The purpose of this article was to describe the clinical and microscopic features of an intraosseous foreign-body  granuloma in the mandible that developed after the traumatic implantation of metal fragments during a work-related  accident. A 65-year-old male patient had a severe pain in the body of mandible. Clinical examination showed facial  asymmetry and a scar, extending to the left mental region. Intraoral examination revealed a soft mass involving the  left alveolar bone with normal appearance of the mucosa surface. Panoramic radiographs showed a radiolucent lesion  along the mandible extending from the central incisive to the first molar. Computed tomography revealed an osteolytic  mass in the same area. His medical history included a work-related accident twenty years prior to evaluation. During  the biopsy an important amount of bright metal-like pieces surrounded by soft tissue were found. A microscopic  examination showed a foreign body associated with an aggregation of multinucleated giant cells. The final diagnosis  was a foreign body granuloma. Even though foreign-body granulomas in the mandible are rare lesions, dentists should  be familiar with their features and include them in the differential diagnosis of tissue masses

Carmo, Elaine Dias do

Carvalho, Yasmin Rodarte

Cavalcante, Ana Sueli Rodrigues

Colombo, Carlos Eduardo Dias

Silveira, Vanessa Ávila Sarmento

The purpose of this article was to describe the clinical and microscopic features of an intraosseous foreign-body granuloma in the mandible that developed after the traumatic implantation of metal fragments during a work-related accident. A 65-year-old male patient had a severe pain in the body of mandible. Clinical examination showed facial asymmetry and a scar, extending to the left mental region. Intraoral examination revealed a soft mass involving the left alveolar bone with normal appearance of the mucosa surface. Panoramic radiographs showed a radiolucent lesion along the mandible extending from the central incisive to the first molar. Computed tomography revealed an osteolytic mass in the same area. His medical history included a work-related accident twenty years prior to evaluation. During the biopsy an important amount of bright metal-like pieces surrounded by soft tissue were found. A microscopic examination showed a foreign body associated with an aggregation of multinucleated giant cells. The final diagnosis was a foreign body granuloma. Even though foreign-body granulomas in the mandible are rare lesions, dentists should be familiar with their features and include them in the differential diagnosis of tissue masses

Sarmento Silveira, Vanessa Avila

do Carmo, Elaine Dias

Dias Colombo, Carlos Eduardo

Rodrigues Cavalcante, Ana Sueli

LAReferencia - Red Federada de Repositorios Institucionales de Publicaciones Científicas Latinoamericanas

Intraosseous foreign-body granuloma in the mandible subsequent to a 20-year-old work-related accident

Acervo Digital da Unesp

Repositori d'Objectes Digitals per a l'Ensenyament la Recerca i la Cultura

E657Med Oral Patol Oral Cir Bucal. 2008 Oct1;13(10):E657-60.                                                                                                                                            Intraosseous foreign-body granuloma in the mandible                                                                           Med Oral Patol Oral Cir Bucal.  2008 Oct1;13(10):E657-60.                                                                                                                                            Intraosseous foreign-body granuloma in the mandibleIntraosseous foreign-body granuloma in the mandible subsequent to a 20-year-old work-related accidentVanessa Ávila Sarmento Silveira 1, Elaine Dias do Carmo 2, Carlos Eduardo Dias Colombo 3, Ana Sueli Rodrigues Caval-cante 4, Yasmin Rodarte Carvalho 5(1) Assistant Professor of Anatomy – PhD, Faculty of Pindamonhangaba (FAPI)(2) Assistant Professor of Pathology – PhD, Bandeirante University of São Paulo (UNIBAN) (3) Assistant Professor – PhD, Department of Dentistry, University of Taubaté (UNITAU). Researcher, Department of Bioscience and Oral Diagnosis, São José dos Campos School of Dentistry, State University of São Paulo (UNESP)(4) Associate Professor of Stomatology – PhD, Department of Bioscience and Oral Diagnosis, São José dos Campos School of Dentistry, State University of São Paulo (UNESP)(5) Associate Professor of Oral Pathology - PhD, Department of Bioscience and Oral Diagnosis, São José dos Campos School of Dentistry, State University of São Paulo (UNESP). BrazilCorrespondence:Dr. Vanessa Ávila Sarmento SilveiraRua Ilha do Sul, 299/61 – Jardim Paraíso. São José dos Campos. São Paulo, Brazil. Zip Code: 12235490. E-mail: vassilveira@yahoo.com.br Received: 17/12/2007Accepted: 24/05/2008Silveira VAS, Carmo ED, Colombo CED, Cavalcante ASR, Carvalho YR. Intraosseous foreign-body granuloma in the mandible subsequent to a 20-year-old work-related accident. Med Oral Patol Oral Cir Bucal. 2008 Oct1;13(10):E657-60.© Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946http://www.medicinaoral.com/medoralfree01/v13i10/medoralv13i10p657.pdfAbstractThe purpose of this article was to describe the clinical and microscopic features of an intraosseous foreign-body granuloma in the mandible that developed after the traumatic implantation of metal fragments during a work-related accident. A 65-year-old male patient had a severe pain in the body of mandible. Clinical examination showed facial asymmetry and a scar, extending to the left mental region. Intraoral examination revealed a soft mass involving the left alveolar bone with normal appearance of the mucosa surface. Panoramic radiographs showed a radiolucent lesion along the mandible extending from the central incisive to the first molar. Computed tomography revealed an osteolytic mass in the same area. His medical history included a work-related accident twenty years prior to evaluation. During the biopsy an important amount of bright metal-like pieces surrounded by soft tissue were found. A microscopic examination showed a foreign body associated with an aggregation of multinucleated giant cells. The final diagnosis was a foreign body granuloma. Even though foreign-body granulomas in the mandible are rare lesions, dentists should be familiar with their features and include them in the differential diagnosis of tissue masses.Key words: Granuloma, foreign-body, mandible, giant cells, inflammation.Indexed in: -Index Medicus / MEDLINE  /  PubMed            -EMBASE, Excerpta Medica-SCOPUS-Indice Médico Español                                                        -IBECS              Article Number: 1111111595              © Medicina Oral S. L. C.I.F. B 96689336 - ISSN 1698-6946               eMail:  medicina@medicinaoral.com IntroductionThere are circumstances in which the substances that provoke the acute inflammatory reaction are particulate and larger than the phagocytes and cannot be digested by the reacting neutrophils, causing another response, namely granuloma-tous inflammation. The macrophages are the basic structural unit of chronic inflammation. After amassing substances that they cannot digest, macrophages develop into epithelioid cells. Granulomas are collections of epithelioid cells, which are frequently surrounded by mononuclear cells. In addition, granulomas are populated by multinucleated giant cells, which are formed by the fusion of  macrophages (1).Granuloma formation has been linked to a variety of conditions. Hannon et al. (2) reported a silica granuloma of the lip. Odell et al. (3) reported a foreign-body giant cell reaction elicited by an haemostatic alginate. However, accidental implantation of dental amalgam occurs more often. Owens et al. (4) published a study showing that oral amalgam tattoos accounted for almost 1% of approxima-tely 19.000 pathology reports on file. The literature reveals a number of studies on granulomas as a result of silicone injection for lip enhancement (5,6). Publication Types: Case Reports E658Med Oral Patol Oral Cir Bucal. 2008 Oct1;13(10):E657-60.                                                                                                                                            Intraosseous foreign-body granuloma in the mandible                                                                           Med Oral Patol Oral Cir Bucal.  2008 Oct1;13(10):E657-60.                                                                                                                                            Intraosseous foreign-body granuloma in the mandibleForeign-bodies can penetrate soft tissues in connection with accidents through open wounds and lacerations (7). The presence of a foreign-body that causes a granulo-ma, impairs the healing of the tissues. Some reports on foreign-body granuloma originating from a traumatic implantation have been published, with different objects, including fish bones (8), teeth (9) and metallic material (10). However, intraosseous foreign-body granulomas associated with work accidents are rarely founded. The purpose of this article was to describe the clinical and microscopic features of a rare intraosseous foreign-body granuloma in the mandible that developed after the traumatic implantation of fragments during a work-related accident.Case ReportA 65-year-old male patient sought assistance and evalua-tion, in the Multidisciplinary Center for Mouth Disease of the Dentistry School of São José dos Campos - UNESP, with the chief  complain of a severe pain in the mandible body, accompanied by a burning sensation. He indicated that the pain and the discomfort had begun 3 weeks earlier and increased when the region was touched.Clinical examination showed facial asymmetry, characteri-zed by a diffuse swelling near the chin and a scar, extending to the left mental region. Submandibular and cervical lymphonodes were negative on palpation.Intraoral examination revealed a soft mass involving the left alveolar bone with normal appearance of the mucosa surface. Panoramic radiograph showed a radiolucent le-sion along the mandible, with a diffuse contour, extending from the central incisive to the first molar. Discrete radio-paque areas and discontinuity of the base of mandible were observed (Figure 1). Computed tomography revealed an osteolytic mass in the same area.His medical history included hypertension and a work-related accident twenty years prior to evaluation, while cutting fiber cement-based roofing with a disk. The disk broke and a fragment struck his face. He received several injuries to facial tissues, a mandible fracture, loose teeth, temporary paresthesia and facial paralysis resulting from damage in some local nerves.The differential diagnosis was a benign neoplasm, such as calcifying cystic odontogenic tumour, because of its radio-graphic appearance as a moderately defined radiolucency containing varying amounts of radiopaque material. An incisional biopsy was performed under local anesthesia, removing many fragments from the lesion. A lot of bright metal-like pieces surrounded by soft tissue diffused in the lesion mass (Figure 2) came to our attention. A microsco-pic examination showed a fibrous connective tissue mass presenting a diffuse and loose granulomatous arrangement with aggregated multinucleated giant cells, many of which surrounded dense, black or yellow foreign material (Figure 3). Some of these particles were birefringent. The final pathological report was a foreign-body granuloma.Subsequent to the biopsy, the intensity of the pain was reduced. After explaining to the patient that the foreign-body granuloma occurred due to his traumatic accident, he became reluctant and declined the treatment. Being aware that the lesion was not a malignant tumour the patient refused to receive further surgery, even though some fragments still remained in the mandible bone tis-sue. Since then, he has been followed every 6 months. In a recent panoramic radiography it was observed that lesion aspects remain unaltered.Fig. 3. Foreign material surrounded by loose granulomatous arrangement with aggregated multinucleated giant cells. Me-dium power.Fig. 1. Panoramic radiography showing foreign-body granu-loma extending from the central incisive to the first molar.Fig. 2. Biopsy fragments presenting metal-like bright pieces associated to soft and hard tissue.Med Oral Patol Oral Cir Bucal. 2008 Oct1;13(10):E657-60.                                                                                                                                            Intraosseous foreign-body granuloma in the mandible                                                                           Med Oral Patol Oral Cir Bucal.  2008 Oct1;13(10):E657-60.                                                                                                                                            Intraosseous foreign-body granuloma in the mandibleE659DiscussionTwo basic categories of etiologic factors are recognized as inducers of granulomatous inflammatory responses. The first comprises inert substance that are unable to incite any specific inflammatory or immune response. These are artificially termed foreign-body typed agents and although non-immunogenic, their chemical properties render them able to generate granulomas which differ in evolution, dynamics, duration, severity and involution rates from the infectious type (1).The case report demonstrated a severe foreign-body reac-tion, probably to a metal fragment from the broken disk and from the material that the patient had been cutting during the original accident. These inert particles were unable to induce an immune-specific reaction, as a result they elicited a foreign-body granuloma in the mandible body. Considering both the fibrous aspects and the light inflammatory infiltrate of the lesion and the evolution period since the accident it is possible to corroborate the lack of immunogenicity on the part of the agent. However, these particles are still found in the lesion because of their size and non digestible characteristic.The foreign-body can be detected as a radiographic fin-ding in a routine exam. A painless reaction is, sometimes, a feature of this lesion, making diagnosis more difficult. In this case report, the accident occurred 20 years prior to examination. The fracture was treated and many years later, due to the severe pain, the patient sought professio-nal care 3 weeks prior to the biopsy. In the literature, the period of evolution for foreign-body granuloma is variable, ranging between a few months and several years (8-11). The variation of the granuloma evolution can usually be associated with pain. Sometimes the foreign-body remains asymptomatic for a long time. Probably, the gradual tissue reaction caused discomfort, compressing adjacent structu-res for which the patient sought medical attention.In this case, the severe pain was the patient chief  com-plains. Possibly, the symptoms were caused by the increase of the lesion and consequently loss of bone in the region. The tooth loss during the accident is another factor to enhance the bone loss, augmenting the proximity of the lesion and the oral mucosa surface to some local nerves. Because a history of injury may often be vague or forgot-ten and due to prolonged latent period, a high index of suspicious is necessary to diagnose a granuloma. Besides that, radiographic findings are usually a combination of osteolytic and/or osteoblastic presentations with failure to visualize the radiolucent foreign body and recent image techniques should be used (12).The radiographic appearance of the granuloma located in the mandible could be similar to other lesions, such us odontogenic neoplasms and cysts, because these entities can produce calcifications, which could resemble the foreign material image. Foreign-body granuloma has frequently been documented as mimicking a variety of neoplasms. Shugar et al. (13) presented a case of a foreign-body in the tongue which masqueraded as a malignancy. Furthermore, the foreign-body granuloma should be inclu-ded in the differential diagnosis in cases of postoperative masses, particularly after a lengthy time interval, because most of them are associated with suture material (11). The use of substances as cosmetic fillers, such as silicone, may be associated with the occurrence of foreign body granulomas (14), and should be included in the differential diagnosis in cases of previous aesthetic procedures.Surgery to the complete removal of  the foreign-body granuloma was the first choice for treatment. However, in this case, after the relief  of the pain, and being aware that it was not a malignant tumor, the patient refused further surgery, avoiding any intervention in the accident local. The radiographic aspects 4 years after biopsy showed that lesion remain unchanged. Therefore, it is reasonable to assume that the lesion is stabilized. As a result the patient will continue to be followed.Foreign bodies in the head and neck are common, in-cluding those of long duration. However, foreign bodies located in the mandible resulted from a traumatic im-plantation are unusual. According to Heo et al. (11) no foreign body granuloma occurring in the mandible area has previously been cited in literature, being his report the first one. No other case report about an intraosseous foreign body granuloma in the mandible subsequent to an accident has been found until this moment. Therefo-re, identification of these lesions is important to prevent inappropriate treatment.Even though intraosseous foreign-body granulomas are rare lesions, dentists should be familiar with their features and include them in the differential diagnosis of tissue masses, mainly in the presence of  previous surgery or accidental trauma history.References1. Mariano M. The experimental granuloma. A hypothesis to explain the persistence of the lesion. Rev Inst Med Trop Sao Paulo. 1995 Mar-Apr;37(2):161-76. 2. Hannon SM, Pickett AB, Frost JM. Foreign-body (silica) granuloma of the lip. J Oral Maxillofac Surg. 1983 Jul;41(7):470-2. 3. Odell EW, Oades P, Lombardi T. Symptomatic foreign body reaction to haemostatic alginate. Br J Oral Maxillofac Surg. 1994 Jun;32(3):178-9. 4. Owens BM, Johnson WW, Schuman NJ. Oral amalgam pigmentations (tattoos): a retrospective study. Quintessence Int. 1992 Dec;23(12):805-10. 5. Schmidt-Westhausen AM, Frege J, Reichart PA. Abscess formation after lip augmentation with silicone: case report. Int J Oral Maxillofac Surg. 2004 Mar;33(2):198-200. 6. Ficarra G, Mosqueda-Taylor A, Carlos R. Silicone granuloma of the facial tissues: a report of seven cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Jul;94(1):65-73. 7. Oikarinen KS, Nieminen TM, Mäkäräinen H, Pyhtinen J. Visibility of foreign bodies in soft tissue in plain radiographs, computed tomography, magnetic resonance imaging, and ultrasound. An in vitro study. Int J Oral Maxillofac Surg. 1993 Apr;22(2):119-24. 8. Lin CJ, Su WF, Wang CH. A foreign body embedded in the mobile tongue masquerading as a neoplasm. Eur Arch Otorhinolaryngol. 2003 May;260(5):277-9. E660Med Oral Patol Oral Cir Bucal. 2008 Oct1;13(10):E657-60.                                                                                                                                            Intraosseous foreign-body granuloma in the mandible                                                                           Med Oral Patol Oral Cir Bucal.  2008 Oct1;13(10):E657-60.                                                                                                                                            Intraosseous foreign-body granuloma in the mandible9. Baldwin JK, Newton GM. A tooth located in the tongue. Oral Surg Oral Med Oral Pathol. 1978 Jun;45(6):860-2. 10. Girdler NM. Unusual delayed sequel to facial trauma. Oral Surg Oral Med Oral Pathol. 1993 Feb;75(2):264. 11. Heo MS, Song MY, Lim JJ, Lee SS. Foreign-body granuloma occurring in the mandible subsequent to orthognathic surgery: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001 Apr;91(4):483-5. 12. Gomaa AF, Ghaith HA. Osteolytic pseudotumor induced by a piece of wood. Kuait Medical Journal. 2005 Dec;37(4):289-91.13. Shugar MA, Kelly JH, Glinski EJ, Strome M. An unusual foreign body of the tongue masquerading as malignancy. Laryngoscope. 1980 Apr;90(4):673-5. 14. Poveda R, Bagán JV, Murillo J, Jiménez Y. Granulomatous facial reaction to injected cosmetic fillers--a presentation of five cases. Med Oral Patol Oral Cir Bucal. 2006 Jan 1;11(1):E1-5. 

Intraosseous foreign-body granuloma in the mandible subsequent to a 20-year-old work-related accident

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Repositori d'Objectes Digitals per a l'Ensenyament la Recerca i la Cultura