British Journal of Oral Surgery (1976), 13, 250-253
SOLITARY
BONE CYST OF THE MANDIBLE-REPORT A CASE C. GAIT, B.D.S.,
OF
F.D.S.R.C.S.(Edin.)l
Withington Hospital, Manchester
The solitary bone cyst has been discussed quite extensively, not only because it provides diagnostic difficulties, but also because its aetiology remains obscure. The names given to the lesion, which include haemorrhagic bone cyst, traumatic bone cyst, extravasation cyst and progressive bone cavity all suggest a particular origin. The title of solitary bone cyst appears to be preferable as it does not imply any specific mode of formation. The most widely held theory of causation of the solitary bone cyst is the traumatic/haemorrhagic theory of l?ommer (1919). This postulates that a traumatic incident to the bone causes intramedullary haemorrhage and subsequent haematoma formation. Liquefaction of the haematoma occurs with new bone formation failing to take place and a cavity ensuing. Rushton (1946) did not believe that trauma plays a significant role, but that intra-bony arterial haemorrhage occurs in the sinusoids of the red bone marrow, followed by haematoma formation and liquefaction. As virtually all of the reported cases have normal serum calcium, phosphorus and alkaline phosphatase levels, it is unlikely that the lesions are due to any Killey and Kay (1964) consider that there may be a physiosystemic imbalance. logical upset of bone reconstruction at a local level, osteoclastosis occurring without subsequent osteoblastic activity. Howe (1965) found that the majority of lesions occur in patients aged 10-20 years and the situation of the lesion is usually anterior to the angle of the mandible, this being the area with the greatest amount of haemopoietic tissue present. Solitary bone cysts can also occur at the apices of lower anterior teeth which have This seems to suggest that the traumatic/ been subjected to occlusal trauma. haemorrhagic theory is the most plausible one to date. CASE REPORT A Iq-year-old schoolgirl was referred to the Oral Surgery Department of Withington Hospital, by her general dental practitioner, with a multilocular radiolucent lesion associated with an unerupted F/, The patient did not complain of any symptoms, the lesion being observed on radiographs taken for F/. Her general health was good, and there was no particular history of injury to the area. On examination she was found to have a lingual swelling in 3x/ region which gave a bluish appearance.
The buccal sulcus opposite Received 26.9.75.
21/12 was also slightly
enlarged,
but
Accepted 28.10.75
Orthodontic Department, l Present address: Leicester Square. London. 250
The Royal Dental Hospital of London,
SOLITARY
BONE CYST OF THE MANDIBLE-REPORT
OF A CASE
251
FIGS. I and z Radiographs
neither
showing
the condition
of the areas was fluctuant
Lingual pre-operatively. mandible are seen.
nor tender
to pressure.
and buccal expansion
The
following
teeth
of the
were
76E32r 1123 567 The I/I were a little mobile, but all of the lower anterior present 76E4321/1214E67’ teeth were of-a good coldur and vital to electric pulp testing. Panoral radiography showed the presence of a large, reasonably well defined multilocular radiolucent lesion extending from the unerupted 51 to 14 region. There was also increased radiolucency at the apices of 21/ (Fig. I). Marked lingual expansion, with some buccal expansion was shown on the occlusal radiograph (Fig. 2). Serum calcium and phosphorus levels were found to be within normal limits, but the alkaline phosphatase level was raised at 200 I.U./litre (normal range 21-128 I.U./litre). After discussion with a chemical pathologist it was considered that the raised alkaline phosphatase levels were not clinically significant in a q-year-old girl.
BRITISH
252
JOURNAL
FIGS.
Radiographs
taken z months post-operatively
OF ORAL
3
SURGERY
and 4 showing satisfactory filling of the defect.
On the clinical and radiological evidence a provisional diagnosis was made of ameloblastoma, and the patient was admitted to hospital for a biopsy of the lesion. Under general anaesthesia a buccal flap was raised and -jj’removed. On opening into the radiolucent area it was found to be completely devoid of contents or lining. A thorough curettage of the area was carried out and the wound closed. A biopsy report of the follicular tissue of 3 showed normal follicle. Post-operative healing was uneventful, the vitality of the lower anterior teeth was also maintained. Radiographs taken 2 months post-operatively show the cavity to be filling in satisfactorily (Figs. 3 and 4).
DISCUSSION ance
The main reason for presenting this paper is the unusual radiological appearThe multilocular appearance that occasionally of this solitary bone cyst.
SOLITARYBONECYSTOFTHEMANDIB&E-REPORTOFACASE
‘. .,
253
It is this appearance occurs in these uncommon cysts has not been’ km&asised. that can make the diagnosis of multilocular lesions of the mandible uncertain and reinforces the view that biopsy of these lesions before embarking on major surgery is essential (Waldron, 1954). A multilocular radiolucent lesion of the mandible exhibiting some of the classical signs of solitary bone cyst such as the ‘scalloping’ effect of the margin of the lesion around the roots of teeth which have retained their vitality, should raise the possibility of a solitary bone cyst in the differential diagnosis. ACKNOWLEDGEMENTS I wish to thank Mr W. Simpson, Consultant Oral Surgeon, Withington Hospital, for his help and permission to report this case, and to Mrs M. Taylor for her secretarial assistance. REFERENCES HOWE, G. L. (196-j). British Journal of Oral Surgery, 3, 55, 77. KILLEY,H. C. & KAY,L. W. (1964). J ournal of the International College of Surgeons, 42, 504. KILLEY, H. C. & KAY, L. W. (1972). Benign Cystic Lesions of the Jaws. Edinburgh: Livingstone. POMMER, G. (1919). Hans Van Haberers Arch. Orthop. Unfallchir, 17, 17. RUSHTON,M. A. (1946). British Dental Journal, 81, 37. STAPHNE,E. C. (1963). OraZ Roentgenographic. Diagnosis. Philadelphia: Saunders. WALDRON, C. A. (1954). Oral Surgery, Oral Medicine and Oral Pathology, 7, 88.
SOLITARY
BONE CYST OF THE MANDIBLE-REPORT A CASE C. GAIT, B.D.S.,
OF
F.D.S.R.C.S.(Edin.)l
Withington Hospital, Manchester
The solitary bone cyst has been discussed quite extensively, not only because it provides diagnostic difficulties, but also because its aetiology remains obscure. The names given to the lesion, which include haemorrhagic bone cyst, traumatic bone cyst, extravasation cyst and progressive bone cavity all suggest a particular origin. The title of solitary bone cyst appears to be preferable as it does not imply any specific mode of formation. The most widely held theory of causation of the solitary bone cyst is the traumatic/haemorrhagic theory of l?ommer (1919). This postulates that a traumatic incident to the bone causes intramedullary haemorrhage and subsequent haematoma formation. Liquefaction of the haematoma occurs with new bone formation failing to take place and a cavity ensuing. Rushton (1946) did not believe that trauma plays a significant role, but that intra-bony arterial haemorrhage occurs in the sinusoids of the red bone marrow, followed by haematoma formation and liquefaction. As virtually all of the reported cases have normal serum calcium, phosphorus and alkaline phosphatase levels, it is unlikely that the lesions are due to any Killey and Kay (1964) consider that there may be a physiosystemic imbalance. logical upset of bone reconstruction at a local level, osteoclastosis occurring without subsequent osteoblastic activity. Howe (1965) found that the majority of lesions occur in patients aged 10-20 years and the situation of the lesion is usually anterior to the angle of the mandible, this being the area with the greatest amount of haemopoietic tissue present. Solitary bone cysts can also occur at the apices of lower anterior teeth which have This seems to suggest that the traumatic/ been subjected to occlusal trauma. haemorrhagic theory is the most plausible one to date. CASE REPORT A Iq-year-old schoolgirl was referred to the Oral Surgery Department of Withington Hospital, by her general dental practitioner, with a multilocular radiolucent lesion associated with an unerupted F/, The patient did not complain of any symptoms, the lesion being observed on radiographs taken for F/. Her general health was good, and there was no particular history of injury to the area. On examination she was found to have a lingual swelling in 3x/ region which gave a bluish appearance.
The buccal sulcus opposite Received 26.9.75.
21/12 was also slightly
enlarged,
but
Accepted 28.10.75
Orthodontic Department, l Present address: Leicester Square. London. 250
The Royal Dental Hospital of London,
SOLITARY
BONE CYST OF THE MANDIBLE-REPORT
OF A CASE
251
FIGS. I and z Radiographs
neither
showing
the condition
of the areas was fluctuant
Lingual pre-operatively. mandible are seen.
nor tender
to pressure.
and buccal expansion
The
following
teeth
of the
were
76E32r 1123 567 The I/I were a little mobile, but all of the lower anterior present 76E4321/1214E67’ teeth were of-a good coldur and vital to electric pulp testing. Panoral radiography showed the presence of a large, reasonably well defined multilocular radiolucent lesion extending from the unerupted 51 to 14 region. There was also increased radiolucency at the apices of 21/ (Fig. I). Marked lingual expansion, with some buccal expansion was shown on the occlusal radiograph (Fig. 2). Serum calcium and phosphorus levels were found to be within normal limits, but the alkaline phosphatase level was raised at 200 I.U./litre (normal range 21-128 I.U./litre). After discussion with a chemical pathologist it was considered that the raised alkaline phosphatase levels were not clinically significant in a q-year-old girl.
BRITISH
252
JOURNAL
FIGS.
Radiographs
taken z months post-operatively
OF ORAL
3
SURGERY
and 4 showing satisfactory filling of the defect.
On the clinical and radiological evidence a provisional diagnosis was made of ameloblastoma, and the patient was admitted to hospital for a biopsy of the lesion. Under general anaesthesia a buccal flap was raised and -jj’removed. On opening into the radiolucent area it was found to be completely devoid of contents or lining. A thorough curettage of the area was carried out and the wound closed. A biopsy report of the follicular tissue of 3 showed normal follicle. Post-operative healing was uneventful, the vitality of the lower anterior teeth was also maintained. Radiographs taken 2 months post-operatively show the cavity to be filling in satisfactorily (Figs. 3 and 4).
DISCUSSION ance
The main reason for presenting this paper is the unusual radiological appearThe multilocular appearance that occasionally of this solitary bone cyst.
SOLITARYBONECYSTOFTHEMANDIB&E-REPORTOFACASE
‘. .,
253
It is this appearance occurs in these uncommon cysts has not been’ km&asised. that can make the diagnosis of multilocular lesions of the mandible uncertain and reinforces the view that biopsy of these lesions before embarking on major surgery is essential (Waldron, 1954). A multilocular radiolucent lesion of the mandible exhibiting some of the classical signs of solitary bone cyst such as the ‘scalloping’ effect of the margin of the lesion around the roots of teeth which have retained their vitality, should raise the possibility of a solitary bone cyst in the differential diagnosis. ACKNOWLEDGEMENTS I wish to thank Mr W. Simpson, Consultant Oral Surgeon, Withington Hospital, for his help and permission to report this case, and to Mrs M. Taylor for her secretarial assistance. REFERENCES HOWE, G. L. (196-j). British Journal of Oral Surgery, 3, 55, 77. KILLEY,H. C. & KAY,L. W. (1964). J ournal of the International College of Surgeons, 42, 504. KILLEY, H. C. & KAY, L. W. (1972). Benign Cystic Lesions of the Jaws. Edinburgh: Livingstone. POMMER, G. (1919). Hans Van Haberers Arch. Orthop. Unfallchir, 17, 17. RUSHTON,M. A. (1946). British Dental Journal, 81, 37. STAPHNE,E. C. (1963). OraZ Roentgenographic. Diagnosis. Philadelphia: Saunders. WALDRON, C. A. (1954). Oral Surgery, Oral Medicine and Oral Pathology, 7, 88.
