By Mark Berman M.S., D.D.S., M.D.; Boyd J Tomasetti D.M.D.; Sara Anderson M.S., D.D.S, M.D.; Adam Gainford D.D.S.; Mark Glasgow D.D.S.
The Denver Health Oral and Maxillofacial Surgery Residency Program treats a wide range of patients in terms of age, demographics and clinical presentation. The program also takes referrals from dentists from across the state and runs a daily outpatient dentoalveolar clinic as well as having three dedicated operating room days where a variety of trauma, TMJ, orthognathic, pathology and reconstructive cases are seen.
Denver Health OMS cares for patients – both adults and pediatric – with a large breadth of odontogenic and non-odontogenic lesions of the head and neck. Below is a review of a recent pathology case.
The program recently saw a 12-year-old female who was referred to Denver Health OMS by a
community dentist for evaluation of a radiolucent lesion of her mandible and multiple papillary lesions of her lips. The lesions, which were noted on a routine exam, were asymptomatic. The patient recently migrated with her family to Denver from Venezuela. Her past medical history was unremarkable. Of note, her mother and her maternal grandmother have had similar lip lesions.
On clinical evaluation, the patient was a well appearing young girl, developmentally appropriate. On extraoral exam, she was noted to have two distinct white, exophytic and papillomatous lesions of her upper lip measuring 1 mm and 3 mm. Intraorally, her mucosa was moist and pink, in mixed dentition without gross caries. Expansion of her right mandibular body that was non-tender to palpation was noted along with a retained primary tooth #S.
Radiographically, there was a mixed dentition with an impacted right maxillary canine as well as second and third molars. There was a well-defined 1.5 cm x 1.5 cm multilocular radiolucency of the right mandible adjacent to impacted tooth #29. There was taurodontism of her molars.
The patient underwent an incisional biopsy of the mandibular lesion. The initial pathology result was ameloblastic fibroma, a mixed odontogenic tumor that contains both epithelial and mesenchymal tissues. Ameloblastic fibromas typically occur in younger patients with a relatively high recurrence rate. Treatment options included segmental mandibulectomy with margins versus a more conservative excisional curettage. Given her age, the patient received excisional curettage of the mandibular lesion to conserve the continuity of her mandible. Interestingly, on the day of her procedure, it was noted that the lip lesions had resolved spontaneously. The excision of the mandibular lesion was uncomplicated intraoperatively and she recovered well post-operatively.
Upon final pathology report, the diagnosis was changed to be ameloblastic fibro-odontoma (AFO), which is an ameloblastic fibroma that also contains evidence of enamel or dentin. Fortunately, AFO lesions have a lower recurrence rate.
It was unusual to see the lip lesions resolve spontaneously prior to biopsy or treatment. Though not conclusive, this could be consistent with focal epithelial hyperplasia, also known as Heck’s disease, which has an association with HPV types 13 and 32. It typically occurs in young patients with a female predilection. Heck’s disease has been reported in multiple ethnic groups including South Americans. Although the lip can be involved, the lateral tongue is the classic presentation. Even though these lesions can resolve spontaneously, recurrence is not uncommon.
Another interesting finding for this patient was Taurodontism of her molars. Taurodontism is a developmental anomaly of teeth that results in enlargement of the pulp chamber with a vertical increase in size. The crowns of the involved teeth are normal appearing. Taurodontism typically appears in molars. Though this finding can be associated with various syndromes, there is no known syndrome which would explain the three distinct clinical features of this patient: ameloblastic fibro-odontoma of the mandible, papillomatous lesions of the lip that resolved spontaneously and multiple teeth with taurodontism.
As Colorado’s primary and essential safety-net institution, Denver Health is a mission-driven organization. It participates in all private and public insurance programs as well as treating self-pay patients. The Denver Health OMS Department will see all patients regardless of their County of Residence and is proud to provide compassionate and innovative care. The Denver Health OMS Department will see all patients regardless of their County of Residence. Referrals can be submitted through its website at https://www.denverhealth.org/services/surgery/oral-and-maxillofacial-surgery or through email DL_OMFS_Referrals@dhha.org.
References
AAOMS Parameters of Care 7th Edition, November 2023
Nasir A, Khare A, Ali I, Khan MI. Ameloblastic fibroma: A case report. Journal of Oral and Maxillofacial Pathology. 2023 Feb;27(Suppl 1):S60-S63.
Ramakrishnan DS, Gouthaman SS, Muthusekhar MR. Ameloblastic fibrosarcoma transformation from ameloblastic fibroma. National Journal of Maxillofacial Surgery. 2022 Aug;13(Suppl 1):S145-S149.
Darling MR, Daley TD. Peripheral ameloblastic fibroma. Journal of Oral Pathology and Medicine. 2006 Mar;35(3):190-2.
Safavi M, Mohammadi F. Ameloblastic Fibro-Odontoma. Fetal and Pediatric Pathology. 2023 Apr;42(2):281-284.
Kalra A, Pajpani M, Webb R. Ameloblastic Fibro-Odontoma. Journal of Dentistry in Children (Chic). 2018 Sep 15;85(3):143-146.
About the authors:
Dr. Mark Glasgow is a graduate of University of Colorado School of Dental Medicine and is a board-certified surgeon who trained at Denver Health. He is the Associate Director of the Department of Surgery and Chair of the OMS Department. Dr. Glasgow has been the program director for the past 12 years and is on faculty in the Plastic and Reconstructive Surgery Division at University of Colorado.
Dr. Mark is a graduate of University of Colorado School of Dental Medicine and is a board-certified surgeon who trained at the Oregon Health & Science University and practiced in Denver for 23 years.
Dr. Sara Anderson is a graduate of NYU College of Dentistry and is a board-certified surgeon who trained at The University of Michigan School of Medicine.
Dr. Boyd Tomasetti, a Past President of AAOMS, is a graduate of Tufts University School of Dental Medicine who trained at Kings County – Downstate Medical Center in Brooklyn and practiced in Littleton for 40 years.
Dr. Adam Gainford is a graduate of UCLA Dental School and did an Advanced Education in General Dentistry Program in the Air Force prior to starting his residency in the Denver Health Oral and Maxillofacial Residency program.
