traumatic neuroma is an exuberant , but non - neoplastic proliferation of a nerve occurring in response to an injury or surgery . the principal features of oral traumatic neuroma are similar to traumatic neuromas elsewhere in the body . clinically , it presents as a firm nodule that is occasionally tender or painful on palpation . strangulation of the proliferating nerve caused by scar tissue , local trauma , or infection may be responsible for the pain . the most common oral sites are the lip , tongue , and mental nerve area . microscopically , it consists of a haphazard proliferation of nerve fascicles , including axons , schwann cells , fibroblasts embedded in the background of a collagen , and sometimes associated with chronic inflammation . eventually , it can present mature ganglion cells , being called pseudoganglioneuroma . it is important to differentiate this condition , from ganglioneuroma , ganglioneuroblastoma , ganglioneuromatous tumor , subgemmal neurogenous plaque , and some neurofibromas,[46 ] in order to avoid misdiagnosis and consequently inadequate treatment . this article describes a case of traumatic neuroma of the oral cavity containing a mature ganglion cell cluster with satellite cells . a search of the english language literature did not reveal cases with these clinical and histopathological features . a 42-year - old latin american female patient was referred to the oral diagnosis clinic ( orocentro ) , piracicaba dental school  unicamp , complaining of a painful swelling in the right side of the mouth persisting for about three years , impairing her to use a complete lower denture . the patient denies trauma or surgery on the oral lesion site and her medical history was noncontributory . intraoral examination showed a painful , submucous mass tumor with fibroelastic consistency , covered by normal mucosa , measuring 4.0  2.0 cm , located on the lingual face of the right mandibular body [ figure 1 ] . our main clinical hypotheses of diagnosis were neural benign tumor or other benign mesenchymal tumor . under local anesthesia , an excisional biopsy was carried out and the microscopical analysis showed a haphazard proliferation of prominent nerve fascicles , including axons with their investitures of myelin , schwann cells , and fibroblasts , embedded in a fibrotic stroma , with focal areas of hyalinized collagen . characteristic clefts - like spaces between the stroma and nervous component were also observed [ figure 2 ] . a large mature ganglion cell cluster surrounded by satellite cells and nerve fiber bundles was found within the stromal fibrosis [ figure 3 ] . the patient has been in follow - up for three years without signs of recurrence . panoramic view of a tumor mass on the lingual surface of the right mandibular body ( black arrow ) . note the extensive alveolar ridge resorption ( white arrows ) nervous component intermingled with rich collagen bundles . note the cleft - like spaces ( h and e , 10 ) mature ganglion cell cluster surrounded by satellite cells and nerve fiber bundles ( h and e , 20 ) . although traumatic neuroma may form on any damaged nerve , it occurs more commonly in small nerves than in large nerves . etiological factors particularly include previous surgical procedures , however , other events such as pressure , ischemia , crushing injuries , lacerations , stretching , cuts , bleeding to the surrounding tissue have also been considered . the most common sites in the mouth are the lip , tongue , and mental nerve area . pain can be present in about 25% of the cases , and perhaps may be due to the constriction of nerves by stromal fibrosis . the relation between the presence of inflammatory cell infiltrate in the injured nerve and pain is uncertain . interestingly , our case showed a painful , submucous nodular lesion in an unusual location , on the ramus and body of the mandible , following the route of the inner oblique line , probably associated with constant trauma caused by the pressure of the overextended denture borders . some authors have reported that disturbances such as paresthesia and anesthesia can be related to the nerve size . our patient did not reveal any sensorial alteration , which implies that probably the lesion developed in the small nerves . microscopically , the fact that some of these lesions contain ganglion cells should not come as a surprise , as this process may represent the involvement of a pre - existing ganglion in this region or involvement of a ganglionized nerve fiber . smith and harn demonstrated the presence of nerve cell bodies in 40 / 44 ( 91% ) lingual nerves in the third molar area after studying the heads of 22 adult human cadavers . because of the relationship of the lingual nerve with the submandibular ganglion it is believed that these cell bodies are parasympathetic . in our case , the possibility that the ganglion cells represent the involvement of these lingual nerve cell bodies can not be discarded . . showed that 6 / 14 cases ( 43% ) of pharyngeal traumatic neuroma contained mature ganglion cells , which denominated pseudoganglioneuroma . thus , pseudoganglioneuroma should be distinguished from other neural lesions presenting ganglion cells , and probably our case represents this same entity . ganglioneuromas occur in patients between 10 and 30 years of age , are well - circumscribed and encapsulated , and are most frequently located in the posterior mediastinum , retroperitoneum , and adrenal glands , being uncommon in the alimentary tract . histologically it is composed of clusters of mono , bi , or multinucleate - ganglion cells deposited in a fibrillar neuromatous stroma . ganglioneuroma in the jaws is exceptional ; to date only five cases have been reported , occurring centrally in the mandible . ganglioneurofibroma presents with more spindled - cell stroma and the number of axons are decreased . ganglioneuroblastoma most commonly occurs in infants and young children and almost never occurs after the age of 10 . histologically , they are considered malignant because they contain primitive neuroblasts along with mature ganglion cells . pseudoganglioneuroma differs histologically from these tumors because the two components , ganglion cells surrounded by satellite cells and the neuroma , do not intermingle and are contained within a fibrous stroma . this was a cutaneous soft - tissue polypoid lesion , and microscopically displayed many isolated ganglion - like cells without satellite cells in the papillary dermis , and fascicles of unmyelinated axons in the lower dermis . subgemmal neural plaques are aggregates of nerve plexus and ganglion cells , usually organized in a neural tumor - like pattern , which incidentally , can be found in specimens of the lateral border of the tongue . clinically , it may be associated with the erythematous area , ulcer , white patch , or hyperplasic papule . the lesions could be reactive , representing neuronal dysplasias , or be a result of trophic influences from gustatory nerve fibers . participation of all elements of the nerve fascicles and identification of a damaged nerve distinguish a traumatic neuroma of neurofibroma . neurofibroma is usually found to be deep - rooted , does not have a predilection for a specific site , and persistently grows causing expansion . microscopically , the cells are arranged in short fascicles , whorls , or even in a storiform pattern . in some patients with von recklinghausen 's disease , scattered , solitary , or clustered mature ganglion cells are observed within the plexiform neurofibromas . there was no history or sign of von recklinghausen 's disease in our patient . in multiple endocrine neoplasia men2b , mucosal neuromas involve the mucosal surfaces of the lips , mouth , eyelids , and intestines . the patients usually present with medullary carcinoma of the thyroid , pheochromocytoma of the adrenal glands , and skeletal anomalies . histologically , the oral lesions present tortuous bundles of nerves , with a prominent perineurium within a fibrous stroma . differently , in the gastrointestinal tract both submucosal and myenteric plexus appear to be hyperplastic , showing schwann cells and ganglion cells . this ganglioneuromatous proliferation can also occur in different settings as von recklinghausen s neurofibromatosis , cowden 's disease , or juvenile polyposis coli . gimnez - bascuana and piqueras - prez reported a case that disclosed features of both granular cell tumor and traumatic neuroma affecting the submandibular salivary gland , called granular cell traumatic neuroma . ide and umemura analyzing the surgical specimen of squamous cell carcinoma of the floor of the mouth , showed a case of traumatic neuroma with intralesional glandular structures , localized in the submucosal tissue of the alveolar mucosa . in this case , probably the residual salivary ducts of the minor salivary glands became incorporated during the development of a traumatic neuroma . we report a case of oral traumatic neuroma with mature ganglion cells and unusual clinical features . it is important to recognize this condition in order to avoid misdiagnosis with other neural tumors associated with ganglion cells . all these conditions may present a clinical diagnostic challenge and inadequate treatment may be administered if they are not adequately recognized .
traumatic neuromas are characterized by the presence of pain , burning , or paresthesia , associated with a history of trauma , normally surgery , in the same site . in the oral cavity , 
 the most commonly affected sites are the lip , tongue , and mental nerve area . 
 pressure on the suspected area usually provokes pain . 
 they microscopically consist of a proliferation of nerve fascicles embedded in a background of collagen . 
 we present a case of a 42-year - old latin american female patient complaining of a painful solitary nodule erupting on the lingual surface of the mandibular body . 
 histopathological analysis showed a traumatic neuroma associated with mature ganglion cells , which is an extremely unusual finding . 
 after complete removal of the lesion the symptoms disappeared . to the best of our knowledge , 
 this is the first case of a unique lesion with unusual clinical and histopathological features reported in the english language literature .