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Case Report

ORAL SURGERY

Large Mandibular Lipoma: A Case Report

Mehdi Keddar

1a*

, Edouard Malengrez

,Cynthia Watteeuw1c

, Laurence Evrard1d

, Firas Shall1e , Christophe Politis1f

1Department of Stomatology and Maxillofacial Surgery, The Brussels University Hospital (H.U.B), Université Libre de Bruxelles 1070-Brussels, Belgium

aDaMD, DDS; e-mail: mehdi.keddar@hotmail.com ; ORCIDiD: https://orcid.org/0009-0005-1715-8968 bMedical student; e-mail: edouard.malengrez@ulb.be cMD, DDS; e-mail: cynthiawatteeuw@gmail.com dMD, DDS, PhD, Director; e-mail: laurence.evrard@ulb.be ; ORCIDiD: https://orcid.org/0000-0001-5581-4093 eMD, DDS; e-mail: firasshall@gmail.com ; ORCIDiD: https://orcid.org/0000-0003-3061-2625 fMD, DDS; e-mail: christophe.politis@gmail.com ; ORCIDiD: https://orcid.org/0000-0002-1076-1327

ABSTRACT

https://doi.org/10.25241/stomaeduj.2024.11(1-2).art. 8

This case report describes an intraoral lipoma in a 29-year-old female, a rare occurrence given the significant size of the lesion, which exceeded the common threshold of 2.5 cm for intraoral lipomas. Typically manifesting in areas such as the buccal mucosa and tongue, the lipoma in this case was located on the buccal mucosa, underscoring the variability in presentation sites. Surgical excision, the standard approach for such tumors, was the chosen treatment, with a successful outcome and no recurrence. This case report adds to the limited body of literature on intraoral lipomas, highlights the potential for atypical presentations in size, and emphasizes the effectiveness of surgical management.

KEYWORDS

Maxillofacial Surgery; Intraoral Lipoma; Lipoma Management; Oral Pathology; Soft Tissue Tumor.

1. INTRODUCTION

Lipomas are the most common benign mesenchymal tumors occurring in humans and are predominantly composed of mature adipocytes. Lipomas mainly occur in various parts of the body, such as the trunk and proximal regions of the extremities, but are uncommon in the oral cavity. These entities represent a mere 1–5% of all benign oral tumors [1], but they present unique diagnostic and therapeutic challenges. Lipomas in the oral cavity do not exhibit a predilection for any specific location, and occurrences have been reported in areas such as the tongue, buccal mucosa, and floor of the mouth. They tend to occur in patients between the ages of 40 and 60, with the average age of occurrence being approximately 52 years, although they can appear at any age. Histologically, oral lipomas present in a spectrum of subtypes, including but not limited to simple lipomas, fibrolipomas, spindle cell lipomas, intramuscular or infiltrating lipomas, and angiolipomas. Each subtype exhibits distinct histopathological features, whose identification is critical for accurate diagnosis and appropriate management. Clinically, oral lipomas often present as asymptomatic, slow-growing masses that may be overlooked or misdiagnosed due to their subtlety and benign nature. This report describes a case involving an adult female patient who underwent successful surgical removal of an intraoral lipoma.

2. CASE PRESENTATION

A 29-year-old woman presented at the Oral and Maxillofacial Surgery Department at HUBruxelles Erasme with a history of intermittent left cheek swelling for several years (Fig. 1).

Figure 1. Preoperative intraoral view.

She was first admitted without appointment, as she described a sudden onset of cheek swelling that could be compatible with cellulitis. The patient had no notable medical history or medication usage to report but disclosed that she smoked approximately 10 cigarettes daily. The patient's oral hygiene was found to be excellent, no cavities were observed, and no pain was elicited during dental percussion. Moreover, an orthopantomogram revealed no significant lesions. Blood work showed no elevation in white blood cells, C-reactive protein (CRP), or other relevant markers of infectious or allergic origin. A

OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.

Peer-Reviewed Article

Citation: Keddar M, et al. Politis C. Large Mandibular Lipoma: A Case Report. Stoma Edu J. 2024;11(1-2):78-81.

Received: February 18, 2024; Revised: March 18, 2024; Accepted: April 01, 2024; Published: May 03, 2024.

*Corresponding author: Dr. Mehdi Keddar, MD, DDS, Department of Stomatology and Maxillofacial Surgery, The Brussels University Hospital (H.U.B),

Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium; Tel. /Fax: +32 (0) 2 555 55 55; e-mail: mehdi.keddar@hotmail.com

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cervical ultrasound revealed a 37-mm mass in the left cheek, initially suggestive of a lipoma (Fig. 2).

Figure 2. Ultrasonographic image depicting a well-defined hypoechoic mass consistent with a lipoma.

This diagnosis was later confirmed by an MRI, which delineated a lesion with fat signal characteristics (hyperintense in T1 and T2, hypointense in T2 with fat saturation, and T1 post-gadolinium with fat saturation), consistent with a lipoma that measured 37 x 13 x 17 mm (length x anteroposterior x craniocaudal). The lipoma was located along the external aspect of the left horizontal mandibular branch (Fig. 3).

Figure 3. MRI scans with A) axial and B) coronal views (T2 fat-saturated), illustrating a homogenous, high-signal intensity mass on T1-weighted images characteristic of a lipoma's fat content

The decision was made to perform an excisional biopsy and excision of the lesion (Fig. 4). The procedure was performed under general anesthesia due to significant anxiety on the part of the patient. An electrocautery unit was used to make an incision along the vestibular sulcus from tooth 33 to 36, which immediately exposed the lipoma. Careful dissection was undertaken to preserve the mandibular nerve, with meticulous attention to hemostasis. The wound was then closed with simple interrupted sutures using 3-0 Vicryl (polyglactin 910).

Figure 4. Operative view after superficial excision showing the mass in situ, B) isolation and exposure of the lipoma, C) post-excision site showing the surgical bed, and D) sutured closure of the surgical site.

The follow-up after 14 days showed an uneventful wound healing process; however, there was a transient hypoesthesia of the mandibular nerve, which resolved completely after one month.

3. DISCUSSION

This case report regarding an intraoral lipoma in an adult female patient underscores the clinical rarity and diagnostic subtleties of these tumors in the oral cavity. Lipomas, which typically occur in other areas of the body, manifest distinctively when they occur in the oral region. This patient's presentation with a non-tender, soft mass and the subsequent imaging and histopathological findings are characteristic of intraoral lipomas and align with reports in the literature [2]. However, this particular lipoma was significantly larger than average, as intraoral lipomas rarely exceed 2.5 cm in diameter [3]. Regarding the localization of intraoral lipomas, the buccal mucosa is the most common site, followed by the tongue; together, these two sites account for 50% of intraoral lipomas. Other notable locations include the lip, palate and floor of the mouth, vestibule, retromolar area, and gingiva [4]. Approximately 5% of lipomas can manifest in multiple forms and are associated with conditions such as neurofibromatosis or familial adenomatous polyposis syndrome [4,5]. However, cases of intraoral lipomas appear to be exclusive and solitary in nature [6]. A notable aspect of this case is the patient's lack of significant medical history, with the exception of tobacco use. Tobacco consumption has not been conclusively linked to the development of intraoral lipomas, which suggests that the occurrence of these tumors could be independent of tobacco use. The exact cause of lipomas is still not fully understood, and the occurrence of lipomas appears to be influenced by multiple factors with no direct correlation to habits such as tobacco consumption. Some researchers have proposed that lipoma formation might be triggered by recurrent minor trauma that potentially stimulates the growth of fatty tissue. However, a definitive link between such trauma and the occurrence of a lipoma remains elusive. Other studies have suggested that these tumors may originate from embryonic multipotential cells, which are dormant until hormonal changes during adolescence activate their differentiation into mature adipose tissue, leading to the gradual emergence of a lipoma [6]. Diverse subtypes of lipomas have been described. In the reported case, the histopathological analysis established a classic lipoma, the most common variant of intraoral lipomas, accounting for between 45% and 50% of all intraoral lipomas (Fig. 5). It has been suggested that oral lipomas are more common in males, while oral fibrolipomas are more frequent in females; however, there is no clear evidence to support these suggestions [7], [6]. Our patient presented with a simple lipoma.

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Case Report

Figure 5. Excised lipoma.

Surgical excision remains the treatment of choice, and there is a less than 1% recurrence rate [6]. Steroid injections in the center of the lipoma have been suggested in the literature as an alternative treatment to reduce the size of tumors of less than

2.54 cm in diameter. Because they cause local fat atrophy, these injections have been associated with few complications [8]. However, the patient described in this report was not a suitable candidate for this treatment. The hypoesthesia, which resolved within a month, is a relatively uncommon but possible postoperative complication related to the location of the lesion. Comprehensive radiographical evaluation is crucial for both the diagnostic process and the surgical planning.

REFERENCES

4. 5 KEY LEARNING POINTS

1. Intraoral lipomas can present beyond typical size ranges, highlighting the need for clinical awareness in differential diagnosis of soft tissue masses, especially for non-tender, slow-growing lesions.

2. Imaging, particularly ultrasound and MRI, is essential for the preliminary identification and characterization of intraoral lipomas.

3. Surgical excision is highly effective for intraoral lipomas, with minimal recurrence and manageable postoperative complications.

4. Histological examination is critical to differentiate between the subtypes of oral lipomas, guiding accurate diagnosis and management.

5. The etiology of intraoral lipomas remains uncertain, underscoring the need for further research into potential lifestyle and genetic factors.

AUTHOR CONTRIBUTIONS

MK, CW, FS Patient management. MK, EM Drafting of the article. LE Revision of the article. CP Revision and final approval of the article.

ACKNOWLEDGMENTS

We extend our deepest gratitude to the patient who consented to the publication of this case, enabling us to share valuable insights with the medical community. Our thanks also go to the entire team at the Stomatology and Maxillofacial Surgery Department at HU Bruxelles Erasme for their exceptional care and dedication in managing this case. Special appreciation is directed towards the radiology department for their expertise and assistance in the diagnostic process, which was pivotal for the successful treatment outcome.

1. Kumaraswamy SV, Madan N, Keerthi R, Shakti S. Lipomas of oral Exp Dent. 2016 Dec 1;8(5):e597-e603. doi: 10.4317/jced.52926. cavity: case reports with review of literature. J Maxillofac Oral Surg. Full text links CrossRef PubMed Google Scholar 2009 Dec;8(4):394-397. doi: 10.1007/s12663-009-0096-6. Epub 2010

5. de Visscher JG. Lipomas and fibrolipomas of the oral cavity.

Apr 24.

J Maxillofac Surg. 1982 Jan 1;10:177-181. doi:10.1016/S0301

Full text links CrossRef PubMed Google Scholar Scopus WoS 0503(82)80036-2

2. Furlong MA, Fanburg-Smith JC, Childers EL. Lipoma of the oral and maxillofacial region: Site and subclassification of 125 cases. Oral Surg CrossRef PubMed Google Scholar WoS Oral Med Oral Pathol Oral Radiol Endod. 2004 Oct;98(4):441-450. doi: 6. Fregnani ER, Pires FR, Falzoni R, Lopes MA, Vargas PA. Lipomas 10.1016/j.tripleo.2004.02.071. of the oral cavity: clinical findings, histological classification and Full text links CrossRef PubMed Google Scholar WoS proliferative activity of 46 cases. Int J Oral Maxillofac Surg. 2003 Feb

3. Azzouz Y, Abidi S, Zidane FZ, Chbicheb S. An unusual intraoral

1;32(1):49-53. doi:10.1054/ijom.2002.0317

lipoma: case report and review of the literature. Pan Afr Med J. 2022 Full text links CrossRef PubMed Google Scholar WoS Apr 26;41:336. doi: 10.11604/pamj.2022.41.336.34808.

7. Salam GA. Lipoma excision. Am Fam Physician. 2002 Mar Full text links PubMed Google Scholar

4. Egido-Moreno S, Lozano-Porras AB, Mishra S, et al. Intraoral 1;65(5):901-905. PMID: 11898962. lipomas: Review of literature and report of two clinical cases. J Clin Full text links CrossRef PubMed Google Scholar

Mehdi KEDDAR

CV MD, DDS Department of Stomatology and Maxillofacial Surgery The Brussels University Hospital (H.U.B) Université Libre de Bruxelles 1070, Brussels, Belgium

Dr. Mehdi Keddar was a doctoral student at the Université Catholique de Louvain (2011-2019) where he obtained his MD title (Doctor of Medicine). He obtained hid DDS title (Doctor of Dental Surgery) after a three-year period of studies (2019-2022) at the Université Libre de Bruxelles. Since 2019 he has been a Resident in Training at the Université Libre de Bruxelles (Stomatology and Maxillo-Facial Residency).

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Questions

1. What is the most common location for intraoral lipomas?

qa. Palate;

qb. Buccal mucosa;

qc. Tongue;

qd. Floor of the mouth.

2. Which imaging technique is NOT typically used for the diagnosis of intraoral lipomas?

qa. Ultrasound;

qb. MRI;

qc. CT Scan;

qd. PET Scan.

3. What is the age range most commonly associated with the occurrence of intraoral lipomas?

qa. 20-30 years; qb. 40-60 years; qc. 10-20 years; qd. 30-40 years.

4. Which of the following is NOT a subtype of oral lipomas mentioned in the report?

qa. Simple lipomas;

qb. Fibrolipomas;

qc. Spindle cell lipomas;

qd. Osteolipomas.

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