Radiolucent lesion with scalloped border above the inferior alveolar canal between roots of mandibular molars. this lesion?
A- Solitary cyst***
B- Aneurysmal bone cyst.
----------------------------
The aneurysmal bone cyst (QOA) is a rare benign lesion in maxillary bones, most often it is in long bones of the skeleton and spine. Some authors speculate that the origin is due to trauma, poor training or a neoplasm. The radiographic appearance can show from a diffuse image to a well-defined image, very similar to the other maxillary lesions making the differential diagnosis broad. With the destruction of the bone cortex it can still form a reactionary image of the periosteum in the form of sun rays, characteristic of a malignant lesion. In this study, we present a case of a female patient, 17 years old, who sought the Maxillofacial Buco Surgery and Traumatology Service of the São Vicente de Paulo-RS Hospital, who presented pain and increased jaw volume. He reported that about a year ago he began to feel unwell in the region next to the right mandibular angle, which was gradually increasing in volume. The radiographic appearance agreed to a malignant lesion. After histopathological confirmation of QOA, the treatment selected for the case was conservative surgery, with curettage of the bone cavity, and was maintained in routine postoperative control with 6 and 18 months. Bone neoformation and cure of the case are verified on panoramic radiographs.
INTRODUCTION:
The aneurysmal bone cyst (QOA) was first identified as a clinocopathological entity by Jaffe and Lichtenstein in 1942 who called it a bone cyst, to define an intraosseous lesion that contains a thin layer of bone, usually when it has a blood-filled and aneurysmal cavity, to emphasize cortical bone loss accompanied by bone expansion. But it is not a true cyst, because it has no epithelial lining.
The World Health Organization defined QOA as an expansive osteolytic lesion consisting of blood-filled spaces and channels divided by septa of connective tissue that may contain osteoid tissue and osteoclasts as giant cells. Although it is a benign lesion, it can behave aggressively locally because of its rapid growth and osteolytic capacity.
QOA is more frequent where there is a relatively high venous pressure and higher marrow content. Since the bones of the skull have low venous pressure, QOA is rare in these areas.2 It has been observed in almost all parts of the skeleton, although more than 50% of the total cases occur in long bones and between 12 and 12 30% occur in the spine.
In gnatic bones it is not common, with approximately 2% reported in the jaws. The most prevalent age is in children and young adults with an average age of approximately 20 years. No gender predilection has been observed, 8 but there is a 3: 1 jaw predilection in relation to the maxilla.4,9,10
The QOA of the jaws can be found in association with other bone lesions such as, central ossifying fibroma, chondroblastoma, giant cell tumor, central giant cell granuloma or fibrous dysplasia, these combined lesions have been designated as QOA -plus. Most of the combined lesions were described in long bones, but oral and maxillofacial literature have also reported that type of case.
Etiology and pathogenesis:
The pathogenesis of aneurysmal bone cyst remains controversial, with theories ranging from a local post-trauma, relative vascular malformation, to the predisposition to develop bone tumors. Although the pathogenesis of the aneurysmal bone cyst is obscure, it is generally considered representative of a reactive process rather than a neoplastic or cystic. In this sense several theories were proposed, including trauma, vascular disturbance, sudden venous occlusion or venous artery bypass.
Clinical features:
The most common clinical manifestation of QOA is facial bulge that normally develops rapidly. It can be observed in some occasions bad occlusion, mobility, migration or resorption of the wrapped teeth. In the maxilla the lesion frequently extended to the adjacent breast.8 The main symptoms of QOA include dull pain and edema. Paresthesia, compression and crepitation are rarely observed. Depending on its location, other symptoms can be found such as headache, diplopia, loss of sight, dental mobility, hearing loss, among others.
During the surgical act when penetrating the lesion there is excessive bleeding. The consistency of the tissue has been comparable to a sponge with large pores embedded in blood, which represent the cavernous spaces of the lesion. The lesion can perforate the cortex and remains covered by periosteum or a thin sheet of bone.
A- Solitary cyst***
B- Aneurysmal bone cyst.
----------------------------
The aneurysmal bone cyst (QOA) is a rare benign lesion in maxillary bones, most often it is in long bones of the skeleton and spine. Some authors speculate that the origin is due to trauma, poor training or a neoplasm. The radiographic appearance can show from a diffuse image to a well-defined image, very similar to the other maxillary lesions making the differential diagnosis broad. With the destruction of the bone cortex it can still form a reactionary image of the periosteum in the form of sun rays, characteristic of a malignant lesion. In this study, we present a case of a female patient, 17 years old, who sought the Maxillofacial Buco Surgery and Traumatology Service of the São Vicente de Paulo-RS Hospital, who presented pain and increased jaw volume. He reported that about a year ago he began to feel unwell in the region next to the right mandibular angle, which was gradually increasing in volume. The radiographic appearance agreed to a malignant lesion. After histopathological confirmation of QOA, the treatment selected for the case was conservative surgery, with curettage of the bone cavity, and was maintained in routine postoperative control with 6 and 18 months. Bone neoformation and cure of the case are verified on panoramic radiographs.
INTRODUCTION:
The aneurysmal bone cyst (QOA) was first identified as a clinocopathological entity by Jaffe and Lichtenstein in 1942 who called it a bone cyst, to define an intraosseous lesion that contains a thin layer of bone, usually when it has a blood-filled and aneurysmal cavity, to emphasize cortical bone loss accompanied by bone expansion. But it is not a true cyst, because it has no epithelial lining.
The World Health Organization defined QOA as an expansive osteolytic lesion consisting of blood-filled spaces and channels divided by septa of connective tissue that may contain osteoid tissue and osteoclasts as giant cells. Although it is a benign lesion, it can behave aggressively locally because of its rapid growth and osteolytic capacity.
QOA is more frequent where there is a relatively high venous pressure and higher marrow content. Since the bones of the skull have low venous pressure, QOA is rare in these areas.2 It has been observed in almost all parts of the skeleton, although more than 50% of the total cases occur in long bones and between 12 and 12 30% occur in the spine.
In gnatic bones it is not common, with approximately 2% reported in the jaws. The most prevalent age is in children and young adults with an average age of approximately 20 years. No gender predilection has been observed, 8 but there is a 3: 1 jaw predilection in relation to the maxilla.4,9,10
The QOA of the jaws can be found in association with other bone lesions such as, central ossifying fibroma, chondroblastoma, giant cell tumor, central giant cell granuloma or fibrous dysplasia, these combined lesions have been designated as QOA -plus. Most of the combined lesions were described in long bones, but oral and maxillofacial literature have also reported that type of case.
Etiology and pathogenesis:
The pathogenesis of aneurysmal bone cyst remains controversial, with theories ranging from a local post-trauma, relative vascular malformation, to the predisposition to develop bone tumors. Although the pathogenesis of the aneurysmal bone cyst is obscure, it is generally considered representative of a reactive process rather than a neoplastic or cystic. In this sense several theories were proposed, including trauma, vascular disturbance, sudden venous occlusion or venous artery bypass.
Clinical features:
The most common clinical manifestation of QOA is facial bulge that normally develops rapidly. It can be observed in some occasions bad occlusion, mobility, migration or resorption of the wrapped teeth. In the maxilla the lesion frequently extended to the adjacent breast.8 The main symptoms of QOA include dull pain and edema. Paresthesia, compression and crepitation are rarely observed. Depending on its location, other symptoms can be found such as headache, diplopia, loss of sight, dental mobility, hearing loss, among others.
During the surgical act when penetrating the lesion there is excessive bleeding. The consistency of the tissue has been comparable to a sponge with large pores embedded in blood, which represent the cavernous spaces of the lesion. The lesion can perforate the cortex and remains covered by periosteum or a thin sheet of bone.
Radiographic characteristics:
The radiographic image is generally radiolucent, which tends to expand and produce bone cortical bulge, which is usually unilocular. Others are described as clearly discernible septa or trabeculations, and some cases are described as multilocular, such as honeycombs or soap bubbles. There may be reabsorption of the roots and displacement of the teeth of the region, these are vital. Rarely, small radiopaque foci, supposedly reactionary bone trabeculae, are observed within the radiotransparency.
The QOA is radiographically very similar to other maxillary lesions, which makes its differentiation difficult. Occasionally the destruction of the bone cortex can be identified. It exhibits an image of periostal reaction in the form of a sunbeam, an effect that is characteristic of osteosarcoma, with which the differential diagnosis must be made.
Histological aspects:
The prominent histological aspect is the cavernous spaces filled with blood, of varying sizes, limited by fusiform cells, flattened and separated by delicate septa of loose connective tissue. Blood filled spaces are not lined by endothelium. The lesion may contain multinucleated cells and osteoid trabeculae, areas of hemorrhage and hemosiderin.
In some cases the wall contains a calcification similar to a lace that is not common in other intraosseous lesions. In approximately 20% of cases, QOA is associated with other lesions, usually a fibroosseous lesion or central granuloma of giant cells.
Differential Diagnosis:
Preoperative diagnosis of QOA can be difficult because of its similarity to other lesions, such as ameloblastoma, giant cell tumor, hyperparathyroidism, myxoma, traumatic bone cyst and ceratocyst odontogenic tumor. Blood aspiration of the lesion should lead the clinician to suspect a vascular lesion or QOA. The absence of noise, palpitation and lack of pulse pressure help clinically differentiate the QOA from a vascular lesion. It is essentially a diagnosis of exclusion.
The definitive diagnosis can only be made after the histopathological examination. The biopsy should be performed only when a vascular lesion has been ruled out. Depending on the histological constitution of the lesion, when there is a large number of multinucleated giant cells, fibroblasts, hemorrhage and hemosiderin, the granuloma picture may resemble giant cells in solid areas, with the presence of osteoid to fibrous dysplasia and fibroma ossifying
Treatment and prognosis:
The treatment for the aneurysmal bone cyst of the jaws has been excision and curettage in some cases and has been complemented with cryosurgery. Recurrence rates vary from 8% to 60%, which in most cases takes place from improper removal of the lesion. Most authors recommend surgical resection for QOA removal. In cases where resection is not recommended, radiation therapy is a therapeutic alternative, but it is not indicated in cases where the patient is young, as there is a significant risk of developing a future sarcoma.
Interferon alfa-2a is another alternative for the treatment of patients with vascular lesions of the head and neck of difficult surgical access, such as aneurysmal bone cyst and central giant cell granuloma. But it can also be used as an adjunctive therapy to surgical treatment. When used before the operation promotes a reduction in the size of the lesion.
Methylprednisolone can be used in combination with calcitonin, it has an angioblastic and fibroblastic inhibitory effect, but this treatment can take a long time with an unpredictable response. Some authors17 reported that surgery may be complicated by massive hemorrhage and need an external carotid artery ligation, or preventive ligation or prior embolization. Others have recommended the immediate reconstitution of the defect caused by the removal of the lesion, with autogenous grafting in cases of cosmetic deformity, and in cases with high risk of fractures and loss of bone continuity.
PRESENTATION OF THE CASE:
A case was presented of a 17-year-old female patient who attended the Maxillofacial Buco Surgery and Traumatology Service of the São Vicente de Paulo Hospital, in Passo Fundo, Brazil, who presented pain and increased jaw volume. He reported that about a year ago he had begun to feel unwell in the region and that six months ago he perceived swelling along the right mandibular angle that was progressively growing.
An extrabuccal clinical examination showed an increase in volume in the region of the right mandibular angle, of hard consistency and painful palpation. In the intra-oral examination, the bottom of the lower right vestibular groove near the region of the lower molars and retromolar area was observed, caused by expansion of the vestibular cortical table. The radiographic examination revealed a multilocular radiolucent area such as soap bubbles next to the basilar of the jaw, in the region of the left angle with a measure about 4 cm in its largest diameter. The corticals were preserved but expanded in the linguovestibular sense.
The surgical treatment was performed in a hospital setting, under general anesthesia and nasotracheal intubation. Asepsis and antisepsis were maintained, field cloths were placed and an extrabuccal incision was made about 1 cm below the lower edge of the mandibular body, just below the location of the lesion and sought to preserve maximum integrity. of adjacent tissues. After confirmation of the absence of malignancy by means of a freeze biopsy, the enucleation of the lesion was performed followed by a curettage of the bone cavity. The regional bleeding control was performed under local anesthesia with a vasoconstrictor associated with controlled hypotension, applied to the patient by the anesthesiologist.
The specimen removed was sent to the Histopathology Laboratory of the University School of Dentistry. The microscopic examination reported a stroma of fibrous connective tissue with numerous young fibroblasts and multinucleated giant cells, presence of numerous sinusoidal spaces partially filled by fibrins and large hemorrhagic areas, osteoid areas and bone tissue formation throughout the lesion and hemosiderin foci. The histopathological diagnosis was aneurysmal bone cyst.
In the postoperative control, a good tissue response was observed, with good scarring and decreased edema. In the bone repair observed through the panoramic radiographic examination performed with 1, 4, 6, 12 and 24 months, no sign of recurrence was evident in this period.
As in the case presented, the most common clinical manifestation of QOA is facial swelling that normally develops rapidly. Bad occlusion, mobility, migration or reabsorption of the involved teeth can also be observed on some occasions and in the maxilla the lesion frequently extends to the adjacent maxillary sinus.
As the radiographic characteristics of this lesion have variations, histopathological confirmation is essential for the definitive diagnosis, especially in the differentiation of malignant tumors. In addition, surgical excision followed by bone curettage proved to be a good treatment of choice for this condition and offered a favorable prognosis, as well as a satisfactory bone repair without recurrence.
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Oral Surgery