Tumors of jaw bones

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  • 1. TUMORS OF JAW BONES TUMOR / NEOPLASM – Abnormal new growth which results from Excessive, Autonomous, Uncoordinated ,Purposeless Proliferation of Cells which continues its growth even after cessation of stimuli.
  • 2. TUMORS OF JAW BONES BENIGN TUMOR Grows slowly Encapsulated MALIGNANT TUMOR Rapid growth Poorly circumscribed, Irregular Adjoining structures Compressed Invasion of adjoining structures Not Fixed No Tendency Fixed to sorrounding structures Tendency towards Ulceration & Hemorrhage Metastasis present Exhibits no Metastasis
  • 3. TUMORS OF JAW BONES    All Tumors - 2 components Parenchyma - Proliferating Tumor Cells - Nature & Evolution Supportive Stroma – Fibrous Connective Tissue & Blood Vessels – Provide Framework on which Parenchymal Tumor Cells Grow Suffix ‘ oma’ - Benign Tumor Malignant tumors of Epithelial Origin - CARCINOMAS Malignant tumors of Mesenchymal Origin - SARCOMAS BENIGN JAW TUMORS – 2 TYPES ODONTOGENIC TUMORS NONODONTOGENIC TUMORS
  • 4. BENIGN JAW TUMORS  CLASSIFICATION OF ODONTOGENIC TUMORS ( KRAMER, PINDBORG , SHEAR – 1992) A. ODONTOGENIC EPITHELIUM 1. Ameloblastoma 2. CEOT / Pindborg’s Tumor 3. Clear Cell Odontogenic Tumor 4. Squamous Odontogenic Tumor B. Odontogenic Epithelium with Odontogenic Ectomesenchyme With / Without Dental Hard Tissue Formation 1. Ameloblastic Fibroma 2. Ameloblastic Fibrodentinoma 5. Compound Odontome 3. OdontoAmeloblastoma 6. Complex Odontome 4. Adenomatoid Odontogenic Tumor ( AOT)
  • 5. CLASSIFICATION OF ODONTOGENIC TUMORS C. Odontogenic Ectomesenchyme with / without Odontogenic epithelium 1. Odontogenic Fibroma 2. Myxoma 3. Benign Cementoblastoma NON ODONTOGENIC TUMORS (WHO Classification) A . OSTEOGENIC NEOPLASMS Cemento Ossifying Fibroma B. NON NEOPLASTIC BONE LESIONS Fibrous Dysplasia Cemento Osseous Dysplasia - Periapical Cemento Osseous Dysplasia - Focal Cemento Osseous Dysplasia - Florid Cemento Osseous Dysplasia
  • 6. Classification Of Non Odontogenic Tumors C. CEMENTO OSSEOUS DYSPLASIAS Cherubism Central Giant Cell Granuloma
  • 7. General Principles in Management of Jaw Lesions  HISTORY OF LESION Duration – Long without Pain – Benign Neoplasm Short , Rapid Growth – Malignant Lesion Mode of Onset - H/o Trauma - Osteogenic Sarcomas Rapid growth – Benign Slow growth - Malignant Site & Shape Progress of Lesion – Stationary, Continous, Intermittent Change in Character of Lesion – Ulcerations, Fluctuation Associated Symptoms – Pain , Paresthetia, Tenderness, Lymphadenopathy, Difficulty in breathing Trismus Recurrence Loss of Body weight Habits
  • 8. General Principles in Management of Jaw Lesions    INSPECTION Number Size Shape Skin Over Swelling PALPATION Consistency Pulsations IMAGING Plain Radiographs CT Scans MRI Angiographic Studies Bone Scans / Scintigraphy Color Surface Pedunculated / Sessile Fixity Lymph Node Examination
  • 9. BIOPSY  EXFOLIATIVE CYTOLOGY FNAC INCISIONAL BIOPSY ASPIRATION BIOPSY EXCISIONAL BIOPSY Exfoliative Cytology - Malignancy ,Scrapings are transfered to slide , stained & examined under microscope Aspiration Biopsy – Nature of lesion FNAC - Deep seated lesions ( salivary glands, neck, ) Excisional Biopsy Incisional Biopsy
  • 10. General Principles in Management of Jaw Lesions   Goal of Treatment Complete Eradication of lesion Preservation of normal tissue Excision with least morbidity Restoration of tissue loss, form , function Long term follow up Gold ,Upton, & Marx 1991 – Terminology for Surgical Excisions Enucleation Curettage Marsupialization Recontouring Resection with Continuity Defect Resection without Continuity Defect Disarticulation
  • 11. General Principles in Management of Jaw Lesions  - ENUCLEATION With / Without CURETTAGE INDICATIONS Small Benign Tumors , Non Aggressive Tumors which tend to grow by Expansion rather than Infiltration Distinct seperation between sorrounding bone & Lesion Cortical margin of bone that separates Tumor / Cyst from bone Indicated in Following Tumors a) Odontogenic Tumors Odontoma Ameloblastic Fibroma Fibroodontoma AOT Cementoblastoma Ameloblastic
  • 12. General Principles in Management of Jaw Lesions B) Non Odontogenic Tumors Ossifying Fibroma Cherubism Central Giant Cell Granuloma C) Other Lesions Hemangioma Neurofibroma Eosinophilic Granuloma Osteoblastoma Neurilemmoma
  • 13. General Principles in Management of Jaw Lesions   MARGINAL RESECTION / PERIPHERAL OSTEOTOMY RESECTION WITHOUT CONTINUITY DEFECT EN – BLOC RESECTION INDICATIONS - Benign lesions with known H/O Recurrence - Lesions that are incompletely Encapsulated - Recurrent Lesions previously treated by Enucleation - Ameloblastoma, CEOT, Myxoma, Ameloblastic Odontoma, Squamous Odontogenic Tumor Benign Chondroblastoma , Hemangiomas Allows for complete Excision of Tumor ,Continuity of Jaw Bone is maintained – Need for Secondary Cosmetic Surgery not required
  • 14. General Principles in Management of Jaw Lesions  SEGMENTAL RESECTION OF JAW - Infiltrative Lesions that have tendency to recur - Lesions which are close to Lower border, Posterior border of mandible, - Lesions that extend to Maxillary sinus / Nasal cavity - Malignant Lesions with high recurrence potential - Maxillary Ameloblastomas with high Recurrence rate
  • 15. MAXILLECTOMY
  • 16. AMELOBLASTOMA History - Cuzack – 1827 - Robinson – Unicentric , NonFunctional , Intermittent in Growth, Anatomically Benign , Clinically Persisitent - WHO – True Neoplasm of Enamel Organ which does not undergo differentiation to the point of Enamel Formation - Benign but locally invasive Epithelial Odontogenic Neoplasm with strong tendency to recur Origin Late Development Source Cell Rests of Enamel Organ Remnants of Dental Lamina Cell Rests of Malassez Follicular Sacs
  • 17. AMELOBLASTOMA - - - Early Embryonic Sources – Disturbances of Developing Enamel organ Dental Lamina Tooth Buds Basal Cells of Surface Epithelium Epithelium of Primordial , Dentigerous , Lateral Periodontal Cyst Heterotropic Epithelium from Pituitary Gland Incidence 18% of all Odontogenic Tumors 3 – 4 th decade of life Site Mandible : Maxilla - 5:1 Mandible – Posterior molar - 60 % Blacks – Anterior Maxilla
  • 18. AMELOBLASTOMA  Clinical Features Early Stages – Asymptomatic Slow growing, Painless, Hard , NonTender, Ovoid Swelling Mobile Teeth, Ill Fitting Denture, Malocclusion, Exfoliation Nasal Obstruction Paresthetia Egg shell crackling Non Encapsulated – invades by destroying rather than pushing Transform in to Malignant form ( 2 – 4 %)
  • 19. AMELOBLASTOMA  Radiological Features Unilocular Radiolucency - 6% Multilocular Radiolucency - 15% Honeycomb Appereance – Multilocular radiolucency with compartmentalized appearance due to Bony Septa – Giant cell lesions Fibro Myxoma Root Resorption ( 30%) Tooth Displacement Buccolingual cortical Expansion - 80% Neurovascular bundle – displaced Desmoplastic Ameloblastoma – Radioopaque – Dense Connectivetissue Anterior Maxilla / Mandible
  • 20. AMELOBLASTOMA  Differential Diagnosis Multilocular lesions - Dentigerous Cyst Cherubism Giant cell granuloma OKC Odontogenic Myxoma ABC
  • 21. AMELOBLASTOMA  TREATMENT Curettage – Should never be considered Unicystic Lesions – Recurrence Rate (18% – 25%) Multicystic Lesions - Recurrence Rate ( 55% - 100%) Microscopically infiltrates Bone beyond Tumor Interface Safe Margin of uninvolved bone of 2 cm should be removed  Multicystic Ameloblastoma – En Bloc Resection without Continuity Defect Segmental Resection with Continuity Defect - Cortical Bone perforated
  • 22. AMELOBLASTOMA  RECONTRUCTION Immediate Reconstruction – Autogenous Free Bone Graft - Iliac / Rib Graft Autogenous Bone Marrow + Reconstruction Plate Bank Allogenic Bone Crib Reconstruction Plate with / without condylar process Vascularized Composite Pedicled Graft of Bone + Myocutaneos tissue
  • 23. AMELOBLASTOMA      Tumor confined to Maxilla without Orbital Floor involvement Partial Maxillectomy Tumor involving Orbital Floor – Total Maxillectomy Tumor involving Orbital Contents – Total Maxillectomy + Orbit Exonteration Tumor involving Skull Base – Neurosurgical Procedure Prognosis Multicystic Ameloblastoma – 50% Recurrence rate – 5 yrs Post op Long Term Follow up Must
  • 24. CALCIFYING EPITHELIAL ODONTOGENIC TUMOR - CEOT / Pindborg’s Tumor Origin – Epithelial remnants of Enamel organ 1% of all Odontogenic Tumors 30 – 50 yrs Mandible – molar 50% associated with unerupted / embedded tooth Painless slow growing , Nasal obstruction, Epistaxis Uni / Multi locular radiolucency with circumscribed / diffuse border Honey comb appereance Driven Snow Appereance – scattered flakes of calcification seen around crown of embedded tooth Recurrence – 15%
  • 25. ADENOMATOID ODONTOGENIC TUMOR AOT 3 – 7% of all Odontogenic Tumors 10 – 20 yrs Females Maxilla ( 65%) – Anterior region Associated with Impacted Canine – 74% Painless swelling Unilocular Radiolucency around crown of impacted tooth - well defined margins. Radiolucency shows Fine Calcifications – Snow Flakes DD – Pindborg’s tumor , CEOC, Amelobastoma Treatment Enucleation – encapsulated - Recurrence rare -
  • 26. ODONTOMA - Growth in which both Epithelial & Ectomesenchymal cells exhibit coplete / incomplete differentiation in to tooth formation 1 – 2 decade Complex - Mandible – 67% , Posterior Jaw Compound - Maxilla , Anterior Jaw Hamartomatous malformation Composite lesion COMPOUND – consist of calcified toothlike structures / miniatured Dwarfed tooth COMPLEX COMPOSITE ODONTOMA Disorderly & Haphazard arrangement of Calcified Dental Structures R/FCompound – Radioopaque Mass with anatomic similarity to normal tooth Complex – Radioopaqe not resembling tooth - Treatment - Enucleation
  • 27. CEMENTOBLASTOMA / TRUE CEMENTOMA - Tumor of connective tissue forming cementum like calcification fused to tooth root 10 – 20 yrs Premolar – Molar region Mandibular lesions – attached to single tooth Maxillary lesions – fused to 2 / more teeth Slow growing lesion ,vital tooth , Resorption of cortical bone R / F – Oval radioopaque mass with radiolucent periphery fused to single / multiple roots DD – Condensing Osteitis, Cementifying Fibroma,Osteoblastoma Treatment – Enucleation, Large lesions can be cut in to smaller pieces
  • 28. CEMENTO OSSIFYING FIBROMA - Benign lesion arising from undifferentiated cells of Periodontal Ligament 3 – 4 decade Females – 5:1 Mandible – Premolar molar Painless slow persistent growth – Facial asymmetry R/F – Early – Radiolucent Late – Radioopaque Tr - Enucleation
  • 29. OSTEOMA - - Benign tumors consist if Mature compact / cancellous bone Peripheral – surface of jaw bone as Polypoid / sessile mass Endosteal – develop centrally within medullary bone Slow growing asymptomatic bony hard masses R / F – Radioopaque mass Tr – surgical excision
  • 30. BENIGN OSTEOBLASTOMA - Central Bone tumor – actively proliferating Osteoblasts, multinucleated Giant cells in Osteoid tissue Males , < 25yrs Post aspect of jaws R / F – Sun ray appereance - Central opacity with thin rim of radiolucency Tr – surgical excision
  • 31. ODONTOGENIC FIBROMA Central Benign Odontogenic Tumor Contains Fibrous CT stroma & inactive Odontogenic Epithelium Intraosseous – Central Gingiva – Peripheral Slow persistent growth, asymptomatic cortical expansion, Mandible Males, Mean age 37yrs R / F – Multiloculated radiolucency,well / ill defined sclerotic margin Root divergence / resorption - Tr – Enucleation & Curettage -
  • 32. ODONTOGENIC MYXOMA - Central benign slow growing , infiltrative tumor of jaws which cause destruction of cortex Found in Tooth bearing areas of jaws Mandible Females Children R / F – Multilocular / soapbubble / honeycomb Recurrence rate – 33% Tr – Resection with / wthout continuity defect