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Oral & Maxillofacial Surgery
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  • 1. Odontogenic TumorsOdontogenic Tumors Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady BDS, MSC, (Egypt) PhD. (Egypt,USA)BDS, MSC, (Egypt) PhD. (Egypt,USA) Oral and Maxillofacial Surgery Dept.Oral and Maxillofacial Surgery Dept. College of Dentistry, King Faisal University, KSA.College of Dentistry, King Faisal University, KSA.
  • 2. Classification of Odontogenic TumorsClassification of Odontogenic Tumors From Neville, et al.From Neville, et al. I.I.Tumors of odontogenicTumors of odontogenic epitheliumepithelium AmeloblastomaAmeloblastoma 1. Malignant1. Malignant ameloblastomaameloblastoma 2. Ameloblastic2. Ameloblastic carcinomacarcinoma B. Clear cell odontogenicB. Clear cell odontogenic carcinomacarcinoma C.AdenomatoidC.Adenomatoid odontogenic tumorodontogenic tumor D.Calcifying epithelialD.Calcifying epithelial odontogenic tumorodontogenic tumor E.Squamous odontogenicE.Squamous odontogenic tumortumor II.II. Mixed odontogenic tumorsMixed odontogenic tumors A.Ameloblastic fibromaA.Ameloblastic fibroma B.Ameloblastic fibro-odontomaB.Ameloblastic fibro-odontoma C.Ameloblastic fibrosarcomaC.Ameloblastic fibrosarcoma D.OdontoameloblastomaD.Odontoameloblastoma E.E. Compound odontomaCompound odontoma F.F. Complex odontomaComplex odontoma III. Tumors of odontogenicIII. Tumors of odontogenic ectomesenchymeectomesenchyme A.Odontogenic fibromaA.Odontogenic fibroma B.Granular cell odontogenicB.Granular cell odontogenic tumortumor C.Odontogenic myxomaC.Odontogenic myxoma D.CementoblastomaD.Cementoblastoma
  • 3.  BENIGN, NO RECURRENCEBENIGN, NO RECURRENCE POTENTIALPOTENTIAL  Adenomatoid odontogenicAdenomatoid odontogenic tumortumor  Squamous odontogenic tumorSquamous odontogenic tumor  CementoblastomaCementoblastoma  Periapical cementoosseousPeriapical cementoosseous dysplasiadysplasia  OdontomaOdontoma  BENIGN, SOME RECURRENCEBENIGN, SOME RECURRENCE POTENTIALPOTENTIAL  Cystic ameloblastomaCystic ameloblastoma (unicystic)(unicystic)  Calcifying epithelial odontogenicCalcifying epithelial odontogenic tumortumor  Central odontogenic fibromaCentral odontogenic fibroma  Florid cementoosseousFlorid cementoosseous dysplasiadysplasia  Ameloblastic fibroma andAmeloblastic fibroma and fibroodontomafibroodontoma  *From Regezi, et al.*From Regezi, et al.  BENIGN AGGRESSIVEBENIGN AGGRESSIVE  AmeloblastomaAmeloblastoma  Clear cell odontogenic tumorClear cell odontogenic tumor (some consider this a(some consider this a carcinoma)carcinoma)  Odontogenic ghost cell tumorOdontogenic ghost cell tumor (COC, solid type)(COC, solid type)  Odontogenic myxomaOdontogenic myxoma  OdontoameloblastomaOdontoameloblastoma  MALIGNANTMALIGNANT  Malignant ameloblastomaMalignant ameloblastoma  Ameloblastic carcinomaAmeloblastic carcinoma  Primary intraosseousPrimary intraosseous carcinomacarcinoma  Odontogenic ghost cellOdontogenic ghost cell carcinomacarcinoma  Ameloblastic fibrosarcomaAmeloblastic fibrosarcoma Biologic Classification of Odontogenic Tumors*Biologic Classification of Odontogenic Tumors*
  • 4. Tumors of OdontogenicTumors of Odontogenic EpitheliumEpithelium
  • 5. AmeloblastomaAmeloblastoma  The ameloblastoma is the most common odontogenic tumor. It is a benign but locally invasive neoplasm derived from odontogenic epithelium. It has three different clinicopathologic subtypes: multicystic (86%), unicystic (13%) and peripheral (extraosseus – 1%). It usually occurs in the 4th and 5th decades without a gender predilection.
  • 6. AmeloblastomaAmeloblastoma  It is typically slow-growing, locally invasive andIt is typically slow-growing, locally invasive and runs a benign course.runs a benign course.  WHO described it as being a benign tumor thatWHO described it as being a benign tumor that is “usually unicentric, non-functional, intermittentis “usually unicentric, non-functional, intermittent in growth, anatomically benign and clinicallyin growth, anatomically benign and clinically persistent.”persistent.”  It may develop from cell rests of the enamelIt may develop from cell rests of the enamel organ; from the developing enamel organ; fromorgan; from the developing enamel organ; from the lining of odontogenic cysts or from the basalthe lining of odontogenic cysts or from the basal cells of the oral mucosa.cells of the oral mucosa.
  • 7.  It may arise from the lining of a dentigerous cyst but more often arises independently of impacted teeth. It is characterized by a progressive growth rate and , when untreated, may reach enormous proportions. Early symptoms are often absent, but late symptoms may include a painless swelling, loose teeth, malocclusion, or nasal obstruction
  • 8. AmeloblastomaAmeloblastoma  Ameloblastomas occur in 3 differentAmeloblastomas occur in 3 different clinico-radiographic situations requiringclinico-radiographic situations requiring different therapeutic considerations anddifferent therapeutic considerations and having different prognoses.having different prognoses.  Conventional Solid/Multicystic (86 % of allConventional Solid/Multicystic (86 % of all cases)cases)  Unicystic (13 % of all cases)Unicystic (13 % of all cases)  Peripheral or Extraosseous (1 % of all cases)Peripheral or Extraosseous (1 % of all cases)
  • 9.  Maxillary tumors frequently perforate into the antrum and may grow freely, with extension into the nasal cavity, ethmoid sinuses, and skull base.
  • 10. Solid or Multicystic Ameloblastoma:Solid or Multicystic Ameloblastoma: Clinical FeaturesClinical Features  Patient Age: Approximately equal frequencyPatient Age: Approximately equal frequency from the third through the seventh decades.from the third through the seventh decades.  Sex Predilection: Approximately equal.Sex Predilection: Approximately equal.  Location: 80 % in mandible; 70 % in posteriorLocation: 80 % in mandible; 70 % in posterior regions.regions.  Radiographic Appearance: Radiolucent lesionRadiographic Appearance: Radiolucent lesion which is usually well-circumscribed; it may bewhich is usually well-circumscribed; it may be unilocular or multilocular (soap-bubble,unilocular or multilocular (soap-bubble, honeycomb); occasionally an ameloblastomahoneycomb); occasionally an ameloblastoma will be ill-defined with a ragged border.will be ill-defined with a ragged border.
  • 11. Solid or Multicystic Ameloblastoma:Solid or Multicystic Ameloblastoma: Histologic FeaturesHistologic Features  There are several microscopic subtypesThere are several microscopic subtypes but these generally have little bearing onbut these generally have little bearing on the behavior of the tumor.the behavior of the tumor.  The follicular and plexiform types are theThe follicular and plexiform types are the most common.most common.  TheThe follicularfollicular type is composed of islandstype is composed of islands of epithelium which resemble the enamelof epithelium which resemble the enamel organ in a mature fibrous connectiveorgan in a mature fibrous connective tissue stoma.tissue stoma.
  • 12. Solid or Multicystic Ameloblastoma:Solid or Multicystic Ameloblastoma: Histologic FeaturesHistologic Features  TheThe plexiformplexiform type is composed of long,type is composed of long, anastomosing cords or larger sheets ofanastomosing cords or larger sheets of odontogenic epithelium. Its stroma tends to beodontogenic epithelium. Its stroma tends to be loose and more vascular.loose and more vascular.  TheThe acanthomatousacanthomatous type shows evidence oftype shows evidence of extensive squamous metaplasia with keratinextensive squamous metaplasia with keratin formation in the island of odontogenicformation in the island of odontogenic epithelium.epithelium.
  • 13. Solid or Multicystic Ameloblastoma:Solid or Multicystic Ameloblastoma: Histologic FeaturesHistologic Features  In theIn the granular cellgranular cell type there istype there is transformation of groups of epithelialtransformation of groups of epithelial cells to granular cells; the nature ofcells to granular cells; the nature of the granular change is unknown.the granular change is unknown. This type is more common inThis type is more common in youngyoung patientspatients and has been shown to beand has been shown to be clinically aggressive.clinically aggressive.
  • 14. Solid or Multicystic Ameloblastoma:Solid or Multicystic Ameloblastoma: Histologic FeaturesHistologic Features  TheThe desmoplasticdesmoplastic form is composed ofform is composed of islands/cords of odontogenic epithelium in aislands/cords of odontogenic epithelium in a very dense collagenous stroma. It has avery dense collagenous stroma. It has a predilection for thepredilection for the anterior maxillaanterior maxilla and becauseand because of the dense connective tissue may appear as aof the dense connective tissue may appear as a radiolucent-radiopaque lesion.radiolucent-radiopaque lesion.  TheThe basaloidbasaloid type is the least common and istype is the least common and is composed of uniform basaloid cells with nocomposed of uniform basaloid cells with no stellate reticulum.stellate reticulum.
  • 15. Solid or Multicystic Ameloblastoma:Solid or Multicystic Ameloblastoma: Additional FeaturesAdditional Features  In some studies solid/multicysticIn some studies solid/multicystic ameloblastomas are reported to be moreameloblastomas are reported to be more common in Blacks.common in Blacks.  While lesions are generallyWhile lesions are generally asymptomaticasymptomatic, ameloblastomas may, ameloblastomas may causecause paresthesiaparesthesia,, painpain particularly ifparticularly if infected and they caninfected and they can erode theerode the cortical palatescortical palates..
  • 16. Radiographic findingsRadiographic findings  Radiographs classically show a well- circumscribed, expansile soap-bubble radiolucency with clearly demarcated borders.  However, the unilocular lesion is indistinguishable from an odontogenic cyst. The extent of root resorption may indicate a neoplastic process.  Well-circumscribed, soap-bubbleWell-circumscribed, soap-bubble  Unilocular – often confused with odontogenicUnilocular – often confused with odontogenic cystscysts  Root resorption – associated with malignancyRoot resorption – associated with malignancy
  • 17. Ameloblastoma VIPAmeloblastoma VIP  What are the main points about this tumor? It is  unencapsulated and infiltrates surrounding bone marrow.  Even though they are locally infiltrative, they do  not metastasize. They may occur in any part of both jaws but most are in the middle and posterior regions of the mandible.  Ameloblastomas are always purely radiolucent and may be unilocular but frequently become multilocular as they increase in size.
  • 18. Solid or Multicystic Ameloblastoma:Solid or Multicystic Ameloblastoma: TreatmentTreatment  Treatments have ranged from simpleTreatments have ranged from simple enucleation and curettage to en bloc resection.enucleation and curettage to en bloc resection.  Marginal resection is the most widely usedMarginal resection is the most widely used method of treatment with the least recurrencesmethod of treatment with the least recurrences reported (up to 15 %).reported (up to 15 %).  Most surgeons advocate a margin of at least 1.0Most surgeons advocate a margin of at least 1.0 cm beyond the radiographic limits of the tumorcm beyond the radiographic limits of the tumor as the tumor often extends beyond the apparentas the tumor often extends beyond the apparent radiologic/clinical margins.radiologic/clinical margins.
  • 19. Solid or Multicystic Ameloblastoma:Solid or Multicystic Ameloblastoma: PrognosisPrognosis  Treatment with curettage has resulted inTreatment with curettage has resulted in recurrence rates ranging from 55-90 %.recurrence rates ranging from 55-90 %.  Treatment with marginal resection has resultedTreatment with marginal resection has resulted in approximately a 15 % recurrence rate.in approximately a 15 % recurrence rate.  Ameloblastomas of this type arising in theAmeloblastomas of this type arising in the maxilla are particularly dangerous as it is oftenmaxilla are particularly dangerous as it is often difficult in getting adequate margins.difficult in getting adequate margins.  Rarely is an ameloblastoma life threatening.Rarely is an ameloblastoma life threatening.
  • 20. tttttt  According to growth characteristics and typeAccording to growth characteristics and type  UnicysticUnicystic  Complete removalComplete removal  Peripheral ostectomies if extension through cyst wallPeripheral ostectomies if extension through cyst wall  Classic infiltrative (aggressive)Classic infiltrative (aggressive)  Mandibular – adequate normal bone around marginsMandibular – adequate normal bone around margins of resectionof resection  Maxillary – more aggressive surgery, 1.5 cm marginsMaxillary – more aggressive surgery, 1.5 cm margins  Ameloblastic carcinomaAmeloblastic carcinoma  Radical surgical resection (like SCCa)Radical surgical resection (like SCCa)  Neck dissection for LANNeck dissection for LAN
  • 21.  The treatment of the classic infiltrative, more aggressive ameloblastoma should not be taken lightly. Mandibular resection must include an adequate zone of normal-appearing bone around the main tumor mass. Extension of tumor into surrounding soft tissues is an ominous sign and demands surgery in these areas as vigorous as within the confines of the bone.  Maxillary ameloblastomas require more aggressive initial management with at least a 1.5 cm margin of radiographically normal bone. Postoperative follow-up is critical for a minimum of 5, and preferably 10, years. Ameloblastic carcinoma should be treated with radical surgical resection as for squamous cell carcinoma, with neck dissection reserved for apparent lymphadenopathy.
  • 22. Types of Surgical Operations Used for the Removal of Jaw Tumors
  • 23. Common types of mandibular resection A.Marginal or segmental resection, which does not disrupt mandibular continuity. B and C, Partiacontinuity. Attempts to leave mandibular condyle tthe apices of adjacent tooth roots are completely uncov-ered during a surgical rginal or segmental resection, which does not ibular resections, which disrupt mandibular te reconstruction are demonstrated.
  • 24. Types of Jaw Tumors and Primary Treatment Modalities
  • 25. Unicystic Ameloblastoma: ClinicalUnicystic Ameloblastoma: Clinical FeaturesFeatures  Patient Age: The patients are younger thanPatient Age: The patients are younger than those with the solid/multicystic form. 50% arethose with the solid/multicystic form. 50% are diagnosed during thediagnosed during the second decade of lifesecond decade of life..  Sex Predilection: ? Same as for the solid??Sex Predilection: ? Same as for the solid??  Location: 90 % occur in the mandible usually inLocation: 90 % occur in the mandible usually in the posterior region.the posterior region.  Radiographic Appearance: Typically appears asRadiographic Appearance: Typically appears as a RL around the crown of an unerupted tootha RL around the crown of an unerupted tooth (most commonly a mandibular third molar).(most commonly a mandibular third molar).
  • 26. Unicystic Ameloblastoma:Unicystic Ameloblastoma: Histologic FeaturesHistologic Features  Three histopathologic variants areThree histopathologic variants are recognized:recognized:  Luminal:Luminal: the tumor is confined to the luminalthe tumor is confined to the luminal surface of the cyst.surface of the cyst.  Intraluminal/plexiform:Intraluminal/plexiform: the tumor projectsthe tumor projects from the cystic lining; sometimes resemblesfrom the cystic lining; sometimes resembles the plexiform type of solid/multicysticthe plexiform type of solid/multicystic ameloblastoma.ameloblastoma.  Mural:Mural: the tumor infiltrates the fibrous cysticthe tumor infiltrates the fibrous cystic wall.wall.
  • 27. Unicystic Ameloblastoma:Unicystic Ameloblastoma: Treatment and PrognosisTreatment and Prognosis  Enucleation of the cyst is probably adequate forEnucleation of the cyst is probably adequate for the luminal and intraluminal/plexiform types.the luminal and intraluminal/plexiform types.  Treatment of the mural type is controversialTreatment of the mural type is controversial with some surgeons believing that local resectionwith some surgeons believing that local resection is best.is best.  10-20 % recurrence after enucleation and10-20 % recurrence after enucleation and curettage with all unicystic ameloblastomas.curettage with all unicystic ameloblastomas.
  • 28. Unicystic AmeloblastomaUnicystic Ameloblastoma
  • 29. Peripheral AmeloblastomaPeripheral Ameloblastoma  These tumors are extraosseous and thereforeThese tumors are extraosseous and therefore occupy the lamina propria underneath theoccupy the lamina propria underneath the surface epithelium but outside of the bone.surface epithelium but outside of the bone.  Histologically, these lesions have the sameHistologically, these lesions have the same features as the intraosseous forms of the tumor.features as the intraosseous forms of the tumor.
  • 30. Peripheral Ameloblastoma: ClinicalPeripheral Ameloblastoma: Clinical FeaturesFeatures  Patient Age: Wide age range butPatient Age: Wide age range but most occur during middle-age.most occur during middle-age.  Gender Predilection: This is notGender Predilection: This is not known.known.  Location: Posterior gingival/alveolarLocation: Posterior gingival/alveolar mucosa is involved most frequently.mucosa is involved most frequently. There is a slight predilection for theThere is a slight predilection for the mandible. The buccal mucosa hasmandible. The buccal mucosa has been the site in a few reported cases.been the site in a few reported cases.
  • 31. Peripheral Ameloblastoma:Peripheral Ameloblastoma: Radiographic & Histologic FeaturesRadiographic & Histologic Features  Radiographic Appearance: Although not inRadiographic Appearance: Although not in bone, a few cases have shown superficial erosionbone, a few cases have shown superficial erosion of the alvelolar bone.of the alvelolar bone.  Histologic Appearance: Islands of ameloblasticHistologic Appearance: Islands of ameloblastic epithelium are observed in the lamina propria;epithelium are observed in the lamina propria; plexiform and follicular patterns are the mostplexiform and follicular patterns are the most common; in 50 % of the cases the tumorcommon; in 50 % of the cases the tumor connects with the basal cell layer of the surfaceconnects with the basal cell layer of the surface epithelium.epithelium.
  • 32. Peripheral Ameloblastoma: TreatmentPeripheral Ameloblastoma: Treatment and Prognosisand Prognosis  Unlike its intraosseous counterpart, this tumorUnlike its intraosseous counterpart, this tumor has an innocuous clinical behavior.has an innocuous clinical behavior.  Patients respond well to local surgical excision.Patients respond well to local surgical excision.  Some reports indicate a 25 % recurrence rate butSome reports indicate a 25 % recurrence rate but in these cases as second surgical procedurein these cases as second surgical procedure results in cure.results in cure.  There has been a rare malignant changeThere has been a rare malignant change reported.reported.
  • 33. Malignant Ameloblastoma andMalignant Ameloblastoma and Ameloblastic CarcinomaAmeloblastic Carcinoma  Less than 1 % of the ameloblastomas show malignantLess than 1 % of the ameloblastomas show malignant behavior with the development of metastases.behavior with the development of metastases.  Malignant ameloblastomaMalignant ameloblastoma is a tumor that showsis a tumor that shows histologic features of the typical (benign)histologic features of the typical (benign) ameloblastoma in both the primary and secondaryameloblastoma in both the primary and secondary deposits.deposits.  Ameloblastic carcinomaAmeloblastic carcinoma is a tumor that showsis a tumor that shows cytologic features of malignancy in the primary tumor,cytologic features of malignancy in the primary tumor, in recurrence and any metastases.in recurrence and any metastases.
  • 34. Malignant Ameloblastoma &Malignant Ameloblastoma & Ameloblastic Carcinoma: ClinicalAmeloblastic Carcinoma: Clinical  Patients range in age from 4-75 with a mean ofPatients range in age from 4-75 with a mean of 30 years.30 years.  Metastasis has occurred from 1-30 years afterMetastasis has occurred from 1-30 years after the initial treatment.the initial treatment.  Metastases most often occur in the lungs and inMetastases most often occur in the lungs and in the case of malignant ameloblastoma raises thethe case of malignant ameloblastoma raises the question of aspiration during surgery. Spreadquestion of aspiration during surgery. Spread has also occurred to the cervical lymph nodeshas also occurred to the cervical lymph nodes and to vertebrae and viscera.and to vertebrae and viscera.
  • 35. Malignant Ameloblastoma &Malignant Ameloblastoma & Ameloblastic Carcinoma: X-RayAmeloblastic Carcinoma: X-Ray  With the malignant ameloblastoma, theWith the malignant ameloblastoma, the appearance is similar to the typicalappearance is similar to the typical solid/multicystic ameloblastoma.solid/multicystic ameloblastoma.  The ameloblastic carcinoma is often moreThe ameloblastic carcinoma is often more aggressive with the lesion appearing as anaggressive with the lesion appearing as an ill-defined radiolucency with corticalill-defined radiolucency with cortical destruction.destruction.
  • 36. Malignant Ameloblastoma &Malignant Ameloblastoma & Ameloblastic Carcinoma: HistologyAmeloblastic Carcinoma: Histology  With the malignant ameloblastoma, both theWith the malignant ameloblastoma, both the primary and metastases show no microscopicprimary and metastases show no microscopic features that differ from those of the typicalfeatures that differ from those of the typical solid/multicystic ameloblastoma.solid/multicystic ameloblastoma.  The ameloblastic carcinoma shows cytologicalThe ameloblastic carcinoma shows cytological features of malignancy in addition to a pattern offeatures of malignancy in addition to a pattern of an ameloblastoma.an ameloblastoma.
  • 37. Malignant Ameloblastoma &Malignant Ameloblastoma & Ameloblastic Carcinoma: Treatment &Ameloblastic Carcinoma: Treatment & PrognosisPrognosis  Long-term follow-up does not permit accurateLong-term follow-up does not permit accurate assumptions to be made but prognosis appearsassumptions to be made but prognosis appears to be poor.to be poor.  Approximately 50 % of the patients withApproximately 50 % of the patients with documented metastases and long-term follow-updocumented metastases and long-term follow-up have died as the result of their disease.have died as the result of their disease.
  • 38. Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor (AOT)(AOT)  Formerly called anFormerly called an adenoameloblastoma, a somewhatadenoameloblastoma, a somewhat deceptive term that should bedeceptive term that should be discarded, the AOT represents aboutdiscarded, the AOT represents about 3-7 % of all odontogenic tumors.3-7 % of all odontogenic tumors.  This epithelial tumor has an inductiveThis epithelial tumor has an inductive effect on the odontogeniceffect on the odontogenic ectomesenchyme with dentinoidectomesenchyme with dentinoid frequently being produced.frequently being produced.
  • 39. Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor (AOT)(AOT)  This is a tumor mostly of teenagers. It occurs in the middle and anterior portions of the jaws in contrast to ameloblastoma which is found mostly in the posterior segment.  Two-thirds occur in the maxilla and it is more common in females. This tumor is encapsulated and is treated by curettage with a recurrence rate approaching zero.  The radiographic appearance is a unilocular radiolucency, often around the crown of an unerupted  tooth in which case they resemble a dentigeous cyst
  • 40. AOT: Clinical FeaturesAOT: Clinical Features  Patient Age: The peak age is in the secondPatient Age: The peak age is in the second decade with a mean around 17 years.decade with a mean around 17 years.  Gender Predilection: Females, 2:1.Gender Predilection: Females, 2:1.  Location: Sixty-five percent of the AOTs occurLocation: Sixty-five percent of the AOTs occur in the maxilla with 65 % occurring in the caninein the maxilla with 65 % occurring in the canine region. Seventy-five percent of the cases areregion. Seventy-five percent of the cases are associated with the crown of an uneruptedassociated with the crown of an unerupted tooth. On rare occasion the lesion istooth. On rare occasion the lesion is extraosseous.extraosseous.
  • 41. AOT: Radiographic and AdditionalAOT: Radiographic and Additional FeaturesFeatures  AOTs typically appear as pericoronalAOTs typically appear as pericoronal radiolucencies, which may have radiopaqueradiolucencies, which may have radiopaque material (“snowflake” calcifications) within thematerial (“snowflake” calcifications) within the lucency.lucency.  These lesions are frequently asymptomatic andThese lesions are frequently asymptomatic and therefore are discovered upon routinetherefore are discovered upon routine radiographic examination. AOTs may also blockradiographic examination. AOTs may also block the eruption of a permanent tooth and bethe eruption of a permanent tooth and be discovered when radiographs are taken todiscovered when radiographs are taken to “search for” the unerupted tooth.“search for” the unerupted tooth.
  • 42. AOT: Histologic FeaturesAOT: Histologic Features  The lesion is usually surrounded by a thick, fibrousThe lesion is usually surrounded by a thick, fibrous capsule.capsule.  The tumor is composed of spindle-shaped epithelialThe tumor is composed of spindle-shaped epithelial cells that form sheets, strands or whorled masses withcells that form sheets, strands or whorled masses with little connective tissue.little connective tissue.  The epithelial cells may form rosette-like structures,The epithelial cells may form rosette-like structures, tubular or duct-like structures may be prominent ortubular or duct-like structures may be prominent or absent.absent.  Calcifications may be observed in the tumor mass.Calcifications may be observed in the tumor mass.
  • 43. AOT: Treatment and PrognosisAOT: Treatment and Prognosis  Enucleation is the treatment ofEnucleation is the treatment of choice as the tumor is easilychoice as the tumor is easily removed from the bone.removed from the bone.  AOTs seldom recur.AOTs seldom recur.
  • 44. Calcifying Epithelial OdontogenicCalcifying Epithelial Odontogenic Tumor (CEOT; Pindborg Tumor)Tumor (CEOT; Pindborg Tumor)  Pindborg tumor accounts for < 1 % of allPindborg tumor accounts for < 1 % of all odontogenic tumors.odontogenic tumors.  It is clearly of odontogenic origin but itsIt is clearly of odontogenic origin but its histogenesis is uncertain.histogenesis is uncertain.  The tumor cells are said to resemble cells of theThe tumor cells are said to resemble cells of the stratum intermedium.stratum intermedium.
  • 45. CEOTCEOT  This tumor forms an amorphous material  that is said to be amyloid or amyloid-like  Whatever it is, it calcifies in a concentrically lamellated  “tree-ring” pattern calcifications.  This explains the name of calcifying epithelial odontogenic tumor. Calcifying epithelial odontogenic tumor in the body of the mandible. It appears as a radiolucent lesion with smokey dense areas.
  • 46. CEOT: Clinical FeaturesCEOT: Clinical Features  Patient Age:Patient Age: Patients ages range from thePatients ages range from the second to the tenth decades with a mean aroundsecond to the tenth decades with a mean around 40 years.40 years.  Gender Predilection:Gender Predilection: There is no reported sexThere is no reported sex predilection.predilection.  Location:Location: 75 % of the CEOTs occur in the75 % of the CEOTs occur in the mandible with most occurring in the posteriormandible with most occurring in the posterior region. A rare peripheral CEOT does occur.region. A rare peripheral CEOT does occur.
  • 47. CEOT: Radiographic FeaturesCEOT: Radiographic Features  CEOTs occur as radiolucent lesionsCEOTs occur as radiolucent lesions with/without opaque foci.with/without opaque foci.  They are usually well-circumscribed and may beThey are usually well-circumscribed and may be unilocular or multilocular.unilocular or multilocular.  Slightly over 50 % of the CEOTs are associatedSlightly over 50 % of the CEOTs are associated with an unerupted tooth.with an unerupted tooth.
  • 48. CEOT: Histologic FeaturesCEOT: Histologic Features  This lesion is typically composed of islands, sheets orThis lesion is typically composed of islands, sheets or strands of polyhedral epithelial cells in a fibrous stroma.strands of polyhedral epithelial cells in a fibrous stroma.  Areas of amorphous, eosinophilic, hyalinizedAreas of amorphous, eosinophilic, hyalinized extracellular material may be scattered throughout.extracellular material may be scattered throughout.  Cells outlines are distinct and intercellular bridges mayCells outlines are distinct and intercellular bridges may be seen.be seen.  Nuclei show considerable variation with giant nucleiNuclei show considerable variation with giant nuclei and pleomorphism observed.and pleomorphism observed.  Calcifications may be noted as well as amyloid-likeCalcifications may be noted as well as amyloid-like material. Liesegang rings also may be present.material. Liesegang rings also may be present.
  • 49. CEOT: Additional Features,CEOT: Additional Features, Treatment and PrognosisTreatment and Prognosis  Bony lesions most commonly present as painless, slow-Bony lesions most commonly present as painless, slow- growing swellings.growing swellings.  Peripheral lesions typically appear as non-specific sessilePeripheral lesions typically appear as non-specific sessile gingival masses.gingival masses.  Conservative local resection is the treatment of choiceConservative local resection is the treatment of choice as these lesions are typically less aggressive than theas these lesions are typically less aggressive than the ameloblastoma.ameloblastoma.  With this treatment the recurrence rate is approximatelyWith this treatment the recurrence rate is approximately 15 % and the overall prognosis is good.15 % and the overall prognosis is good.
  • 50. Calcifying Epithelial Odontogenic Tumor (CEOT; Pindborg Tumor)Calcifying Epithelial Odontogenic Tumor (CEOT; Pindborg Tumor)
  • 51. Mixed OdontogenicMixed Odontogenic TumorsTumors This group of tumors is composed ofThis group of tumors is composed of proliferating odontogenic epithelium inproliferating odontogenic epithelium in a cellular ectomesenchyme resemblinga cellular ectomesenchyme resembling the dental papilla.the dental papilla.
  • 52. Ameloblastic FibromaAmeloblastic Fibroma Clinical FeaturesClinical Features  This true mixed odontogenic tumor is more commonThis true mixed odontogenic tumor is more common in patients in the first and second decades of life with ain patients in the first and second decades of life with a mean of 14 yearsmean of 14 years seldom is it seen beyond age 20.  It is slightly more common in males than females.It is slightly more common in males than females.  Approximately 70 % of the ameloblastic fibromasApproximately 70 % of the ameloblastic fibromas occur in the posterior mandible.occur in the posterior mandible.  Local swelling or failure of teeth to erupt on time or in proper alignment may call attention to the tumor.
  • 53. Ameloblastic Fibroma:Ameloblastic Fibroma: Radiographic FeaturesRadiographic Features  Generally, these lesions appear as either aGenerally, these lesions appear as either a unilocular or multilocular radiolucency.unilocular or multilocular radiolucency.  They tend to be well-defined and may have aThey tend to be well-defined and may have a sclerotic border.sclerotic border.  Approximately, 50 % are associated with anApproximately, 50 % are associated with an unerupted tooth.unerupted tooth.
  • 54. Ameloblastic Fibroma: AdditionalAmeloblastic Fibroma: Additional Features, Treatment and PrognosisFeatures, Treatment and Prognosis  The tumor is often encapsulated with smallThe tumor is often encapsulated with small tumors usually being asymptomatic. Largertumors usually being asymptomatic. Larger tumors produce swelling, which can expand thetumors produce swelling, which can expand the cortex and be quite pronounced.cortex and be quite pronounced.  Most ameloblastic fibromas are treated byMost ameloblastic fibromas are treated by conservative surgical excision; however, a 20 %conservative surgical excision; however, a 20 % recurrence rate has led some surgeons torecurrence rate has led some surgeons to recommend a more aggressive approach.recommend a more aggressive approach.
  • 55. Ameloblastic Fibro-odontomaAmeloblastic Fibro-odontoma  This lesion is defined as a tumor with generalThis lesion is defined as a tumor with general features of an ameloblastic fibroma butfeatures of an ameloblastic fibroma but containing enamel and dentin.containing enamel and dentin.  Some investigators believe that this entity is butSome investigators believe that this entity is but a stage in the development of an odontoma;a stage in the development of an odontoma; however, most agree that progressive destructivehowever, most agree that progressive destructive tumors are true neoplasms.tumors are true neoplasms.
  • 56. Ameloblastic Fibro-odontoma:Ameloblastic Fibro-odontoma: Clinical and Radiographic FeaturesClinical and Radiographic Features  Patient Age:Patient Age: Most common in the 5-12 year age rangeMost common in the 5-12 year age range with a mean of 10 years.with a mean of 10 years.  Gender Predilection:Gender Predilection: None.None.  Location:Location: It is more common in the premolar/molarIt is more common in the premolar/molar regions of both jaws.regions of both jaws.  Radiographic Features:Radiographic Features: Usually appears as a well-Usually appears as a well- defined unilocular or rarely multilocular radiolucencydefined unilocular or rarely multilocular radiolucency with variable amounts of calcified material which iswith variable amounts of calcified material which is radiopaque. Therefore, it may appear as a mixed,radiopaque. Therefore, it may appear as a mixed, radiolucent-radiopaque lesion.radiolucent-radiopaque lesion.
  • 57. Ameloblastic Fibro-odontoma:Ameloblastic Fibro-odontoma: Histologic FeaturesHistologic Features  The soft tissue component is identical to theThe soft tissue component is identical to the ameloblastic fibroma. The calcified portionameloblastic fibroma. The calcified portion consists of foci of enamel and dentin matrixconsists of foci of enamel and dentin matrix formation in close relationship to the epithelialformation in close relationship to the epithelial structures.structures.
  • 58. Ameloblastic Fibro-odontoma:Ameloblastic Fibro-odontoma: Treatment and PrognosisTreatment and Prognosis  The ameloblastic fibro-odontoma is usuallyThe ameloblastic fibro-odontoma is usually treated by conservative curettage with the lesiontreated by conservative curettage with the lesion separating easily from the surrounding bone.separating easily from the surrounding bone.  Prognosis is excellent and recurrence is unusual.Prognosis is excellent and recurrence is unusual.
  • 59. OdontomaOdontoma  The tumors in which odontogenic differentiation is fully expressed are the odontomas. In these tumors, the epithelium an ectomesenchyme realize their potentialand make enamel and dentin respectively.  As a result, these tumors are mostly radiodense.  In the compound odontoma, multiple small and malformed tooth-like structures are formed creating a “bag of marbles” radiographic appearance Compound odontoma, photomicrograph of decalcifed specimen. Note the structure that resembles a tooth with a pulp (P), a surrounding mantle of dentin (D) capped by enamel (E). E D P
  • 60. OdontomaOdontoma  The odontoma is the most common odontogenicThe odontoma is the most common odontogenic tumor.tumor.  It is not a true neoplasm but rather is considered to beIt is not a true neoplasm but rather is considered to be a developmental anomaly (hamartoma).a developmental anomaly (hamartoma).  Two types of odontomas are recognized:Two types of odontomas are recognized:  Compound: this type of odontoma is composed of multipleCompound: this type of odontoma is composed of multiple small tooth-like structures.small tooth-like structures.  Complex: this lesion is composed of a conglomerate mass ofComplex: this lesion is composed of a conglomerate mass of enamel and dentin, which bears no anatomic resemblance toenamel and dentin, which bears no anatomic resemblance to a tooth.a tooth.
  • 61. Odontoma: Clinical FeaturesOdontoma: Clinical Features  Patient Age:Patient Age: Most cases are recognized duringMost cases are recognized during the second decade of life with a mean of 14the second decade of life with a mean of 14 years.years.  Gender Predilection:Gender Predilection: Approximately equal.Approximately equal.  Location:Location: Somewhat more common in theSomewhat more common in the maxilla. Themaxilla. The compound typecompound type is more often inis more often in thethe anterior maxillaanterior maxilla while the complex typewhile the complex type occurs more often in the posterior regions ofoccurs more often in the posterior regions of either jaw.either jaw.
  • 62. Odontoma: Clinical FeaturesOdontoma: Clinical Features  Both types of odontoma are found in the early years, usually in the teens or early twenties. Compound odontoma is more common in the anterior jaw segment whereas the complex type is found more commonly in the posterior jaws.  Many are associated with an unerupted tooth. Odontomas behave more like developmental abnormalities (hamartomas) than true neoplasms.  Although they may reach a large size, they do eventually cease growing in contrast to true neoplasms which show continuous growth.
  • 63. Odontoma: Radiographic FeaturesOdontoma: Radiographic Features  Early lesions are radiolucent with smooth, well-Early lesions are radiolucent with smooth, well- defined contours.defined contours.  Later a well-defined radiopaque appearanceLater a well-defined radiopaque appearance develops.develops.  The compound type shows apparent toothThe compound type shows apparent tooth shapes while the complex type appears as ashapes while the complex type appears as a uniform opaque mass with no apparent toothuniform opaque mass with no apparent tooth shapes present.shapes present.
  • 64. Odontoma: Additional FeaturesOdontoma: Additional Features  Most odontomas are small and do not exceed the sizeMost odontomas are small and do not exceed the size of a normal tooth in the region.of a normal tooth in the region.  However, large ones do occur and these may causeHowever, large ones do occur and these may cause expansion of the jaw.expansion of the jaw.  Most odontomas are asymptomatic and as a result areMost odontomas are asymptomatic and as a result are discovered upon routine radiographic examination.discovered upon routine radiographic examination.  Odontomas may block the eruption of a permanentOdontomas may block the eruption of a permanent tooth and in these cases are often discovered whentooth and in these cases are often discovered when “searching for” the “missing” tooth radiographically.“searching for” the “missing” tooth radiographically.
  • 65. Odontoma: Histologic FeaturesOdontoma: Histologic Features  The compound odontoma is composed ofThe compound odontoma is composed of enamel, dentin and cementum arrange inenamel, dentin and cementum arrange in recognizable tooth forms; some enamel matrixrecognizable tooth forms; some enamel matrix may be retained in immature andmay be retained in immature and hypomineralized specimens.hypomineralized specimens.  The complex odontoma is composed of enamel,The complex odontoma is composed of enamel, dentin and cementum but these tissues aredentin and cementum but these tissues are arranged in a random manner that bears noarranged in a random manner that bears no morphological resemblance to a tooth.morphological resemblance to a tooth.
  • 66. Odontoma: Treatment andOdontoma: Treatment and PrognosisPrognosis  Odontomas are treated by simpleOdontomas are treated by simple local excision and the prognosis islocal excision and the prognosis is excellent.excellent.
  • 67. ? ?
  • 68. Odontogenic MyxomaOdontogenic Myxoma  Tissue that is cell-poor and rich in mucopolysaccharide  ground substance such as hyaluronic acid and chondroitin sulfate is said to be myxoid tissue.  Tumors that have the same histologic quality are called myxoma (mix-oma). They are uncommon.  Within the skeleton, they occur almost exclusively in  the jaws. Extragnathic skeletal lesions are a rarity.  Those that occur in the jaws are said to be of odontogenic origin but there is no hard evidence that it is so.
  • 69. Odontogenic MyxomaOdontogenic Myxoma  Myxoma is a tumor that occurs over a wide age range but most occur in the second and third decades.  It is an unencapsulated, locally infiltrating tumor. If allowed to reach a large size, it takes a big operation to remove it.  Like many odontogenic tumors, when small it is ordinarily unilocular but becomes multilocular as it enlarges. Since it does not produce a calcified matrix material, it is purely radiolucent.
  • 70. Odontogenic Myxoma: Clinical andOdontogenic Myxoma: Clinical and Radiographic FeaturesRadiographic Features  Patient Age: 10-50 years with a mean around 30Patient Age: 10-50 years with a mean around 30 years.years.  Gender Predilection: Reported to be aboutGender Predilection: Reported to be about equal.equal.  Location: May occur in any area of the jaws butLocation: May occur in any area of the jaws but more common in the mandible.more common in the mandible.  Radiographic Appearance: Radiolucent lesionRadiographic Appearance: Radiolucent lesion often with a multilocular appearance. Theoften with a multilocular appearance. The borders may be indistinct.borders may be indistinct.
  • 71. Odontogenic MyxomaOdontogenic Myxoma
  • 72. Odontogenic Myxoma: HistologicOdontogenic Myxoma: Histologic FeaturesFeatures  The tumor is composed of loosely arrangedThe tumor is composed of loosely arranged stellate, spindle-shaped and round cells in anstellate, spindle-shaped and round cells in an abundant, loose myxoid stroma with fewabundant, loose myxoid stroma with few collagen bundles.collagen bundles.  Epithelial cells are not required for diagnosis.Epithelial cells are not required for diagnosis.  The odontogenic myxoma may be confusedThe odontogenic myxoma may be confused with a chrondromyxoid fibroma or with myxoidwith a chrondromyxoid fibroma or with myxoid change in an enlarged dental follicle or papilla.change in an enlarged dental follicle or papilla.
  • 73. Odontogenic Myxoma: TreatmentOdontogenic Myxoma: Treatment and Prognosisand Prognosis  Small odontogenic myxomas are treated bySmall odontogenic myxomas are treated by curettage, while larger lesions may requirecurettage, while larger lesions may require surgical resection.surgical resection.  Odontogenic myxomas are not encapsulated andOdontogenic myxomas are not encapsulated and tend to infiltrate adjacent tissues.tend to infiltrate adjacent tissues.  Recurrence rates of up to 25 % are reported.Recurrence rates of up to 25 % are reported.  Overall, the prognosis is good for mostOverall, the prognosis is good for most odontogenic myxomas.odontogenic myxomas.
  • 74. Odontogenic MyxomaOdontogenic Myxoma
  • 75.  This tumor typically occurs around the roots of the lower posterior teeth. Like virtually all odontogenic tumors, it is benign but it expands the jaw, causes pain and requires surgical removal. Radiographically it appears as a ball of dense material attached to the end of the root CementoblastomaCementoblastoma
  • 76. Tumors of OdontogenicTumors of Odontogenic EctomesenchymeEctomesenchyme
  • 77. (Central) Odontogenic Fibroma:(Central) Odontogenic Fibroma: Clinical FeaturesClinical Features  Fewer than 50 cases have been reported in the EnglishFewer than 50 cases have been reported in the English literature.literature.  Patient Age: Patients have ranged in age from 9-80Patient Age: Patients have ranged in age from 9-80 years old with a mean of 40 years.years old with a mean of 40 years.  Gender Predilection: Females, 7.4:1 in one study.Gender Predilection: Females, 7.4:1 in one study.  Location: Sixty percent occur in the maxilla whereLocation: Sixty percent occur in the maxilla where most are located anterior to the first molar. When inmost are located anterior to the first molar. When in the mandible, approximately 50 % occur in thethe mandible, approximately 50 % occur in the posterior jaw.posterior jaw.
  • 78. Odontogenic Fibroma:Odontogenic Fibroma: Radiographic AppearanceRadiographic Appearance  The odontogenic fibroma usually appears as aThe odontogenic fibroma usually appears as a well-defined, unilocular radiolucency. It is oftenwell-defined, unilocular radiolucency. It is often associated with the apical area of an eruptedassociated with the apical area of an erupted tooth.tooth.  Larger lesions are often multilocular.Larger lesions are often multilocular.  Many odontogenic fibromas have scleroticMany odontogenic fibromas have sclerotic borders. Root resorption is common.borders. Root resorption is common.
  • 79. Odontogenic Fibroma: AdditionalOdontogenic Fibroma: Additional FeaturesFeatures  Small odontogenic fibromas are usuallySmall odontogenic fibromas are usually asymptomatic.asymptomatic.  The larger lesions may be associated withThe larger lesions may be associated with localized bony expansion of the jaw or with thelocalized bony expansion of the jaw or with the loosening of adjacent teeth.loosening of adjacent teeth.
  • 80. Odontogenic Fibroma: HistologicOdontogenic Fibroma: Histologic FeaturesFeatures  Some authors have described two separate types ofSome authors have described two separate types of odontogenic fibromas.odontogenic fibromas.  TheThe simple odontogenic fibromasimple odontogenic fibroma is composed ofis composed of stellate fibroblasts arranged in a whorled pattern withstellate fibroblasts arranged in a whorled pattern with fine collagen fibrils and a lot of ground substance.fine collagen fibrils and a lot of ground substance.  Foci of odontogenic epithelium may or may not beFoci of odontogenic epithelium may or may not be present.present.  Occasionally, foci of dystrophic calcification may beOccasionally, foci of dystrophic calcification may be present.present.
  • 81. Odontogenic Fibroma: HistologicOdontogenic Fibroma: Histologic FeaturesFeatures  TheThe WHO type odontogenic fibromaWHO type odontogenic fibroma appearsappears as a fairly cellular fibrous connective tissue withas a fairly cellular fibrous connective tissue with collagen fibers arranged in interlacing bundles.collagen fibers arranged in interlacing bundles.  Odontogenic epithelium in the form of longOdontogenic epithelium in the form of long strands or isolated nests is present throughoutstrands or isolated nests is present throughout the lesion.the lesion.  Calcifications composed of cementoid and/orCalcifications composed of cementoid and/or dentinoid may be present.dentinoid may be present.
  • 82. Odontogenic Fibroma: TreatmentOdontogenic Fibroma: Treatment and Prognosisand Prognosis  The odontogenic fibroma is usually treated byThe odontogenic fibroma is usually treated by enucleation and curettage.enucleation and curettage.  There have been few recurrences, this theThere have been few recurrences, this the prognosis is good.prognosis is good.
  • 83. Mixed Odontogenic TumorsMixed Odontogenic Tumors  Ameloblastic fibromaAmeloblastic fibroma,, ameloblasticameloblastic fibrodentinomafibrodentinoma,, ameloblastic fibro-odontoma,ameloblastic fibro-odontoma, odontomaodontoma  Both epithelial and mesenchymal cellsBoth epithelial and mesenchymal cells  Mimic differentiation of developing toothMimic differentiation of developing tooth  Treatment – enucleation, thorough curettageTreatment – enucleation, thorough curettage with extraction of impacted toothwith extraction of impacted tooth  Ameloblastic fibrosarcomas – malignant, treatAmeloblastic fibrosarcomas – malignant, treat with aggressive en bloc resectionwith aggressive en bloc resection
  • 84. Related Jaw LesionsRelated Jaw Lesions  Giant Cell LesionsGiant Cell Lesions  Central giant cellCentral giant cell granulomagranuloma  Brown tumorBrown tumor  Aneurysmal bone cystAneurysmal bone cyst  Fibroosseous lesionsFibroosseous lesions  Fibrous dysplasiaFibrous dysplasia  Ossifying fibromaOssifying fibroma  Condensing OsteitisCondensing Osteitis
  • 85. Central Giant Cell GranulomaCentral Giant Cell Granuloma  This is a neoplastic-like reactive proliferation of the jaws that accounts for less than 7% of all benign lesions of the jaws in tooth-bearing areas.  It commonly occurs in children and young adults with a slight female predilection.  The lesion is more common in the mandible than maxilla underlying anterior or premolar teeth. Expansile lesions can cause root divergence or resorption.
  • 86. Central Giant Cell GranulomaCentral Giant Cell Granuloma  The clinical features vary according to the type of development the lesion assumes. Lesions may be slow-growing and asymptomatic or rapidly expanding with pain, facial swelling and root resorption.  The fast growing variants have a high rate of recurrence.  Because of the higher incidence of these lesions among girls and women of child-bearing years, hormonal influences have been suggested as influential in their development.
  • 87. Central Giant Cell GranulomaCentral Giant Cell Granuloma  Neoplastic-like reactive proliferationNeoplastic-like reactive proliferation  Common in children and young adultsCommon in children and young adults  Females > males (hormonal?)Females > males (hormonal?)  Mandible > maxillaMandible > maxilla  Expansile lesions – root resorptionExpansile lesions – root resorption  Slow-growing – asymptomatic swellingSlow-growing – asymptomatic swelling  Rapid-growing – pain, loose dentition (highRapid-growing – pain, loose dentition (high rate of recurrence)rate of recurrence)
  • 88. Central Giant Cell GranulomaCentral Giant Cell Granuloma  Radiographic findingsRadiographic findings  Unilocular, multilocular radiolucenciesUnilocular, multilocular radiolucencies  Well-defined or irregular bordersWell-defined or irregular borders  HistologyHistology  Multinucleated giant cells, dispersed throughout aMultinucleated giant cells, dispersed throughout a fibrovascular stromafibrovascular stroma
  • 89. Central Giant Cell GranulomaCentral Giant Cell Granuloma
  • 90. Central Giant Cell GranulomaCentral Giant Cell Granuloma  TreatmentTreatment  Curettage, segmental resectionCurettage, segmental resection  Radiation – out of favor (risk of sarcoma)Radiation – out of favor (risk of sarcoma)  Intralesional steroids – younger patients, very largeIntralesional steroids – younger patients, very large lesionslesions  Individualized treatment depending onIndividualized treatment depending on characteristics and location of tumorcharacteristics and location of tumor
  • 91. Brown TumorBrown Tumor  Local manifestation of hyperparathyroidLocal manifestation of hyperparathyroid  Histologically identical to CGCGHistologically identical to CGCG  Serum calcium and phosphorusSerum calcium and phosphorus  More likely in older patientsMore likely in older patients
  • 92. Fibrous DysplasiaFibrous Dysplasia  Monostotic vs. polystoticMonostotic vs. polystotic  MonostoticMonostotic  More common in jaws and craniumMore common in jaws and cranium  PolystoticPolystotic  McCune-Albright’s syndromeMcCune-Albright’s syndrome  Cutaneous pigmentation, hyper-functioningCutaneous pigmentation, hyper-functioning endocrine glands, precocious pubertyendocrine glands, precocious puberty
  • 93. Fibrous DysplasiaFibrous Dysplasia  Painless expansile dysplastic process ofPainless expansile dysplastic process of osteoprogenitor connective tissueosteoprogenitor connective tissue  Maxilla most commonMaxilla most common  Does not typically cross midline (one bone)Does not typically cross midline (one bone)  Antrum obliterated, orbital floor involvementAntrum obliterated, orbital floor involvement (globe displacement)(globe displacement)  Radiology – ground-glass appearanceRadiology – ground-glass appearance
  • 94. Fibrous DysplasiaFibrous Dysplasia
  • 95. Fibrous DysplasiaFibrous Dysplasia  Histology – irregular osseous trabeculae inHistology – irregular osseous trabeculae in hypercellular fibrous stromahypercellular fibrous stroma  TreatmentTreatment  Deferred, if possible until skeletal maturityDeferred, if possible until skeletal maturity  Quarterly clinical and radiographic f/uQuarterly clinical and radiographic f/u  If quiescent – contour excision (cosmesis orIf quiescent – contour excision (cosmesis or function)function)  Accelerated growth or disabling functionalAccelerated growth or disabling functional impairment - surgical intervention (en bloc resection,impairment - surgical intervention (en bloc resection, reconstruction)reconstruction)
  • 96. Ossifying FibromaOssifying Fibroma  True neoplasm of medullary jawsTrue neoplasm of medullary jaws  Elements of periodontal ligamentElements of periodontal ligament  Younger patients, premolar – mandibleYounger patients, premolar – mandible  Frequently grow to expand jaw boneFrequently grow to expand jaw bone  RadiologyRadiology  radiolucent lesion early, well-demarcatedradiolucent lesion early, well-demarcated  Progressive calcification (radiopaque – 6 yrs)Progressive calcification (radiopaque – 6 yrs)
  • 97. Ossifying FibromaOssifying Fibroma
  • 98. Ossifying FibromaOssifying Fibroma  Histologically similar to fibrous dysplasiaHistologically similar to fibrous dysplasia  TreatmentTreatment  Surgical excision – shells outSurgical excision – shells out  Recurrence is uncommonRecurrence is uncommon
  • 99. Aspiration Value: To investigate the fluid content of soft, cheesy, or rubbery masses, whose characterisitcs suggest that they may contain fluid. Aspirate:  Straw-colored fluid (may has cholesterol crystals)…. Odontogenic & some Fisural Cysts & ooccasionally Cystic Ameloblastoma.  Thick, yellowish-white, granular fluid (containing Keratin)…. Epidermoid & Keratocyst.  Thick, homogenous, yellowish to gray (Sebum)…. Sebaceous Cyst.  Thickest, yellowish, cheesy substance “with Difficulty” (contains Keratin, sebum, sweat, and exfoliated squamous cells…. Dermoid Cyst.
  • 100.  Dark, amber-colored fluid…. Thyroglossal duct Cyst.  Colorless, cloudy, somewhat frothy “has a high lipid content” (Lymph fluid)…. Cystic Hygroma and Lymphangioma.  Bright-red Blood (oxygenated hemoglobin)…. Ateriovenous Malformation.  Dark venous blood (Bluish Blood)…. Early Hematoma, Aneurysmal bone cyst & Hemangioma.  Small amounts of blood that require negative pressure for withdrawal (is not uncommon with many central lesions of bone)…. Idiopathic bone cavity, Central giant cell granuloma, Inflammatory lesions & Metastatic lesions.
  • 101.  Pus (yellow, or yellowish-white)…. Abscess (painful, warm, fluctuant swelling)  Pus with sulfur Granules (firm yellow granules)…. Actinomycosis.  Sticky, clear, viscous fluid (concentrated Mucous)…. Mucocele, Ranula& some minor salivary gland Tumors.  Air…. Air filled space (max sinus), Subcutanous Emphysema.  -Ve …. Cellular Mass (Tumor).
  • 102. Features obtained by Palpation o Surface Temperature. o Anatomic regions and Planes involved. o Mobility. o Extent. o Borders of the mass. o Consistency of surrounding tissue. o Thickness of overlying tissue. o Size ad Shape.
  • 103. o Consistency. o Fluctuance and Emptiability. o Painless, Tender, or Painful. o Unilateral or Bilateral. o Solitary or Multiple. Percussion: Auscultation:
  • 104. Bone Lesions The differential diagnosis of bone lesions can be more challenging than that of soft tissue for a number of reasons: Less common than soft tissue lesions (except reactive lesions secondary to degenerative pulpal disease). Most osseous lesions are centrally located and not accessible to visual examination or palpation.
  • 105. Bone lesions are frequently asymptomatic and found on routine radiographic examination, so the history is often less informative. In addition, the jaws have a number of unique pathologic entities as compared with other bones.
  • 106. Classification of Osseous lesions of the Jaws 5 categories: 1. Cysts. 2. Odontogenic tumors. 3. Benign nonodontogenic tumors. 4. Malignant tumors. 5. Diseases of bone:  inflammatory (specific, nonspecific).  primary diseases.
  • 107. Terminology for Surgical Procedures Enucleation. Curettage. Marsupialization. Resection without Continuity Defect (RsCD). Resection with Continuity Defect (RcCD). Disarticulation. Recontouring.
  • 108. Cysts  Lateral periodontal cyst  Radicular cyst and periapical dental granuloma  Hyperplastic dental follicle  Follicular cysts (dentigerous, primordial)  Odontogenic keratocyst  Calcifying and keratinizing odontogenic cyst  Fissural cysts  Traumatic cysts  Lingual bone defect
  • 109. G M Kerato . Stati c Lat Period.Gorli n Dentig.
  • 110. Odontogenic Tumors  Ameloblastoma  odontogenic adenomatoid tumor  Squamous odontogenic tumor  Calcifying epithelial odontogenic tumor  Odontogenic fibroma  Odontogenic myxoma  Ameloblastic fibroma  Odontoma (ameloblastic, cystic(  Ameloblastic fibro-odontoma  Periapical cemental dysplasia  Cementoblastoma
  • 111. Ameloblastom a Pindborg T. Ameloblastom a
  • 112. Ameloblastic Fibroma Odontog. Fibroma Comp. Odontom Odontog. Myxoma Complex Odontom
  • 113. Benign Nonodontogenic Tumors  Central giant cell granuloma  Aneurysmal bone cyst  Myxoma  Chondroma  Osteoma  Fibroma  Congenital arteriovenous malformation  Hemangioma  Melanotic neuroectodermal tumor  Fibro-osseous lesion  Ossifying fibroma  Cementifying fibroma  Monostotic fibrous dysplasia  Polyostotic fibrous dysplasia
  • 114. Cent. Hemangioma Osteoma Aneurysmal B. Cent. G. C. G.
  • 115. Ossifying Fibroma Fibro-oss. Dysplasia Fibrous Dyspalsia Fibrous Dyspalsia
  • 116. Malignant Tumors  Metastatic carcinoma  Osteosarcoma  Chondrosarcoma  Ewing's sarcoma  Burkitt's lymphoma  Multiple myeloma  Langerhans cell disease (acute disseminated(
  • 117. Diseases of Bone Inflammatory:  Osteomyelitis  Condensing osteitis  Osteitis  Langerhans cell disease  Infantile cortical hyperostosis : Primary  Paget's  Cherubism  Hyperparathyroidism  Osteogenesis imperfecta  Osteopetrosis  Achondroplasia  Multiple diaphyseal sclerosis 
  • 118. Bone Infection Langerhans C. H. Osteoradionecros is Ch. Supp. Osteomy. Inflammator y
  • 119. Primary Cherubis m Paget’s
  • 120. Florid Oss. Dysplasia Osteopetrosi s
  • 121. Importance of History Informations For Asymptomatic Lesions (discovered on routine radiographic examination)… Some initial assumptions may be based on… Pt. Age……..(as new lesions) Ex;  < 50 y: Odontogenic tumors.  < 40 y: Paget's disease, metastatic carcinoma (excluding breast carcinoma), and multiple myeloma.
  • 122. BIOPSYBIOPSY
  • 123. Definition:Definition:  Removal of tissue from living beings forRemoval of tissue from living beings for macroscopic examination ,microscopicmacroscopic examination ,microscopic  analysis, bacterial analysis & combination ofanalysis, bacterial analysis & combination of above is called “BIOPSYabove is called “BIOPSY
  • 124. BIOPSYBIOPSY
  • 125. INDICATIONSINDICATIONS 1.To determine the nature of lesion which does not1.To determine the nature of lesion which does not readily respond to conservative & simple therapy.readily respond to conservative & simple therapy. 2.To determine the nature of the lesion which is2.To determine the nature of the lesion which is unknown.unknown. 3.To establish the diagnosis where there is3.To establish the diagnosis where there is suspecious of neoplasm.suspecious of neoplasm. 4.To determine nature of any intraosseous lesion4.To determine nature of any intraosseous lesion which can’t be identified radiographically.which can’t be identified radiographically. 5.To determine the nature of all abnormal tissue5.To determine the nature of all abnormal tissue removed from the oral cavity including cysts &removed from the oral cavity including cysts & granulomas.granulomas.
  • 126. Contraindications:Contraindications: A.A. Relative contraindicationsRelative contraindications:: 1.In cases of inflammatory lesions may be due to1.In cases of inflammatory lesions may be due to allergy ,viral ,fungal, or bacterial lesion. e.g.allergy ,viral ,fungal, or bacterial lesion. e.g. candidiasis.candidiasis. 2.Compromised generalised health of patient. e.g.2.Compromised generalised health of patient. e.g. patient on anticoagulant therapy.patient on anticoagulant therapy. 3.Proximity of lesions to vital , anatomic,3.Proximity of lesions to vital , anatomic, physiologic, neural, vascular, or glandularphysiologic, neural, vascular, or glandular structures.structures.
  • 127.  B)B) Absolute contraindications:Absolute contraindications: 1.Pulsatile vascular lesions. e.g. angiosarcoma.1.Pulsatile vascular lesions. e.g. angiosarcoma. 2.Pigmented lesion should not be biopsied. e.g.2.Pigmented lesion should not be biopsied. e.g. Melanoma.Melanoma. 3.Intrabony radiolucent lesions should not be3.Intrabony radiolucent lesions should not be biopsied or removed without priorbiopsied or removed without prior investigational aspirationinvestigational aspiration
  • 128. ARMAMENTERIUM:ARMAMENTERIUM: 1.Mouth mirror & probe,1.Mouth mirror & probe, colourless antisepticcolourless antiseptic agent.agent. 2.LA & syringe.2.LA & syringe. 3.Surgical scalpel.3.Surgical scalpel. 4.Long pointed surgical4.Long pointed surgical scissors.scissors. 5.Tissue forceps5.Tissue forceps 6.Biopsy punch6.Biopsy punch 7.Bone burs7.Bone burs 8.Periosteal elevator8.Periosteal elevator 9.Chiesel9.Chiesel 10.Bow curette10.Bow curette 11.Suture material11.Suture material 12.Needle holder12.Needle holder 13.Sponges13.Sponges 14.Wide mouthed bottle14.Wide mouthed bottle with10% neutralwith10% neutral buffered formalinbuffered formalin
  • 129. Points must be considered to ensurePoints must be considered to ensure obtaining proper specimenobtaining proper specimen 1.Do not paint the surface of the area to be biopsied with1.Do not paint the surface of the area to be biopsied with iodine or other highly coloured antiseptic.iodine or other highly coloured antiseptic. 2.Don’t inject LA into the lesion.2.Don’t inject LA into the lesion. 3.Use sharp scalpel to avoid tearing of tissue.3.Use sharp scalpel to avoid tearing of tissue. 4.Use care not to mutilate the specimen when grasping it4.Use care not to mutilate the specimen when grasping it with forceps.with forceps. 5.Fix the tissue immediately upon removal in 10%5.Fix the tissue immediately upon removal in 10% formalin or 70% alcohol.formalin or 70% alcohol. 6.If the specimen is thin, place it upon a piece of glazed6.If the specimen is thin, place it upon a piece of glazed paper & drop into fixative which prevents curling ofpaper & drop into fixative which prevents curling of tissue.tissue.
  • 130. TYPES OF BIOPSYTYPES OF BIOPSY 1.Excisional biopsy1.Excisional biopsy 2.Incisional biopsy2.Incisional biopsy 3.Punch biopsy3.Punch biopsy 4.Needle/trephine/drill4.Needle/trephine/drill 5.Aspiration biopsy5.Aspiration biopsy 6.Exfoliative cytology6.Exfoliative cytology
  • 131.  Illustration of excisional biopsy of soft tissue lesion. A, Surface view. Elliptic incision is made around lesion . A, Surface view. Elliptic incision. B, Side view, Incision is made deep enough to remove lesion completely. C, End view. Incision are made convergent to depth of wound. If excision is made in this way, closure will be facilitated.
  • 132.  A, Illustration showing desirability of obtaining deep specimen rather than broad and shallow specimen when incisional biopsy is performed. If malignant cells are present only at base of lesion, broad and shallow biopsy might not obtain these diagnostic cells. B, Illustration showing desirability of obtaining incisional biopsy at margin of soft tissue lesion. Junction of lesion with normal tissue frequently provides pathologist with more diagnostic information than if biopsy were taken only from center of lesion.
  • 133. Illustration demonstrating desirability of obtaining more than one incisional biopsy if characteristics of lesion differ from one area to another. Frequently one area of lesion appears histologically different from another (A). When obtaining biopsy on buccal or labial mucosa, incision is usually carried to depth of musculature (B).
  • 134.  Illustration showing use of traction suture piaced through specimen. While lesion is incised, traction suture is use to lift specimen from wound bed. Suture can then be tied and left attached to lesion to identify margin of specimen.
  • 135.  Illustration showing principles used in closing an elliptic biopsy wound. Mucosa should be undermined bluntly with scissors to width of original ellipse in each direction. This allows approximation of wound margins without tension.
  • 136. EXCISIONAL BIOPSYEXCISIONAL BIOPSY *Definition*Definition: Total excision of a small lesion: Total excision of a small lesion for microscopic study is calledfor microscopic study is called ““excisional biopsy”.excisional biopsy”. *Use*Use : Lesions smaller than 1cm in: Lesions smaller than 1cm in diameter.diameter.
  • 137. MethodMethod  Give LA which should not be closer than 2cmGive LA which should not be closer than 2cm from the site.from the site.  Stabilize the lesion via the suture.Stabilize the lesion via the suture.  Incise mucosa around the base of the lesion inIncise mucosa around the base of the lesion in an elliptical shape.an elliptical shape.  Place specimen immediately in a fixative.Place specimen immediately in a fixative.  Close the wound using suture.Close the wound using suture.
  • 138. INCISIONAL BIOPSYINCISIONAL BIOPSY Definition:Definition: Some lesions are too large to excise initiallySome lesions are too large to excise initially without having established diagnosis or are ofwithout having established diagnosis or are of such a nature that excision would be inadvisablesuch a nature that excision would be inadvisable in such instances a small section is removed forin such instances a small section is removed for examination called incisional or diagnosticexamination called incisional or diagnostic biopsy.biopsy. UseUse : For large lesions: For large lesions
  • 139. MethodMethod  Administer LA.Administer LA.  Identify the apparent junction between normal tissue &Identify the apparent junction between normal tissue & the lesion select the specimen across region.the lesion select the specimen across region.  Stabilize the specimen with a suture.Stabilize the specimen with a suture.  Dissect the specimen from the edge of the lesion &Dissect the specimen from the edge of the lesion & include a margin of apparently normal tissue.include a margin of apparently normal tissue.  The specimen should include representative area of theThe specimen should include representative area of the lesion.lesion.  Place the specimen immediately in a prescribedPlace the specimen immediately in a prescribed specimen bottle containing 10% formalin.specimen bottle containing 10% formalin.  Close surgical site by sutures.Close surgical site by sutures.
  • 140. PUNCH BIOPSY:PUNCH BIOPSY:  A surgical instrument is used to punch out aA surgical instrument is used to punch out a representative portion of tissue.representative portion of tissue.  Since resulting specimen is often damagedSince resulting specimen is often damaged by the procedure so biopsy by scalpel isby the procedure so biopsy by scalpel is preffered.preffered.
  • 141. Needle/trephine/drill biopsy:Needle/trephine/drill biopsy:  Use : to biopsied deep-seated fibro-osseousUse : to biopsied deep-seated fibro-osseous lesions.lesions.  The resulting specimen is smaller may be non-The resulting specimen is smaller may be non- representative & again often damaged by therepresentative & again often damaged by the procedures so they are not often used.procedures so they are not often used.
  • 142. Aspiration biopsyAspiration biopsy  UseUse – Applicable to many cystic & fluctuant lesions– Applicable to many cystic & fluctuant lesions Method-Method- Clean the tissue over the proposed aspiration site.Clean the tissue over the proposed aspiration site. -Inject LA solution over the lesion.-Inject LA solution over the lesion. -Select a wide bore needle & 10 ml syringe.-Select a wide bore needle & 10 ml syringe. -Penetrate tissue & aspirate fluid.-Penetrate tissue & aspirate fluid. -Transfer the aspirate into a screw top specimen bottle.-Transfer the aspirate into a screw top specimen bottle.