Maxillomandibular brown tumor--a rare complication of chronic renal failure

Massive Exophytic Brown's Tumor of the Bilateral Maxilla with Mandibular Involvement

ABSTRACT

Brown's tumor is a benign bone lesion that occurs in the setting of hyperparathyroidism and can affect the facial skeleton. It often presents as a single lesion and is usually less than 3 centimeters. To our knowledge, no cases have been reported to have bilateral involvement of the maxilla and mandible with the largest dimension measuring over 7 centimeters. This report describes such a case and provides a review of the literature.

[Application of digital mandibular movement record and masticatory muscle electromyography in the evaluation of stomatognathic function in patients with mandibular tumor]

OBJECTIVE

To study the clinical characteristics of mandibular movement and masticatory muscle function in preoperative and postoperative patients with unilateral mandibular tumors in the region of mandibular body and ramus by combining digital mandibular movement records with electromyography, and to preliminarily explore the relationship and mechanism between movement and masticatory muscle function.

METHODS

Six preoperative patients with tumor in unilateral body and ramus of mandible were included, and three postoperative patients with unilateral segmental resection and reconstruction of mandibular bone were included. The mandibular movement recording system and surface electromyography system were used to collect the movement trajectory of the patients' mandibular marginal movement and chewing movement, and the surface electromyography of bilateral masseter and temporalis was recorded concurrently. The surface electromyography of bilateral masseter and temporalis was collected when the patients were at relaxation and at maximal voluntary clenching (MVC). The motion trajectory was observed on the digital virtual model, and the motion amplitude and direction of mandibular marginal movements were analyzed. The characteristics of masticatory electromyogram (EMG) activity in affected and unaffected sides at relaxation, MVC and bilateral mastication were analyzed, and the asymmetry indexes and activity indexes were calculated.

RESULTS

The preoperative mean maximum opening of the patients was (35.20±6.87) mm. Three patients had mild mouth opening limitation, and all the patients' mouth opening trajectory was skewed to the affected side. During lateral movements, the mean range of motion of the affected side [(10.34±1.27) mm] and that of the healthy side [(6.94±2.41) mm] were significantly different. The maximum opening of the postoperative patients was (30.65±17.32) mm, and the mandibular marginal movement characteristics were consistent with those of the patients before surgery. During MVC in the preoperative patients, the median EMG activities of the masseter muscle [44.20 (5.70, 197.90) μV] and the temporalis muscle [42.15 (22.90, 155.00) μV] on the affected side were slightly lower than those of the masseter [45.60 (7.50, 235.40) μV] and the temporalis muscle [63.30 (44.10, 126.70) μV] on the healthy side. In the postoperative patients, individualized changes occurred. Some patients suffered from weakened electromyographic activity on the affected side, while some other ones showed hyperelectromyographic activity on the affected side.

CONCLUSION

Both benign and malignant tumors as well as their surgery can cause abnormal mandibular movements and change of electromyographic activity of bilateral masseter and temporalis muscles.

The Use of Virtual Surgical-Guided Osteoplasty for Maxillofacial Brown Tumors

A 28-year-old African American female with end-stage renal disease on dialysis secondary to preeclampsia presented to the office as a referral for large multifocal tumors of maxilla and mandible. Surgical pathology and laboratory findings were supportive of secondary hyperparathyroidism leading to multifocal brown tumors. She underwent osteoplasty after using virtual surgical planning to create stereolithic models to visualize the tumor and fabricate cutting guides to minimize the risk of injury to adjacent nerves and teeth. Brown tumors can be resistant to medical management with unreliable regression in size. With the advent of customized surgical guides, more precise and judicious surgery can be performed on these types of tumors safely.

Spontaneous and Excellent Healing of Bilateral Brown Tumors in Mandible after Endocrinal Therapy and Subtotal Parathyroidectomy: Case Report with 4-Year Follow-Up

Primary hyperparathyroidism is an endocrine disorder occurring due to increased secretion of parathormone resulting in a complex of clinical, anatomical, and biochemical alterations. On the other hand, excision of a parathyroid adenoma can normalize the metabolic status. A 24-year-old man was referred to the hospital with bilateral swelling and spontaneous gingival bleeding from posterior of the mandible also with radiolucent well-demarcated lesions bilaterally in the mandibular third molar regions. After consultations, the patient was hospitalized in the endocrinology department where further tests were performed due to highly increased PTH level as 714 pg/ml. Bilateral brown tumors started to regress spontaneously, and no additional surgery was required after subtotal parathyroidectomy was performed. The presented case is the first patient whose bilateral brown tumors in the jaws spontaneously and totally healed after subtotal parathyroidectomy and endocrinal therapy who was strictly followed up for 4 years even though the lesions were associated with impacted third molars.

A rare case of regression of brown tumors of tertiary hyperparathyroidism after parathyroidectomy and renal transplant: A 5-year follow-up

Tertiary hyperparathyroidism (HPT) is a rare condition that affects patients with secondary HPT, which develop hyperplasia of the parathyroid glands, thus causing an increase in parathyroid hormone levels. Bone alterations are the main consequences of this condition including the development of osteolytic lesions called brown tumor. This article reports an unusual case of brown tumors located in the maxilla and mandible in a 19-year-old man with chronic renal failure with hyperplasia of the parathyroid glands. The lesions regressed approximately 5 months after the parathyroidectomy. At this same time, the patient underwent renal transplant. The patient was followed for 5 years, showing improvement in overall clinical status. There was also improvement of the results of laboratory tests and the pattern of trabecular bone. The correct diagnosis of oral lesions was of great relevance for the conservative treatment could have been chosen.

Management challenges with brown tumor of primary hyperparathyroidism masked by severe vitamin D deficiency: a case report

Background

Hyperparathyroidism is a disease characterized by excessive secretion of parathyroid hormone, the hormone responsible for calcium and phosphate homeostasis in the body. It can be of three types: primary, secondary, or tertiary. It is essential to bear in mind that in any one patient more than one type of hyperparathyroidism may be found, which may create perplexity regarding the etiology of the case. Hyperparathyroidism can become apparent early in its course when a patient presents with symptoms of abdominal pain, recurrent renal calculi, repeated fractures, or behavior changes. It is generally accepted that bone involvement is a late manifestation of primary hyperparathyroidism. It is imperative to consider that some patients, such as our patient described in this report, may be previously asymptomatic clinically and on the basis of laboratory findings and present with only late skeletal manifestations. Brown tumors are one of the mimickers of lytic lesions of the jaw and need to be ruled out early in the course of management. Researchers in several studies published in high-impact journals have recommended the use of high-dose vitamin D as safe in patients with primary hyperparathyroidism without the risk of raising calcium levels significantly. In our patient, we observed considerable hypercalcemia after high-dose vitamin D therapy, and we propose exercising discretion with the use of high-dose therapies.

Case presentation

We report a case of a 21-year-old Arab woman with a brown tumor who presented with hypocalcaemia. She presented with a mixed picture of primary hyperparathyroidism and severe vitamin D deficiency.

Conclusions

Brown tumors, although thought to be a forgotten entity with the advent of early screening for hypercalcemia, is still prevalent, as a handful of patients may present late in the disease course with no early markers, such as in our patient. We emphasize using a holistic approach for early diagnosis and adopting a restricted attitude to treating these benign entities, especially in the context of cosmesis for sensitive locations such as the face. In addition, we express caution in using daily supplementation with a high vitamin D dose to improve vitamin D status and decrease parathyroid hormone.

Mandibular Brown Tumor of Secondary Hyperparathyroidism Requiring Extensive Resection: A Forgotten Entity in the Developed World?

Brown tumor of hyperparathyroidism (BTHPT) is rare in the United States and not frequently seen in clinical practice. This is likely because early diagnosis and prompt treatment of this disease process prevent the progression and development of BTHPT. Conversely, BTHPT is more common in underdeveloped countries where fewer patients have access to health care and hyperparathyroidism (HPT) goes untreated. It has been reported that the incidence of BTHPT in underdeveloped countries can be as high as 58 to 69 percent in patients with primary HPT. We present a case report of a patient in the United States with a large mandibular BTHPT requiring an extensive resection in the setting of secondary HPT. Despite being rare in this country, it is important for nephrologists, primary care physicians, and oral health care providers to be able to recognize this entity, so that intervention may be rendered early.

[Brown tumor of the mandible revealing primary hyperparathyroidism: report of a case]

Les tumeurs brunes sont des manifestations osseuses classiques des hyperparathyroïdies (HPT). Elles surviennent habituellement lors des formes sévères accompagnées de signes de résorption osseuse périostée. La mandibule en constitue une localisation habituelle mais rarement révélatrice. Leur traitement repose essentiellement sur la paratharoïdectomie. Nous décrivons un cas de tumeur brune de la mandibule chez un patient de 46 ans; ainsi que son évolution favorable après para thyroïdectomie.

Craniofacial brown tumor as a result of secondary hyperparathyroidism in chronic renal disease patient: A rare entity

Brown tumors are erosive bony lesions caused by rapid osteoclastic activity and peritrabecular fibrosis due to primary or secondary hyperparathyroidism resulting in a local destructive phenomenon. The differential diagnosis based on histological examination is only presumptive. Clinical, radiological and laboratory data are necessary for definitive diagnosis. Here, we report a very rare case of brown tumor involving maxilla and mandible, which is the result of secondary hyperparathyroidism in 30-year-old female patient with chronic renal disease.

Bilateral maxillary brown tumors in a patient with primary hyperparathyroidism: Report of a rare entity and review of literature

Brown tumors are erosive bony lesions caused by rapid osteoclastic activity and peritrabecular fibrosis due to hyperparathyroidism, resulting in a local destructive phenomenon. The classical "brown tumor" is commonly seen in ends of long bones, the pelvis and ribs. Facial involvement is rare and, when present, usually involves the mandible. We report a case of 60-year-old male with a rare initial presentation of primary hyperparathyroidism with bilateral maxillary brown tumors. The present case represents the third report of the bilateral maxillary brown tumors in a patient with primary hyperparathyroidism. Differential diagnosis is important for the right treatment choice. It should exclude other giant cell lesions that affect the maxillae.

Brown tumour of the maxilla and mandible: a rare complication of tertiary hyperparathyroidism

Hyperparathyroidism is nowadays diagnosed early and asymptomatically with the improvements in routine biochemical tests and radiological procedures. The late bony complications of the disease have therefore started to decline rapidly. Brown tumours are one of the bony complications of hyperparathyroidism. The mandible is the predominantly affected site in the maxillofacial area. Maxillary involvement is rare. Here, an extremely rare case of a 19-year-old male patient with brown tumours in his maxilla and mandible associated with tertiary hyperparathyroidism is presented. A thorough diagnostic work-up was carried out and treatment options for both hyperparathyroidism and brown tumours were discussed. The importance of different radiological evaluation methods and the consultation between the oral and maxillofacial surgeons, general practitioner dentists, endocrinologists and radiologists are emphasised.

Surgical approach and clinical outcome of a deforming brown tumor at the maxilla in a patient with secondary hyperparathyroidism due to chronic renal failure

Brown tumors are relatively uncommon but they are serious complications of renal osteodystrophy. We describe a 31-year-old woman with end-stage renal disease who had undergone hemodialysis for nine years and developed severe secondary hyperparathyroidism and a maxilla brown tumor despite increasing doses of oral calcitriol and calcium carbonate. The fast increase of the right maxillary bone tumor led to indication of parathyroidectomy (PTx). Despite normalization of serum PTH there was a slow regression of the mass and the patient still complained about her appearance after two-years of follow-up. Excision of the maxillary mass followed by recontouring of the maxilla was then performed, with adequate masticator rehabilitation.

Brown tumors of the jaws associated with primary or secondary hyperparathyroidism. A clinical study and review of the literature

PURPOSE

The aim of this article is to present the development of brown tumors in the jaws as a definite feature of hyperparathyroidism (HPT), whether primary or secondary.

PATIENTS AND METHODS

The study included 2 cases of primary HPT and 3 cases of secondary HPT associated with brown tumors in the jaws. The patients presented in our clinic at the "G. Papanikolaou" Hospital in Thessaloniki for treatment of their disease. The patients were 4 women and 1 man, and patient's ages ranged from 21 to 76 years. Four cases of the brown tumors involved the mandible, and 1 case involved the maxilla and the maxillary sinus. The surgical excision of bone lesions and treatment of primary or secondary HPT were performed on the patients in our study.

RESULTS

Patient 1 (primary HPT, caused by an adenoma of the right parathyroid glands) was treated with surgical removal of the maxillary lesion and excision of the adenoma. Three years later, the patient is free of the disease, with no recurrence of the brown tumor. Patient 2 (primary HPT, caused by an adenoma of the right parathyroid glands) was treated with excision of the adenoma. One year later, a second bone lesion developed in the mandible, and 3(1/2) of the fourth parathyroid (right) glands was removed. The patient is being observed. The other 3 patients with brown tumors associated with secondary HPT were treated with excision of the bone lesions; HPT was treated with hemodialysis (2 patients) and renal transplantation (1 patient). For the patients treated with hemodialysis, the disease is under control and there is no recurrence of the brown tumors. The patient who underwent transplantation is free of the disease 7 years later.

CONCLUSIONS

Primary or secondary HPT may be recognized by the presence of an osteolytic lesion with giant cells, a condition referred as "brown tumor." The most useful therapy for patients with brown tumors is surgical excision of bone lesions and therapy (surgical or medical) for primary or secondary HPT.

[Brown tumor of the maxilla in patient with secondary hyperparathyroidism]

Brown tumor or parathyroid osteopathy is a kind of bony lesion caused by hyperparathyroidism. It appears as an expansive osteolytic lesion mostly in mandible, ribs, pelvis and femur, but rarely in the upper jaw. Bone resorption is the result of osteoclastic activity due to an increased activity of parathyroid hormone. A 25-years-old male patient was operated on due to clinicaly and radiographicaly obvious maxillary tumor and increased values of parathyroid hormon (PTH-1 050 ng/l). The level of calcium in blood was normal (Ca 2.34 mEq/L). The patient was dialyzed for years because of the chronic renal failure. Histopathologic analysis confirmed brown tumor, that appeared as bony lesion of secondary hyperparathyroidism due to the chronic renal failure. The operation of the upper jaw had been performed before parathyroidectomy, due to an excessive growth of tumor followed by heavy epistaxes. The subsequent parathyroidectomy was followed by the regression of remaining bony lesions.

Fibro-osseous and giant cell lesions, including brown tumor of the mandible, maxilla, and other craniofacial bones

Fibro-osseous, osseous, cartilaginous, and giant cell lesions of the mandible, maxilla, and other craniofacial bones share overlapping clinical, radiologic, and pathologic features that may lead to diagnostic confusion and possible misdiagnosis. The value of combined clinical-radiologic-pathologic correlation in the diagnosis of these lesions is paramount to achieving the correct diagnosis with subsequent implementation of appropriate therapeutic intervention.

Multiple and synchronous peripheral giant cell granulomas of the gums

The presence of multiple giant cell lesions in the maxillofacial region is suggestive of hyperparathyroidism or neurofibromatosis. A case of synchronous, multiple peripheral giant cell granulomas is reported, bilaterally affecting the mandibular gums and also the upper right maxillary gingival mucosa, without concomitant systemic disease. Only 2 cases of central giant cell granulomas, and no cases of peripheral giant cell granulomas exhibiting similar characteristics, have been reported in the literature to date.