A 21-year-old black male patient who attended the maxillofacial surgery service of the San Vicente University Hospital Fundación de de de de la Universidad de Antioquia, an asymptomatic increase in volume unknown by dentist in an institution is presented.
Intraorally, excellent dental integrity and good dental occlusion are observed, but there is an increase in vestibular volume that compromises the body and symphysis, while lingually, expansion of the table is only in the lower canine area.
In the initial panoramic radiography, a radiolucent image of 10 cm in length, multiloculated, located from distal tooth 46 to mesial 33 was observed.
Mesial root of 46 and root of 45 showed rhizolysis, with possible pulp necrosis.
The teeth 46, 45 and 44 had minimal mobility; the other teeth had normal vitality and the lower dental canal was rejected.
There is no change in the sensitivity of the chin nerve.
1.
The patient authorizes the completion of all treatment by signing the informed consent.
Prior to the initial biopsy it was aspirated producing a citrin liquid and the first histopathological study found a loose connective tissue, some multinucleated giant cells with few nuclei and a thin band epithelial tissue was considered insufficient evidence of keratin.
However, a diagnosis of keratocystic odontogenic tumor was made by the presence of a keratin band.
connective tissue found with an intense epithelial infiltrate, the inflammatory lesion was infected and the patient had to be hospitalized due to the severity of the clinical picture; this condition was used to perform a second procedure under general anesthesia 8 days later
The ambiguity of the diagnosis and the aggressiveness of the lesion was decided to perform the intervention with the first diagnosis (keratocystic odontogenic tumor -exkeratocyst-).
With this diagnosis it was decided to plan an aggressive surgical treatment and it was decided to order the realization of the endodontics from 46 to 33 (9 teeth) prior to the surgical procedure, since the apices of the dental cavity were immersed recurrence.
This endodontic treatment lasted 3 months due to the difficulty of sealing the canals by the presence of a drainage through the pulp chambers of an amber liquid, after this time the production of liquid ended.
1.
The surgical phase was performed under general anesthesia.
A distal trapezoid flap was raised from 46 to distal 33.
Reflecting the flap is an expanded table throughout its extension and perforated in the bicuspid area ( teeth 44 and 45) where biopsies had been previously performed.
We proceeded to remove all expanded vestibular cortex until complete access to cystic cavity.
A thick fibrous capsule covering the bone defect is found and removed.
It is milled with rotary cutting instruments of the bone cavity and the entire bone defect is painted with Carnoy's solution.
Some perforations of the lingual cortical bone are observed, which are cauterized with electro scalpel due to the risk of invasion of the tumor to soft tissues of the tongue.
Due to the weakening of the mandibular basal edge, a reconstruction plate is placed to prevent an intra- or postoperative fracture.
Before suturing the flap, a bone defect with collagen flar was filled and analgesics and antibiotics were administered.
The tissue obtained is sent to pathology.
The histopathological report of the surgical specimen shows a fibroconnective tissue without epithelium and a postsurgical diagnosis of aneurysmal bone cyst was obtained.
Due to the fact that in the second biopsy an epithelium appeared, it was proved impossible to consider it as a diagnostic error; however, evaluating the three histopathological samples, it was considered that this epithelial tissue of the second biopsy was the product of the initial bone inflammatory reaction, while the cyst was not neuroepithelial.
The patient was evaluated at 8 and 15 days and then at 2 months, 10 months and 2 years.
At the follow-up appointment at 2 months, pulp necrosis and fistula were found at level 47, which was adjacent to the lesion and the apex of the mesial root had been amputated during the surgical procedure.
Endodontics was performed and the infection resolved.
She also had paresthesia of the right chin nerve and B tablets were prescribed for one month.
A new postsurgical evaluation was carried out at 10 months and an adequate process of bone healing was found, but there was an occlusion sequel, since the teeth that remained without bone support because they were immersed in the bone defect.
Two years later, a new clinical and radiographic review was carried out which found that: from teeth 44 to 33 remain in open bite, 44 are also slightly vestibularized.
The panoramic radiograph shows good bone filling, but in the three-dimensional tomography shows that there is a defect of about 6 mm in diameter that compromise the apex of 44 and 43 years later that persists paresthesia two years later.
Intraoral imaging shows that the increase produced by the expansion of the lingual table lesion in teeth 43, 44 and 45 still persists.
