Fernando Kendi Horikawa

Mucocele of the glands of Blandin–Nuhn—clinical, pathological, and therapeutical aspects

PurposeThis study aims to review anatomical, clinical, and pathological concepts as well as to discuss the most adequate therapeutic approach to the mucoceles of the glands of Blandin–Nuhn.DiscussionThe glands of Blandin–Nuhn are localized in the ventral part of the tongue, next to the apex in the lingual median plane. Development of a mucocele in this site is rarely seen; besides, as the glands of Blandin–Nuhn are not encapsulated and are directly overlapped to the muscle tissues, their manipulation tends to be different from the other oral mucoceles.ConclusionAs Blandin–Nuhn mucoceles are uncommon and their clinical appearance could be similar to other lesions, it is important that health professionals know their clinical and histopathological features to avoid having them misdiagnosed.

Single puncture for TMJ arthrocentesis: An effective technique for hydraulic distention of the superior joint space.

Temporomandibular joint arthrocentesis is a method of flushing out the synovial fluid that is currently performed by providing a double puncture to the upper joint space. The traditional 2-needle technique has some restrictions, such as the difficulty in performing it in the presence of intra-articular adherences and in the female patients, because the space is very small. The adoption of a single-needle for fluid injection might have some advantages with respect to the traditional 2-needle approach in terms of easily, time of execution and tolerability. We describe a single needle technique and we recommend the use.

Ameloblastic Fibroma: a Case Report

| Ameloblastic fibroma is a rare benign odontogenic tumor in which both epithelial and ectomesenchymal components are neoplastic. A 24-year-old male patient was referred to the Stomatology Department with difficulty to chew and swelling in the right posterior region of the mandible. The panoramic radiograph showed a well-circumscribed, unilocular radiolucent lesion with partially radiopaque borders involving first and second unerupted molars. Computed tomography imaging presented a hypodense image with well-delimited isodense content, bulging and rupture of cortical bones. The patient underwent an incisional biopsy. Microscopically, the lesion was composed of many mesenchymal tissue cells in strand form, arranged in cords, islands and nests of odontogenic epithelium; the diagnostic was ameloblastic fibroma. The patient was referred to the hospital for enucleation and curettage of the lesion and extraction of the associated teeth. After 8 months of follow-up, no recurrence was observed. This case emphasizes the importance of differential diagnosis, anatomopathological exam, and both clinical and imaging follow-up, since this kind of tumor can recur and progress to malignancy. DESCRIPTORS | Odontogenic Tumors; Oral Pathology; Ameloblastic Fibroma. RESUMO | Fibroma ameloblástico: um estudo de caso • O fibroma ameloblástico é um tumor odontogênico benigno raro no qual os componentes epiteliais e ectomesenquimais são neoplásicos. Paciente de 24 anos de idade foi encaminhado à clínica de Estomatologia devido à dificuldade de mastigar e edema na região posterior direita da mandíbula. A radiografia panorâmica evidenciou uma lesão radiolúcida unilocular, circunscrita, com bordas parcialmente radiopacas envolvendo o primeiro e segundo molar não irrompidos. A tomografia computadorizada apresentou imagem hipodensa, com conteúdo isodenso, bem delimitada, com abaulamento e rompimento das corticais ósseas. O paciente foi submetido a uma biópsia incisional. Microscopicamente, a lesão foi composta por tecido mesenquimal rico em células, formando cordões, ilhas e ninhos de epitélio odontogênico, cujo diagnóstico foi de fibroma ameloblástico. O paciente foi encaminhado ao hospital para enucleação e curetagem da lesão com extração dos dentes associados. Após 8 meses de acompanhamento, não se observou recorrência. Este caso enfatiza a importância do diagnóstico diferencial, exame anatomopatológico, e acompanhamento clínico e radiográfico, uma vez que este tumor pode recidivar e evoluir para malignidade. DESCRITORES | Tumores Odontogênicos; Patologia Oral; Fibroma Ameloblástico. CORRESPONDING AUTHOR | • Juliane Piragine Araujo Department of Radiology, School of Dentistry, University of São Paulo • Av. Professor Lineu Prestes, 2227, Cidade Universitária São Paulo, SP, Brazil • 05508-000 Email: jupiragine@usp.br • Received Aug 20, 2015 • Accepted Oct 13, 2015 • DOI http://dx.doi.org/10.11606/issn.2357-8041.clrd.2015.12951 251 Ameloblastic fibroma: a case report 252 ● Clin Lab Res Den 2015; 21 (4): 251-257 INTRODUCTION Ameloblastic fibroma (AF) is a rare benign odontogenic tumor, originating from the odontogenic epithelium and odontogenic mesenchyme,1 and it is classified as a true mixed tumor.2 According to Barnes et al.,2 mixed odontogenic tumors include: ameloblastic fibrodentinoma (AFD), ameloblastic fibro-odontoma (AFO), odontoma complex and compound, odontoameloblastoma, calcifying cystic odontogenic tumor, dentinogenic ghost cell tumor, and ameloblastic fibroma. To some authors, mixed odontogenic tumors are different developmental stages of the same lesion.1 The incidence of odontogenic tumors in a study by Nalabolu et al. was 2.17% of a total 7,400 oral biopsies. The AF corresponded to 0.6% of all odontogenic tumors.3 The mean age was 14.8 years (ranging from 7 weeks to 62 years).2 AF occurs more frequently in the mandible and the posterior region is more affected than the anterior region.1,4 Clinical and radiographic features of odontogenic tumors, as well as their prognosis and malignant transformation are conflicting.1 The radiographic features include well-defined, unior multilocular radiolucency, and, in most cases, a radiopaque boundary.2,4 This case report describes the case of a young man affected by mandibular AF, associated with first and second molars on the right side. CASE REPORT A 24-year old male was referred to the Stomatology Department of the School of Dentistry, University of São Paulo, complaining of difficulty chewing and a progressive, asymptomatic increase in the size of his right mandible, which he noticed about 15 days before examination. The patient had no relevant medical history. Extraoral examination revealed facial asymmetry, bulging of the right lower third of the face, intact skin, no palpable lymphonodes, and no paresthesia. The intraoral examination revealed a tumor in the right mandible, with an ulcerated surface, a reddish color, well-defined borders, and measuring approximately 3 cm. Absence of the second premolar and the first and second molars was noted in the region of the tumor. Figure 1 | Extraoral examination revealed facial asymmetry with bulging of the lower third of the face and intact skin, on the right side. Carvalho EM • Horikawa FK • Guimaraes L • Viveiros SK • Lemos CA • Araujo JP • Clin Lab Res Den 2015; 21 (4): 251-257 ● 253 A panoramic radiograph (PR) revealed a unilocular, radiolucent lesion with a partially defined radiopaque boundary, associated to non-erupted first and second molars displaced towards the base of the mandible. Helicoidal computed tomography (HCT) soft window image revealed a hypodense image with isodense content, and cortical bulging with rupture of alveolar crest. Figure 2 | A,B: An ulcerated tumor due to chewing, affecting the posterior right mandible and causing expansion of the cortical bone. Figure 3 | A: A panoramic radiograph shows a well-delimited radiolucent lesion with partially radiopaque borders. B, C: HCT coronal and axial view of tissues shows a well-delimited, unilocular, hypodense lesion with isodense content, with cortical expansion and rupture, affecting the posterior right mandible. Ameloblastic fibroma: a case report 254 ● Clin Lab Res Den 2015; 21 (4): 251-257 INVESTIGATION, HISTOPATHOLOGY AND TREATMENT The patient was submitted to an incisional biopsy under local anesthesia, and the tissue was sent for histopathological analysis. Microscopically, the tumor consisted of odontogenic epithelium lying in mesenchymal tissue resembling embryonic tooth pulp. The odontogenic epithelium consisted of short and long narrow cords or islands, usually two cells thick, with cuboidal or columnar cells sometimes in anastomosing arrangement. The final histopathological diagnosis was ameloblastic fibroma. Therefore, surgery was indicated and performed under general anesthesia, with curettage of the lesion and tooth extraction (Figure 5). AF diagnosis was confirmed. A helicoidal tomography was performed 8 months after surgery (Figure 6). The patient has been followed-up with no evidence of recurrence, and has been asymptomatic ever since (Figure 7). Figure 4 | Benign neoplasm consisting of mesenchymal tissue associated with odontogenic epithelium arranged in short and long, narrow cords or islands (H&E 200x). Figure 5 | A-C: Trans-surgical procedure: enucleation with curettage of the surrounding bone and removal of the affected tooth. D: An extracted specimen. Carvalho EM • Horikawa FK • Guimaraes L • Viveiros SK • Lemos CA • Araujo JP • Clin Lab Res Den 2015; 21 (4): 251-257 ● 255 Figure 6 | A: Five months after surgery, the patient presented symmetry. B, C: Intraoral examination revealed normal alveolar ridge and intact surface. Figure 7 | A, B: HCT coronal view shows an area of bone defect from surgery, with no evidence of lesion. C, D: HCT axial view shows a hyperdense area, suggesting a process of bone repair in the right mandible. Ameloblastic fibroma: a case report 256 ● Clin Lab Res Den 2015; 21 (4): 251-257 DISCUSSION Ameloblastic fibroma of the jaw is a benign, relatively rare, mixed odontogenic tumor, whose epithelial and mesenchymal components are neoplastic.2,4 This tumor is usually diagnosed in the first and second decades of life (72.4%), when odontogenesis is complete (80% of cases), and affects mainly the mandible.1,4 In this case, the lesion was diagnosed in the third decade of life, and occurred in the posterior region of the mandible. However, some cases of AF in the maxilla have also been reported.1,5 AF does not have a specific sign or symptom, and it is often observed in a routine radiograph, in the form of cysts and other odontogenic tumors.2 In this case, the patient never complained about the absence of his right lower molars. His chief complaint was just difficulty chewing due to the large mass of tissue in this region. Most cases of AF present painless swelling, or are discovered due to disturbances of tooth eruption. Radiographically, the tumor presents a welldemarcated radiolucency, often associated with a malpositioned tooth.2 In addition, a multilocular pattern often characterizes larger tumors (75% of the cases), and a unilocular pattern is more common in smaller lesions (up to 4 cm),6 as was this case. Differential diagnosis of AF lesions must be made, distinguishing ameloblastoma, odontogenic myxoma, dentigerous cysts, odontogenic keratocysts, central giant cell granuloma, and histocytosis.7 Histological examination of AF showed strands, cords, and islands of odontogenic epithelium in a primitive connective tissue stroma closely resembling the dental papilla. No hard tooth structures were detected in any of the primary tumors.4 Tumors with AF histomorphology may form dysplastic dentin; in this case, they are called ameloblastic fibrodentinoma.2 Some authors state that AF is a separate, specific neoplastic entity that does not develop into a more differentiated odontogenic tumor.

Fibroma ossificante central em maxila: relato de caso

Fibroma ossificante central (FOC) e neoplasia fibro-ossea benigna que foi primeiramente descrita por Menzel em 1872. O FOC tambem e chamado de Fibroma Cementificante ou Fibroma Cemento-Ossificante por apresentar um tecido fibrocelular composto de material mineralizado que microscopicamente apresenta trabeculas ou esferulas de material osseo ou cementoide em estroma de tecido conjuntivo fibroso. O FOC acomete em sua maioria mulheres, entre a segunda e quarta decada de vida, mais comumente na regiao posterior de mandibula e possui como caracteristica um crescimento volumetrico lento e indolor. Apesar de evidencias cientificas sobre a malignizacao do FOC nao terem sido encontradas, a ausencia de tratamento implica em continuo crescimento da lesao podendo levar a assimetria facial e disturbios na acuidade visual. Neste relato, nos descrevemos o caso de paciente diagnosticada com FOC em hemimaxila esquerda, atendida no servico de cirurgia e traumatologia bucomaxilofacial do Hospital Regional de Osasco “Dr.Vilvaldo Martins Simoes”, em Osasco-SP, Brasil. Descritores: Neoplasias Osseas; Fibroma Ossificante; Maxila.

The use of a bite fork to help mobilize the maxilla after downfracture during the Le Fort I osteotomy. A technical note

IntroductionThe Le Fort I osteotomy is indicated to reposition the maxilla in the surgical correction of dentofacial deformities. Although it is a known surgical step, like any surgical procedure, it can have complications and difficulties; among these, the initial mobility of the jaw is very common after completing all corticotomies.MethodsThe authors present a technique in which the bite fork is used as an auxiliary tool in maxilla downfracture, especially in cases of maxillary impaction where vertical space is created on the walls of the corticotomy.FindingsAs the bite fork acts as a scraper with a long leverage arm, an advantage would be the better distribution of forces along the corticotomy, minimizing the risk of bad fracture and facilitating maxillary downfracture movement.

Inicial nasal mucosa detachment using piezoelectric device in the Le Fort I osteotomy: A technical note

In maxillary Le Fort I type osteotomy the detachment of the nasal mucosa should be done carefully. Piezoelectric surgery contributed much to increase the safety of osteotomies, despite the initial advantage of minimizing the risk of injury in nervous tissue, mainly in bilateral sagittal split osteotomy; we use the piezoelectric device for the initial detachment of the nasal mucosa in the maxillary osteotomy.