456
Neurofibroma of the Palatal Mucosa. A Case Report* Ralph P.
Pollack
in the periodontal literature. In this case female with a presented complaint of a lump in the maxillary left report, 27-year-old a mass 15 revealed 8 x 4 mm on the palatal evaluation palatal tissue; periodontal mucosa. After removal, the region healed without recurrence. The patient was referred to her physician for a physical, and no evidence of neurofibromatosis was found elsewhere, suggesting that this case represented an example of an isolated oral neurofibroma lesion. J Periodontol 1990;61:456-458. Neurofibromas
have not been reported
a
Key Words: Neurofibroma.
Neurofibromas have been reported in the oral surgical literature, but not as yet in the periodontal literature, and have never been associated with periodontal pockets. They are classified as benign neural sheath neoplasms1 consisting of spindle cells with wavy nuclei and the lesion is not
encapsulated. They have been located in soft tissues such as the cheek, palate, tongue, and lips2 and have also been noted in the
intra-osseous tissue as well.3"5 Neurofibromas differ clinically and histologically from neurofibromatosis. Neurofibromatoses are a set of disorders which cause tumors to develop along nerves and may involve soft and hard tissues. This is an autosomal dominant disorder which may be inherited from a parent who has neurofibromatosis or may be a spontaneous mutation. Today, there are two recognized types. The most common is neurofibromatosis 1, previously known as Von Recklinghausen's neurofibromatosis or peripheral neurofibromatosis. The other is neurofibromatosis 2, previously known as acoustic neurofibromatosis or central neurofibromatosis.6 The oral lesions in the disease neurofibromatosis have the same histopathological findings as the solitary neurofibromas. This article will discuss an isolated lesion of neurofibroma as it presented upon a routine periodontal evaluation. A 6 mm palatal periodontal pocket was associated with this mass. CASE REPORT A 27-year-old female presented to this office with a chief complaint of a lump in the maxillary left palatal tissue with a duration of approximately 10 months. Lymphadenopathy was not noted. Periodontal evaluation revealed a thickened "Private
practice,
North Dartmouth, MA.
Figure I. Kodachrome of the maxillary left posterior sextant. An enlarged (15 x s x 4 mm) is noted on the palatal surface of the first and second molars. Periodontal probing of a 6 mm pocket was noted on the interproximal region between the molars. mass
15 x 8 x 4 mm on the palatal mucosa of the maxleft first and second molars (Fig. 1). A 6 mm periodontal pocket was associated with this lesion (Fig. 2). Utilizing local anesthesia, mepivacaine hydrochloride 2%, and Levonordefrin 1:20,000, the entire lesion was removed and the tissues submitted for a histopathological review. mass
illary
Histopathology shows the keratinized squamous mucosa and subThe lesion is not encapsulated, but is well demarcated from the surrounding submucosal connective tissue. Figure 4 is an enlarged view showing that within the submucosa there is a lesion composed of spindle cells with wavy nuclei. There is only moderate vascularity.
Figure 3 mucosa.
Volume 61 Number 7
POLLACK
457
V
Figure 2. Kodachrome of the palatal mucosa. This magnified view shows periodontal probe with a 6 mm depth between the maxillary left molars.
a
Figure 4. Photomicrograph showing higher power view of Figure 3. The wavy nuclei and spindle cells are evident throughout this photo ( & E stain, original magnification 312.5).
V Figure 3. Photomicrograph showing the mucosa and submucosa of the palatal tissue ( & E stain, original magnification 31.25). The neurofibroma is not encapsulated but is well demarcated from the surrounding connective tissue.
Clinical Course Prior to removal of this undiagnosed mass, plaque control, and scaling and root planing sessions were performed by a hygienist. After removal of this lesion, the region healed without recurrence. Figure 5 is a 10 month post operative Kodachrome. After the histopathological diagnosis of neurofibroma was established, this patient was referred to her physician. This physical examination consisted of evaluating her abdominal and back regions for any café-au-lait macules and palpation of her extremities. Since none of these signs were noted, the physician's conclusion was that "no evidence of neurofibromatosis was present." DISCUSSION Although this neurofibroma was a rare occurrence along the marginal palatal tissue, it should be thought of when an
Kodachrome of the maxillary left palatal region 10 months after the removal of the lesion. No recurrence was noted.
Figure 5.
idiopathic enlarged, firm mass is noted. Patients with a histopathological diagnosis of neurofibroma should be referred to their physician for further possible diagnosis of neurofibromatosis. The diagnosis of neurofibromatosis 1 can only be made if the following signs are noted: 1. six
or more
café-au-lait macules7 greater than 5 mm over 15 mm in diameter in
prepubertal individuals, and post-pubertal individuals; in
2. two or more neurofibromas of any type or one plexiform neurofibroma; 3. opticglioma; 4. two or more Lisch nodules in the iris of the eye. The diagnosis of neurofibromatosis 2 is primarily made when bilateral eighth nerve masses are diagnosed by CAT scan or MRI. After a careful physical examination by this patient's physician, no other signs nor symptoms that would establish the diagnosis of neurofibromatosis were detected.
458
J Periodontol July 1990
NEURO-FIBROMA OF THE PALATAL MUCOSA
Acknowledgment A special acknowledgment and thanks to Dr. Steven Greenwood for his assistance with the histopathological data. REFERENCES 1. Shklar G, Meyer I. Neutrogenic tumors of the mouth and jaws. Oral Surg Oral Med Oral Path 1963; 16:1075-1093. 2. Bhaskar SN. Synopsis of Oral Pathology. 3rd ed. St. Louis: C.V. Mosby. 1969:419. 3. Singer CF, Jr., Gienger GL, Kullbom TL. Solitary intraosseous neurofibroma involving the mandibular canal: Report of case. Surgery 1973; 31:127-129.
4.
Gnepp DR, Keyes
GG. Central neurofibromas of the mandible: Re-
port of two cases. J Oral Surg 1981; 39:125-127. 5. Prescott GH, White RE. Solitary, central neurofibroma of the
man-
dible: Report of case and review of the literature. J Oral Surg 1970; 28:305-309. 6. National Institutes of Health. Neurofibromatosis. Bethesda, MD. National Institutes of Health Consensus Development Conferences Statement. Vol. 6; Number 12, (July, 1987). 7. Lorson EL, DeLong , Osbon DB, Dolon KD. Neurofibromatosis with central neurofibroma of the mandible: Review of the literature and report of case. J Oral Surg 1977; 35:733-738. Send reprint requests Dartmouth, MA 02747.
Accepted
for
to:
publication
Dr.
Ralph Pollack,
December
29, 1989.
41 State
Road, North
Neurofibroma of the Palatal Mucosa. A Case Report* Ralph P.
Pollack
in the periodontal literature. In this case female with a presented complaint of a lump in the maxillary left report, 27-year-old a mass 15 revealed 8 x 4 mm on the palatal evaluation palatal tissue; periodontal mucosa. After removal, the region healed without recurrence. The patient was referred to her physician for a physical, and no evidence of neurofibromatosis was found elsewhere, suggesting that this case represented an example of an isolated oral neurofibroma lesion. J Periodontol 1990;61:456-458. Neurofibromas
have not been reported
a
Key Words: Neurofibroma.
Neurofibromas have been reported in the oral surgical literature, but not as yet in the periodontal literature, and have never been associated with periodontal pockets. They are classified as benign neural sheath neoplasms1 consisting of spindle cells with wavy nuclei and the lesion is not
encapsulated. They have been located in soft tissues such as the cheek, palate, tongue, and lips2 and have also been noted in the
intra-osseous tissue as well.3"5 Neurofibromas differ clinically and histologically from neurofibromatosis. Neurofibromatoses are a set of disorders which cause tumors to develop along nerves and may involve soft and hard tissues. This is an autosomal dominant disorder which may be inherited from a parent who has neurofibromatosis or may be a spontaneous mutation. Today, there are two recognized types. The most common is neurofibromatosis 1, previously known as Von Recklinghausen's neurofibromatosis or peripheral neurofibromatosis. The other is neurofibromatosis 2, previously known as acoustic neurofibromatosis or central neurofibromatosis.6 The oral lesions in the disease neurofibromatosis have the same histopathological findings as the solitary neurofibromas. This article will discuss an isolated lesion of neurofibroma as it presented upon a routine periodontal evaluation. A 6 mm palatal periodontal pocket was associated with this mass. CASE REPORT A 27-year-old female presented to this office with a chief complaint of a lump in the maxillary left palatal tissue with a duration of approximately 10 months. Lymphadenopathy was not noted. Periodontal evaluation revealed a thickened "Private
practice,
North Dartmouth, MA.
Figure I. Kodachrome of the maxillary left posterior sextant. An enlarged (15 x s x 4 mm) is noted on the palatal surface of the first and second molars. Periodontal probing of a 6 mm pocket was noted on the interproximal region between the molars. mass
15 x 8 x 4 mm on the palatal mucosa of the maxleft first and second molars (Fig. 1). A 6 mm periodontal pocket was associated with this lesion (Fig. 2). Utilizing local anesthesia, mepivacaine hydrochloride 2%, and Levonordefrin 1:20,000, the entire lesion was removed and the tissues submitted for a histopathological review. mass
illary
Histopathology shows the keratinized squamous mucosa and subThe lesion is not encapsulated, but is well demarcated from the surrounding submucosal connective tissue. Figure 4 is an enlarged view showing that within the submucosa there is a lesion composed of spindle cells with wavy nuclei. There is only moderate vascularity.
Figure 3 mucosa.
Volume 61 Number 7
POLLACK
457
V
Figure 2. Kodachrome of the palatal mucosa. This magnified view shows periodontal probe with a 6 mm depth between the maxillary left molars.
a
Figure 4. Photomicrograph showing higher power view of Figure 3. The wavy nuclei and spindle cells are evident throughout this photo ( & E stain, original magnification 312.5).
V Figure 3. Photomicrograph showing the mucosa and submucosa of the palatal tissue ( & E stain, original magnification 31.25). The neurofibroma is not encapsulated but is well demarcated from the surrounding connective tissue.
Clinical Course Prior to removal of this undiagnosed mass, plaque control, and scaling and root planing sessions were performed by a hygienist. After removal of this lesion, the region healed without recurrence. Figure 5 is a 10 month post operative Kodachrome. After the histopathological diagnosis of neurofibroma was established, this patient was referred to her physician. This physical examination consisted of evaluating her abdominal and back regions for any café-au-lait macules and palpation of her extremities. Since none of these signs were noted, the physician's conclusion was that "no evidence of neurofibromatosis was present." DISCUSSION Although this neurofibroma was a rare occurrence along the marginal palatal tissue, it should be thought of when an
Kodachrome of the maxillary left palatal region 10 months after the removal of the lesion. No recurrence was noted.
Figure 5.
idiopathic enlarged, firm mass is noted. Patients with a histopathological diagnosis of neurofibroma should be referred to their physician for further possible diagnosis of neurofibromatosis. The diagnosis of neurofibromatosis 1 can only be made if the following signs are noted: 1. six
or more
café-au-lait macules7 greater than 5 mm over 15 mm in diameter in
prepubertal individuals, and post-pubertal individuals; in
2. two or more neurofibromas of any type or one plexiform neurofibroma; 3. opticglioma; 4. two or more Lisch nodules in the iris of the eye. The diagnosis of neurofibromatosis 2 is primarily made when bilateral eighth nerve masses are diagnosed by CAT scan or MRI. After a careful physical examination by this patient's physician, no other signs nor symptoms that would establish the diagnosis of neurofibromatosis were detected.
458
J Periodontol July 1990
NEURO-FIBROMA OF THE PALATAL MUCOSA
Acknowledgment A special acknowledgment and thanks to Dr. Steven Greenwood for his assistance with the histopathological data. REFERENCES 1. Shklar G, Meyer I. Neutrogenic tumors of the mouth and jaws. Oral Surg Oral Med Oral Path 1963; 16:1075-1093. 2. Bhaskar SN. Synopsis of Oral Pathology. 3rd ed. St. Louis: C.V. Mosby. 1969:419. 3. Singer CF, Jr., Gienger GL, Kullbom TL. Solitary intraosseous neurofibroma involving the mandibular canal: Report of case. Surgery 1973; 31:127-129.
4.
Gnepp DR, Keyes
GG. Central neurofibromas of the mandible: Re-
port of two cases. J Oral Surg 1981; 39:125-127. 5. Prescott GH, White RE. Solitary, central neurofibroma of the
man-
dible: Report of case and review of the literature. J Oral Surg 1970; 28:305-309. 6. National Institutes of Health. Neurofibromatosis. Bethesda, MD. National Institutes of Health Consensus Development Conferences Statement. Vol. 6; Number 12, (July, 1987). 7. Lorson EL, DeLong , Osbon DB, Dolon KD. Neurofibromatosis with central neurofibroma of the mandible: Review of the literature and report of case. J Oral Surg 1977; 35:733-738. Send reprint requests Dartmouth, MA 02747.
Accepted
for
to:
publication
Dr.
Ralph Pollack,
December
29, 1989.
41 State
Road, North
