120 Journal of Indian Society of Periodontology - Vol 16, Issue 1, Jan-Mar 2012

Case Report
Address for
correspondence:
Dr. Monika Goswamy,
B-206 Trimurty Apts, Opp.
Telecom Colony, Model
Town, Jaipur - 302 017,
Rajasthan, India.
E-mail: raomonikag@
yahoo.co.in
Submission: 31-03-2010
Accepted: 30-11-2011
Department of
Periodontics, Jaipur
Dental College, Dhand,
Jaipur, Rajasthan, India
Osseous choristoma of the
periodontium
Monika Goswamy, Syeda Tabasum, Praveen Kudva, Shikha Gupta
Abstract:
Osseous choristoma is a rare, benign lesion of the oral cavity occurring usually on the tongue. It appears as
a tumorous mass of normal bony structure with mature cells in an ectopic position. Some lesions represent
developmental malformations, whereas others may be reactive lesions, after trauma or chronic irritation. This is the
frst ever reported case of an osseous choristoma of the periodontium in the lingual aspect of posterior mandible.
Key words:
Choristoma, mandible, osseous, trauma
INTRODUCTION
O
sseous and cartilaginous lesions of the
intraoral soft tissues are uncommon.
Kroll and co-workers reported 24 cases of
intraoral soft tissue osseous lesions. They
favored the term, choristoma, for these lesions,
since they represented tumor like growths of
histologically normal tissue in an abnormal
location.
[1]
According to some investigators,
choristoma refers to a tumor like growth that
has developed from groups of primordial cells
located at a site remote from the original tissue or
organ.
[2]
The term osteoma is defned as a benign,
progressively enlarging, neoplasm of bone
originating from osteogenic tissue, and closely
associated with a part of the skeletal structure.
However, most investigators claim that the
biologic behavior of the lesion does not fulfll the
criteria of a true neoplasm, and there isnt a close
relation to the skeleton.
[3]
Osseous choristoma
(OC) is a rare tumor composed of normal
lamellar bone occurring at a site where bone is
not normally found.
[1]
Choristomas occur most
frequently in the tongue
[4]
and less commonly on
other sites such as buccal mucosa
[5,6]
and alveolar
mucosa.
[7,8]
The occurrence of such lesions in the
periodontium is very rare. We report a case of
an osseous choristoma which was present on the
lingual aspect of the left second premolar and
frst molar region.
CASE REPORT
A 46-year-old male reported to Postgraduate
Clinic, Department of Periodontics, Jaipur Dental
College and Hospital, Rajasthan, India, for the
evaluation of an abnormal growth on the lower
jaw [Figure 1]. He was otherwise in good health,
and his medical history and family history were
noncontributory. The patient reported that the
growth present lingually in relation to the left
second premolar and frst molar had been there
for four years. It started as a small growth, but
increased in size in the last four months. The
lesion was asymptomatic, however, the lesion
started to interfere with mastication.
Visual examination revealed a slightly elevated
mass on the lingual aspect of lower left second
premolar and first molar. Also, the patient
had bilateral mandibular tori in relation to the
mandibular second premolars. The overlying
mucosa appeared normal and the margins
were well defned. Palpation revealed a frm,
non-tender, well-circumscribed, non-motile,
and sessile mass, approximately 10 mm in
diameter. A clinical attachment loss of 12 mm
was recorded between the mandibular left
second premolar and frst molar. A mandibular
occlusal and panoramic radiograph revealed
a well circumscribed, radiopaque spherical
mass on the lingual aspect of the left side of the
lower jaw.
The differential diagnosis included a peripheral
ossifying fibroma and fibrous hyperplasia.
Removal of the mass was accomplished by
both sharp and blunt dissection under local
anesthesia. The excised mass was approximately
10 mm in diameter. The specimen was fxed in
10% formalin and submitted for histopathologic
examination. The patient was prescribed oral
amoxicillin 500 mg t.i.d (thrice daily) for seven
days. There were no postoperative complications,
and clinical and radiographic examinations, three
months postoperatively, revealed normal healed
area and no recurrence of the mass.
The pat hol ogi c speci men consi st ed of
10.80.8 cm, smooth-surfaced white tan mass
[Figure 2]. Microscopic examination showed a
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DOI:
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Journal of Indian Society of Periodontology - Vol 16, Issue 1, Jan-Mar 2012 121
Goswamy, et al.: Osseous choristoma of the periodontium
Figure 1: Tumor mass irt mandibular left second premolar and frst Molar
Figure 3: Microphotograph of the histological slide from the excisonal biopsy
Figure 2: The excised specimen
Figure 4: Microphotograph of the histological slide from the excisonal biopsy
Figure 5: Post operative at 1-year
well circumscribed mass composed of well formed lamellar
bone with Haversian canals surrounded by dense fbrous
connective tissue. Overlying epithelium was ortho-keratinized
stratifed squamous epithelium [Figures 3 and 4]. One year
follow-up showed no recurrence [Figure 5].
DISCUSSION
A choristoma (heterotopic tissue) is defned as a histologically
normal tissue proliferation or nodule of a soft tissue type not
normally found in the anatomic site of proliferation. Several
different tissue types may occur in the mouth as choristomas.
These include bone, cartilage, gastric mucosa, glial tissue, and
tumor-like masses of sebaceous glands.
[2]
However, the most
frequently observed choristomas of the oral cavity are those
that consist of bone.
[7,9]
These lesions have also been called soft
tissue osteomas, but osseous choristoma is a more accurate
term, as the lesions are not true neoplasms.
[1]
The age range for reported cases of intraoral choristomas
is between 8 and 73 years; however, the majority have been
diagnosed in women between the age of 20 and 40 years. Most
intraoral choristomas develop in the area of the foramen
caecum, but lesions have been reported in the anterior and
ventrolateral surface of the tongue; in the buccal mucosa and
the lingual alveolus of the mandible. Clinically, it develops as
a frm nodular or pedunculated lesion between 0.5 and 2.0 cm
in size. Most patients are unaware of the lesion, but symptoms
of pain, dysphagia, gagging, choking, and nausea have been
reported.
[7]
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122 Journal of Indian Society of Periodontology - Vol 16, Issue 1, Jan-Mar 2012
Goswamy, et al.: Osseous choristoma of the periodontium
Since the intraoral choristoma is rare, most such lesions are
misdiagnosed as other soft tissue tumors. The differential
diagnosis for intraoral choristoma depends on the location of
the lesion. When lesion is located near the foramen caecum,
lingual thyroid nodule must be considered. Hyperplastic
lingual tonsil and salivary gland neoplasm should also be
included in the differential diagnosis. When the lesion is
located in the anterior and lateral aspect of the tongue, fbroma,
granular cell tumor, and neural tumor should be considered.
Lesions on the ventral surface of the tongue may resemble
salivary gland neoplasms, mucous retention phenomena,
lipomas, neural tumors. OCs of the tongue are mostly
asymptomatic, although some patients may present symptoms
of pain, dysphagia, foreign body sensation, throat irritation,
snoring, nausea, and compromised tongue mobility.
[1,2]
When the lesion is located on the alveolar ridge, peripheral
giant cell granuloma or fbrous hyperplasia should be included.
In the differential diagnosis, when the lesion is pedunculated
and has a verrucal surface, it may clinically resemble a
papilloma.
[7]
Although there are various theories regarding the etiology
of OCs, their exact origins remain unknown and both
developmental and trauma origins have been reported.
Ossification of branchial arch remnants, ossified calcified
lymphatic tissue, and remnants of the thyroid gland have all
been suggested as possible etiologies.
[1,2,5,7]
In the case reported
here, trauma is considered a possible etiological factor.
Histologically, the intraoral choristoma consists of a
well- circumscribed mass of viable lamellar bone with a
well-developed Haversian canal system, a well-developed
mass of viable cartilage, or a mixture of bone and cartilage
surrounded by dense fbrous connective tissue. Occasionally,
hematopoietic or fatty marrow has been reported in the
osseous lesions. Osteoblastic or osteoclastic activity is rarely
present.
[7]
Unilateral intraoral masses may be attributed to a number of
pathological conditions of various origins. In the differential
diagnosis of the present case, peripheral ossifying fbroma,
heterotopic ossifcation, and torus were considered.
Peripheral ossifying fbroma (POF) can arise from mesenchymal
cells of periodontal ligament which are capable of producing
hyperplasia. Pluripotent cells of periodontal ligament transform
or metaplastically change in osteoblasts, cementoblasts, and
fbroblasts. POF must be associated with gingival tissue and
diagnosis cannot be used for lesion at other oral sites. Shepherd
reported this entity as alveolar exostosis in 1844. It is a painless,
hemorrhagic, lobulated mass of gingiva, or alveolar mucosa
with large layers of ulceration. Early lesions are irregular and
red, but older lesions have smooth salmon pink surface and
are indistinguishable from irritation fbroma. POF are 1-2 cm
in size and can enlarge up to 4 cm. Early growth is rapid, and
occasionally, multiple lesions can occur. Microscopically,
submucosal proliferation of primitive, oval mesencymal cells
in the hall mark of POF. Islands and trabaculae of woven or
lamellar bone with osteoblastic rimming surrounded by chronic
infammatory cells can be seen. POF is exclusively found on
alveolar bone surface. No cartilage or marrow is produced by
POF. Whereas OC shows submucosal proliferation of normal
mature bone or cartilage embedded in fbrovascular stroma
with psuedoencapsulation. Lamellar bone with fatty marrow
can be present.
[10]
Heterotopic ossifcation shows plump fbroblasts and reactive
bone with osteoblastic rimming and is usually present in the
muscle.
[11]
A possibility of multiple tori was thought. But a torus
arises from the bone which was not seen in our case.
The intraoral choristoma is treated by means of surgical
excision. In most cases with follow-up, recurrence has not
been reported. Similarly, in the presented case, there was no
recurrence after one year of follow-up [Figure 5].
The lesion reported here is a rare type of Osseous choristoma
and is the frst ever reported case of OC originating from the
periodontium. The number of reported cases is insuffcient, to
completely describe OC. In order to increase awareness and
knowledge regarding OC, new case reports should include
clinical, radiographic, and histological fndings and follow-up
reports.
REFERENCES
1. Krolls SO, Jacoway JR, Alexander WN. Osseous choristomas
(osteomas) of intraoral soft tissues. Oral Surg Oral Med Oral
Pathol 1971;32:588-95.
2. Chou LS, Hansen LS, Daniels TE. Choristomas of the oral cavity:
A review. Oral Surg Oral Med Oral Pathol 1991;72:584-93.
3. Vered M, Lustig JP, Buchner A. Lingual osteoma: A debatable
entity. J Oral Maxillofac Surg 1998;56:9-13.
4. Van der Wal N, Van der Waal I. Osteoma or chondroma of the
tongue; a clinical and postmortem study. Int J Oral Maxillofac
Surg 1987;16:713-7.
5. Long DE, Koutnik AW. Recurrent intraoral osseous choristoma.
Report of a case. Oral Surg Oral Med Oral Pathol 1991;72:337-9.
6. Gaitn-Cepeda LA, Quezada-Rivera D, Ruz-Rodrguez R.
Osseous choristoma of the oral soft tissue. Case report. Med Oral
2003;8:220-3.
7. Tohill MJ, Green JG, Cohen DM. Intraoral osseous and
cartilaginous choristomas: Report of three cases and review of
the literature. Oral Surg Oral Med Oral Pathol 1987;63:506-10.
8. Sheridan SM. Osseous choristoma: A report of two cases. Br J Oral
Maxillofac Surg 1984;22:99-102.
9. Shimono M, Tsuji T, Iguchi Y, Yamamura T, Ogasawara M,
Honda T, et al. Lingual osseous choristoma. Report of 2 cases. Int
J Oral Surg 1984;13:355-9.
10. Buchner A, Hansen LS. The histomorphologic spectrum of
peripheral ossifying fbroma. Oral Surg Oral Med Oral Pathol
1987;63:452-61.
11. Vencio EF, Alencar RC, Zancope E. Heterotopic ossifcation of
anterior maxilla. J Oral Pathol Med 2007;36:120-2.
How to cite this article: Goswamy M, Tabasum S, Kudva P,
Gupta S. Osseous choristoma of the periodontium. J Indian Soc
Periodontol 2012;16:120-2.
Source of Support: Nil, Confict of Interest: None declared.
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