A 13-year-old girl reported to the Department of Orthodontics and Dentofacial Orthopaedics, Army College of Dental Sciences, Secunderabad, with the chief complaint of forwardly placed upper front teeth and spacing [Figures 1a, 2a and 3a].
A full set of records needed for treatment planning were obtained which included:
Study models
Lateral cephalogram
Orthopantomogram (OPG)
Intraoral periapical (IOPA) X-rays of all the anterior teeth
Extraoral and intraoral photographs.
Analysis of the records showed the patient to be a skeletal Class II malocclusion with a deficient mandible which necessitated functional orthopedic therapy with the "Twin-Block appliance" to aid in mandibular advancement enabling correction of the sagittal skeletal discrepancy initially. The case would be reassessed for further dental treatment after completion of the functional phase. The functional appliance was a two-piece type with separate upper and lower components fabricated in heat-cured acrylic resin. Retention was obtained with stainless steel ball end clasps [Figure 4].
The patient reported with a diffuse swelling measuring approximately 40 mm in height and 53 mm in length on the left side of the face in the submandibular region after a period of 40 days [Figures 1b and 2b]. Case history revealed that the swelling developed over a period of 3 days with no signs of any respiratory tract infection or fever. On extraoral examination, a single, diffuse nonmovable swelling was observed in the left submandibular region which was nontender on palpation and firm in consistency. Intraoral examination showed no lesions, ulcerations or any tooth-related anomaly [Figure 3b]. Moreover, the oral hygiene status of the patient was also good. Bimanual palpation of the submandibular gland showed a normal gland texture. Salivary gland duct evaluation showed no abnormality with no history of "meal time syndrome." Salivary flow tests were done, and results were within normal limits. Lymph node examination of the body in general was carried out to rule out generalized lymphadenopathy. The only positive clinical finding was a slight reduction in mouth opening owing to the swelling present in the region. A provisional diagnosis of reactive lymphadenopathy was made.
The functional therapy was immediately discontinued. Diagnostic IOPAs of the developing second molar regions as well as an OPG were recorded [Figure 5]. The patient was advised investigations including a complete blood picture, ultrasonographic (USG) evaluation of the left submandibular gland region [Figure 6] and a FNAC. The blood reports were nonspecific with the only significant finding being a mildly elevated erythrocyte sedimentation rate. USG scan revealed that the left submandibular gland was slightly enlarged as compared to the right with altered echotexture and increased vascularity on color Doppler. Enlarged cervical lymph nodes were noted at Levels I mainly and few in Level II and III during USG examination, with the largest one measuring 2.3 cm x 1.0 cm. Acid-fast bacillus smear and Mantoux test were done to rule out tuberculosis, and the test results were negative. Microscopic evaluation of the FNAC from left submandibular gland revealed few cells. It contained mostly blood and occasional salivary gland acini which were inadequate for diagnosis.
A final diagnosis of reactive lymphadenopathy with submandibular gland sialadenitis was given. After discussion with an oral surgeon, a period of observation without using any medication and temporary discontinuation of the appliance was decided on. The patient reported to the clinic 3 days later without any swelling which was surprising considering its size on initial presentation. As a matter of precaution, orthodontic appliance therapy was temporarily halted for another 3 weeks. The patient started wearing the removable functional appliance after completion of the period of observation. Treatment progressed smoothly with no further recurrence in symptoms.