Retro and prospective analysis of complex treatment of a patient with a polyostotic form of osteoclastoma of the maxillofacial region: clinical observation

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Introduction

Currently, benign tumors and tumor-like bone lesions account for 40–50 % of all cases of bone neoplasia. However, these figures may be reduced due to the difficulties of differential diagnosis and the possible long-term asymptomatic course of the disease [1–7]. One example of such tumors is osteoblastoclastoma (osteoclastoma), localized in various parts of the skeleton, often in the jaw bones, especially in the body of the lower jaw. The prevalence of this disease in women of reproductive age (18 to 35 years) is twice as high as in men.

There are cellular, cystic and lytic forms of osteoblastoclastoma, which differ in growth rates and the nature of bone tissue lysis. Resection of the affected bone areas with simultaneous reconstructive restoration of the integrity of the jaw is the optimal and most rational surgical method for treating this pathology1 [1; 2]. Malignant variants of osteoblastoclastoma are less common and are classified by origin and degree of lytic destructive activity [8–10].

The literature, both domestic and foreign, covers in detail aspects of surgical technique and tactics of managing patients with osteoblastoclastoma of the jaw bones [3]. However, there is very little information on the treatment of the polyostotic form of the disease. In this regard, the analysis of the presented clinical case is relevant.

The aim of the study is to analyze a clinical case of complex treatment of a patient with a polyostotic form of osteoclastoma of the jaw bones.

Clinical Case

Patient M., 19 years old, came to the clinical dental hospital of Perm State Medical University in 2006 with complaints about the presence of a neoplasm in the area of ​​the lower jaw on the right (Fig. 1, a, b), mobility of the lower teeth and paresthesia in the area of ​​the lower lip on the right.

 

Fig. 1. The patient's appearance before complex treatment: a – full face, b – profile (2006)

 

The diagnosis of osteoclastoma of the lower jaw on the right (ICD code – D 16.5) was verified by performing an incisional biopsy followed by pathohistological examination.

An individual comprehensive treatment plan was developed by an interdisciplinary team consisting of a maxillofacial surgeon, an orthopedic dentist and an anesthesiologist, and consisted of the following stages: planning the resection zone; conducting an anthropometric study to select an implant; preliminary orthopedic preparation for surgery; planning anesthesia; surgical treatment; delayed prosthetics; rehabilitation.

At the stage of choosing surgical treatment options, autoplasty, replacement of the postoperative defect with a reconstructive plate or an orthotopic implant made of carbon-carbon material "Uglekon-M" were considered. Taking into account the properties of implant systems made from the “Uglekon-M" material, in particular high biological inertness, dimensional stability over time, compliance of the structure and physical and mechanical characteristics with the native bone indicators, the possibility of restoring the shape of the face, and the absence of the need for additional surgical interventions, the choice was made in favor of this implant material.

At the first stage, preliminary orthopedic preparation was carried out, which consisted of the manufacture and fixation of a non-removable orthopedic structure to hold the fragments of the lower jaw. Then we proceeded to the next stage – the surgical treatment itself. Under endotracheal anesthesia, the tumor was removed with partial resection of the lower jaw and simultaneous replacement of the postoperative defect with an orthotopic carbon implant “Uglekon-M” (Fig. 2), wound suturing and drainage installation. Since the implant was individually modeled according to the shape and dimensions of the suspected defect, a good aesthetic and functional result was ensured.

 

Fig. 2. Installation of an orthotopic implant made of Uglekon-M material

 

Based on the results of the pathohistological examination, the diagnosis was confirmed: osteoblastoclastoma of the lower jaw.

On the control orthopantomogram, an implant is fixed in the area of the defect of ​​the lower jaw on the right, the fixation is satisfactory. The shadows of metal-density ligature sutures are visible in the area of ​​the right lower jaw branch and the chin section of the lower jaw (Fig. 3).

 

Fig. 3. Orthopantomogram, condition six months after surgery (removal of osteoclastoma of the lower jaw in the body area on the right with simultaneous replacement of the defect with an orthotopic carbon implant "Uglekon-M")

 

The patient was discharged in satisfactory condition on the 10th day after the operation.

Six months after the surgery, a removable dental prosthesis with a metal base and clasp fixation was made and fixed to the patient's lower jaw. The patient had no complaints and did not attend examinations as part of the dispensary observation due to her residence in a remote area of ​​the Perm Territory.

In 2011, during pregnancy, the patient noticed the appearance of a neoplasm and its growth in the frontal region of the upper jaw on the left. In the postpartum period he contacted the Clinical Hospital of Perm State Medical University.

A CT scan of the upper jaw was performed. In the area of ​​the frontal part of the upper jaw on the left, a neoplasm of a non-uniform structure, cellular in shape in the projection of teeth 1.3–1.1, with a cuff-shaped thickening of the alveolar part was found (Fig. 4).

 

Fig. 4. CBCT: tumor in the upper jaw area, 2011

 

After receiving the results of an incisional biopsy, a diagnosis of osteoclastoma of the frontal maxilla was established (ICD 10 code – D16.4). A resection dentofacial prosthesis for the upper jaw was made according to the defined boundaries of the partial resection of the upper jaw. Surgical treatment was performed – removal of a neoplasm in the area of ​​the frontal part of the upper jaw on the left with partial resection of the upper jaw, with closure of the surgical wound with a flap from the mucous membrane of the cheek and one-stage replacement of the defect with a resection prosthesis. In the postoperative period, a course of anti-inflammatory therapy was administered. As a result of additional examination, a control CBCT scan revealed a neoplasm in the frontal part of the lower jaw on the right side from the lingual side. An incisional biopsy was performed. The diagnosis was established: D16.5 – osteoclastoma of the lower jaw on the right, relapse (Fig. 5), confirmed by the results of pathohistological examination.

 

Fig. 5. CBCT: osteoclastoma of the lower jaw on the right, relapse, 2011

 

Patient M. was re-hospitalized for planned surgical treatment.

Due to the presence of a polyostotic form of osteoclastoma of the jaw bones in the patient, autotransplantation was contraindicated. After conducting an anthropometric study and selecting an orthotopic carbon implant, the neoplasm was removed with partial resection of the chin section of the lower jaw and replacement of the carbon orthotopic implant of the lower jaw "Uglekon-M" with a new one.

During the surgical intervention, complete osseointegration was revealed and formation of a bone-implant unit with the ingrowth of bone tissue into the structures of the implant made of carbon-carbon composite material (Fig. 6).

 

Fig. 6. Osteoclastoma of the lower jaw on the right, relapse (intraoperative), 2011

 

Results and discussion

In December 2023, the patient was called to the Clinical Hospital of Perm State Medical University for a follow-up examination. Upon examination, the facial configuration and shape of the lower jaw were satisfactory, the scar in the submandibular region was pink, smooth, and even. The movements of the temporomandibular joints are synchronous, smooth, and painless. The mouth opens freely, up to 4.0 cm. In the oral cavity: the crown of tooth 3.7 is completely destroyed, its roots are pigmented. On the lingual side in the projection of tooth 3.7, a bulge of the outer cortical plate of a round shape with a diameter of up to 1.5 cm was found, painless upon palpation. Percussion of tooth 3.7 is moderately painful. The mucous membrane above the neoplasm is not changed in color, there is a pale pink scar in the area of ​​the implant. The midline is located centrally, the defects of the dental arches are replaced by removable dentures for the upper and lower jaw. When palpating the lower jaw, no mobility is determined in the area of ​​the bone-implant junction. The patient is satisfied with the achieved treatment result (Fig. 7).

 

Fig. 7. Condition when viewed (side view, bottom view, straight), 2023

 

When collecting the patient's life history, it was found that in 2016 there was a second pregnancy, which ended in childbirth. In the summer of 2023, the patient noticed a change in the shape of the alveolar part in the area of ​​tooth 3.7, but did not seek medical help. CBCT was performed –
a focus of bone rarefaction was found, heterogeneous in density in the projection of tooth 3.7, up to 1.5 cm (Fig. 8). Bulging of the cortical plate on the lingual side. here are no signs of relapse of the neoplasm in the upper jaw and in the area of ​​implant fixation on the lower jaw. Osteointegration is observed at the border of the bone-implant unit. A preliminary diagnosis is chronic periodontitis of tooth 3.7, neoplasm in the area of ​​the alveolar process of the lower jaw on the left.

 

Fig. 8. OPTG: neoplasm in the lower jaw area on the left, 2023

 

Patient M. underwent extraction of tooth 3.7, scraping of the neoplasm was performed, the material was sent for cytological examination. Given the clinical picture of the polyostotic form of osteoclastoma, in terms of differential diagnostics, it was recommended to conduct an X-ray examination of all bone structures in order to exclude myeloma disease. After receiving the research results, myeloma disease was not confirmed.

As a result of X-ray, cytological examination and subsequent pathohistological examination, the diagnosis was established: fibroma of the lower jaw on the left, the presence of relapse of osteoblastoclastoma was not confirmed. In April 2024, the fibroma of the lower jaw on the left was removed at the Clinical Hospital of Perm State Medical University using intraoral access. At the time of discharge, the patient's condition was satisfactory, orthopedic treatment and further dispensary observation were recommended for the patient.

Conclusions

A rare clinical case of treatment of a patient with localization of osteoclastoma in the lower jaw on the right, in the frontal part of the upper jaw on the left, with recurrence of the formation in the lower jaw on the right in the late stages after treatment is presented, which indicates the presence of a polyostotic form of osteoclastoma of the jaw bones in the patient.

The emergence of a new focus and relapse of the neoplasm occurred after a previous pregnancy, therefore, a connection between this pathology and changes in hormonal levels occurring during pregnancy cannot be ruled out, however, this factor has not been confirmed and requires study.

The analysis of the described clinical situation allowed us to prove that timely surgical treatment and verification of the diagnosis provide a good result, while regular dispensary observation in the form of examination at least once a year for patients who underwent surgery to remove osteoclastoma is strictly mandatory. Particular attention in this aspect should be paid to women of reproductive age.

The use of implants made of carbon-carbon composite material "Uglekon-M" in the polyostotic form of osteoclastoma is the method of choice, which has proven its effectiveness in replacing post-resection defects of the lower jaw.

About the authors

S. I. Rapekta

E.A. Vagner Perm State Medical University

Author for correspondence.
Email: Rapsvi@mail.ru
ORCID iD: 0009-0005-9643-8473

PhD (Medicine), Associate Professor, Head of the Department of Dental Surgery and Maxillofacial Surgery

Russian Federation, Perm

N. B. Astashina

E.A. Vagner Perm State Medical University

Email: Rapsvi@mail.ru
ORCID iD: 0000-0003-1135-7833

DSc (Medicine), Head of the Department of Orthopedic Dentistry

Russian Federation, Perm

O. S. Tursukova

E.A. Vagner Perm State Medical University

Email: Rapsvi@mail.ru
ORCID iD: 0009-0001-2069-7197

PhD (Medicine), Deputy Chief Physician for Quality Control and Safe Medical Activity of Dental Clinical Hospital of E.A. Vagner Perm State Medical University, Maxillofacial Surgeon

Russian Federation, Perm

V. E. Kibanova

E.A. Vagner Perm State Medical University

Email: Rapsvi@mail.ru
ORCID iD: 0009-0009-1113-522X

Resident of the Department of Dental Surgery and Maxillofacial Surgery

Russian Federation, Perm

References

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