^athology

Osteoblastoma of the mandible with root résorption:A case report

Mustafa Öztürk. DDS, PhDVNker Özec, DDS /Handan Aker, MDVAhmet Müslehiddinoglu, MD''

Ttiis article reviews the clinical behavior, histologie teatures, ditferential diagnosis, and treatment of a be-nign osteoblastoma. Benign osteoblastcma is a rare tumor constituting 1 % ot all primary bone tumors.Only 15% of osteoblastoma s occur in the skull and jaw bones. The mosl common clinical presentation is apaintul or tender swelling. A case is presented of a 21 -year-old female who had noted discomfort lor ap-proximately 2 years, and the pain was not relieved by any analgesic. The choice ot treatment was local ex-cision and curettage In this case, root résorption of the adjacent tooth, which is not a characteristic behav-ior ol osteoblastoma, is seen, (Quintessence Int 2003:34:135-138)

Key words: mandible, osteoblastoma, tumor

Benign osteoblastoma is a rare tumor of bone repre-senting fewer than I^D of all tumors of tbe maxillo-

facial region. The tumor is most often found in thevertebral coiumn, sacrum, calvarium, long bones ofthe appendicular skeleton, and in tbe small bones ofthe hands and feet. Although the etiologj' of osteoblas-toma is unknown, it is considered to be a true neo-plasm of bone.'-'

In review of tbe literature, the ages of tbe patientspresenting lesions of the jaws ranged from 3 to 78years, but nearly 90°i) of the patients were less than 30years old. Tbe male to female ratio was 2 to 1, Patientsusually reported pain and swelling. Dull, aching pain,usually locahzed and often occurring insidiously, is themain complaint, and the pain is t 'pically not respon-sive to aspirin. The swelling may be tender to palpa-tion and the teeth may hecome tender or mobile if thesupporting bone is involved. The duration of symp-toms varies from a few months to 3 years.' ' ' '

^Associafe Professor, Department of Oral and Ma;<illotacial Surgery,Faulty of Dentistry, Cumhuriyet University, Sfvas, Tur1<ey

^Research Assistant, Department of Oral and MaxJIIolaoial Suigery, Faculty

of Dentistry, Cumfiuriyet University, Sivas, Turkey

-Professor, Departmenl oí Patfiology, Faculty of Medioine, CumhuriyetUniversity, Srvas, Turkey,

'Research Assistant, Department of Pathology, Faculty of Medicine,Cumhuriyet University, Sivas, Turkey.

Reprint requests: Dr Mustafa Ôztùrfi, Faculty of Dentistry, University ofCumhuriyet, Campus Sivas, TlJrkiye. E-mail: mozturk©cumhuriyet,edu.tr

The radiographie appearance is extremely variedand is largely dependent upon the degree of calcifica-tion, Weli-circumscribed lesions on radiographs baveusually consisted of combinations of radiolucent andradiopaque patterns, A tbin peripheral radiolucencymay be noted; however, sclerosis of perilesional boneis usually absent,'-^^

Treatment of osteoblastoma typically includes twooptions: local excision witb vigorous curettage, fol-lowed by bur ablation of tbe margins witb copious irri-gation, or block resection. Data suggest tbat postopera-tive radiation therapy is not usually indicated, and onlyaggressively expanding lesions or recurrent growthsshould receive this additional mode of therapy,' ^"

A case of osteoblastoma of the mandible and rootrésorption of tbe adjacent tootb are presented in tbispaper, Tbe differential diagnoses are also discussed.

CASE REPORT

A 21-year-old female was admitted to tbe Oral andMaxillofaciai Surgery Department of CumburiyetUniversity, Faculty of Dentistri', Sivas, Turkey, in May2000, witb a chief complaint of a painftil swelling onthe buccal aspect of the left mandibular first molar,Tbe patient bad noted discomfort for approximately 2years, and the pain was not relieved by any analgesic.In June 1998, witb a cbief complaint of pain, she pre-sented to a general dentist, A periapical radiographwas taken, and the dentist prescribed antibiotics.

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Fig 1 Panoramic radiograpii showing osteoblastoma in ttiemandibular left moiar region.

Fig 3 Panoramic radiograpti 8 months after the opération.

Fig 2 Periapical radiograpii.

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Fig 4 Irregular trabecuiae cl new bone witii large numbers olplymp osteobiasts, Muitinucleated giant cells and thin-walled vas-cular channels are also seen (iiematoxyiin-eosin stain; originalmagnification X25).

A panoramic radiograph taken at the dental schoolrevealed a well-circumscribed mottled opacity with alucent rim (Fig 1). In the periapical radiograph thatwas taken by tbe general practitioner, a lesion with a1.5 X 1,2-cm diameter was seen producing résorptionof half of the root structure (Fig 2), In the panoramicradiograph taken two years iater, tbe lesion had en-larged to 3 X 2,5 cm in diameter, and root résorptionhad extended to involve the cervical area of the tooth.

Upon intraorai examination, a conspicuous hardswelling was observed in the first molar region thatwas tender to palpation and measured 2 x 2 cm inarea. The overlying mucosa was intact. There was noextraora! facial deformity, no complaint of paresthesia,and no limitation of opening capacity. Mobility of theadjacent tooth was noted. Based on clinical and radio-graphic findings, a presumptive diagnosis of ossifyingfibroma was made.

Under local anesthesia, the mandibular first molarwas extracted without exerting any excessive force dur-ing extraction, and the tooth separated cleanly fromthe lesional tissue. Local excision and curettage wasperformed until the visible lesion was removed to anapparently normal bone margin. The patient recovereduneventfully from the surgery and was well 8 monthslater. At follow-up evaluation in February 2001, the pa-tient was asymptomatic and the radiographie examina-tion showed no sign of recurrence (Fig 3),

PATHOLOGIC EXAMINATION

The surgical specimen consisted of multiple irregularfragments of hard, granular, brown-yellow tissue, mea-suring 3 X 2.5 X 2 cm in aggregate. It was composedof haphazardly interconnecting trabecuiae of woven

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bone. The trabeculae were rimmed by osteoblasts andsurrounded by loose connective tissue (Fig 4),Numerous extravasated red blood cells and multinu-cleated giant cells were also scattered through thestroma. C^iologic atypia and abnormal osteoblasticmitotic activity were not observed. Distinct demarca-tion from the surrounding tissue was noted.Maturation, indicated by mineralization of tbe osteoidmatrix, was seen progressing toward lamellar boneformation witb varying degrees of calcification.

DISCUSSION

Benign osteoblastoma is a relatively rare tmnor consti-tuting lOb of all primary bone tumors. Only lS /o of tbeseoccur in tbe skull and jaw bones. The posterior tooth-bearing regions are the usual sites of involvement in thejaws, Tbe maxilla is rarely affected. The most cotnmonclinical presentation is a painful or tender swelling.'-^'

Radiographie findings and the biologic behavior ofosteoblastoma are not constant, varying from case tocase, Osteoblastoma may recur and show aggressivebehavior or sarcomatous transformation,^ •'^'-^Osteoblastoma accompanied by an aneurysmal bonecyst or a simple bone cyst has also been reported,*

In the current case, histologie evaluation revealedvarying amounts of poorly cellular bone in a ricblyvascular fibrous stroma. At tbe surface of tbe bony tra-bcculae, proliferating osteobiasts were present,Multinucleated osteoclast-like giants cells were alsoobserved. Tbe loose fibrous connective tissue areascontained many congested vessels, and hemorrhage.

Males seem to be affected more commonly than fe-males, by an approximate 2:1 ratio."" Tbe study sub-ject is female. The patient bid ber periapical radi-ograph for two years prior to presenting to our clinic.We compared the periapical radiograph with thepanoramic radiograph taken in May 2000. As a result,we saw that in two years, the lesion expanded approx-imately 1.5 cm in every direction. This data supportsthe slow-growing nature of the lesion. Also, the rootrésorption seen in the periapical radiograph contin-ued, eventually involving the cervical area of thetooth. Root résorption is not a common feature in os-teoblastoma. The lesion also expanded through thebody of the mandible and, although it involved the su-perior border of the inferior alveolar canal, there wasno complaint of paresthesia,

Osteoblastoma must be differentiated fi-om a num-ber of bone-producing lesions sucb as osteoid os-teoma, cementoblastoma, and osteosarcoma. Aneur-ysmal bone cyst, central giant cell granuloma, ossifyingfibroma, and fibrous dysplasia also have some histo-logie similarities.'•^•'

The distinction between osteoid osteoma and os-teoblastoma is primarily dependent on the size of the le-sion. Classically, a lesion is considered osteoid osteomawhen it is less than 2 cm in diameter and osteoblastomawhen greater than 2 cm. In addition, however, osteoidosteoma radiographically typically produces a markedperipberal sclerosis in tbe bone adjacent to tbe lesion,Tbe pain in osteoid osteoma is also cbaracteristicallynocturnal, and relieved by salicylates. '"

Cementoblastoma is considered an odontogenicequivalent of the osteoblastoma. It arises from tbe rootsurface of a tootb, and tbe difference between cemen-toblastoma and osteoblastoma depends on whetber ornot tbe lesion is fused to tbe root. In tbe current case,tbe adjacent mandibular first molar was mobile andwas extracted very simply witbout extra force exerted.The lesion did not appear to be attached to tbe toothroot. It should be remembered that osteoblastoma maysecondarily involve a tooth as in our case.'" "

Although the clinical and radiographie features ofossifying fibroma may be similar to osteoblastoma,pain is not a usual feature in ossifying fibroma.^

Radiograpbically, fibrous dysplasia exhibits a poorlydefined margin in contrast to the well-circumscribedappearance of osteoblastoma, and upon histologieevaluation, new bone formation is lamellar and lacksosteoblastic and/or osteoclastic activity. '"

Differentiation of osteoblastoma from osteosar-coma may sometimes be difficult, especially the scle-rosing form of osteosarcoma in wbicb osteoid andnew bone production is prominent and cellular atypiais not pronounced. Presence of cytologie pieomor-phism and fine, compacted osteoid strands and mitoticfigures favor a diagnosis of osteosarcoma.'

Aggressive osteoblastomas sbow a tendency forlocal invasion and recurrence but do not show metas-tasis. Tbe aggressive osteoblastoma is similar to benignosteoblastoma bistologically: however, tbe aggressivevariant is said to exbibit epitbelioid osteoblasts,-'

According to Obkubo et al,- tbe tendency for recur-rence is due to inadequate therapy. Indeed when tbeinitial treatment of osteoblastoma is conservative, tberecurrence risk increases. Tberefore, block resectionbas been recommended,^' Sometimes, complete re-gression may occur even with limited treatment,^

CONCLUSION

Although in tbe present case the subject is a female androot résorption of the adjacent tootb was seen, the loca-tion of the tumor, the age of tbe patient, tbe duration ofthe symptoms, and the radiograpbic and histologie fea-tures are appropriate to the literature. The absence ofrecurrence is largely due to adequate initial treatment.

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REFERENCES

1. Ahmed MS, Nwoku AL, Benign osteoblastoma of themandibular ramus: Review ot the literature and report of acase. I Oral Maxillofac Surg 2000;58:1310-1317.

2. Ataoglu O, Oygur T Yamalik K, Yucel E. Recurrent os-teoblastoma of the mandible: A case report. ) Orai Max-iilofac Surg 1994;52:8fi-90.

3. Guest PG, Junier RP, Osteoblastoma: A case report and de-scription of the aeeess used to the retromaxiliary area. Brit )Oral Maxiilofac Surg 199t;29:333-335.

4. Ohkubo T. Hernandez JC, Ooya K, Krutchkoff DJ.Aggressive osteoblastoma of tiie maxilla. Oral Surg OralMed Oral Pathol t989;68:69-73.

5. Peters TED, Oiiver DR, McDonald JS. Benign osteobias-toma of the mandible: Report of a case. J Oral MaxiilofacSurg 1995;53:1347-1349.

6. Ribera MJ. Osteobiastoma in the anterior maxilla mimickingperiapicai pathosis of odontogenic origin. J Endod 1996;22:22-23,142-146,

7. Bertoni F, Unni K, McLeod RA, Dahlin D. Osteosarcomaresembiing osteoblastoma. Cancer 1985;55:416-426.

8. Mirra JM, Kendrick RA, Kendrick RE. Pseudomaiignant os-teoblastoma versus arrested osteosareoma: A case report.Cancer 1976,37:2005-2014.

9. Svenson B, Isacsson G. Benign osteoblastoma associatedwith an aneurysmal bone cyst of the mandibuiar ramus andcondyie. Orai Surg Oral Med Orai Pathol 1993;76:433-436,

10. Regezzi JA, Sciubba J. Orai Pathoiogy Ciinicai PathologicCorrelations, ed 3. Phiiadephia: Saunders, 1999:363.

11. Huvos AG. Bone Tumors, Diagnosis, Treatment, andPrognosis, ed 2. Phiiadeiphia: Saunders, 1991:51.

138 Volume 34, Number 2, 2003

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