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Idiopathic bone cavity of the mandible

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Case 17181

Idiopathic Bone Cavity of the Mandible

Published on 22.03.2021

DOI: 10.35100/eurorad/case.17181 ISSN: 1563-4086

Section: Musculoskeletal system

Area of Interest: Bones Head and neck Case Type:

Clinical Cases

Authors: Dima Al Jahed, MD1,2, Gerd Jacomen, MD3, Didier Dielen MD4, Filip Vanhoenacker, MD, PhD2,5,6 Patient: 14 years, male

Clinical History:

A 14-year-old male patient presented to the department of maxillofacial surgery for further work-up of a radiolucent lesion within the left mandible, which was incidentally found on a routine panoramic radiograph. There is a history of trauma from a previous fall on the chin 5 years prior to the current admission.

Imaging Findings:

Cone Beam Computed Tomography (CBCT) showed a unilocular, well-defined radiolucent lesion with thin sclerotic margins in the body of the mandible (Fig. 1A, B). The lesion had a slight polylobular morphology and caused thinning of the buccal and lingual cortex. Although there was an intimate relationship with the apex of tooth 43, erosion was absent (Fig. 2B).

Fat-suppressed (FS) T2-weighted MR images demonstrated a hyperintense, well-delineated lesion with slight polylobular margins in the median aspect of the mandible body (Fig. 3A,3B).

Coronal T1-weighted MR images before (Fig. 3C) and after (Fig. 3D, 3E) intravenous gadolinium contrast injection showed subtle peripheral rim enhancement.

Discussion:

Idiopathic Bone Cavity (IBC) or Simple Bone Cyst (SBC) is a benign intraosseous cavity of unknown aetiology, frequently observed among young adults [1-5].

IBC is a pseudocyst as it lacks epithelial lining and is either empty or filled with serous or sanguineous fluid and is therefore sometimes designated as a “haemorrhagic bone cyst”. IBC is also referred to as Traumatic Bone Cyst because association with trauma has been reported in some cases with symptoms including pain, tooth sensitivity and paraesthesia. However, in most cases, the lesion is asymptomatic with inapparent traumatic events and is incidentally discovered on radiographs performed for dental purposes [1,4].

It is important to distinguish IBC from more worrisome odontogenic lesions. The main imaging modalities are panoramic radiography and (CBCT), and in selected cases, Magnetic Resonance Imaging (MRI) may be helpful for further characterisation and additional information regarding soft tissue extension [2,3,4].

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The typical radiographic appearance of IBC is a radiolucent and unilocular lesion with well-circumscribed borders, expanding between the roots of teeth, with no or slight cortical expansion. The corpus of the mandible is the most frequently affected area. Despite its potential expansile nature, teeth displacement or root resorption are rare, and the lamina dura is usually intact or only partly disrupted [1-4].

(CB)CT scan usually demonstrates a central, well-defined, mildly expansile or nonexpansile, thin-walled lytic lesion, with little or no marginal sclerosis.

MRI usually confirms the cystic nature of the lesion by showing its fluid content. Fluid-fluid levels are rarely seen in non-complicated lesions. However, fractured IBCs may contain blood products and fluid-fluid levels. On MRI, the lesion shows low signal intensity on T1-weighted images, and high signal intensity on T2-weighted or Short Tau Inversion Recovery (STIR) images [1-4].

The above described radiological features are pathognomonic and usually sufficient to establish the diagnosis of IBC without any need for further invasive assessment. However, in rare cases, clinical imaging is in conclussion necessitating histopathological examination of biopsy specimens to reach a final diagnosis and distinguish the lesion from other radiolucent lesions of the jaws [1,2,4]. Histological examination in our case revealed the absence of epithelial lining.

IBC is mostly a self-limiting benign lesion that heals spontaneously after skeletal maturity. Therefore, a short-term follow up would mostly be the best approach and unnecessary extensive surgical intervention should be avoided.

Symptomatic cases could warrant a limited exploration and curettage with appropriate follow-up. The overall prognosis is excellent [1-5].

Written informed patient consent for publication has been obtained.

Differential Diagnosis List: Idiopathic Bone Cavity, Aneurysmatic bone cyst, Ameloblastoma, Odontogenic keratocyst (OKC), Radicular cyst

Final Diagnosis: Idiopathic Bone Cavity References:

Bernaerts A, Vanhoenacker FM, Hintjens J, Chapelle K, Salgado R, De Foer B, et al (2006). Tumors and tumor-like lesions of the jaw: radiolucent lesions. JBR-BTR 89(02):81–90 (PMID: 16729445)

Avril L, Lombardi T, Ailianou A, Burkhardt K, Varoquaux A, Scolozzi P, et al (2014). Radiolucent lesions of the mandible: a pattern-based approach to diagnosis. Insights Imaging 5(01):85–101 (PMID: 24323536)

Dunfee BL, Sakai O, Pistey R, Gohel A (2006). Radiologic and pathologic characteristics of benign and malignant lesions of the mandible. Radiographics 26(06):1751–1768 (PMID: 17102048)

Bali A, Vanhoenacker FM, Vanhoenacker C, Bernaerts A (2020). Semin Musculoskelet Radiol 24(5):549-557. doi:

10.1055/s-0040-1705118 (PMID: 33036042)

Dekeyzer S, Vanhoenacker FM, Chapelle K Idiopathic bone cyst of the mandible (2010). JBR-BTR. 93(3):132–3.

DOI: http://doi.org/10.5334/jbr-btr.239 (PMID: 20726359)

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Figure 1

a

Description: Panoramic reformatted CBCT image shows a well-defined radiolucent lesion on the midline in the mandible (white arrows) with associated cortical thinning. Origin: © Department of Radiology, General Hospital Sint-Maarten, Mechelen, Belgium, 2020

b

Description: Lateral scout view of the CBCT shows a well-defined lesion in the mandible (white arrow).

Origin: © Department of Radiology, General Hospital Sint-Maarten, Mechelen, Belgium, 2020

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Figure 2

a

Description: CBCT axial image shows a well-defined, mildly expansile lesion in the body of the mandible causing thinning of the lingual (black arrow) and buccal cortex (white arrow).Origin:

© Department of Radiology, General Hospital Sint-Maarten, Mechelen, Belgium, 2020

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b

Description: CBCT sagittal reformatted image demonstrates a well-defined radiolucent lesion (white arrow) involving the body of the mandible causing thinning the lingual (black arrow) and buccal cortex (white arrow). There is intimate relationship with tooth 43 without apex erosion. Origin: © Department of Radiology, General Hospital Sint-Maarten, Mechelen, Belgium, 2020

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Figure 3

a

Description: Axial T2-weighted magnetic resonance imaging (MRI) demonstrates an unilocular, well- defined hyperintense lesion in the mandibular body (white arrow). Origin: © Department of Radiology, General Hospital Sint-Maarten, Mechelen, Belgium, 2020

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b

Description: Coronal fat-suppressed T2-weighted magnetic resonance imaging (MRI) demonstrates a well-defined hyperintense lesion in the mandibular body (white arrow). Origin: © Department of Radiology, General Hospital Sint-Maarten, Mechelen, Belgium, 2020

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c

Description: Coronal T1-weighted MR image shows a well-defined hypointense lesion in the mandibular body (white arrow). There is a slight polylobular morphology. Origin: © Department of Radiology, General Hospital Sint-Maarten, Mechelen, Belgium, 2020

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d

Description: Coronal fat-suppressed T1-weighted MR image after intravenous gadolinium contrast administration shows a subtle peripheral rim enhancement (white arrows). Origin: © Department of Radiology, General Hospital Sint-Maarten, Mechelen, Belgium, 2020

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e

Description: Coronal T1-weighted subtraction MR image of the images before and after contrast administration shows a subtle peripheral rim enhancement (white arrows). Origin: © Department of Radiology, General Hospital Sint-Maarten, Mechelen, Belgium, 2020

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