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Mandibular traumatic peripheral osteoma: a case report

Ruggero Rodriguez y Baena, MD, DDS,a Silvana Rizzo, MD, DDS,b Giacomo Fiandrino, MD,c
Saturnino Lupi, DDS,d and Silvestre Galioto, MD,e Pavia, Italy
UNIVERSITY OF PAVIA

An osteoma is a slow-growing, benign lesion comprising mature bone tissue. Osteomas rarely occur in
maxillary bones, with the exception of the maxillary sinuses. Various possible etiologies have been proposed,
including congenital anomalies, chronic inflammation, muscular activity, embryogenetic changes, and trauma. Here
we present a case of an osteoma of the buccal plate of the mandible at the site where a sports-related traumatic injury
occurred 15 years earlier. Both conventional and 3-dimensional x-ray examinations were used for diagnosis and
preoperative evaluation of the possible involvement of the adjacent anatomic structures. The lesion was treated
surgically without complications and the patient made a complete recovery. Histologic tests confirmed the
preoperative diagnosis. A review of the international literature is also presented. (Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 2011;112:e44-e48)

An osteoma is a benign lesion characterized by the


proliferation of compact or spongy bone.1 Various etiopathogenetic hypotheses have been proposed for osteoma formation. Some1-3 have hypothesized that the
lesion is caused by congenital anomalies. Another proposal, which is no longer held, was that chronic inflammation caused neoplastic proliferation.4,5 The development of these formations may be a result of trauma6 or
embryogenetic changes. In addition, others7-10 have
hypothesized that muscular traction contributes to neoplastic changes in the bone. The lesion has 3 forms:
central, peripheral, or extraosseous. The central form
derives from the endosteum and the peripheral form
derives from the periosteum, whereas the extraosseous
form develops in muscular tissue structures.10-12 This
lesion has a higher prevalence in males with almost
double the number of cases in men than in women.13,14
The peripheral form has particular growth characteristics that make it the easiest form to diagnose because
it can be verified clinically and x-ray images are clear.3
a

Associate Professor of Clinical Dentistry, Oral Surgery, and Implantology, Department of Oral Sciences S.Palazzi, University of Pavia,
Pavia, Italy.
b
Full Professor of Oral Surgery, Department of Oral Sciences S.Palazzi, University of Pavia, Pavia, Italy.
c
Researcher, University of Pavia, Anatomic Pathology Section, Department of Human and Hereditary Pathology, Pavia, Italy.
d
Dentist, Department of Oral Sciences S.Palazzi, University of
Pavia, Pavia, Italy.
e
Associate Professor of Oral & Maxillofacial Surgery, Department of
Oral Sciences S.Palazzi, University of Pavia, Pavia, Italy.
Received for publication Jan 23, 2011; returned for revision May 1,
2011; accepted for publication May 19, 2011.
1079-2104/$ - see front matter
2011 Mosby, Inc. All rights reserved.
doi:10.1016/j.tripleo.2011.05.006

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Peripheral osteomas are mainly found in the frontal,


ethmoid, and maxillary sinuses,15-17 whereas maxillary
and mandibular bone sites are less frequent.9,10,14,18 In
maxillary bone, however, osteomas are the most frequent lesion among those that form hard tissue.19 In
mandibular bone, the lesions most frequently develop
in the condyle, angle, and margin.3,20,21
Histologically, 3 types of osteoma can be identified:
compact, spongy, and mixed22. When an exophytic
lesion presents inside the oral cavity, still firmly fixed
to the underlying bone and of a bony consistency, a
differential diagnosis should be made between an osteoma or a more common exostosis. A peripheral osteoma can be distinguished from an exostosis on the
basis of an accurate case history and clinical characteristics, but there are no histologic differences.22 Exostosis is a bony growth in the lingual plate of the
maxillary bones, usually symmetric, well circumscribed, associated with inflammatory or traumatic phenomena, and characterized by limited growth. It has
nothing in common with benign neoplasia.23,24 The
term osteoma, therefore, is reserved exclusively for
those lesions that demonstrate independent growth and
clinical characteristics of benign tumors.22,25 The initial
development of an osteoma is, with some exceptions,26
asymptomatic1,16 and osteomas are often identified incidentally on radiographs obtained to investigate the
underlying causes of violent headaches, sinusitis, and
rhinitis.27 The slow and progressive growth of osteomas causes subsequent swelling and an asymmetric
appearance,16 which prompts clinical evaluation. On
x-rays, the lesion is radiopaque with well-defined margins.28 Computed tomography (CT) scans should be
obtained for a complete preoperative evaluation of the
lesion.10,25

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Fig. 1. Preoperative clinical presentation with evident swelling in the mandibular zone (arrow).

A peripheral osteoma can be completely cured by


surgical intervention, and there is no recurrence.28,29
Surgery consists of removing the lesion at the base
where it enters the cortical bone.8,9,28 The choice of
therapy should be based on the general risks of the
operation itself to the patient and the risk of damaging
important anatomic structures adjacent to the lesion. In
the present case, the mandibular and mental neurovascular bundles could be damaged during surgical resection of the lesion because of its close proximity to the
mental foramen and nerve.
The purpose of this article is to add another case to
the literature showing a clear association of a previous
trauma with osteoma formation.

Rodriguez y Baena et al. e45

Fig. 2. Panoramic radiograph showing a radiopaque mass in


the first molar region.

Fig. 3. Posterior-anterior radiograph. The radiopaque mass


seems to enter the mandible.

CASE HISTORY
The patient was male, aged 25 years, who presented with
evident swelling of the right cheek. His previous history
included trauma to the right mandible during a baseball game
when he was 10 years old. The hematoma was notable. The
lesion was noticed by the patient 5 years earlier and had
shown slow and progressive growth until a visible deformity
could be seen in the right genial zone, causing concern to the
patient (Fig. 1). General clinical examination showed no
changes in organs or systems, and laboratory tests were
normal. Local examination showed a painless, cherry-sized
swelling in the right mandibular zone. The swelling was of a
hard bony consistency and was firmly attached to the mandible. There were no painful symptoms or lesions of the perioral
skin or the oral mucosa. The patient could open his mouth
normally without any deviations. A panoramic x-ray examination and posterior-anterior (PA) cranial x-ray examination,
which revealed the bony origin of the lesion, were performed
(Figs. 2 and 3). A CT scan was performed to allow for a more
accurate diagnosis (Figs. 4-6) (CT scanner: Siemens Somaton
Definition, Siemens Spa, Milan Italy; pixel size: 0.2441, field
of view: 12.50, algorithm: H60s). The lesion was located in
the mandible on the buccal plate, distal to the mandibular
foramen, above the external oblique line. The maximum
diameter of the lesion was approximately 1.5 cm. Radio-

graphically, the lesion appeared typically sessile and


mushroom-shaped with a narrow base that widened (Fig.
6). The base was 8 mm from the mandibular foramen, and the
mandibular nerve did not appear to be involved (Fig. 5). The
continued growth, together with the esthetic transformation
and the patients concern, led to the decision to surgically
enucleate the lesion. The operation was conducted by an
intraoral vestibular incision to the mandible, with a paramarginal linear incision to elevate a full-thickness flap of the
right-side incisor distal to the third ipsilateral molar. The edge
was delicately freed with location of the mental foramen
noted and isolation and protection of the neurovascular bundle. The lesion was located and completely exposed following
the subperiosteal cleavage plane (Fig. 7). It was then resected
at the base, first with the help of rotating instruments cooled
with saline and finally with manual chisels. The procedure
was completed with bone files at the residual site (Fig. 8).
After surgical resection, the wound edges were stitched with
3/0 resorbable thread. Upon release from hospital, the patient
was prescribed amoxicillin plus clavulanic acid (1 g every 12
hours for 4 days, Augmentin, GlaxoSmithKline S.p.a., Verona, Italy) and ketorolac as needed (maximum of 3 tablets a
day, Toradol, Recordati S.p.a, Milan, Italy). The patient was

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Rodriguez y Baena et al.

Fig. 4. Axial CT section. The osteoma is 1.5 1.5 mm large


and the bone insertion is evident.

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Fig. 6. Three-dimensional reconstruction of the lesion. The


osteoma (A) enters the bone above the external oblique line
(B) and appears well separated from the mental foramen (C).

Fig. 7. (a) Intraoperative image of the isolated lesion. (b) The


mental foramen can be seen mesially.

Fig. 5. Coronal CT section. The osteoma (A) is rounded and


sessile. The mandibular canal (B) can be seen.

given precise oral hygiene guidelines. The healing was uneventful and no complications were observed (Fig. 9). Histologic tests confirmed the preoperative diagnosis and showed
compact mature bone (Figs. 10 and 11). The postoperative
follow-up consisted of an annual clinical check-up and x-ray
examination (PA projection).

DISCUSSION
Only 4 cases of peripheral osteoma of certain traumatic origin are reported in the literature, 3 of which
were at the mandibular angle9,30 and 1 in the lingual

zone.9 In the present case, however, the lesion was


located in the vestibular lower premolar zone, behind
the mandibular foramen in correspondence with the end
of the external oblique line. The continued slow growth
and the site and asymmetry of the lesion led to a preoperative differential diagnosis of peripheral osteoma, which
was confirmed histologically. A 3-dimensional CT scan
allowed for better resolution and the location of the
lesion was confirmed more precisely,10,25 excluding
involvement of the bony wall of the mandibular
canal, which was approximately 3 mm from the base
of the neoformation.
Although removal of a peripheral osteoma is not
compulsory, it was indicated in this case, both by the
continued growth in a young patient and the esthetic
implications of the patients obvious facial asymmetry.

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Fig. 8. Site of the lesion after complete enucleation.

Rodriguez y Baena et al. e47

Fig. 10. Histology shows a well-defined lesion consisting of


compact mature lamellar bone with very few fibrovascular channels (hematoxylin and eosin [H&E], magnification 100).

Fig. 9. Clinical presentation after patients complete recovery


(arrow). Compare with Figure 1.

Recurrence of peripheral osteoma after resection is


extremely rare,28,31 and there are no reports of malignant transformation.31 In maxillofacial surgery, access
to lesions in the lower jaw can be oral or cutaneous.
In this case, oral access was selected to more easily
locate the neurovascular bundle and for esthetic reasons. The tissue covering the osteoma was intact and
well vascularized, and there was no inflammation.32
Histologically, the lesion was made up of well-defined,
highly calcified bone tissue, which identified it as a
compact osteoma.22
Gardner syndrome must be excluded in patients with
osteoma.33-35 This syndrome comprises gastroenteric
polypus, skin and soft tissue tumors, skeletal abnormalities, such as osteoma and hypercalcification of the
skull or the maxillary bones, and, finally, multiple
embedded or supernumerary teeth. The differential diagnosis of oral and maxillofacial phenomena is essential because presentation in this zone precedes the for-

Fig. 11. Closer view showing rare osteocytes entrapped


within lamellar bone (H&E, magnification 400).

mation of gastroenteric polyps, which have a certain


malignant evolution.17
The etiology of peripheral osteomas is not clear, and
there are 3 theories of its origin: developmental, neoplastic, and reactive. The theory that a peripheral osteoma is a growth anomaly seems improbable because
most cases are observed in patients no longer in a
formative period of growth. The neoplastic theory contradicts the extremely slow growth. The reactive theory
is the most likely in cases of confirmed trauma.
Our patient was a baseball player who clearly
remembered having suffered a sports-related injury
in the zone where the osteoma developed. It is therefore likely that the trauma provoked a subperiosteal
hematic extravasation that led to a neoplastic degen-

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Rodriguez y Baena et al.

eration of the tissues involved. The patients complete recovery and nonrelapse must be confirmed by
long-term follow-up.
CONCLUSIONS
A peripheral osteoma of traumatic origin is a rare
benign lesion of the mandible and few cases are reported
in the literature. The presented case seems to confirm that
the origin of the lesion was a trauma that had occurred 15
years earlier. An accurate preoperative study was performed using conventional and 3-dimensional radiographs
and represented the base for a correct diagnosis and the
surgical strategy. Although osteomas are benign lesions,
long-term follow-up should be performed to confirm complete recovery.

18.

19.

20.
21.
22.

23.

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Reprint requests:
Ruggero Rodriguez y Baena, MD, DDS
Department of Oral Sciences S.Palazzi
University of Pavia
P.le Golgi 2
27100 Pavia, Italy
ruggero.rodriguez@unipv.it