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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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CASE REPORT
Year : 2006  |  Volume : 24  |  Issue : 3  |  Page : 155-157
 

Aneurysmal bone cyst of the coronoid process of the mandible


Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
V Rattan
Unit of Oral and Maxillofacial Surgery, Oral Health Sciences Centre, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.27898

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   Abstract 

A rare case of aneurysmal bone cyst (ABC) located in the coronoid process of the mandible in a 12-year-old girl is presented. Treatment consisted of excision of the lesion through preauricular, submandibular and intraoral approach. An access osteotomy distal to second molar region was required to gain access to medial side of the coronoid process. To our knowledge, this is the third case of an aneurysmal bone cyst of the coronoid process of mandible. While examining a patient with a large expansile intrabony jaw cavity with thin peripheral bone, which is filled with blood without presence of bruit, thrills and pulse pressure, the diagnosis of aneurysmal bone cyst should be on top of the differential diagnosis list. Seventy-four to eighty-five percent of aneurysmal bone cysts of jaws occur in 10-20 years age group. Therefore, a pediatric dentist may be the first person to see such a lesion.


Keywords: Aneurysmal bone cyst, coronoid process of mandible, cyst of mandible


How to cite this article:
Rattan V, Goyal S. Aneurysmal bone cyst of the coronoid process of the mandible. J Indian Soc Pedod Prev Dent 2006;24:155-7

How to cite this URL:
Rattan V, Goyal S. Aneurysmal bone cyst of the coronoid process of the mandible. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2019 Oct 18];24:155-7. Available from: http://www.jisppd.com/text.asp?2006/24/3/155/27898



   Introduction Top


Aneurysmal bone cyst (ABC) is a benign osseous lesion recognized as a distinct clinicopathological entity by Jaffe and Lichtenstein in 1942.[1] The term aneurysmal is used to define the blow-out distension of part of the contour of the affected bone that results in a striking radiographic appearance. The lesion causes local expansion of the affected bone and its growth is non-infiltrative, leaving only a thin layer of overlying subperiosteal new bone. The aneurysmal bone cyst occurs most frequently in the long bones, the vertebrae and the pelvis and rarely in the maxilla and mandible. The lesion is not a true cyst as it lacks epithelial lining. The clinical signs and symptoms of aneurysmal bone cyst are nonspecific and often do not enable a diagnosis to be made clinically. Therefore, these lesions can be misdiagnosed and mismanaged. Seventy-four to eighty-five percent of aneurysmal bone cysts of the jaws occur in 10-20 years age group.[2],[3] Therefore, a pediatric dentist may be the first person to see such a lesion. The molar region and ramus of the mandible are the commonest sites for an aneurysmal bone cyst to occur.[4] Only two cases involving the coronoid process of the mandible have been reported previously.[5],[6] To our knowledge this is the third case being reported involving the coronoid process of the mandible.


   Case Report Top


A 12-year-old female patient reported with a chief complaint of pain and swelling on right side of the face for the preceding 2 months. There was associated difficulty in opening of the mouth. The examination revealed a hard tender 6 x 5 cm diffuse swelling over the right cheek region. There was eggshell crackling in the temporal region. Intraorally, there was expansion of the mandible, extending from right retromolar region to ascending ramus of the mandible. An orthopantomograph showed a well-defined radiolucency involving the coronoid process and ascending ramus of the mandible. Aspiration with 18 G needle and a 10 cc syringe revealed dark coloured blood. A computerized tomographic (CT) scan was taken, which showed a large lytic lesion involving the coronoid process with thin peripheral cortical bone [Figure - 1]A and B. The lesion had caused partial resorption of the zygomatic arch. An incisional biopsy under general anesthesia was taken through intraoral incision over the ascending ramus. The cavity was filled with blood and there was no epithelial lining or bony septae in the cavity. The bony window was enlarged. It was decided to pack-open the cavity with petrolatum gauge with an aim to decrease the size of the lesion. Every time during changing of pack, excessive bleeding was encountered and it was accompanied with severe pain. Histopathological examination of the lesion showed vascular spaces, separated by septae composed of loose arrangement of spindle cells interposed with benign giant cells, consistent with the diagnosis of aneurysmal bone cyst [Figure - 2]A and B. Over a period of 1 month, the patient's swelling, pain and bleeding during changing of the pack increased.

Complete excision of the lesion under general anesthesia was planned. The lesion was approached through submandibular, extended pre-auricular and intraoral incisions. An osteotomy distal to the second molar was carried out to gain access on to medial side of the coronoid process. The zygomatic arch was found to be thinned and partially resorbed. Care was taken to not apply excessive pressure during retraction on to the thinned zygomatic arch, to prevent its fracture. In the process of separating the lesion from firmly attached muscles, whole of the ramus along with the condyle got disarticulated. The lesion was removed from the ascending ramus extracorporeally. The margins of the bone were trimmed with large bur and the third molar tooth bud was removed from within the disarticulated mandible. The mandible, free of lesion, was fixed back to its original position with six-hole 2.5 mm mini bone plate and six screws. Intermaxillary fixation was done for 4 weeks. The patient's recovery was uneventful. Two-year follow-up CT scan showed near normal dimensions of the zygomatic arch and no evidence of recurrence. There was normal function and esthetics with no growth abnormalities.


   Discussion Top


The coronoid process may be involved primarily by the aneurysmal bone cyst or secondarily via extension from the lesion involving ascending ramus of the mandible. The coronoid process has a tendency to balloon up and may encroach on the infratemporal and temporal fossae. The pressure of the expanding lesion may cause resorption of the zygomatic bone, as in the present case. The large cyst may be difficult to remove because of difficult access to infratemporal fossa. Recurrences have been reported due to difficult access and incomplete removal.[3]

Preoperative diagnosis of aneurysmal bone cyst can be difficult because of similarity to other lesions like ameloblastoma, giant cell tumor, hyperparathyroidism, myxoma, traumatic bone cyst and odontogenic keratocyst. Aspiration of blood from the lesion should give suspicion of vascular lesion or aneurysmal bone cyst. Absence of bruits, thrill and lack of pulse pressure helps to differentiate aneurysmal bone cyst from a vascular lesion clinically. Definitive diagnosis can be made only after incisional biopsy. Biopsy should be attempted only when vascular lesion has been ruled out.

Radiographically the appearance of aneurysmal bone cyst of jaws is of a well-circumscribed usually unilocular radiolucency, but it can be multilocular mixed radiolucent-radiopaque lesion.[7] CT scan is far superior to plain radiography and often reveals a thin cortex of bone, expansile nature of lesion and fluid-fluid levels within the lesion. Fluid-fluid levels are due to layering of solid blood components within the cyst. Magnetic resonance imaging is superior to CT scan in showing the soft tissues and fluid-fluid levels because it has the advantage of both tissue contrast and sensitivity to hemorrhage.

Surgery is the treatment of choice for these lesions although calcitonin injections have been tried, but therapeutic response is unpredictable.[8] In the present case, open packing failed to resolve the lesion; rather there was rapid vascularization of the lesion as it was accompanied with excessive bleeding and pain during changing of pack. The exposure of the lesion through temporal, submandibular and intraoral route and access osteotomy at molar region, provided complete access to the lesion. The disarticulated mandible was used successfully as free autograft with good functional and cosmetic outcome. This avoided any need for harvesting bone graft from a second surgical site, thus reducing morbidity.

 
   References Top

1.Jaffe HL, Lichtenstein L. Solitary unicameral bone cyst with emphasis on the roentgen picture, the pathologic appearance and pathogenesis. Arch Surg 1942;44:1004-25.  Back to cited text no. 1    
2.Padwa BL, Denhart BC, Kaban LB. Aneurysmal bone cyst- "Plus": A report of three cases. J Oral Maxillofac Surg 1997;55:1144-52.  Back to cited text no. 2  [PUBMED]  
3.Motamedi MH. Destructive aneurysmal bone cyst of the mandibular condyle: Report of case and review of literature. J Oral Maxillofac Surg 2002;60:1357-61.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Bataineh AB. Aneurysmal bone cyst of the maxilla: A clinicopathological review. J Oral Maxillofac Surg 1997;55: 1212-6.  Back to cited text no. 4  [PUBMED]  
5.Matsuura S, Tahara T, Ro T, Masumi T, Kasuya H, Yokota T. Aneurysmal bone cyst of the coronoid process of the mandible. Dentomaxillofac Radiol 1999;28:324-6.   Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Martins WD, Favaro DM. Aneurysmal bone cyst of the coronoid process of the mandible: A case report. J Contemp Dent Pract 2005;6:130-8.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Kaffe I, Naor H, Calderon S, Buchner A. Radiological and clinical features of aneurysmal bone cyst of the jaws. Dentomaxillofac Radiol 1999;28:167-72.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Rapidis AD, Valliantou D, Apostolidis C, Lagogiannis G. Large lytic lesion of ascending ramus, the condyle and the infratemporal region. J Oral Maxillofac Surg 2004;62:996-1001.  Back to cited text no. 8    


    Figures

[Figure - 1], [Figure - 2]


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    Abstract
    Introduction
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