Swollen Face

Group E
MIND: A Classification System for Jaw Pathoses
 CLINICAL
DIFFERENTIATION
 Inflammatory swellings
Inflammation can be due to

● Extrinsic/external factors: radiation and

chemical agents lead to inflammatory
lesion (osteoradionecrosis and
osteochemonecrosis)
● Reactive lesion: in response to chronic
irritation (central giant cell granuloma and
aneurysmal bone cyst) Inflammatory jaw swellings include abscesses,
● Infections: Intraosseous lesions caused osteomyelitis, fascial space infections, periodontal
3

by infections in the oral cavity (bacterial infections . Abscesses may be classified

anatomically into pericoronitis (pericoronal
infections) abscesses), periodontal abscess, gingival abscess,
● Immunologic origin: rheumatoid arthritis
4

and periodontal-endodontic abscess . Jaw swellings

presented as a chronic disorder of TMJ of inflammatory origin are considered dental
5

emergencies . They may be life-threatening in some

disorder 6,7

cases if not promptly and adequately manage

 Tumour swellings
Risk and contributing factor:
•Tobacco
•Alcohol
•Betel quid/pan chewing
•Viruses
•Candida albicans
•Genetic susceptibility
•Potentially malignant disorders
•Nutrition
History taking
 Inflammatory Tumor Cyst

Duration ● Shorter duration and
painful: acute
● Longer duration with
slight pain: chronic
inflammation
● Longer duration without
pain: benign
● Shorter duration without
pain: malignant
● Shorter duration and
can be painful:
inflammatory cysts
● Longer duration with
early asymptomatic
characteristic:
developmental cysts

Mode of onset Developed spontaneously ● Noticed casually and ● Developmental cysts:

and grown rapidly with severe swelling was gradually unknown
pain increasing in size ● Inflammatory cysts:
multiple factors
occurring due to
inflammation

Nature of pain Pain precede swelling Swelling precede pain Swelling precede pain

Fever Associated with fever Not associated with fever Not associated with fever

Progress of the Decreased in size ● Slow progress: benign Increased in size

swelling ● Fast growth: malignant
Local Examination
Inspection-
 Inflammatory Tumor Cyst

Skin over the Red & edematous Tense, glossy with ● Expansion of
swelling venous prominence: bone may result
sarcoma with rapid in facial
growth asymmetry
● Soft and
translucent
swelling in
some cases

Cardinal signs of inflammation

1. Calor (Heat)
2. Rubor (Redness)
3. Dolor ( Pain)
4. Tumor (Swelling)
5. Loss of function
Local Examination
Palpation -
 Inflammatory Tumor Cyst

Temperature Local temperature raised due Local temperature raised No changes.

to infection due to well vascularized
tumour

Tenderness Tender Not tender Not tender

Surface ● Smooth Irregular and rough Round and Smooth

● Osteomyelitis: nodular
surface

Edge ● Acute inflammatory Benign growth: Well ● Well-defined

swellings: ill defined or defined margins margins.
indistinct margins Malignant growth: irregular ● Margins will yield
● Chronic inflammatory margins to the pressure of
swellings: well defined the finger and will
margins not slip away

Consistency Brawny bilateral induration of ● Stony hard- Cystic (contains liquid)

upper neck: Ludwig’s angina carcinoma
● Variables in
consistency indicates
malignancy
General Examination
Inflammatory Tumour Cysts

● Give idea about site ● Essential in some

of metastasis cases
● Might help in
diagnosing Nevoid
Basal Cell Carcinoma
Differential Diagnosis
 Ameloblastoma
Justification
● Between the age of 20-60 years
● 80%-85% occur in the mandible, molar
region
● Slow growing, bony hard swelling
● Facial asymmetry
● Buccal and cortical bone expansion
● Resorption of roots adjacent to tumour,
clinically missing teeth.
● Large lesions may present with mobile
teeth, pain and paresthesia.
 Differential Diagnosis: Odontogenic
Keratocyst (OKC)
Justification:
• Swelling is located in the mandibular
posterior region
• Large OKC are associated with swelling
and pain
• OKC enlarges in an anteroposterior
direction within the bone, however it
does not cause cortical plate expansion
 Calcifying Epithelial Odontogenic Tumor
(CEOT)
Justification
• Between 30 and 50 years of age
• No sex predilection
• Most commonly found in
mandibular posterior areas
• Painless and slow growing swelling
• Oftenly found around crown of
impacted tooth
 Odontogenic myxoma
Justification
• Between ages 23-30 years
• No sex predilection
• slight predilection for
occurrence in mandible
• Pain may be present and slow
growing swelling
• tumor maybe associated with
missing or embedded teeth
 Dentigerous Cyst
● Large DC / Painless
● Occurs in lower posterior region -
may be associated with impacted 8
● Clinically missing 37 & 38
● Bony expansion

- Age: 10-30 (pt age 55)

- Male predominance (pt is female)
Provisional Diagnosis
AMELOBLASTOMA

Age 55 years old (3rd-7th decades)

Site Most common in mandible

Clinical features 1. Slow growing

2. Expansion of jaw
3. Smooth surface
4. Paresthesia (uncommon but can be)

Intraoral examination
5. Ill defined swelling
6. Non tender and hard on palpation
7. Buccal and lingual cortical plate expansion
VIGNETTE TWO
Radiographic Differential Diagnosis
Ameloblastoma

• Occurs in mandible, most often in molar-ascending ramus area

• Multilocular lesion having a “soap bubble” or “honeycombed” - correlates with the
case, which states that the lesion is a multilocular radiolucency
• Buccal and lingual cortical expansion
• Resorption of roots of teeth adjacent to
the tumour is common
• Unerupted tooth (mandibular 3rd molar) is
usually associated with the radiolucency
Odontogenic keratocyst

• Mandible is predominantly affected, with marked tendency to involve

posterior body and ramus - this correlates with the case, which occurs in
left body and ramus of mandible
• Demonstrates a well-defined radiolucent area with smooth and often
corticated margins - large lesion appear as a multilocular radiolucency
• Unerupted tooth is involved in some cases
• Tend to grow in an anteroposterior direction
within medullary cavity of the bone
without causing obvious bone expansion
• In this case, there was buccal and lingual
cortical expansion, which is not seen in OKC
Hence, OKC is ruled out
Odontogenic myxoma

• Can appear as a unilocular or multilocular radiolucency (tennis racket-

like/step ladder-like pattern) - correlates with the case, which is a
multilocular radiolucency (pattern was not mentioned in the case)
• Affects mandible more often - usually premolar and molar region, rarely in
ramus region - lesion in this case
occurs in body and ramus region
• Ruled out as odontogenic myxoma
occurs more often between age
25 to 30 years
Aneurysmal bone cyst

• Mandible affected more often - molar/posterior body and ramus region more
involved - correlates with the case, which occurs in body and ramus region of
mandible
• Marked cortical expansion - correlates with the lesion in this case (buccal and
lingual expansion)
• Ruled out as it occurs in young patients
(peak in 2nd decade)
Brown tumor of hyperparathyroidism

• Appear as well demarcated unilocular or multilocular radiolucency

• Commonly affect mandible, clavicles, ribs and pelvis
• Long standing lesion may produce significant cortical expansion
• Ruled out as there is no hemorrhage and hemosiderin deposition
within the tumor
Histological features noted in the photomicrograph.
1. Island of epithelium resemble enamel
organ epithelium in a mature fibrous
connective tissue stroma.
2. The epithelial nest consist of a core of
loosely arranged angular cells resembling
the stellate reticulum of enamel organ.
3. A single layer of tall columnar ameloblast
like cells surrounds this central core.
4. The nuclei of these cells are located at the
opposite pole to the basement membrane-
reverse polarity.
5. In other areas , the peripheral cells may be
Follicular pattern of ameloblastoma
more cuboidal and resembles basal cells.
Diagnosis - Ameloblastoma (follicular)
• Swelling since
2 years
• Non-tender
• Hard on
palpation &
consistency
• Mandibular
posterior
region
 Multilocular radiolucent lesion

Buccal & lingual cortical expansion

Resorption of roots of adjacent to

the tumor (missing 37 & 38)

● Central core : loosely arranged cells

resembling stellate reticulum
● Peripheral cell : single layer tall columnar
ameloblast-like cells
 SURGICAL MANAGEMENT

• Radical and conservative surgical excision

• En bloc resection
• Segmental resection
• Curettage
• Chemical and electrocautery
• Chemotherapy
• Radiation
 Curettage
• Removal of tumor by scraping it
from surrounding normal tissues
• Least desirable form of therapy
• Extension of tumor nests
beyond the clinical and
radiographic margins of the
lesion may lead to failure of the
treatment
En bloc resection
• Removal of tumor with a rim of
uninvolved bone safe margin
but maintaining continuity of
jaw
• Tumor tissue does not invade
the haversian system of
compact bone (mandible can be
eroded but less likely to be
invaded)
Segmental resection
• Hemimaxillectomy and
hemimandibulectomy is the
most commonly used
treatment
• Have had the least number of
recurrence
• If pathologist examination
establishes the mass as
ameloblastoma that has not
penetrated the basement
membrane, no further
surgery is done

• If the lesion has penetrated

the basement membrane
more the bone should be
removed with curettage

• In all cases, periodic follow-

up is always indicated