Defects on the lingual surface of the mandible near the angle

D E F E C T S ON THE LINGUAL S U R F A C E OF THE M A N D I B L E N E A R THE ANGLE

WARREN HARVEY, F.D.S.Glas., Edin., Eng., M.R.C.S., L.R.C.P. and HENRY W. NOBLE, Ph.D., F.D.S., R.C.P.S.(Glasg.)

Glasgow Dental Hospital and School

DURING the examination of over 95 ° mandibles, we found defects or cavities on the lingual surface of six bones, and through Dr. Don Brothwell were led to details of another, case known to Dr. Dan Morse of the Tuberculosis Sanitorium, Peoria, Illinois, as shown below:

TABLE I

Mandibles with

Defects

o

I(L&R)

I(L&R)

Number Examined

35

I66

177

575

Source

Skulls of I5 Races in University Anatomy Department, and Dental Hospital, Glasgow.

Skulls from W. Bengal, Bihar, and Orissa in India, in University Anatomy Department, Glasgow.

I696-I852 skulls in St. Brides Church, Fleet Street, London.

Stone age to Mediaeval skulls in British Museum (detailed origin available).

Lent by Prof. Causey, Roy. Coll. Surg.

750-500 B.c., Robinson Site, Tennessee, U.S.A.

Details of these defects are given in Table II.

Impressions were taken of the first seven of these defects, and castings in metal have proved to be a useful record.

Personal communications revealed that in London Professor Rushton had seen several clinical cases which at operation had similar bony defects compared with those detailed in Table II ; Mr. Norman Rowe knew of three cases, so did Professor Kramer, and Dr. Frank Ingram had seen four cases. In Glasgow we found records of two similar cases, a third under observation and a fourth related case (Camilleri, I963). Nowhere in the literature did we find records of the study of dry mandibles with these lingual defects near the angle.

75

76 BRITISH JOURNAL OF ORAL SURGERY

TABLE II

Identity of

Skull

27

I9I

RCS

8

32

80

RCS

B5z

B52

Origin

St. Brides

Glasgow Anat. Dept.

Roy. Col. Surg. Eng.

Glasgow Dent. Hosp.

Glasgow Anat. Dept.

Glasgow Anat. Dept.

Roy. Col. Surg. Eng.

Tennessee

Tennessee

Race

British

Indian

?

Indian

Indian

Indian

?

Amer-indian

Amer-indian

Age Sex

70 F

45 F

50 M Figure I

25 M

55 F Figure 3

55 M

50 M Figure 5

50 F Figure 7

50 F

Defect m . m .

deep

1-5

1. 5

2'5

6

not

not

Lateral bone

m.m. left

6

6

8

6

5

6

3

known

known

Position

Below 8/*

Below /8-

Below /8*

Below 76/

Below 87/

Below 8/

Below 8/*

L. Angle

R. Angle I I

Radiolucent Area

Vague

Fair Figure 2

Vague

Vague Figure 4

Fair

Clear Figure 6

Clear

* Continuous with mylohyoid groove.

Review o f Relevant Literature

In I942 Stafne described 35 radiolucent areas he had seen near the angle of the mandible below the inferior alveolar canal; these cavities, as he called them, occurred in 28 men and six women, aged 33 to 72 and mostly about 5o; there was no history of t rauma, no pain, no bone or blood abnormalities; the cavities were I to 3 centimetres round, or oval parallel to the lower border of the mandible. By 1958 Stafne had seen 113 of these cases, and some had revealed no change in size over I I years. M u c h has been written about the possible etiology of radiolucent areas in the mandible, with lively comment by that elusive author 'Can tab ' !

We have tried to see i f any of these reports showed a similar picture to that seen in our collection of dry mandibles, with the results shown in Table I I I .

All these cases had a radiolucent area near the angle of the mandible, and were proved to have a defect on the lingual surface of the bone.

All the above reports concern cases with radiolucent areas and lingual defects near the angle which were below the inferior alveolar canal; the following cases (Table IV) have similar features but the defects were related to the sublingual gland, and were therefore above the mylohyoid muscle and the inferior alveolar canal in the anterior part of the mouth.

DEFECTS ON THE LINGUAL SURFACE OF THE MANDIBLE 77

TABLE III

Author Symptoms Sex Age Position Contents

Peterson, I944 None

Slavin, I95O

Jacobs, I955

Thoma, I955

Fordyce, 1956

Bernstein, Lam & Pomije, 1958

Choukas & Toto, I96o

Seward, I96O

Amaral & Jacobs, I96I

Hayes, I96I

Olech & Arora, I96I

Bergenholtz & Persson, 1963

Simpson, I965

Orr & 1 Midgeley * unpub- lished

Plumpton

None

Soreness

None

None

None

None

Facial pain

None

None

Pain from denture

Pain in T.M.J.

None

None

None

None

None

M 45 Coloured

M 35

Not given 40 +

40 +

M 28

M 48

M 40

M 32

M 60

F 43

M 43

M 5o Filipino

M 56

M 72

M 37

M 56

R. Angle

s/

L. Angle

L. Angle

/78

8/

Behind Facial Notch

At Facial Notch

R. Angle

L. Angle

R. Angle

/67

m

8/

Serous and mucous glands--called 'Parotid'

Submaxillary gland

'No gland tissue'

Lymph node, thick walled blood vessels

Normal salivary gland tissue

Normal salivary gland tissue

None

Salivary gland

Salivary gland on sialography

Salivary gland on sialography

Salivary gland

Serous and a few mucous glands

Striated muscle

Fat, lymph node, blood vessels, fibrous tissue

Fat, connective tissue, bone, striated muscle

None

Pain

None

None

M

F

M

M

47 7/

45 L. Angle

50 /8

52 /8

None

Pleomorphic adenoma

Fat

Salivary gland


Since we could find only one instance of bone being sectioned--the case of Bernstein, Lam and Pomije ( i958)- -we felt that it might be of great interest to examine sections of our collection of these six bony defects.

Author

Richard & Ziskind, I957

Araiche & Brode, 1959

Bergenholtz & Persson, I963

Camilleri, 1963

Palladino, Rose & Curran, 1965

Symptoms

None

Pain

None

Vague pain & swelling

None

TABLE IV

Sex Age

M 46

M 55

M 58

F 31

M 40

Position

/34

5-I/

/3

2i/

43/

Contents

Salivary gland tissue


Fibrous tissue & bone fragments

Mucous gland tissue


FIG. I FIG. 2

Fig. I . - -A small defect just below the mylohyoid line.

Fig. 2.--Although six millimetres of bone remain laterally between the depth of the defect and the lateral surface of the mandible, the radiolucent area is easily seen since it lies over the inferior alveolar canal and therefore the bone

is less dense.


FIG. 3 FIG. 4

Fig. 3 . - -An obvious defect near the lower border of the mandible.

Fig. 4 . - -F ive millimetres of bone remain laterally between the depth of the defect and lateral surface of the mandible below the inferior alveolar canal

causing some difficulty in identifying the defect radiographically.

FIG. 5 FIG. 6

Fig. 5 . - -This is the deepest defect seen in this series of mandibles.

Fig. 6 . - -A dramatic clear radiolucent area with sclerosed margins; resembles some of Stafne's cases.

This


FIG. 7 This mandible 75o-5oo B.C. has

deep bilateral defects.

Histological Examination In the case of defects involving the calcified tissues the possibility always

exists that information concerning the manner of development of the lesion may be obtained from a study of the incremental growth pattern present. The incremental growth pattern of the area of the mandible in which these defects were situated is relatively simple. The inferior dental canal may be regarded as a stationary feature while increments are added to the outer and inner plates of compact bone and to the surface of the lower border of the mandible.

When thin bone sections which had been removed from the area containing the defect in each mandible were subjected to microscopical examination (Fig. 8) the following appearances were observed.

I. The surface of the depression showed an osteoclastic resorption in every case.

2. Slight traces of bone redeposition upon the resorbed surface were to be seen in two of the six cases.

3- The margins of the defect cut cleanly across the incremental growth lines of the inner compact plate of bone and no deformity of these growth lines could be detected which might suggest the presence of the lesion during an earlier stage of bone growth (Fig. 9).

4. In each case the bone at the base of the defect had been thickened by the formation of additional bone in advance of the resorbing surface. In one case this was not possible owing to the proximity of the inferior dental canal (Fig. io).

The microscopical findings therefore completely exclude the possibility that this defect could have arisen as a result of the eruption to the surface of some

D E F E C T S O N T H E L I N G U A L S U R F A C E O F T H E M A N D I B L E 81

FIG. 8 FIG. 9

Fig. 8.--Coronal section through lower border of mandible containing defect illustrated in Figure 3. x 5.

Fig. 9 . - -The lamellar bone formed by the surface apposition on the lower border and the haversian bone replacing it from with- in are interrupted by the resorbed surface of the defect. The normal archi- tecture of the bone border- ing the defect does not suggest any interference with its earlier develop-

ment. x IO.

Fig. io.--Sect ion through the defect shown in Figure L The proximity oftheinferior ,dental canal has not per- mit ted bone deposition in advance of the resorption.

xS. FIG. IO

822 B R I T I S H JOURNAL OF ORAL SURGERY

earlier existing central condition. The microscopical appearances also exclude the possibility that the growing mesoderm of the developing mandible could have enclosed a lobe of the salivary gland during bone development.

The most probable explanation is that a localised area of surface bone resorption, stimulated by some means as yet unknown, has progressed to a variable degree in each of the mandibles examined. Bone deposition ahead of this resorbing area has been stimulated and has obscured the condition radiographically in its early stages. A strong possibility exists that, because of the fact that it is only detected radiographically in the most advanced cases, it may be present clinically in many more cases than is otherwise suspected.

DISCUSSION

As in Stafne's cases there seems to be a sex difference in these cases, with 24 males to eight females (sex was not stated in two cases).

The defect was on the left in 16 cases, right in 18 cases and bilateral in two. Pain occurred in six of the 25 clinical cases. It is intriguing to find that mandible 8 age 25 in Table II seems to be the youngest instance so far recorded; as had been shown in Table II, only the deep defects leaving little bone show clearly like Stafne's original cases, and it is possible that these cases are commoner than we have been led to believe. We venture to suggest that mandible B52 in Table II from the Robinson Site, Tennessee, 75o-5oo B.C. may be the oldest known case.

In 15 of the 25 clinical cases normal salivary gland tissue was found; this emphasises the views of Fordyce (1956) and Seward (196o) that sialography may be of considerable help in the diagnosis; the case of Simpson (1965) is a warning that neoplastic change can occur.

It is surprising that these defects do not seem to occur more often in relation to the parotid gland. It is fascinating that Stafne's experience of radiolucent areas near the angle is so vast.

SUMMARY

Details are given of 9 defects on the lingual surface near the angle in 7 mandibles out of a series of over 95 o examined. An extensive search of the literature failed to reveal comparable osteological findings but reports of 2o clinical cases were discovered where similar defects below the mylohyoid line were seen during surgery or after sialography. Salivary gland tissue was shown to be present in I I of these defects. Attention is drawn to 5 reported clinical cases which occur in the anterior part of the mandible with similar defects, 4 of which contained salivary tissue; these defects are in closer relation to the roots of the teeth because they lie above rather than below the mylohyoid line. Histological examination of the defects favours an explanation involving localised resorption of an earlier intact inner cortical plate and does not support any explanation based upon disturbance during the development of the salivary gland tissue in close approximation to the spread of ossification in the mandible. The thickness and nature of bone remaining determines the density of the radiological picture--shallow defects may therefore be much commoner than at present suspected.


POSTSCRIPT

Since, in our series o f mandibles the occurrence o f defects in the Ind ian series seemed so frequent , a request was made to the Denta l Counci l o f India concerning any k n o w n figures for the incidence o f this defect in that country . I n July I967 a letter was received f rom Dr . A. M. Cooper , Professor o f A n a t o m y of Madras , wi th the following figures:

'Very well marked, average 12 mm. × 8 m m . - - L , 1.18 % ]

'Very well marked, average I2 ram. × 8 mm.- -R , o'47% t

'Very well marked, small 4 mm. x 4 mm.- -bo th sides, o.24%J

in 627 mandibles of South India

REFERENCES

AMARAL, W. J. & JACOBS, D. S. (I96I). Aberrant salivary gland defect in the mandible, Oral Surg. I4, 748.

ARAICHE, M. & BRODE, H. (1959). Aberrant salivary gland tissue in the mandible, Oral Burg. I2, 727 .

BERGENHOLTZ, A. & PERSSON, G. (1963). Idiopathic bone cavities, Oral Surg. I6, 703. BERNSTEIN, H. F., I_,AM, R. C. & POMIJE, F. W. (I958). Static bone cavities of the mandible:

review of the literature and report of a case, y. Oral Surg. i6, 46. CAMILLERI, G. (1963). Salivary gland inclusion in the mandible, Brit. D.y. I I4 , 515 . 'CANTAB. B.C.' alias RUSHTON, M. A. (I946). Solitary bone cysts in the mandible, Brit. D.J.

8I, 37. see also DRINNAN, A. J. (1967). Brit. D. J. 122, 288

CHOUKAS, N. C., & TOTO, P. D. (I96o). Etiology of static bone defects of the mandible, J. Oral Surg. 18, I6.

FORDYCE, G. L. (1956). The probable nature of so-called latent haemorrhagic cysts of the mandible, Brit. D. J. I o I , 40.

HAYES, H. (I96I). Aberrant submaxillary gland tissue presenting as a cyst of the jaw, Oral Surg. I4, 313.

JACOBS, M. H. (1955). Traumatic bone cyst, Oral Surg. 8, 940. OLECH, E. & ARORA, B. K. (I961). Lingual mandibular bone defect, Oral Surg. I42, I36O. PALLADINO, V. G., ROSE, S. A. & CURRAN, W. (I965). Salivary gland tissue in the mandible

and Stafne's mandibular 'cysts', J.A.D.A. 7o, 388. PETERSON, L. W. (1944). Cystic cavity in the mandible: report of a case, J. Oral Surg. 2

182. RICHARD, E. L. & ZISKIND, J. (1957). Aberrant salivary gland tissue in the mandible,

Oral Surg. I o, 86. SEWARD, G. R. (196o). Salivary gland inclusions in the mandible, Brit. D.J. lO8, 321. SIMPSON, W. (1965). A Stafne's mandibular defect containing a pleomorphic adenoma:

report of case, J. Oral Surg. 23, 553. SLAVIN, M. I. (195o). Ectopically placed parotid gland in the mandible, Oral Surg. 3, 1372. STAFNE, E. C. (1942). Bone cavities situated near the angle of the mandible., J.A.D.A. 29,

1969. - - ( 1 9 5 8 ) . Oral Roentgenographic Diagnosis, p. 162, Saunders, Philadelphia and London. THOMA, K. H. (1955). Case report of a so-called latent bone cyst, Oral Surg. 8, 963.

Documents

Defects on the lingual surface of the mandible near the angle