Oral Radiology

https://doi.org/10.1007/s11282-019-00370-9

CASE REPORT

Benign osteoblastoma of the palate: a rare clinical presentation

Dhanya Mary Sam1 · Sreeja P. Kumar1 · Beena Varma1 · Anju P. David1 · Rakesh Suresh1

Received: 6 August 2016 / Accepted: 6 December 2018

© Japanese Society for Oral and Maxillofacial Radiology and Springer Nature Singapore Pte Ltd. 2019

Abstract
Osteoblastoma is a rare, benign type of osteoblastic tumor. It constitutes approximately 1% of all primary bone tumors.
Osteoblastoma most commonly affects the long bones; it very rarely affects the jaw bones. Because of its clinical and histo-
logical similarity with other bony tumors, such as osteoid osteoma and fibro-osseous lesions, osteoblastoma is a diagnostic
challenge. Very few cases of osteoblastoma involving the maxillofacial region have been reported to date. We herein describe
a 15-year-old female patient with osteoblastoma that presented as a palatal swelling of 6 months’ duration.

Keywords  Benign · Lesion · Osteoblastoma · Pain · Radiolucent · Radiopaque · Swelling

Introduction
Osteoblastoma is a rare benign osteoblastic tumor of bone.
It accounts for 1% of all bone tumors, and approximately
11% of bone osteoblastomas occur in the skull [1]. “This
lesion was first reported by Jaffe and Mayer in 1932 as an
osteoblastic osteoid tissue-forming tumor. This tumor has
also been called ‘giant osteogenic fibroma’ and ‘giant oste-
oid osteoma” [2]. Jaffe and Lichenstein termed this lesion as
“benign osteoblastoma” in 1956, which was later adopted by
the World Health Organization [2]. Osteoblastoma is most
prevalent in the second decade of life.
Most bony lesions pose a diagnostic challenge to the cli-
nician because they exhibit very close clinical, radiological,
and histological interrelations. We herein report one such
case of osteoblastoma with a rare clinical presentation and
provide a brief review of the literature.
Case report
A 15-year-old female patient presented to the Department
of Oral Medicine and Radiology with a 6-month history of
a swelling on the front region of the palate. The swelling
* Dhanya Mary Sam
dhanya16888@gmail.com
1
Department of Oral Medicine and Radiology, Amrita School
of Dentistry, AIMS Campus, Ponekkara, Kochi 682041,
India
was sudden in onset and had not changed in size since its
appearance. 1 week after the appearance of the swelling,
the patient developed pain in the upper left front teeth. The
pain was sharp, pricking, localized, and intermittent and
became aggravated during biting. She consulted a dentist
in her locality, and endodontic treatment was begun for the
involved teeth. After completion of the treatment, however,
the swelling did not decrease in size and the patient was
referred to our department. The patient’s medical history
was not contributory.
Extraoral examination revealed no significant findings.
Intraoral examination revealed a solitary ovoid swelling of
approximately 1.5 × 2.0 cm with well-demarcated borders on
the left side of the anterior region of the hard palate (Fig. 1).
The swelling was present on the anterior third of the hard
palate, 1 cm away from the region of the upper left cen-
tral and lateral incisors and 5.0–5.5 cm posteriorly, in front
of the hard–soft palate junction. The overlying mucosa and
the surrounding areas had a normal appearance. The surface
of the swelling was smooth with no signs of discharge or
ulcerations. The swelling was tender on palpation and firm
to hard in consistency. Tenderness on percussion was noted
in the associated teeth (central and lateral incisors with slight
extrusion of the lateral incisor (Fig. 2). There was no mobil-
ity of the teeth. As a part of the chairside investigation, elec-
tric pulp testing was performed in relation to the upper left
central and lateral incisors by keeping the upper right central
and lateral incisor as the control teeth. Testing revealed that
the upper left central incisor was nonvital.

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Fig. 1  Intraoral photograph with mirroring. A well-circumscribed

solitary ovoid swelling (arrows) of approximately 1.5 × 2.0 cm is seen
on the left anterior hard palate with normal overlying mucosa

Fig. 3  Intraoral periapical radiograph. An oval-shaped periapical

mixed radiolucent lesion (arrows) is shown in the middle third region
of the radicular region between the upper left central and lateral inci-
sors with a radiolucent rim. Loss of the lamina dura is evident in the
periapical region of these two teeth

Fig. 2  Intraoral photograph from the anterior view. Extrusion of the

upper left central incisor is demonstrated (arrow)

Considering the patient’s history, clinical examination

findings, and chairside investigation findings, a provisional
diagnosis of a radicular cyst of the upper left central inci-
sor and differential diagnoses of an impacted supernumer-
ary tooth and odontoma were given. Further investigations
included intraoral periapical radiographs, maxillary true
occlusal radiographs, and cone beam computed tomogra-
phy (CBCT).
Intraoral periapical radiographs of the upper left cen-
tral and lateral incisors revealed an oval-shaped periapi-
cal mixed radiopaque/radiolucent lesion of approximately
1 × 1 cm in the middle third region of the radicular por-
tion of these two teeth (Fig. 3). The lesion was well cir-
cumscribed by a radiolucent rim, and loss of the lamina
dura in the periapical regions of these two teeth was also
appreciated. A maxillary occlusal radiograph showed that
the lesion had caused divergence of the roots of the upper
left central and lateral incisors (Fig. 4). CBCT revealed
Fig. 4  Occlusal radiograph of the maxilla. Significant root divergence
of the upper left central and lateral incisors have been caused by the
lesion
a mixed hyperdense/hypodense lesion of 1 × 1 cm in the
inter-radicular region of these two teeth (Fig. 5). The sag-
ittal section revealed that the lesion was 1 mm away from
the apices of the teeth and was causing displacement of the
teeth (Fig. 6). A well-defined hypodense rim was clearly
visible on the coronal sections of CBCT (Fig. 7). Based
on the radiographic appearance and location of the lesion,
a radiographic provisional diagnosis of odontoma and a

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Oral Radiology
Fig. 5  Axial cone beam computed tomography image. A lesion of
mixed density and size of approximately 1 × 1 cm (arrows) is shown
on the palatal side of the upper left  central and lateral incisors. The
lesion extends between both of the roots with an unclear border and is
displacing the teeth
Fig. 6  Sagittal cone beam computed tomography image. Clear
demarcation of the lesion is present from the apex of the upper left
central incisor
differential diagnosis of other fibro-osseous lesions of the
maxilla were given.
Because the lesion was not very vascular and was well
circumscribed, it was excised in toto and submitted for histo-
pathological examination. Complete hemostasis and primary
closure were performed. Histopathological examination of
the specimen revealed irregular trabeculae of bone along
with areas of osteoid and woven bone in a cellular fibrous
connective tissue stroma. Large osteocytes were seen within
the trabeculae. Numerous osteoclasts (multinucleated giant
cells) were seen in lacunae in the resorptive areas of the
bony trabeculae. The fibrous stroma interspersing the bone
Fig. 7  Coronal cone beam computed tomography image. A defined
hypodense rim (arrow) is present around the lesion
Fig. 8  Histopathological (×10) magnified findings. Abundant irregu-
lar trabeculae of lamellar and woven bone are present in a highly vas-
cular fibrous stroma
trabeculae was composed of spindle- and stellate-shaped
fibroblasts with numerous small and medium-sized capil-
laries. Focal collections of multinucleated giant cells were
also seen in the stroma, close to the bony trabeculae (Fig. 8).
Based on this histopathological report, a diagnosis of
benign osteoblastoma was made. Healing was uneventful
without any swellings or other complications.
Discussion
Benign osteoblastoma rarely occurs in the jaws. Trauma,
inflammation, an abnormal local response of the tissues to
injury, and local alterations in bone physiology are some of
the reported etiologies of this tumor [3]. There are two main
clinicopathological entities of osteoblastoma: the benign and
aggressive forms. The benign form, which grows slowly
over many years and has a well-defined sclerotic margin, is
fairly well vascularized with a mild inflammatory response
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[4]. The aggressive form of osteoblastoma exhibits locally
aggressive behavior with a propensity to recur and has atypi-
cal histopathological features, often making differentiation
from low-grade osteosarcoma difficult [5]. Osteoblastomas
can also be classified as cortical, medullary, or periosteal
depending on which component of the bone is involved [6].
Those involving the jaws are either medullary or periosteal,
with the cortical variant commonly seen in extragnathic
sites [7]. Barlow et al. [8] suggested that pain is an early
symptom in patients with the cortical type of osteoblastoma
because of restriction of expansion by cortical bone and
close proximity to the periosteum, which has a rich nerve
supply. Conversely, when the tumor arises from medullary
bone, impingement on the periosteum occurs only when the
tumor becomes large in size. Pain is also an early symptom
because of prostaglandin 2 production; prostaglandin 2 is not
present in giant cell tumors, for which pain is present only
in advanced lesions [8].
Generally, this lesion affects patients in the first three dec-
ades of life, with a male:female ratio of 2:1. The patient’s
age in the present case was within the reported age range of
conventional osteoblastomas; i.e., 5–24 years, the second
decade being the most prevalent age [9]. The patient was
female, whereas the literature suggests a male predilection.
Osteoblastoma occurs more frequently in the spinal column
and long bones. Other less common sites are the bones of
the skull cap, extremities, and face [9]. Of the reported cases
of benign osteoblastoma, only 10–15% involved the jaws; of
these, the mandibular posterior region was affected in most
cases [9]. Only two cases of benign osteoblastoma have been
reported in the palate (posterior aspect) [10, 11]. Our patient
was a female with osteoblastoma of the maxillary anterior
region. Benign osteoblastoma clinically presents with slight
pain, swelling, and expansion of the bony cortex. It has a
limited growth potential and typically does not exceed 4 cm
in diameter [3]. This is consistent with our case except that
our patient exhibited no cortical expansion.
The radiographic findings of osteoblastoma are not very
consistent and vary from case to case depending on the dura-
tion of the tumor. A combination of radiopaque and radio-
lucent patterns, depending on the degree of calcification,
and the absence of perilesional sclerotic border are general
radiographic findings of benign osteoblastomas [3]. This
radiographic presentation was present in our case.
Histologically, osteoblastoma is a bone-forming tumor
characterized by osteoid and woven bone deposition and
abundant osteoblasts that are frequently in close associa-
tion with newly formed bone; these findings are consistent
with the present case. The most widely accepted treatment
for benign osteoblastoma is surgical excision. A more con-
servative approach of surgical curettage has been suggested
in the literature. Nowparast et al. [12] stated that benign
osteoblastoma has a good prognosis and is best treated by
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Oral Radiology
curettage or conservative surgical excision. Wozniak et al.
[4] in their case report involving malignant transformation
of an osteoblastoma of the mandible, suggested complete
resection with the margins located in the normal tissues as
the treatment of choice and recommend additional radio-
therapy and/or chemotherapy in more aggressive cases. The
reported recurrence rate of benign osteoblastoma is 13.6%,
which makes surgical excision of the entire tumor the main
treatment of choice because there is high chance of recur-
rence when curettage is performed [3].
Conclusion
We have herein reported an interesting case of osteoblastoma
with distinct clinical, histological, and radiographic patterns.
To the best of our knowledge, this is the first reported case of
benign osteoblastoma in the anterior maxillary region pre-
senting in a female patient. Although benign osteoblastoma
is a rare tumor, our case report suggests that it can be consid-
ered as a differential diagnosis for a swelling in the anterior
region of the maxilla mimicking a periapical pathosis.
Compliance with ethical standards 
Conflict of interest  All authors declare that they have no conflict of
interest.
Research involving human participants  All procedures followed were
in accordance with the ethical standards of the responsible committee
(institutional and national) and with the Helsinki Declaration of 1964
and later versions.
Informed consent  Informed consent was obtained from the patient.
Research involving animal rights  This article does not contain any
studies with animal subjects performed by any of the authors.
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