CASE HISTORY-4

OPD No. 433772/09 Date: 21-12-2017

Name: Mrs. Anita Gupta Occupation: House wife

Age: 42yrs Sex: Female

Religion: Hindu Address: Aliganj, Lucknow

Contact no. 08874952205

Chief complaint
Patient complained of swelling in lower left front tooth region of the jaw since 1.5years

History of present illness

Patient gave history of painless swelling in lower left front tooth region since 1.5 yr. It was
gradual and of the same size since she noticed. No relevant history of any pain, bleeding or
discharge & medication. No other associated symptoms.

Past dental history: Nothing significant

Past medical history: Nothing significant

Family history: Nothing significant

Personal history:
Habit: Nothing significant
Diet: Mixed
Marital status: Married
GENERAL CLINICAL EXAMINATION

Built: Moderately built

Nourishment: Moderately nourished
Gait: No abnormality detected
Skin: No abnormality detected
Hair: No abnormality detected
Nails: No abnormality detected
Sclera: No abnormality detected
Conjunctiva: No abnormality detected
Pallor: No abnormality detected
Cyanosis: No abnormality detected
Edema: no abnormality detected

Vital sign:

Pulse Rate: 72 beats /min Temperature: 98.9˚F

Respiratory Rate: 14 cycles/ min Blood Pressure: 130/90 mm Hg.

EXTRA ORAL EXAMINATION

Face: Symmetrical and straight profile

Nose: No abnormality detected
Eyes: No abnormality detected
Ears: No abnormality detected
TMJ: No abnormality detected
Muscles of mastication: No abnormality detected
Lips: Competent
Lymph Nodes: no abnormality detected
INTRA ORAL EXAMINATION

Soft tissue examination

Buccal mucosa: No abnormality detected
Labial mucosa: No abnormality detected
Palate: No abnormality detected
Tongue: No abnormality detected
Floor of mouth: No abnormality detected
Gingiva
• Color:Pink with melanin pigmentation
• Size: Normal
• Contour: Lost wrt 42,41,31
• Position: Recession present wrt 42,41,31
• Surface texture: Stippling absent wrt 42,41,31
• Consistency: Soft and edematous wrt 42,41,31
• Bleeding on probing: Present
• Periodontal pocket: Absent
Vestibule: Vestibular obliteration wrt. 34,35
Tonsils: No abnormality detected
Oropharynx: No abnormality detected
Duct orifices: No abnormality detected

Hard tissue examination

Teeth present
11,12,13,14,15,16,17,18,21,22,23,24,25,26,27,28,31,32,33,34,35,37,38,41,42,443,45,46,4
7,48,
Teeth Missing: Missing 36 (due to extraction)
Caries: Absent
Tenderness on percussion: Absent
Non vital teeth: Absent
Fractured teeth: Absent
Mobility: Grade I- 42, 41, 31
 Restored teeth: Absent
Wasting disease: Attrition- Generalized attrition present
Root stump: Absent
Occlusion: Angle class I relation
Deposits: Supra and subgingival calculus & Extrinsic stains

EXAMINATION OF THE LESION

Soft tissue examination
Inspection:
A Solitary circumscribed dome shaped swelling was present in the left buccal vestibule wrt
33,34, 35 measuring about 3x3cm extending antero-posteriorly from distal aspect of 32 to distal
aspect of 35, supero-inferiorly from marginal gingiva to vestibular area. Mucosa over swelling
was smooth with slightly bluish tinge in the superior mid-region.

Palpation:
All Inspectory findings were confirmed. On palpation swelling was non tender, hard with,
cortical expansion, nonfluctuant, noncompressible, and nonreducible. Diascopy test was
negative.
Hard tissue examination
Inspection: Distal inclination of crown wrt 33 and mesial inclination of 34
Palpation: On palpation Inspectory findings was confirmed.
Percussion; On vertical and horizontal percussion it was nontender

Aspiration: On aspiration frank blood was aspirated

Summary
Here was a patient named Anita Gupta, aged 40years female patient, reported to our
departmental OPD with the complaint of swelling in left back tooth region since 1 and 1/2 yr. It
was gradual and same size since she noticed. No relevant history of any pain, bleeding or
discharge & medication. No other associated symptoms. On intraoral examination solitary
circumscribed dome shaped swelling was present in the left buccal vestibule wrt 33,34, 35
measuring about 3x3cm extending anterio-posteriorly from distal aspect of 32 to distal aspect of
35, super-inferiorly from marginal gingiva to vestibular area. Mucosa over swelling was smooth
with slightly bluish tinge in the superior mid-region. On palpation swelling was non tender, hard
with, cortical expansion, non-fluctuant, not compressible, and not reducible. On aspiration frank
blood was aspirated.

PROVISIONAL DIAGNOSIS
• Chronic generalized gingivitis with localized periodontitis irt 42,41,31

DIFFERENTIAL DIAGNOSIS
• Central Hemangioma
• Traumatic bone cyst

INVESTIGATION
• Pulp vitality test
• IOPAR wrt 33,34,35
• Occlusal
• OPG
• Hematological – TLC, DLC, HB% ,ESR, CT, BT
Hb: 15 g%

TLC: 7,000/mm3

DLC: N-60%, E-2%, B-0.4%,L-25%, M-5%

ESR: 15 mm/hr

CT: 4 min

BT: 5 min

RADIOLOGICAL DIAGNOSIS
Aneurysmal bone cyst
HISTOLOGICAL FINDINGS
The H/E sections show areas of numerous blood filled spaces lined by endothelial cells. The
adjacent connective tissue was predominantly made up of fibromyxomatous tissue. Areas of
dystrophic calcification were seen. The overall features were suggestive of traumatic bone cyst.

FINAL DIAGNOSIS
Aneurysmal Bone cyst
Chronic generalized gingivitis with localized periodontitis wrt 42,
41, 31

TREATMENT PLANNING- Enucleation of cyst

CLINICAL PICTURES

EXTRA-ORAL

INTRA-ORAL

FNAC
 IOPAR

OCCLUSAL VIEW

PG
 INTRA-OP

HISTOPATHOLOGICAL
POST OP