68

J Indian Sot

Pedo Prev Dent June 2002

Odontogenic myxoma in a child : Diagnostic and treatment dilemmas.

Sarode.T. NAIR Pa, Malik N.A.b, Mumbai.
* ; _ .; Y,

. : : .- ..: : -;-! .r I

HOSPITAL DENTAL COLLEGE.

(A rare case of odontogenic myxoma of the mandible in a 10 year old child has been reported and an attempt has been made to critically analyze the case as well as the diagnostic dilemmas related to myxomatous tumours to improve our knowledge and skills in their management. ~7 J Indian Sot Pedo Prev Dent 2002 ; 20 : 2 : 68-72 Keywords : Odontogenic myxoma, J Mandible, ; Child, Myxomatous tumours

Radiologically,its

appearance ranges from a unilocular peri-

coronal radiolucency to multilocular radiolucency with variable trabecular pattern giving rise to a Honey-comb, Soap bubble or Tennis racket appearance14. burst appearence The sunray or sunhas also been reported in literature. Dis-

placement of teeth rather than resorption is more common Often displacement of tooth follicles may take place. Mandibular lesions cross the midline while maxillary do not. A lot of controversy regarding the borders of the lesions have been mentioned in literature6. They range from well defined to diffused marginsThe not typical. cyst radiological features of myxoma are

yxomatous tumors of the jaw bones have always been

a subject of discussion as the controversies regarding the origin, clinical and radiological features, treatment and recurrence rate associated with the tumors still prevail. Odontogenic myxoma is a rare benign neoplasm. Various theories regarding the origin of the tumor have been pro-

The differential diagnoses for myxoma are as below:

??

Dentigerous Periapical

??

cyst

??

posed as follows: 1. Dental papilla 2. Dental follicle 3. Periodontal ligament

?? ??

Lateral periodontal cyst Ameloblastoma lntraosseous Hemangioma Cherubism Giant cell lesions Metastatic tumours

I . ,_ :.

??

??

??

4. Degeneration of fibroma 5. Non-Odontogenic mesenchyme Myxoid tissue is not a native tissue in children or adults. It is only found in the umbilical cord of the foetus2. Recent ultra structural studies have proved the that myxoblasts mucoid i.e. modified fibroblasts secrete intracellular matrix

Macroscopically, the lesion appears to be a soft gelatinous yellowish grey mass which is often non-encapsulated. Cut surface of the lesion exhibits characteristic slimy appearance. Histopathologically, it consists of triangular stellate cells with long processes intermeshing with each other. The intercellular matrix is mucoid and the cytoplasm is slightly basophillic, finely granular and with a well defined nucleus Mitotrc figures are few. Cells may show pleomorphism. Tiny caprllanes are often seen. Variable amount of collagen fiepibres are presentbased on which it is designated as myxofibroma or fibromyxoma. Islands or nests of odontogenrc thelium are often present. Bone may be rarely present I. Recent ultrastructural studies8 have proved that myxoma is a tumor of fibroblasts, modified in such a way that they form

to form the myxoid tissuez3. Clinically, odontogenic myxoma is a benign invasive, slowly enlarging mass causing marked asymmetry of the face. It commonly involves the mandibular premolar and molar regions. Females have a higher predilection than males It usually occurs in second or third decades of life and causes expansion of the bony cortices, displacement and loosen_. i :. ing of teeth. Pain is a rare feature.

a. b

Former Professor

Post-graduate and Head

Student, . I

a matrix composed of glycosaminoglycans and do not form collagen fibrils designated as myxoblasts.

Dept. of Oral and Maxillofacial Surgery

Sar0de.T. P, Malik N.A.

Fig.3:Preoperative Mandible

- Right Lateral Oblique View of

Fig.1 :Preoperative

- Frontal View

Fig.2: Preoperative - Intraoral View ,I_

Fig.4: Axial CT scans - showing expansion of buccal and ligual cortices with areas of erosion ,*,-. f

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J Indian Sot Pedo Prev Dent June 2002

Fig.8:Tumour

Specimen

Fig.5 3 D CT Scan

Fig.9:Photomicrograph

of the specimen

Fig.G:lntraoperative - Exposure of tumour mass by intraoral approach

Fig.7:Surgical
; ?

defect after excision of tumour mass

. . 4

Fig. ,l 0:Postoperative

- Frontal View

Sar0de.T. P, Malik N.A.

71

Fig.ll:Postoperative - Intraoral wound healing

Fig.13: 4 months, Postoperative - Right Lateral Oblique View of Mandible

Fig.14: 6 months, P o s t o p e r a t i v e regeneration of bone Fig.1 2: Immediate Postoperative - Right Lateral Oblique View of Mandible

OPG

showing

. I

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J Indian Sot Pedo Prev Dent June 2002

,
CASE REPORT A 10 year old child reported to the Maxillofacial OPD, N.H.D.C. with swelling of right side of face involving the body and ramus mandible since 30-35 days. The swelling was diffuse, firm, non-fluctuant, hard and tender on palpation. lntraorally the swelling presented as an exophytic growth on the distolingual aspect of right first molar and was firm in consistency, tender and lobulated. The mucosa overlying the swelling was pale pink in colour. Expansion of buccal and lingual cortical plates of ramus and body of the mandible was also evident. Preoperative right lateral oblique view of mandible showed a well defined unilocular pericoronal radiolucent lesion extending from the right ascending ramus till lower right first molar. The developing tooth follicle of lower right second molar was seen and the condyle was uninvolved. 3D CT scans showed expansion of both the buccal and lingual cortical plates with a focal area of erosion. The coronoid process and condyle were uninvolved. The inferior border of the mandible and posterior border of ramus showed no evidence of expansion. An incisional biopsy of the patient was done and the overall histopathological picture was suggestive of Non-odontogenit fibroma.The patient was taken up for surgery under gen3. 4.

I. Though the tumour is locally aggressive, the tumor mass excised in toto was well encapsulated. 2. Considering the age of the patient, the deformity caused by mandibular resection would be more. 3. The recurrence rate in children has not been detected. 4. The post operative radiographs taken after4 and 6 months showed regeneration of bone. Keeping in mind the high recurrence rate 2 associated with odontogenic myxoma, regular follow up visits are required. Moreover, because of rarity of occurrence of the myxoma, it is not possible to speculate whether the recurrence is more frequent in adults or in children. However, a surgeon must always make an attempt to critically analyse the features such as diagnostic dilemmas related to these tumors to improve our knowledge and skills in management of myxomatus tumors of the jaw bones. REFERENCES : 1. Shaefer WG, Hine M K. Levy B M. A Textbook of Oral Pathology, Philadelphia, P.A. Saunders, 1983. pp 160-161, 295297.
2.

David L. Schneck, Gross, Tabor Odontogenrc Myxoma: Report of

two cases with Reconstruction Consrderatrons. J. Oral Maxillofacial Surgery,199351 :935-940 MC Clure D K. Dahlin D C. Myxoma of Bone: Report of three cases Mayo Clinic Proc 1977:52:249 Chuchurru J.A, Luberti R, Cornicehi J C Dominguez F.Y. Myxoma of mandrble with unusual Radiographic Appearances J Oral Maxillofacial Surgery, 1985:43:987-990

eral anaesthesia. An intraoral approach was taken and the tumour mass was excised in toto The teeth 47,46,85,84.83 were extracted. Dental follicles of 45, 44 and right inferior alveolar nerve were protected Peripheral ostectomy was completed. The excised tumor was ivory in colour, well encapsulated and firm with lobulated surface. Cut surface was slimy and gelatinous. The tissue mass was sent for histopathological examination and was reported to be a Odontogenic myxoma. Post operative wound healing was satisfactory and patient has been regularly followed up since 1 year. DISCUSSION The typical myxoma of the jaw bones, though benign, is locally aggressive and the lack of encapsulation produces a lesion difficult to eradicate and requires a more radical form of treatment. Reports of surgical treatment of odontogenie myxoma range from conservative enucleation curettage to peripheral resectior?. Considering the incisional biopsy report, the tumor was excised and peripheral ostectomy was done. There was no evidence of involvement of inferior border of mandible and posterior border of ramus and hence, left intact. The conservative line of treatment followed by us is justified as : and

5.

Peltola J, Magnusson B. Happonen RP. Borrman H. Odontogenic Myxoma- A Radiographic study of 21 Tumors. Br J Oral Maxillofacial Surgery 1994 :32:298-302

6.

Kaffe I, Naor H, Buchner A Clinical and Radiological features of Odontogenrc Myxoma of the Jaws Dentomaxrllofacial Radiology 1997:26:299-303

7.

Keszler A, Dominguez F V. Giannunzio G Myxoma in Childhood, An analysis of 10 cases J Oral Maxillofacral Surgery, 1995:53:518521

8.

Stootweg P J, van den Bos T. Straks W Glycosaminoglycans in

myxoma of the jaw. A biochemical study. J Oral Pathology 1985:14:299

Reprint requests to: Dept. of Oral and Maxillofacial Surgery, Nair Hospital Dental College, Mumbai Central, Mumbai- 400008, Maharashtra.