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The described bone expansion and perforation of bone are typical of the behavior of a neoplasm, including a neoplasm of tooth origin such as an odontogenic myxoma. The age of the patient, however, is not consistent given that odontogenic myxomas rarely occur after 50 years of age. Nonetheless, odontogenic myxoma should be placed high on the differential diagnosis. The histology of this case is not supportive of an odontogenic myxoma.
Odontogenic myxoma occurs in the jaw bones, usually in the tooth-bearing areas of the jaw. It is an uncommon, benign, but locally aggressive neoplasm. Nearly all cases so far have been described in the jaw bones. Therefore, it is of tooth origin, and is believed to be from the mesenchymal portion of a tooth germ, most likely of the dental papilla. It has the potential for extensive bony destruction and extension into the surrounding structures. It is less common than odontomas and ameloblastomas. For that reason, a pathologist who is not familiar with the histology of a tooth germ can mistake a myxoid dental follicle for an odontogenic myxoma. Almost 75% of odontogenic myxomas occur in patients around 23-30 years of age with a slight female predilection (1:1.5 male-to-female). It rarely occurs in patients over 50 or under 10 years of age. It occurs almost equally in the maxilla and mandible with a slight predilection for the posterior mandible. A few cases are described in the ramus and condyle, non-tooth bearing areas.
Odontogenic myxoma is slow growing, persistent and destructive. Most cases are expansile and can displace and resorb teeth. In the maxilla, they usually invade the maxillary sinuses and at times (though rarely) cross the midline to the opposing sinus. Radiographically, the majority present as expansile and multilocular, though some are unilocular with or without scalloped borders, and rare cases present with a diffuse and mottled appearance which can be mistaken for a malignant neoplasm. Grossly, this lesion is gelatinous in nature, making curettage alone difficult; the more fibrotic odontogenic myxomas (also known as odontogenic myxofibroma or fibromyxoma) have more body and are easier to curette. Histologically, it is made up of loose and delicate fibrous connective tissue. The fibroblasts are stellate and are suspended on a delicate network of collagen fibrils. Immunohistochemistry studies suggest that the spindle-shaped cells constituting this neoplasm have a combined fibroblastic and smooth muscle typing, suggesting that it is of myofibroblastic origin. Small blood vessels are present, as are small odontogenic epithelial islands on occasion. Sometimes, this lesion is fibrotic, making it easier to curette. The treatment of choice is surgical excision ranging from segmental resection with clear bony margins of up 1.5cm to prevent recurrence of the neoplasm. Curettage with and without cauterization is used for treatment, but is associated with a high recurrence rate. Reconstruction can be immediate or delayed, and can include an autologous bone graft from the anterior or posterior iliac crest. Fibula-free vascular osteocutaneous bone graft is another reconstructive modality, as is distraction osteogenesis. Immediate postoperative follow up is weekly for approximately one month, then monthly for the next five months and twice a year for the next five years.