This would produce a localized area of osteomyelitis with subsequent bone necrosis and sequestration."įigure 3: The bone in the photomicrograph appears nonvital, and it has bacterial colonies adherent on its surface. Kessler points out that "if the mylohyoid line is elevated and closer to the mucosal surface beneath the ulcer, microorganisms and resultant inflammation may more easily extend to involve the bony protuberance. The position makes the area more vulnerable to trauma, ulceration, and fracture.įigure 2: The periapical radiograph from this case is typical because LMS does not show radiographic changes, since the lesions involve only a limited area of the lingual cortical plate. He further explains that this line of muscle runs along the length of the mandible but is superiorly positioned in the second and third molar region. The line represents the attachment of the lingual border of the mandible where the mylohyoid muscle inserts. He expands this theory to explain that the preponderance of cases is documented in the area of the mylohyoid line. Kessler (2005) suggests that there may be some peculiarity of the anatomic site that predisposes the mandibular lingual region of the mouth to the development of this type of lesion. The radiograph presented in this case is typical with LMS because it appears normal and does not show radiographic changes, since the lesions involve only a limited area of the lingual cortical plate (see Figure 2). It is suggested that the molar region may be more susceptible to this type of sequestration and that mild trauma may be enough to trigger the changes in bone and cause the ulceration. The tongue may become ulcerated from rubbing the bone fragments.Įleven cases of lingual mandibular sequestration were documented by Peters and colleagues in 1993. Ulceration may occur along with the appearance of osseous fragments. Patients describe the pain as one of a "dull ache" that often intensifies with chewing and swallowing. (2010) report osteonecrosis associated with the use of alendronate (Fosamax), the development of lingual mandibular sequestration, and the subsequent failure of dental implants in some cases. Osteonecrosis associated with bisphosphonate therapy is also mentioned because the drugs suppress osteoclasts and inhibit the remodeling of bone. Osteonecrosis is also associated with several predisposing factors: dental extractions, trauma, systemic factors such as diabetes, immunosuppression, Paget's disease, osteopetrosis, and radiation therapy. Additionally, pressure from eating may cause a chronic type of inflammation and pressure within the tissues and the bone due to constant forces in the molar region, ultimately producing necrotic bone. When a tooth is extracted, the area is more vulnerable to irritation because of this loss of protection. The natural alignment of the teeth usually provides a sheltered environment, protecting the tissue from chronic assault and contamination from debris. The diagnosis is lingual mandibular sequestration (LMS), which arises, as the name implies, in the mandibular molar region. He is not aware of any trauma to the area in question.įigure 1: Clinical slide of LMS depicting ulcerated lesion with evident bone fragment. The patient reports a dull pain that is more pronounced when chewing. ![]() Several months later, the pain returned with an obvious lesion on the lingual area of No. The patient was referred back to his general dentist. No pathology was found, and no clinical or radiographic findings were noted at the time. ![]() The patient was referred to the oral pathology department of your health facility months earlier with similar complaints. 31 lingual with a shooting pain on the right side from mandible to the chin (see Figure 1). Burkhart, RDH, patient is a 45-year-old male who has complaints of tenderness in the region of No.
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