elevatordentistry , elevator dentistry , clinical case in dentistry


Case 2 l A Multilocular Radiolucency

 

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Summary

  • A 45-year-old African man presents in the dental accident and emergency department with an enlarged jaw . You need to make a diagnosis and decide on treatment.

 

History

 

Complaint

  • The patient’s main complaint is that his lower back teeth on th right side are loose and that his jaw on the right feels enlarged.

 

History of Complaint

  • The patient has been aware of his teeth slowly becoming looser over the previous 6 months. They seem to be ‘moving’ and are now at a different height from his front teeth, making eating difficult. He is also concerned that his jaw is enlarged and that there seems to be reduced space for his tongue.
  • He has recently had the lower second molar on the right extracted. It was also loose, but extraction does not seem to have cured the swelling. Although not in pain, he has finally decided to seek treatment.

 

Medical History

  • He is otherwise fit and healthy

Examination

 

Extraoral Examination

  • He is a fit-looking man with no obvious facial asymmetry but has a slight fullness of the mandible on the right. Palpation reveals a smooth, rounded, bony hard enlargement on the buccal and lingual aspects. Deep cervical lymph nodes are palpable on the right side. They are only slightly enlarged, soft, not tender and freely mobile.

 

Intraoral Examination

  • There is a large swelling of the right posterior mandible visible in the buccal sulcus, its anterior margin is relatively well defined and level with the first premolar. The lingual aspect is not visible, but the tongue appears displaced upwards and medially, suggesting significant lingual expansion. The mucosa over the swelling is of normal colour, without evidence of inflammation or infection. There are two relatively small amalgams in the lower right molar and the second premolar.
  • If you could examine the patient, you would find that all his upper right posterior teeth have been extracted and that the lower molar and premolars are 2–3 mm above the height of the occlusal plane. These teeth are grade 3 mobile but still are vital.

 

What are the Red Spots On the Patient’s Tongue?

  • Fungiform papillae. They appear more prominent when the tongue is furred, as in this case, when the diet is not very abrasive.

 

On the Basis of What You Know So Far, What Types of Condition Would You Consider is Present?

  • The history suggests a relatively slow-growing lesion, which is, therefore, likely to be benign. Although this is not a definitive relationship, there are no specific features suggesting malignancy, such as perforation of the cortex, soft tissue mass, ulceration of the mucosa, numbness of the lip or devitalization of teeth. The character of the lymph node enlargement does not suggest malignancy. The commonest jaw lesions that cause expansion are odontogenic cysts. The commonest odontogenic cysts are the radicular (apical inflammatory) cyst, dentigerous cyst and odontogenic keratocyst. If this is a radicular cyst, it could have arisen from the first molar, although the occlusal amalgam is relatively small and there seems to be no reason to suspect that the tooth is not vital.
  • A residual radicular cyst arising on the extracted second or third molar would be a possibility. A dentigerous cyst could be the cause if the third molar is unerupted. The possibility of an odontogenic keratocyst seems unlikely because these cysts do not normally cause much expansion. An odontogenic tumour is a possible cause, and an ameloblastoma would be the most likely one because it is the commonest and arises most frequently at this site and in this age group. There is a higher prevalence in Africans than in other racial groups. An ameloblastoma is much more likely than an odontogenic cyst to displace teeth and make them grossly mobile. A giant cell granuloma and numerous other lesions are possibilities but are all less likely.