ossifying fibroma, hemangiomas, hyperplastic gingival inflammation, and a malignant tumor. Peripheral giant cell granuloma is an exophytic lesion that is seen exclusively in the gingiva, but clinically it is very similar to pyogenic granuloma. The treatment of pyogenic granuloma is excisional biopsy, except when the procedure would produce marked deformity. After excision, recurrence occurs in approximately 10% of the cases. In some cases, re-excision is necessary.

Reference

Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3rd ed. St. Louis, MO: Saunders/Elsevier; 2009.

CASE #76

History: A 15-year-old boy was referred by his general dentist to the oral surgeon because of pain and swelling over the left side of his face. The patient stated that the pain started two weeks previously, was intermittent, and had increased in intensity in the last couple of days. His last dental appointment for a cleaning was five years ago, and his past medical history was unremarkable.

Extraoral exam: The patient had mild and tender swelling over the left side of his face. No neurological deficit was present. Normal mouth movements were observed.

Intraoral exam: Within normal limits.

The general dentist had taken a panoramic radiograph and provided it to the oral surgeon. The panoramic radiograph and a cropped image of the left mandible are shown below. Click to enlarge.

1\What is the most likely preliminary diagnosis?

A\Myxoma

B\Adenomatoid odontogenic tumor

C\Osteosarcoma

D\Idiopathic bone cavity

E\None of the above

The oral surgeon decided to consult with an oral and maxillofacial radiologist, who evaluated the radiograph and provided a report to the oral surgeon. The following is from the report:

There is a large radiolucent lesion that is well-defined and partially corticated, extending from the neck of the left condyle and the ramus to the mesial root of tooth #19. Tooth #17 is apically and distally displaced (almost to the left angle of the mandible). Expansion is observed over the inferior border of the lesion. No calcifications are observed within the lesion.

The radiologist recommended advanced imaging to further evaluate the lesion.

2\Which of the following is the most likely advanced imaging suggested by the radiologist?

A\Cone-beam computed tomography (CBCT)

B\Computed tomography (CT)

C\Magnetic resonance imaging (MRI)

D\Nuclear medicine

The patient was referred to an imaging center for a CBCT scan. The images were available a few days later, and the radiologist evaluated the available images, including the CBCT volumes. He complemented the initial panoramic radiography report with a note that there was significant expansion of the lesion in the cross-sectional images.

3\What is the most likely diagnosis?

A\Ameloblastic fibroma

B\Ameloblastic fibro-odontoma

C\Ameloblastoma

E\Odontogenic keratocyst

The oral surgeon performed an excisional biopsy. The histopathology report confirmed the diagnosis.

Diagnosis: Amelobastoma

Which of the following statements is true regarding ameloblastomas?

A. They are associated with an impacted tooth.

B. They are not common in children.

C. The lesions are usually associated with pain and swelling.

D. They have a significant potential for recurrence.

E. All of the above are true.

F. Both B and C are true.

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CASE #75
History: A 5-year-old girl presented to the pediatric dentist for a new-patient exam. The patient reported no pain, history of trauma, or allergies. Her past medical history was unremarkable, and she was not taking any medication.

Extraoral exam: Within normal limits.

Intraoral exam: Within normal limits, except for an unusual presentation of the mandibular incisors.

Intraoral images are shown below. Click to enlarge.

The pediatric dentist decided to order an anterior occlusal radiograph (not available), and he noted that teeth and had only one root, and teeth and had only one root.

Based on the clinical presentation and the radiographic findings, please answer the following question.

1\Which of the following is the most likely condition affecting the front teeth?

A/Fusion

B\Gemination

C\Concrescence

D\None of the above

Diagnosis: Gemination

The pediatric dentist decided to observe and follow-up the patient until the normal exfoliation.

2\All the following characteristics are associated with gemination, EXCEPT:

A\Most common in the primary dentition

B\Most common in the anterior mandible

C\Usually associated with syndromes

D\High susceptibility for caries



3\Which of the following factors has been suggested as an etiology of gemination?

A. Trauma

B. Vitamin deficiency

C. Genetic conditions

D. All of the above

E. Both B and C

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The answers and discussion for case 74 #
1\D 2\A 3\D 4\D
Discussion
Odontomas are common odontogenic tumors, constituting approximately 20% of all odontogenic tumors. The term odontoma is used to identify a tumor that is radiographically and histologically characterized by the production of mature enamel, dentin, cementum, and pulp tissue. All of these components are present in different degrees of differentiation. In some situations, odontomas interfere with the normal eruption of permanent teeth.
Odontomas are broadly classified into compound and complex odontomas. Complex odontomas are not as common as compound odontomas. Occasionally, these tumors become large, causing expansion of bone followed by facial asymmetry. There is no gender predilection, and the majority of cases occur in the second decade of life and are found on routine radiographs for evaluating nonerupting permanent teeth.
Radiographically, a complex odontoma appears as a radiopaque mass that does not resemble tooth structure. Histologically, a complex odontoma is characterized by sheets of immature tubular dentin with encased, hollow, tooth-like structures. Ghost cells are especially seen in complex odontomas.
The treatment of choice is surgical excision of the lesion followed by histopathology analysis to confirm the diagnosis.
Reference
Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3rd ed. St. Louis, MO: Saunders/Elsevier; 2009.

Case 74 #
History: A 16.5-year-old girl presented to the oral surgeon for evaluation of a radiopaque lesion on the upper left maxilla. The patient reported no pain. Three months prior, the patient had several teeth extracted because of gross caries. The dentist who extracted the teeth saw the radiopaque area on a panoramic radiograph and referred the patient to the oral surgeon for evaluation and treatment. The patient’s past medical history was unremarkable.
Extraoral exam: Within normal limits.
Intraoral exam: There was adequate healing of the extraction sites. The patient reported no pain upon palpation of the upper left maxilla.
The oral surgeon ordered a cone-beam CT (CBCT) scan. Cropped image from the panoramic radiograph and coronal, sagittal, and axial CBCT images, as well as 3D reconstructed views, are shown below. Click to enlarge.
The radiologist included three potential differential diagnoses, one of which was odontoma. The radiologist also advised the dentist to order additional images to better evaluate the lesion.

1\Which of the following is the MOST LIKELY diagnosis suggested by the radiologist?
A\Complex odontoma
B\Compound odontoma
C\ Fibro-odontoma
D\None of the above

2\Which of the following was probably NOT recommended by the oral radiologist?
A\ Maxillary occlusal radiograph
B\Computed tomography
C\Periapical radiograph
D\Ultrasound
E\CBCT

3\Which of the following is probably the next best step?
A\Incisional biopsy
B\Excisional biopsy
C\ Prescription of antibiotics
D\Surgical excision of the lesion
E\None of the above

The oral surgeon performed a surgical excision of the lesion. The histopathology report was available a few days later and confirmed the radiologist's diagnosis.
Diagnosis: Complex odontoma
The answers and discussion will be available by the end of the week insha Allah
This case is from Dr,bicuspid
Good luck

Answers and discussion for case 73 #

1\Undetermined (the correct answer)

2\Odontogenic keratocyst (correct!)

3\Incisional biopsy (correct!)

4\Odontogenic keratocyst (correct!)

5\Nevus cell carcinoma syndrome (correct!)

Discussion

Odontogenic keratocyst (OKC) is a benign odontogenic cyst that arises from cell rests of the dental lamina. This cyst shows a different growth mechanism and biological behavior from the more common dentigerous cyst and radicular cyst. An unerupted tooth is involved with the lesion in 25% to 40% of the cases. OKC is associated with nevoid cell carcinoma syndrome.

Odontogenic keratocyst may be found in patients who range in age from infancy to old age; about 60% of the cases are diagnosed in people between 10 and 40 years of age. Small OKCs are usually asymptomatic and discovered only during the course of a radiographic examination. Large OKCs may be associated with pain, swelling, and drainage.

Radiographically, odontogenic keratocyst demonstrates a well-defined radiolucent area with smooth and often corticated margins. Large lesions may appear multilocular.

The treatment is enucleation of the cyst together with curettage. In contrast to other odontogenic cysts, odontogenic keratocyst often tend to recur after treatment. Many surgeons recommend peripheral osteotomy of the bony cavity to reduce the frequency of recurrence.

References

Neville BW, Damm DD, Allen CM, Bouquot JE. Oral and Maxillofacial Pathology. 3rd ed. St. Louis, MO: Saunders/Elsevier; 2009.
White SC, Pharoah MJ. Oral Radiology: Principles and Interpretation. 6th ed. St. Louis, MO: Mosby; 2009

Case 73 #

History: A 55-year-old man presented to his family dentist because he wanted implants. His past medical history included hypertension and also a partial colon resection because of cancer five years ago. He reported no allergies.

Extraoral exam: Within normal limits with no lymphadenopathy.

Intraoral exam: Tooth #17 was partially erupted. The patient had no swelling and no pain upon palpation.

The dentist ordered a cone-beam CT (CBCT) scan and noted a lesion over the left mandible that was associated with tooth #17.

Images of the left mandible are shown below. Click to enlarge. In order: reformatted cropped panoramic radiograph, cropped image, 3D reconstruction, and coronal view.

Which of the following is the LEAST LIKELY diagnosis?
Dentigerous cyst
Idiopathic bone cavity
Unicystic ameloblastoma
Odontogenic keratocyst

Radiographic findings

The dentist referred the patient to an oral surgeon for an evaluation. The surgeon consulted with an oral and maxillofacial radiologist. The following is from the radiology report:

There is a hypodense lesion (radiolucent), well-defined and corticated, located distally to the crown of tooth #17 (partially impacted). The hypodense area extends distally approximately 8 mm. The major diameter is 11.33 mm. The inferior alveolar canal is slight apically displaced and located inferiorly in relation to the lesion. There is mild to moderate expansion in the cross-sectional views.



Based on the radiology report, what is the likely nature of the lesion?
Malignant
Benign
Undetermined
None of the above

Based on the radiology report, which of the following is the MOST LIKELY diagnosis?
Unicystic ameloblastoma
Idiopathic bone cavity
Odontogenic keratocyst
Fibrous dysplasia
None of the above

Which of the following is the MOST LIKELY next step?
Incisional biopsy
Swab and cytology
Excisional biopsy
None of the above

Histopathology

The oral surgeon scheduled the patient for an incisional biopsy. The following is from the histopathology report:

Histological examination of hematoxylin and eosin stained slides demonstrate a fibrous cyst wall with a uniform stratified squamous epithelium, six to eight cells in thickness. The epithelium is distinctive for a layer of columnar, palisading, hyperchromatic basal cells. Rete ridges are absent, and focally the epithelium is detached from the underlying fibrous tissue. The luminal surface is parakeratotic with a corrugated appearance. The lumen contains keratinaceous material.



Based on the histopathology report, which of the following is the final diagnosis?
Ameloblastic fibroma
Dentigerous cyst
Idiopathic bone cavity
Odontogenic keratocyst
Residual cyst
Diagnosis: Odontogenic keratocyst

Treatment

The patient was scheduled for a conservative resection of the lesion with a safe margin to prevent potential recurrence.



Which of the following syndromes is associated with odontogenic keratocyst?
Down syndrome
Nevus cell carcinoma syndrome
Edwards syndrome
None of the above
The answers and discussion will be available by the end of the week insha Allah
This case is from Dr.Bicuspid
Good luck

Case 72 #

History: A 58-year-old man reported with the chief complaints of pain and swelling in the left side of his face for the past seven to eight days. Pain was severe and increased during the night. The swelling was insidious in onset and was associated with fever. Patient's medical history was unremarkable. He also gave a history of pus discharge from left upper posterior region, intraorally.

Extraoral exam:

Skin over the swelling was normal.
A 2 x 3-cm warm, diffuse swelling was noticed in the left preauricular region.
Intraoral exam:
Obliteration of vestibule was noticed in upper posterior region.
On further examination, root stumps of left maxillary first molar teeth (26) along with pus discharge from an intraoral sinus in the same region was noticed.
Panoramic radiograph revealed 2 x 3-cm radiolucency in the periapical region of 26. On correlation of clinical and radiological findings, a provisional diagnosis of infected radicular cyst was made.

The decision to enucleate the lesion through an intraoral approach was made. Pus and thick epithelial lining were significant findings.

Click the images below to enlarge.
The enucleated soft tissue was submitted for histopathologic examination, which turned out to be infected radicular cyst.

Discussion

Radicular cyst is an inflammatory cyst associated with the root apex of a nonvital tooth. It can occur at any age. Clinically, these cysts are associated with a tooth that is carious, has undergone previous restorative care, has sustained trauma, or is an apparent failure of root canal therapy.

Radiographically, an apical radiolucency will be noted, and rarely will there be bony expansion unless there is secondary infection.

Radicular cysts are definitely resolved if the tooth and the apical lesion are removed.

References

1. Rajendran R, Sivapathasundharam B, eds. Shafer's Textbook of Oral Pathology. 5th ed. New Delhi, India: Elsevier; 2006:376-377.

2. Neville BW, Damm DD, Allen CM, Bouquot J. Oral and Maxillofacial Pathology. 3rd ed. Philadelphia, PA: W.B. Saunders; 200

Case 72 #
History: A 58-year-old man reported with the chief complaints of pain and swelling in the left side of his face for the past seven to eight days. Pain was severe and increased during the night. The swelling was insidious in onset and was associated with fever. Patient's medical history was unremarkable. He also gave a history of pus discharge from left upper posterior region, intraorally.

Extraoral exam:

Skin over the swelling was normal.
A 2 x 3-cm warm, diffuse swelling was noticed in the left preauricular region.
Intraoral exam:
Obliteration of vestibule was noticed in upper posterior region.
On further examination, root stumps of left maxillary first molar teeth (26) along with pus discharge from an intraoral sinus in the same region was noticed.
Panoramic radiograph revealed 2 x 3-cm radiolucency in the periapical region of 26. On correlation of clinical and radiological findings, a provisional diagnosis of infected radicular cyst was made.

The decision to enucleate the lesion through an intraoral approach was made. Pus and thick epithelial lining were significant findings.

Click the images below to enlarge.
The enucleated soft tissue was submitted for histopathologic examination, which turned out to be infected radicular cyst.

Discussion

Radicular cyst is an inflammatory cyst associated with the root apex of a nonvital tooth. It can occur at any age. Clinically, these cysts are associated with a tooth that is carious, has undergone previous restorative care, has sustained trauma, or is an apparent failure of root canal therapy.

Radiographically, an apical radiolucency will be noted, and rarely will there be bony expansion unless there is secondary infection.

Radicular cysts are definitely resolved if the tooth and the apical lesion are removed.

References

1. Rajendran R, Sivapathasundharam B, eds. Shafer's Textbook of Oral Pathology. 5th ed. New Delhi, India: Elsevier; 2006:376-377.

2. Neville BW, Damm DD, Allen CM, Bouquot J. Oral and Maxillofacial Pathology. 3rd ed. Philadelphia, PA: W.B. Saunders; 2009:130-134.

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