MANDIBULAR IDIOPATHIC OSTEOSCLEROSIS OR CONDENSING OSTEITIS. A CASE REPORT

Headnote

Abstract

Idiopathic sclerosis is described as a radiopacity condition with unclear origin, of different shape and size, not associated with pathologic conditions of dental pulp, inflammatory and neoplastic process. Condensing osteitis is characterized by periapical bone formation. Such bone changes could be found accidentally on radiographic examination. The aim of the present case report refers to a female patient with radiopacity lesion of mandible in the left premolar region with clinical manifestations - tension and pain on percussion, caused by the lower second premolar. The surgical protocol includes bone lesion removal and apicoectomy of the lower left second premolar, followed by pathohistological examination. Clinically, this condition resembled condensing osteitis, pathohistological results showing idiopathic sclerosis changes. The postoperative period produced no complications.

Keywords: enostosis, osteosclerosis, apicoectomy, treatment.

1.INTRODUCTION

Idiopathic sclerosis is described as a radiopacity condition with unclear origin, of different shape and size, not associated with the pathologic condition of dental pulp, or with inflammatory and neoplastic processes [1]. Most commonly, the female sex is affected, with mandible localization (premolar and molar region) [2]. Rarely, subjective complaints, such as pain due to inferior alveolar nerve compression, could be observed. Condensing osteitis is another condition characterized by periapical bone formation, observable in vital teeth in association with occlusal trauma, pulp and periapical inflammation, localized bony reaction to low-level inflammatory factors [3,4]. Condensing osteitis is a radiopacity condition associated with chronic inflammation. It is a uniform, dense mass close to the tooth apex with well-defined borders and loss of lamina dura apically and widening of the periodontal ligament [5,6]. Condensing osteitis is localized mainly in the first lower molar, followed by the second lower molar [7]. The diagnosis of condensing osteitis is based on clinical and radiographic characteristics, the treatment of choice being root canal treatment [8]. When the lesion is symptomatic, the treatment protocol includes conservative endodontic treatment or tooth removal [7].

The aim of the present case report refers to a female patient with radiopacity lesion of mandible in the left premolar region with clinical manifestations - tension and pain on percussion, caused by the lower second premolar, to which a diagnostic and a treatment are proposed.

2.MATERIALS AND METHODS

Case Report

A 35 year-old female patient referred to the Department of Oral Surgery, Faculty of Dental Medicine, Medical University - Plovdiv, Bulgaria. The chief complaints are pain during mastication and tension in the left lower jaw side since 2 weeks. The pain relieves by analgesic drugs. No data of systemic disorders. On extraoral examination no facial facial asymmetry was revealed. Intraoral examination evidenced intact lower left second premolar, mild to moderate pain on percussion and pain on palpation in the periapical region. After clinical examination, a small periapical radiograph is prescribed, which revealed radiopacity sclerotic mass with welldefined borders associated with the apex of the lower left second premolar. There are no other radiological findings.

The informed consent was signed by the patient. For effective root canal treatment uses conventional endodontic instruments - hand files up to size 30, irrigation protocol with 2.5% sodium hypochlorite NaOCl, 40% citric acid and final root canal obturation carried out with a bioceramic-based root canal sealer (Fig. 1).

Mandibular nerve block in combination with terminal infiltration anaesthesia containing 4% articaine hydrochloride, 1:100 000 epinephrine is performed, followed by trapezoidal flap reflection after one horizontal and two vertical releasing incisions without gingival sulcus involvement, bone cutting with conventional rotatory instruments, root apical resection (Fig. 2).

The bone material is taken over for biopsy. The full-thickness mucoperiosteal flap is replaced in initial position, single interrupted sutures with non-resorbable suture material being done. Histopathological examination (BN 26743/26.11.19) revealed lamelar bone tissue and bone enostosis, but no inflammatory process. The patient is asymptomatic several days after operation. Postoperative radiography 2 months later showed a normal radiographic aspect (Fig. 3).

3.RESULTS AND DISCUSSION

Idiopathic mandibular osteosclerosis, also known as mandibular enostosis, is a region of increased bone. More commonly, the shape should be round or elliptical, without bone expansion. Other names of these disorders are bone island, bone scar, focal periapical osteopetrosis, etc. The frequency rate of idiopathic sclerosis in Bulgarian population does not exceed 4% [2]. Sisman, Ertas, Ertas et al. [9], who investigated 2,211 patients, i.e. 2,211 ortopantomography cases, determined a frequency of 6.1% (135 patients), more prevalent in the lower jaw, and affecting mainly the molar periapical region. The study conducted by Solanki, Jain, Singh et al. [10] revealed that idiopathic osteosclerosis affects mainly females, compared to males, occurring between the third and fourth decade. Our case appeared in the fourth decade. Differential diagnosis includes osteoma, focal cemento-osseous dysplasia, ossifying fibroma, cemento-ossifying fibroma, osteogenic sarcoma, multiple myeloma with osteosclerosis, aneurysmal bone cyst, sialolithiasis, etc. [11-14]. Radiographically, the main difference between idiopathic osteosclerosis and condensing osteitis is that idiopathic osteosclerosis is visible by welldefined borders with non-clear transition to the adjacent bone, while condensing osteitis has illdefined borders [15]. We noticed controverse conclusions in literature. For example, Ledesma, Jimenez-Farfan, Hernandez [16] considered that idiopathic osteosclerosis in the maxillomandibular area has well-defined borders, in 21% of cases being characterized by ill-defined borders. These conditions require different treatment approaches - conservative endodontic treatment, tooth extraction, apical resection. More numerous asymptomatic cases are needed for check-up [17]. Our case is similar to that presented by Ozcan and Uyar [18], that of a 21 year-old male patient with condensing osteitis of the lower left first premolar, for which they suggested apicoectomy, followed by biopsy. In some cases, condensing osteitis caused pathologies such as root resorption, tooth impaction and tooth displacement [19,20].

4.CONCLUSIONS

The present clinical case showed the paramount importance of medical history, clinical and paraclinical examination (radiography and biopsy) for a proper diagnosis of localised changes in the lower jaw bone structure, revealing that apical surgery is considered a safe procedure to preserve the teeth with clinical manifestation and well-defined radiopacity lesion.

References

References

1. Tolentino ED, Gusmao PH, Cardia GS et al. Idiopathic Osteosclerosis of the Jaw in a Brazilian Population: a Retrospective Study. Acta Stomatol Croat. 2014; 48(3):183-92.

2. Ugrinov R. Tumors in maxillofacial and cervical regions. Sofia: Kiwi; 2009..

3. Rodrigues P, Mendes J, Delgado A, Rua J, Guerreiro E, Simöes C, Lopes A, Dionisio T, Xavier I. Condensing osteitis in the diagnosis consultation at Egas Moniz University Clinic. Ann. Med. 2019; 51(Supp1): 129. doi:10.1080/07853890.2018.1562738

4. Pechalova P. Introduction to oral surgery. Plovdiv: Medical University; 2016.

5. Miloglu O, Yalcin E, Buyukkurt M-C et al. The frequency and characteristics of idiopathic osteosclerosis and condensing osteitis lesions in a Turkish patient population. Med Oral Patol Oral Cir Bucal. 2009;14(12):640-5.

6. Dukić W, Filipović-Zore I, Bago I. Condensing Osteitis - Case Report. Acta Stomatol Croat. 2006;40(2):182-8.

7. Holly D, Jurkovic R, Mracna J. Condensing osteitis in oral region. Bratisl Lek Listy. 2009; 110(11): 713-715.

8. Silva BSF, Bueno MR, Yamamoto-Silva FP, Gomez RS, Peters OA, Estrela C. Differential diagnosis and clinical management of periapical radiopaque/ hyperdense jaw lesions. Braz Oral Res. 2017;31:e52. doi: 10.1590/1807-3107BOR-2017.vol31.0052.

9. Sisman Y, Ertas ET, Ertas H, Sekercid AE. The Frequency and Distribution of Idiopathic Osteosclerosis of the Jaw. Eur J Dent. 2011; 5(4) :409-14.

10. Solanki J, Jain R, Singh R, Gupta S, Arya A, Tomar D. Prevalence of Osteosclerosis Among Patients Visiting Dental Institute in Rural Area of Western India. J Clin Diagn Res. 2015;9(8):ZC38-40.

11. Mihaylova Hr, Stanimirov P. Craniofacial Localization of Multiple Myeloma - A Case Report. Int J Sci Res. 2013;4(3):988-91.

12. Mihaylova Z, Stanimirov P, Aleksiev E. Aneurysmal bone cyst of the mandible, mimicking follicular cyst. Medinform J Med Dent Sci. 2019;6(1):987-91.

13. Atanasov D. Sialolithiasis or complex odontoma? Folia Med (Plovdiv). 2003;45(2): 46-7.

14. Bhandari R, Sandhu SV, Bansal H, Behl R, Bhullar RK. Focal cemento-osseous dysplasia masquerading as a residual cyst. Contemp Clin Dent. 2012; 3(Suppl1):S60-2.

15. Shintaku W. Bony Lesions. In: Migliorati C, Panagakos F, eds. Diagnosis and Management of Oral Lesions and Conditions. Rijeka: IntechOpen;2014. pp. 27-42.

16. Ledesma-Montes C, Jimenez-Farfan MD, Hernandez-Guerrero JC. Idiopathic osteosclerosis in the maxillomandibular area. Radiol. Med. 2019;124(1):27-33.

17. Jain PG, Nair P, Choudhary PJ, Sathe R, Sood M, Agra K. Sclerosing Lesions of the Jaw Bones: a Prevalence Study in Bhopal Population. Int J Recent Sci Res. 2018;9(4):25764-9.

18. Ozcan E, Uyar HA. Unusual treatment of symptomatic condensing osteitis related to mandibular premolar teeth: a case report. Cumhur Dent J. 2012;15(4):340-3.

19. Ustad F, Alwadai GS, Ali FM. A Rare Case of Condensing Osteitis Associated with Root Resorption. J Int Oral Health. 2016; 8(1):140-2.

20. Oshima S, Suzuki J, Yawaka Y. Idiopathic osteosclerosis in the mandible associated with abnormal tooth root formation. Pediatr Dent. J. 2010;20(1):91-4.