Clinical Pathologic Conference Case 4: A painless gingival swelling in the area of teeth #23 and #24

Abstract

A 36-year-old female presented to the general dentist with a painless gingival swelling, which had been present for 8 months in the region of the lower left lateral and central incisors. The patient had a negative medical history besides seasonal allergies and elevated cholesterol, treated with diet modifications. She had previously undergone orthodontic treatment. Clinical examination revealed crowding of the mandibular anterior teeth. Purplish-red swellings of the mandibular facial interdental papillae from canine to canine were noted, but this change was most obvious in the region of the lower left lateral and central incisors (Figure 1). The discoloration extended to the area below the attached gingiva from canine to canine as well. The crestal gingiva was red, and there was bleeding, which may have been spontaneous or caused by provocation. Periapical radiography showed a radiolucent area with an ill-defined border, localized mainly to the lower left lateral and central incisors (Figure 2). The trabecular pattern was completely lost, and the epicenter appeared to be located between the lower left lateral and central incisors at the vertical mid-portion of the roots. The lesion was causing divergence of the roots. Additionally, there was loss of the lamina dura on both roots, as well as irregular, nondirectional external resorption on both roots. The pulp canals appeared normal. A sagittal cone beam computed tomography (CBCT) scan showed apparent loss of cortical bone (Figure 3). The radiolucency extended from below the apices of the incisors to the crowns of the incisors. The axial CBCT showed the radiolucency thinning and effacing the facial and lingual cortex of the mandible, with tumor expansion on the facial aspect (Figure 4). Fig. 2Radiolucency with ill-defined borders causing divergence of the roots in the area of the lower left lateral and central incisors. View Large Image Figure Viewer Download Hi-res image Fig. 3Sagittal cone beam computed tomography (CBCT) scan showing loss of cortical bone. View Large Image Figure Viewer Download Hi-res image Fig. 4Axial cone beam computed tomography (CBCT) scan showing radiolucency thinning and effacing the facial and lingual cortex of the mandible, with tumor expansion on the facial aspect. View Large Image Figure Viewer Download Hi-res image