Intra-osseous
lipoma of the maxillary
tuberosity
W. H. To, K. H. Ycung Dentd
Unit, Queen Elizabeth
Hospitul,
Kowloon,
Hong Kong
SUMMARY. Lipoma is an uncommon lesion in the head and neck region. Intra-bony lipoma of the jaws is extremely rare. A case which affected the maxillary tuberosity in a patient with a history of irradiation treatment to the nasopharynx is reported.
medical history revealed that the patient had received a total dose of irradiation of 6210 CGY in fractions over a period of 43 days to her submandibular triangle and nasopharynx. using the technique as described by Ho (1982). In 1988, the patient had developed a carcinoma of the rectum which was treated surgically.
INTRODUCTION Lipoma is a benign tumour of mature fat cells and is a common soft tissue tumour (Osment, 1962; Brasfield & Das Gupta, 1969). Reports of intraosseous lipomata of the body wc_re reviewed by Hart in 1973 who found only 28 cases reported over a duration of 100 years. Amongst those 28 cases, only four affected the jaw bones. Rarkcr and Sloan (1986) reported a case which affected the mandible in relation to a retained root apex. There arc eight reported cases affecting the jaw bones in the literature (Table). This paper reports a lipoma of the maxillary tuberosity in a patient who had received a total dose of irradiation of 6210 CGY for the treatment of a malignancy in her nasopharynx 6 years previously.
A history of the present complaint showed that the patient had experienced chronic pain over her left maxillary tuberosity for 2 months. Intra-oral examination revealed an enlarged maxillary tuberosity which was nearly in contact with the lower alveolus when the mandlblc was at rest, the overlying mucosa was intact, and normal in appearance and firm to palpation. A radiograph (Figs 1A & B) showed an enlarged, round tuberosity approximately 3 cm in diameter with a radio-opaque A differential diagnosis of retained root with centre. chronic infection, cementoma, odontoma, adenomatoid odontgenic tumour, ameloblastic odontoma and amcloblastic fibro-odontoma was made. The possibility of primary malignant lesion or secondary mctastatic lesion was also considered. The lesion was biopsied under local anaesthesia with antibiotic cover. A buccal mucoperiosteal flap was raised and the buccal cortex found to bc thin and adherent to the mucoperiosteal flap. The lesion consisted of some peripheral shell-like cancellous bone and a central semi-solid yellowish structure which was excised for histological
Case report A 66-year-old Chinese woman who had suffered from a metastatic squamous cell carcinoma of her right submandibular lymph node with unknown primary site in 1983, was referred from the Oncology and Radiotherapy Department for management of jaw pain in 1989. The
Table-Summary
of documented casesof intra-bony lipomata of the jaws
Author
Age (years)
Sex
Site
Oringer (1918)
37
F
Mandible: under roots
Clinical prcscntation
Histological diagnosis
Pain elicited by pressure
Lipoma
Asymptomatic
Fibrolipoma
Swelling and cortical expansion Had lastc. local pain and swelling
Lipoma Lipoma
Periodontal
Lipoma
--
Newman
(lY57)
65
M
44 21
-
Miller e/ nl. (1982)
51
M
Heir & Geron (1983)
43
F
Barker
53
F
66
F
Salzer 6i Salrer-Kuntschik Johnson (1969)
& Sloan (19X6)
Present case
(196.5)
M
of left second molar Mandible: near right third molar Maxilla Mandible: cyst around right second and third molars Mandible: impacted left third m&l Mandihle: left anterior ramus Mandible: retained root apex of right third molar Maxilla: left maxillary tuherosity
122
‘l‘rigeminal Kctaincd
disease ncuropathy
root
Vague pain in jaws
Lipoma Lipoma
Lipoma
Intra-osseous lipoma of the maxillary tuberosity The palatal aspect ot the tuberoslty was examination. fractured bucally with digital pressure for reduction of size of the bony defect and the wound closed primarily. Microscopic examination showed a discrete lesion composed of mature adipose tissue cells. Small foci of osscous mctaplasia were present. The findings were consistent with those of lipoma (Fig. 2). Therefore, the patient was rc-operated under local anacsthesia for complete excision of the lesion. IIcaling was satisfactory without any evidence of developing osteoradionecrosis. A &months postoperative radiograph showed good contour and recovery. The patient remains asymptomatic and able to wear full dentures without problems.
Fig. IA - Orthopantomogram showing the enlarged left maxillary tubcwsity
with a radio-opaque
centre.
123
DISCUSSION is an uncommon tumour of the head and neck region (Shafer et al.. 198.3; Lucas. 1984.). IIarziotis (1971) reviewed the literature for the years 1945 to 1967 and revealed 145 cases of oral lipoma and found that the lesion usually affects male patients aged over 40 years. The commonest site is the buccal mucosa, followed in decreasing order by the tongue, floor of the mouth, buccal sulcus, palate, & Dyson, 1966; Seldin lips and gingivac (MacGregor 1973; Cannell et ef al., 1967; Grcer & Richardson. al.. 1976). lntra-osseous lipoma is a rare lesion; it has been reported in several bones by Cornil and Kanvicr (1869); ISrault (1901); Whersig (1910); Dickinson et ~1. (1951); Child (19.55); Caruolo and Dahlin (1953) and Dahlin (1957). FIart in 1973 reviewed the literature over a period of 100 years and found only 28 cases. Of these 28 cases, only 4 affected the jaws. Barker and Sloan (1986) reported a cast affecting the mandible in relation to a retained root. They also discussed possible aetiological factors of infarction, ischacmia and trauma and suggested that trauma might be the aetiology in their case. The lipoma reported in thisgaper affected a female patient who received irradiation of 6210 CGY for the treatment of a nasopharyngcal tumour in 1983. The maxillary tuberosity was within the irradiation field. It is a well established fact that radiotherapy induces biological trauma to the adjacent tissue and this suggests that ischacmia. infarction and trauma are probably the joint actiological factors of the present case. It GM that three out of the also be seen from the Table eight cases (37.5%) reported in the literature were related to retained roots or previous extraction sites. This further suggests that trauma may be a contributing factor. It is also interesting to see that even in a patient who received irradiation of 6210 CGY to her nasopharynx and nearby structures. the wound healing capacity of the maxillary tubcrosity was unimpaired. This is partly due to modern radiotherapeutic techniques which reduce the incidence of osteoradionccrosis. Lipoma
Fig. IB - A closeup view of the lesion.
Acknowledgements The authors would like to thank Dr F. F. Y. Ghan. Consultant Oral Surgeon for allowing us to report this case. Dr J. Chan. Pathologist of OEI I. I long Kong for the preparation of the photomicropraphs script.
and Mis\
(MC):
Ycung
for typing the manw
References Barker. G. R.&Sloan. P. (19%). Intraosscouslipomas: fc;~l~re~of;~tnandihularcascwithpossibleactiol~~~y.
Yi~.2-Photomicro~mphsho~in~thcm;~turcf~~tczlIswith~or~1c intcrsperscd hone islands. (H Xr E. Original magnification~50)
Clinical Hriti.ds
JournulOruluntl Ma.rilk~facialSur~~~r~, 24,450. I3rasficld.R. I>.& I~asGupta.‘l‘. K. (1969).Sofftissu~tumours: Benign tulnouraof;ldiposctiasue. Ccrwrr. 19.3. 13r;3ult. A. (1901) Dcstumcurs. In: i~n,fllc~/d’/lis/olo,~ie /‘u//wIogiqu~~. .Trd Ed.. V. CorniI.and I Ramicr. (A.) Pari\: Ancicnnc I .ibraire Gcrmcr Uaillitirc. Caruo1o.J. IT.& IMilin.D. C..(lOS3). Lipc~n~ain~olvinpl~o~~c ~~ntl~irnulatingnl;Ili~~~~~nl I~onclumour. RcpOrl0fc~lW. f r~~~(vli~~,q.SIo~:lln~rin,~. Mu,vo C~linic, u1.36 I
124
British Journal of Oral and Maxillofacial
Surgery
Cannell, H.. Langdon, J. I).. Patel, M. F. & Rapidis. A. D., (1976). I.ipom;~tainoraltissues.lourrwlofMaxillo-~u~iu/ Surgery, 4, I 16. Chi1d.P. L. (19.55). Lipomaoftheoscalcis. Rcportofacasc. American Jourr~uloj‘~~liniculI’u/holo~~y, 2S, 1050. C0rnil.V. & Ranvier. 1.. (1869). IMu,lucld’f/isrologie Pathologic/w. 1st Ed. pp. 393. Paris: Ancicnnc I .ihraric Germcr Baillii-re. Dahlin. D. C..f 1957). Borw Tumows. 2nd Ed. Sprineficld: . I
Dickinson. A. B., Ayrcs. W. W., Mason. M. W. &Miller. W. R. (1951). Lipornaofboncofintraosscousorigin.Joumulol Bo,lctoldJoilr/Surgc,~y, 33-A, 257. Grcer.R.O.& Richardson.J.F.,( l973).‘I‘henatureoflipom~~s andtheirsignificancein thcoralcavity. OrulSurgcr~. Owl Medicine. Orul Pu[hology36,55 I. JoLo,rcr/ofRorleand [Iart, J. A. L.. (1073). Intraosscouslipolna. JointSursqery, SSB, 624. I latr.iotis. J. Ch.. (1971). I~ipomaoftheoralcavity. OrulSwgery. Oral Medicine. Orul Puthology, 31, SI I. IHcir. G. M. & Geron. P. R.. (19X3). Mandibularintraosseous lipoma relatedto trigeminal neuropathy. C‘/inicn/Preve,lrivc, Denlislry. 5, 13. I lo, J H. C.. ( 1982). Nasopharynx. In: 7’reulnrc,nrofCNn(.er, 1st Ed..pp249-267. I.ondon:ChapmanandHall. Johnson,E.C. (1969). Intraosseouslipomas. Reportofcasc. Jounralo/OrulStrr~ery, 27,868. . Lucas.R. B. I1984j. Farirol~~avof7ior~oursofrhrOrulTissuc~s. 3rdEd.d~ l7(; 179. ~di~~urgh&L.ond;;n:Churchill Livingstonc. MacGrcgor.A.J.&Dyson.D. P.(I9~).Orallipom;~.ARcview ofthclitcratureandrcportoftwelvcncwcases. Orul Suqery, Orul Medicine, Oral Patho/ogg. 21,770. Miller, W. B.. Ausich,J. E.. McDaniel, R. K. Kc1.ongo.J. J ,, (1982). Mandibul;~rintraosseouslipoma.Jo~rmcr/qfOru/u~~t/ MaxilloJirciulSur~er~~, 40,594.
Newman.C. W.(l957).Fibrolipomaofthemandihlc. Rcportof case. JournulOralSur~ery. 15,251. OralSurgery. Orul 0ringer.M. J. 1948. Lipomaofthcmandiblc. Medicine, Oral Pathology, I, 1134. Osmcnt, L. S. (1962). Cutancouslipomasand lipomatosis. Surgeryin Gynaecology & 0hsretric.s. 127,129. Salzer. M. &Saber-Kuntschil, M. (1965). ZurFragcdct sogenanntenzentralcn knochenlipome. Ucim~ezu~ purholo~ischen Anatornir und zurullgemeinen Purhologie, 132,36S. Seldin.II.M.,Scldin.I~.,Rakowcr.I~.&Jarrett,W.J.(l9h7). I.ipomasoftheoralc;~vity. Reportof26cases. Journalof OrulSurgcry, 25,270. Shafer. W. G..Hine. M. K., Levy. B. M. (19X3). A Texrhook oJ Orulfurhology, 3rd Ed,p 152. Philadelphia: W. B. Saunders. W1lcrsig.G. (1910). I.ipomadesknochenmarks. %nrruh/artJirr u~~g~~tneitiei’uthologieundporhologi.s~heA~~~~rt~~~i~~, 21,243.
The
Authors
E. W. H. ‘l-o HDS, FRACDS, FFDRCS Medical Student University of Lciccster, UK K. II. Yeung BDS, FRACDS Dental Officer Queen Elizabeth 34 Wylie Road Kowloon. Hong Kong
Hospital
Paper received 13 May 199 I Accepted21 August 1991
lipoma of the maxillary
tuberosity
W. H. To, K. H. Ycung Dentd
Unit, Queen Elizabeth
Hospitul,
Kowloon,
Hong Kong
SUMMARY. Lipoma is an uncommon lesion in the head and neck region. Intra-bony lipoma of the jaws is extremely rare. A case which affected the maxillary tuberosity in a patient with a history of irradiation treatment to the nasopharynx is reported.
medical history revealed that the patient had received a total dose of irradiation of 6210 CGY in fractions over a period of 43 days to her submandibular triangle and nasopharynx. using the technique as described by Ho (1982). In 1988, the patient had developed a carcinoma of the rectum which was treated surgically.
INTRODUCTION Lipoma is a benign tumour of mature fat cells and is a common soft tissue tumour (Osment, 1962; Brasfield & Das Gupta, 1969). Reports of intraosseous lipomata of the body wc_re reviewed by Hart in 1973 who found only 28 cases reported over a duration of 100 years. Amongst those 28 cases, only four affected the jaw bones. Rarkcr and Sloan (1986) reported a case which affected the mandible in relation to a retained root apex. There arc eight reported cases affecting the jaw bones in the literature (Table). This paper reports a lipoma of the maxillary tuberosity in a patient who had received a total dose of irradiation of 6210 CGY for the treatment of a malignancy in her nasopharynx 6 years previously.
A history of the present complaint showed that the patient had experienced chronic pain over her left maxillary tuberosity for 2 months. Intra-oral examination revealed an enlarged maxillary tuberosity which was nearly in contact with the lower alveolus when the mandlblc was at rest, the overlying mucosa was intact, and normal in appearance and firm to palpation. A radiograph (Figs 1A & B) showed an enlarged, round tuberosity approximately 3 cm in diameter with a radio-opaque A differential diagnosis of retained root with centre. chronic infection, cementoma, odontoma, adenomatoid odontgenic tumour, ameloblastic odontoma and amcloblastic fibro-odontoma was made. The possibility of primary malignant lesion or secondary mctastatic lesion was also considered. The lesion was biopsied under local anaesthesia with antibiotic cover. A buccal mucoperiosteal flap was raised and the buccal cortex found to bc thin and adherent to the mucoperiosteal flap. The lesion consisted of some peripheral shell-like cancellous bone and a central semi-solid yellowish structure which was excised for histological
Case report A 66-year-old Chinese woman who had suffered from a metastatic squamous cell carcinoma of her right submandibular lymph node with unknown primary site in 1983, was referred from the Oncology and Radiotherapy Department for management of jaw pain in 1989. The
Table-Summary
of documented casesof intra-bony lipomata of the jaws
Author
Age (years)
Sex
Site
Oringer (1918)
37
F
Mandible: under roots
Clinical prcscntation
Histological diagnosis
Pain elicited by pressure
Lipoma
Asymptomatic
Fibrolipoma
Swelling and cortical expansion Had lastc. local pain and swelling
Lipoma Lipoma
Periodontal
Lipoma
--
Newman
(lY57)
65
M
44 21
-
Miller e/ nl. (1982)
51
M
Heir & Geron (1983)
43
F
Barker
53
F
66
F
Salzer 6i Salrer-Kuntschik Johnson (1969)
& Sloan (19X6)
Present case
(196.5)
M
of left second molar Mandible: near right third molar Maxilla Mandible: cyst around right second and third molars Mandible: impacted left third m&l Mandihle: left anterior ramus Mandible: retained root apex of right third molar Maxilla: left maxillary tuherosity
122
‘l‘rigeminal Kctaincd
disease ncuropathy
root
Vague pain in jaws
Lipoma Lipoma
Lipoma
Intra-osseous lipoma of the maxillary tuberosity The palatal aspect ot the tuberoslty was examination. fractured bucally with digital pressure for reduction of size of the bony defect and the wound closed primarily. Microscopic examination showed a discrete lesion composed of mature adipose tissue cells. Small foci of osscous mctaplasia were present. The findings were consistent with those of lipoma (Fig. 2). Therefore, the patient was rc-operated under local anacsthesia for complete excision of the lesion. IIcaling was satisfactory without any evidence of developing osteoradionecrosis. A &months postoperative radiograph showed good contour and recovery. The patient remains asymptomatic and able to wear full dentures without problems.
Fig. IA - Orthopantomogram showing the enlarged left maxillary tubcwsity
with a radio-opaque
centre.
123
DISCUSSION is an uncommon tumour of the head and neck region (Shafer et al.. 198.3; Lucas. 1984.). IIarziotis (1971) reviewed the literature for the years 1945 to 1967 and revealed 145 cases of oral lipoma and found that the lesion usually affects male patients aged over 40 years. The commonest site is the buccal mucosa, followed in decreasing order by the tongue, floor of the mouth, buccal sulcus, palate, & Dyson, 1966; Seldin lips and gingivac (MacGregor 1973; Cannell et ef al., 1967; Grcer & Richardson. al.. 1976). lntra-osseous lipoma is a rare lesion; it has been reported in several bones by Cornil and Kanvicr (1869); ISrault (1901); Whersig (1910); Dickinson et ~1. (1951); Child (19.55); Caruolo and Dahlin (1953) and Dahlin (1957). FIart in 1973 reviewed the literature over a period of 100 years and found only 28 cases. Of these 28 cases, only 4 affected the jaws. Barker and Sloan (1986) reported a cast affecting the mandible in relation to a retained root. They also discussed possible aetiological factors of infarction, ischacmia and trauma and suggested that trauma might be the aetiology in their case. The lipoma reported in thisgaper affected a female patient who received irradiation of 6210 CGY for the treatment of a nasopharyngcal tumour in 1983. The maxillary tuberosity was within the irradiation field. It is a well established fact that radiotherapy induces biological trauma to the adjacent tissue and this suggests that ischacmia. infarction and trauma are probably the joint actiological factors of the present case. It GM that three out of the also be seen from the Table eight cases (37.5%) reported in the literature were related to retained roots or previous extraction sites. This further suggests that trauma may be a contributing factor. It is also interesting to see that even in a patient who received irradiation of 6210 CGY to her nasopharynx and nearby structures. the wound healing capacity of the maxillary tubcrosity was unimpaired. This is partly due to modern radiotherapeutic techniques which reduce the incidence of osteoradionccrosis. Lipoma
Fig. IB - A closeup view of the lesion.
Acknowledgements The authors would like to thank Dr F. F. Y. Ghan. Consultant Oral Surgeon for allowing us to report this case. Dr J. Chan. Pathologist of OEI I. I long Kong for the preparation of the photomicropraphs script.
and Mis\
(MC):
Ycung
for typing the manw
References Barker. G. R.&Sloan. P. (19%). Intraosscouslipomas: fc;~l~re~of;~tnandihularcascwithpossibleactiol~~~y.
Yi~.2-Photomicro~mphsho~in~thcm;~turcf~~tczlIswith~or~1c intcrsperscd hone islands. (H Xr E. Original magnification~50)
Clinical Hriti.ds
JournulOruluntl Ma.rilk~facialSur~~~r~, 24,450. I3rasficld.R. I>.& I~asGupta.‘l‘. K. (1969).Sofftissu~tumours: Benign tulnouraof;ldiposctiasue. Ccrwrr. 19.3. 13r;3ult. A. (1901) Dcstumcurs. In: i~n,fllc~/d’/lis/olo,~ie /‘u//wIogiqu~~. .Trd Ed.. V. CorniI.and I Ramicr. (A.) Pari\: Ancicnnc I .ibraire Gcrmcr Uaillitirc. Caruo1o.J. IT.& IMilin.D. C..(lOS3). Lipc~n~ain~olvinpl~o~~c ~~ntl~irnulatingnl;Ili~~~~~nl I~onclumour. RcpOrl0fc~lW. f r~~~(vli~~,q.SIo~:lln~rin,~. Mu,vo C~linic, u1.36 I
124
British Journal of Oral and Maxillofacial
Surgery
Cannell, H.. Langdon, J. I).. Patel, M. F. & Rapidis. A. D., (1976). I.ipom;~tainoraltissues.lourrwlofMaxillo-~u~iu/ Surgery, 4, I 16. Chi1d.P. L. (19.55). Lipomaoftheoscalcis. Rcportofacasc. American Jourr~uloj‘~~liniculI’u/holo~~y, 2S, 1050. C0rnil.V. & Ranvier. 1.. (1869). IMu,lucld’f/isrologie Pathologic/w. 1st Ed. pp. 393. Paris: Ancicnnc I .ihraric Germcr Baillii-re. Dahlin. D. C..f 1957). Borw Tumows. 2nd Ed. Sprineficld: . I
Dickinson. A. B., Ayrcs. W. W., Mason. M. W. &Miller. W. R. (1951). Lipornaofboncofintraosscousorigin.Joumulol Bo,lctoldJoilr/Surgc,~y, 33-A, 257. Grcer.R.O.& Richardson.J.F.,( l973).‘I‘henatureoflipom~~s andtheirsignificancein thcoralcavity. OrulSurgcr~. Owl Medicine. Orul Pu[hology36,55 I. JoLo,rcr/ofRorleand [Iart, J. A. L.. (1073). Intraosscouslipolna. JointSursqery, SSB, 624. I latr.iotis. J. Ch.. (1971). I~ipomaoftheoralcavity. OrulSwgery. Oral Medicine. Orul Puthology, 31, SI I. IHcir. G. M. & Geron. P. R.. (19X3). Mandibularintraosseous lipoma relatedto trigeminal neuropathy. C‘/inicn/Preve,lrivc, Denlislry. 5, 13. I lo, J H. C.. ( 1982). Nasopharynx. In: 7’reulnrc,nrofCNn(.er, 1st Ed..pp249-267. I.ondon:ChapmanandHall. Johnson,E.C. (1969). Intraosseouslipomas. Reportofcasc. Jounralo/OrulStrr~ery, 27,868. . Lucas.R. B. I1984j. Farirol~~avof7ior~oursofrhrOrulTissuc~s. 3rdEd.d~ l7(; 179. ~di~~urgh&L.ond;;n:Churchill Livingstonc. MacGrcgor.A.J.&Dyson.D. P.(I9~).Orallipom;~.ARcview ofthclitcratureandrcportoftwelvcncwcases. Orul Suqery, Orul Medicine, Oral Patho/ogg. 21,770. Miller, W. B.. Ausich,J. E.. McDaniel, R. K. Kc1.ongo.J. J ,, (1982). Mandibul;~rintraosseouslipoma.Jo~rmcr/qfOru/u~~t/ MaxilloJirciulSur~er~~, 40,594.
Newman.C. W.(l957).Fibrolipomaofthemandihlc. Rcportof case. JournulOralSur~ery. 15,251. OralSurgery. Orul 0ringer.M. J. 1948. Lipomaofthcmandiblc. Medicine, Oral Pathology, I, 1134. Osmcnt, L. S. (1962). Cutancouslipomasand lipomatosis. Surgeryin Gynaecology & 0hsretric.s. 127,129. Salzer. M. &Saber-Kuntschil, M. (1965). ZurFragcdct sogenanntenzentralcn knochenlipome. Ucim~ezu~ purholo~ischen Anatornir und zurullgemeinen Purhologie, 132,36S. Seldin.II.M.,Scldin.I~.,Rakowcr.I~.&Jarrett,W.J.(l9h7). I.ipomasoftheoralc;~vity. Reportof26cases. Journalof OrulSurgcry, 25,270. Shafer. W. G..Hine. M. K., Levy. B. M. (19X3). A Texrhook oJ Orulfurhology, 3rd Ed,p 152. Philadelphia: W. B. Saunders. W1lcrsig.G. (1910). I.ipomadesknochenmarks. %nrruh/artJirr u~~g~~tneitiei’uthologieundporhologi.s~heA~~~~rt~~~i~~, 21,243.
The
Authors
E. W. H. ‘l-o HDS, FRACDS, FFDRCS Medical Student University of Lciccster, UK K. II. Yeung BDS, FRACDS Dental Officer Queen Elizabeth 34 Wylie Road Kowloon. Hong Kong
Hospital
Paper received 13 May 199 I Accepted21 August 1991
