Traumatic Bone Cyst: Is Trauma Always the Cause or, Symptoms Always Lacking? A Case Report of an Unusual Case  

Dr. Agrawal Swapnil G.1 , Dr. Nayyar Abhishek S.2 , Dr. Panda Arun, Professor3 , Dr. Sabnis Rajesh4 , Dr. Wadhwani Ritesh5 , Abhishek Singh Nayyar6
1. Department of Oral and Maxillofacial Surgery, SD Dental College, Parbhani, Maharashtra, India
2. Department of Oral Medicine and Radiology, SD Dental College, Parbhani, Maharashtra, India
3. Department of Oral and Maxillofacial Surgery, SD Dental College, Parbhani, Maharashtra, India
4. Department of Oral and Maxillofacial Surgery, SD Dental College, Parbhani, Maharashtra, India
5. Department of Oral Pathology and Microbiology, SD Dental College, Parbhani, Maharashtra, India
6. 44, Behind Singla Nursing Home, New Friends’ Colony, Model Town, Panipat-132 103, Haryana, India
Author    Correspondence author
International Journal of Clinical Case Reports, 2015, Vol. 5, No. 30   doi: 10.5376/ijccr.2015.05.0030
Received: 09 Jul., 2015    Accepted: 10 Jul., 2015    Published: 13 Jul., 2015
© 2015 BioPublisher Publishing Platform
This is an open access article published under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Preferred citation for this article:

Dr. Agrawal Swapnil G., Dr. Nayyar Abhishek S., Dr. Panda Arun, Professor, Dr. Sabnis Rajesh, Dr. Wadhwani Ritesh and Abhishek Singh Nayyar, 2015, Traumatic Bone Cyst: Is Trauma Always the Cause or, Symptoms Always Lacking? A Case Report of an Unusual Case, International Journal of Clinical Case Reports, 5(30) 1-4 (doi: 10.5376/ijccr.2015.05.0030)

Abstract

Lucas was the first to describe traumatic bone cyst (TBC) in the year 1929 as a cyst that was unique in that it lacked a well defined epithelial lining, so could not be classed with other epithelium-lined pathologic cavities defined as true cysts. The lesion is mainly diagnosed in younger age groups with an equal distribution between males and females and with the majority of TBCs being found in the body region of the mandible in the pre-molar-molar region. The lesion is usually asymptomatic and is often discovered co-incidentally on routine radiographic examination. The definitive diagnosis of traumatic bone cyst is invariably achieved at surgery. Surgical intervention reveals a void within the bone and healing generally ensues following intervention. Herewith, we are presenting a case of a symptomatic, traumatic bone cyst that involved the body region of mandible and was with a possible idiopathic origin.

Keywords
TBC; Enucleation; Cystic lining; Scalloping effect; Unilocular radiolucency

Lucas was the first to describe traumatic bone cyst (TBC) in the year 1929. However, it is not considered a true cyst because it lacks a well defined epithelial lining. Traumatic bone cyst has been described in the literature as simple or solitary bone cyst, hemorrhagic bone cyst, extravasation cyst, progressive bone cavity and unicameral bone cyst because of a lack of comprehensive understanding of the true etiology and pathogenesis of the cyst(Arsinoi et al., 2006). The lesion mainly is diagnosed in younger age groups with no specific sex predilection. The majority of traumatic bone cysts are located in the body region of the mandible, especially in the pre-molar-molar region. The lesion is usually asymptomatic unless secondarily infected and is often discovered on routine radiographic examination. The teeth in the affected region usually are vital and there is no evidence of mobility, displacement or resorption of their roots (Howe, 1965; Hansen et al., 1974). On radiographic examination, a traumatic bone cyst usually appears as a well-defined radiolucency, the margin of the radiolucency may vary from a well-defined delicate corticated outline to ill-defined borders that blend imperceptibly with the adjacent normal bone. The boundary usually is well-defined in the alveolar processes around the teeth than in the inferior border of the body of mandible leading to a considerate "scalloping effect" extending between the roots of the teeth that is characteristic of the traumatic bone cytsts (Howe, 1965; Arsinoi et al., 2006). The definite diagnosis of a traumatic bone cyst is almost invariably arrived-at during surgery which reveals a void within the bone without epithelial lining, occasionally with blood or a scanty, serosanguineous fluid, pooling-out during exploration of the cystic lesion. The histopathological examination often remains inconclusive and reveals fibrous connective tissue and normal bone in a non-epithelialised bony cavity. A biopsy and analysis of a healing cyst may also falsely indicate the presence of a fibro-osseous lesion, ossifying fibroma or, fibrous dysplasia, because of the presence of new immature bone (Sharma, 1983). Although the treatment of the simple bone cysts of the long bones often is more aggressive and includes intra-lesional injections of steroids with or without curettage of the bony walls of the cystic void, healing generally ensues following intervention as curettage of the bony walls induces hemorrhage leading to the formation of a clot eventually getting replaced by bone during the course of healing. In some cases, spontaneous resolution of the cystic lesions without any active intervention has also been reported (Howe, 1965; Feinberg et al., 1984; Szerlip, 1966). These lesions can recur but the probability is relatively rare with only a few cases reported in the literature and in them also, fresh trauma or other confounding factors in the form of a deficient blood supply leading to a localized aberration in the normal process of bone remodeling or metabolic derangements, are more plausible explanations for the causation of the cystic lesions.

Case Report
A 29 year old male patient reported to the Department with the chief complaint of pain and swelling in lower left front tooth region of jaw since 1 month.The swelling was solitary, in mandibular left canine- premolar region, oval in shape, approximately 2cm x 3 cm in size, with well-defined margins, firm in consistency, non-tender and with no rise in local temperature. Swelling was associated with mild intermittent pain. Pain was of gradual onset, dull aching type, with no aggravating factors. Pain used to get relieved on taking over the counter (OTC) analgesics. It was not associated with fever. On examination of the teeth in close proximity to the swelling, canine and premolars were found to be non-vital. Aspiration done revealed a blood tinged, straw colored fluid from the swelling. Based on the presenting features in clinical examination, a provisional diagnosis of a radicular cyst was made. Incisional biopsy of the lesion was inconclusive so, complete enucleation of the lesion under local anesthesia was planned. Pulp therapy of 33 and 34 was performed. Patient was started on antibiotics (Augmentin, 625 mg tds and Metronidazole, 400 mg bd) a day prior to the planned surgery. With all aseptic precautions, regional anesthesia was achieved using 2% lignocaine and 1: 100000 adrenaline. Using no.15 BP blade and handle, a crevicular incision was placed from 32 to 35, with anterior releasing incision. Mucoperiosteal flap was reflected using Molt’s no. 9 periosteal elevator. The cyst had caused complete resorption of the buccal cortical plate in canine-premolar region. The peri-cystic tissue was found to be thick during surgical removal. The cystic lining on bony side was absent. Lesion was found to be involving mental nerve on that side. The nerve was detached from the lesion and complete enucleation of the lesion was performed. Peripheral ostectomy of the bony walls using large round bur was performed. Apicectomy and retrograde filling was performed with the root canal treated teeth. Complete wound debridement was done using povidone -iodine and saline solutions. Closure was achieved using 3-0 vicryl sutures. Post- operative antibiotics and anti-inflammatory drugs were prescribed for an extended period of 7 days. Post-operative healing was satisfactory. Patient experienced paraesthesia over left side of lower lip which was relieved in a month. On histopathological examination, the lesion was found to be ‘traumatic bone cyst’. There was no recurrence reported during a follow-up for one year.
Discussion
In the presented case, the clinical and radiographic features were suggestive of an infected radicular cyst while the histopathological examination revealed it to be a case of traumatic bone cyst. It was a case with a possible idiopathic origin. The etio-pathogenesis of traumatic bone cysts still remains a matter of debate as the exact etiology is still unknown and several hypotheses have been putforth but none has been sufficiently substantiated to be responsible for the pathogenesis that eventually leads to the development of a traumatic bone cyst. Trauma, however, has been recognized as one of the most frequently discussed etiological factors that lead to the development of a traumatic bone cyst as has also been proposed by Blum and Thoma although it was not found in the present case. It has been proposed that trauma leads to intra-osseous hematoma formation with subsequent clot formation that lyses in the process, simultaneously; destroying the adjacent bone by enzymatic activity according to Olech theory (Howe, 1965). Thoma also suggested that trauma initiates a subperiosteal hematoma formation compromising blood supply to the affected area, leading to osteoclastic bone resorptions, and eventual, cystic degeneration in the course of events (Arsinoi et al., 2006). Our case does correlate with the literature on aspect of age as the patient was young however other features associated with the present case did not confirm to the existing literature. The lesion was symptomatic (associated with swelling and pain) as against most of the other TBCs which are discovered co-incidentally on routine radiographic examinations aimed at with some other diagnostic interest. The radiographic findings also did not support the diagnosis. Still, the operative and histopathological findings of the case are in support of the previous literature. Trauma can be an important factor in the development of TBCs although other compounding factors including the type and intensity of the injury, the impact of trauma and the time that elapses from the time the trauma is received have to be clearly elicited before arriving at any final conclusion (Howe, 1965; Arsinoi et al., 2006). Clear, complete and detailed reporting of cases is the only way in hastening the process of a definitive diagnosis with instillation of a proper treatment. In our case, the cyst seemed to be with a possible idiopathic origin. There was no recurrence reported during a one year follow-up. Recurrence or, persistence of the lesion however is most unusual, although reported. Periodic radiographic examination should be continued until complete resolution has been confirmed. After surgical exploration, with or without curettage of the bony walls, obliteration of the defect by new bone formation is generally rapid. The prognosis also has generally been reported to be excellent.



References
Arsinoi A Xanthinaki,Konstantinos I Choupis,Konstantinos Tosios,Vasilios A Pagkalos, and Stavros I Papanikolaou,2006, Traumatic bone cyst of the mandible of possible iatrogenic origin: A case report and brief review of the literature,Head & Face Medicine,2:40
http://dx.doi.org/10.1186/1746-160X-2-40
Feinberg S.E., Finkelstein M., Page H.L., Dembo J., 1984,Recurrent traumatic bone cysts of the mandible,Oral Surg.,57:418-422
http://dx.doi.org/10.1016/0030-4220(84)90162-2
Hansen L., Sapone J., and Sproat R., 1974,Traumatic bone cysts of jaws: Report of sixty-six cases,Oral Surg.,37:899-910
http://dx.doi.org/10.1016/0030-4220(74)90442-3
Howe G.L., 1965, Haemorrhagic cysts of the mandible, Br. J. Oral Surg., 3:55-91
http://dx.doi.org/10.1016/S0007-117X(65)80011-7
http://dx.doi.org/10.1016/S0007-117X(65)80008-7
Sharma J.N., 1983,Hemorrhagic cyst of the mandible in relation to horizontally impacted third molar,Oral Surg. Oral Med. Oral Pathol.,55:17-18
http://dx.doi.org/10.1016/0030-4220(83)90299-2

Szerlip L., 1966, Traumatic bone cysts: Resolution without surgery, Oral Surg., 21: 201-204
http://dx.doi.org/10.1016/0030-4220(66)90243-X

International Journal of Clinical Case Reports
• Volume 5
View Options
. PDF(422KB)
. FPDF
. HTML
Associated material
. Readers' comments
Other articles by authors
pornliz suckporn porndick pornstereo . Dr. Agrawal Swapnil G.
. Dr. Nayyar Abhishek S.
. Dr. Panda Arun, Professor
. Dr. Sabnis Rajesh
. Dr. Wadhwani Ritesh
. Abhishek Nayyar
Related articles
. TBC
. Enucleation
. Cystic lining
. Scalloping effect
. Unilocular radiolucency
Tools
. Email to a friend
. Post a comment