Dental Health Imaging, Jobs, Education & Resources

Dolphine Oda, BDS, MSc (Pathology)
Dr. Tracy Johnson (Oral & Maxillofacial Surgery)

History
This 30-year-old female presented for wisdom tooth removal.  At examination of the patient it was noted that there was swelling in the region of the right posterior maxilla.  How long the lesion had been present was unknown.  
Medical History
Unremarkable
Clinical and Radiographic Findings
A large asymptomatic swelling was identified by the oral surgeon in the right posterior maxilla.
It was confirmed by a panoramic radiograph which showed a well-demarcated mixed radiolucent/radiopaque lesion between teeth #s 3 and 4 (Figure 1).  It had expanded buccally and palatally and had extended superiorly into the right maxillary sinus. It was displacing teeth #s 3 and 4. The lesion was measured as 2 x 2 x 1.7 cm in size. The involved teeth were vital.

Treatment
Under IV sedation, the area was surgically exposed where the overlying bone was found to be very thin (Figure 2). The bone was removed and the lesion exposed (Figure 3). The area was curetted, irrigated and closed. There was a small perforation through the maxillary sinus but that healed along with the rest of the area without any complications.
Excisional Biopsy
Histologic examination reveals multiple and multisected pieces of soft tissue embedded in five separate blocks. All specimens showed evidence of a neoplasm made up of myxoid connective tissue containing calcified material (Figures 4-6). The connective tissue comprised the bulk of the specimen and was loose and vascular and was made up of spindle-shaped cells that were positive with smooth muscle actin but negative with S-100. Some of the finbroblasts were forming whorls. The calcified material was cementum-like. Occasional odontogenic epithelial islands were identified.

Figure 2 This photograph is taken during surgery partially exposing the encapsulated lesion with intact thin bone covering the lesion.

Figure 3 This photograph is taken during surgery with some bone removed and the myxoid looking lesion partially exposed and in the process of being curetted.

Figure 4 Low power (x40) H & E histology shows myxoid connective tissue with focal spindle-cell whorling and cementum-like calcifications.

Figure 5 High power (x100) H & E histology with closer look of the myxoid connective tissue, spindle-cell whorling and cementum-like calcified material.

Figure 6 High power (x200) H & E histology with even closer look of the myxoid connective tissue, spindle-cell whorling and cementum-like calcified material.
 
Final Diagnosis
http://dental.washington.edu/departments/oral-surgery/case-of-the-month-diagnosis.html