The document discusses different types of biopsies used in maxillofacial fields including incisional, excisional, fine-needle aspiration, and frozen section biopsies. It provides details on techniques, indications, and principles for successful outcomes for each type of biopsy. Key principles include obtaining a representative tissue sample, proper handling and fixation of specimens, and avoiding techniques that could distort tissues.
2. • Biopsy is the surgical removal of a tissue specimen from a living
organism for microscopic examination and final diagnosis.
• A biopsy is a minor surgical procedure and, depending on whether
the entire pathologic lesion or part of it is removed, is either an
excisional biopsy or incisional biopsy. Furthermore, aspiration or
needle biopsy uses a needle to withdraw a sample from the lesion for
examination.
3. Principles for Successful Outcome of Biopsy
• In clinically suspicious lesions, biopsy must be carried out early.
• The choice of the biopsy technique to be employed is determined by
the indications of each case.
• Direct injection of the local anesthetic solution inside the lesion is to
be avoided, because there is a possibility of causing distortion to the
tissues.
4. Principles for Successful Outcome of Biopsy
• The use of the electrosurgical blade is to be avoided, due to the
resulting high temperature, which causes coagulation and
destruction of tissues.
• The tissue specimen must not be grasped with forceps. When their
use is necessary, though, the normal part of the removed tissue
should be grasped.
• The tissue specimen taken should be representative.
5. Principles for Successful Outcome of Biopsy
• Immediately after its removal, the tissue specimen should be placed
in a container with fixative. Keeping the tissue specimen outside of
the container for a prolonged period dries the specimen, while there
is a risk of it falling or being misplaced.
• The fixative solution to be used is 10% formalin, and not water,
alcohol, or other liquids that destroy the tissues.
6. Principles for Successful Outcome of Biopsy
• It is recommended that the container to be sent to the laboratory is
plastic to avoid risk of breakage during its transfer and subsequent
loss of the specimen.
• The label with the name of the patient and date should be placed on
the side of the container, and not on the lid. This way the possibility
of mix-up at the laboratory after opening is avoided.
7. Instruments and Materials
• The instruments necessary for performing surgical biopsy of soft and
hard tissues are the following:
local anesthesia syringe. Scalpel handle and blade.
Surgical–anatomic forceps. Hemostat.
Needle holder. Curved scissors.
Suction tip. Periosteal elevator.
Periapical curette. Bone file.
Rongeur.
9. • The materials considered necessary for biopsy are:
local anesthetic cartridge and needle for anesthesia, sutures, surgical
dressing, gauze, and vial containing 10% formalin solution for
placement of specimen.
• As for aspiration biopsy, the necessary instruments and materials
include the following: trocar needle or a simple low- gauge needle,
plastic disposable syringe, glass slides, and fixative material.
10. Excisional Biopsy
• This technique entails removal of the entire lesion, along with a
border of normal tissues surrounding the lesion.
• The indications for employing incisional biopsy are the following:
- Small lesions, whose size ranges from a few millimeters to one or
two centimeters.
- Specific clinical indications that the lesion is benign.
11. Generally, the procedure for performing the
biopsy is as follows:
• After administration of local anesthesia, which is performed at the
periphery of the lesion and not directly inside the lesion.
12. Two elliptical incisions are made on normal tissue
surrounding the lesion, which are joined at an
acute angle.
13. The lesion is then removed, the mucosa is
undermined using blunt scissors, the wound
margins are re-approximated,
15. • If the lesion is located at the gingiva or palate, suturing may be not
possible. In such a case, a surgical dressing is applied and the wound
heals by secondary intention.
• It is recommended that the lesion be grasped at its base using
forceps or a suture.
16. • If the lesion were to be grasped at the center and not at its base, the
histological presentation could be altered and could cause problems
in diagnosis.
26. Peripheral giant cell granuloma at
the region of the maxillary central
incisor
Incision peripheral to the lesion
Peripheral Giant Cell Granuloma
27. Reflection of lesion with broad end of
periosteal elevator
Surgical field after removal of lesion
Peripheral Giant Cell Granuloma
28. Application of surgical dressing at area
of removal of lesion
Postoperative clinical photograph 15
days later
Peripheral Giant Cell Granuloma
29. Hemangioma of Cheek
Small hemangioma of buccal mucosaElliptical incision at normal tissue border
surrounding lesion
Excision of lesion with scalpel
30. Hemangioma of Cheek
Surgical field after removal of hemangioma
Undermining of mucosa of
wound
margins from underlying soft
tissues with blunt scissors
Suturing of wound with interrupted sutu
31. Hemangioma of lower lip
Hemangioma of lower lip
Demarcation of wedge-shaped
incision
Which includes the entire lesion
32. Hemangioma of lower lip
Suturing begins at mucosa and ends on skinHemostats just inside of wound margins aid
in
hemostasis of surgical field before suturing
33. Peripheral Fibroma of Gingiva
Peripheral fibroma of gingiva located in
the region of the lateral and central
incisor
of the maxilla
Incision on normal tissue peripheral to lesionReflection of lesion with broad end
of periosteal elevator
34. Peripheral Fibroma of Gingiva
Surgical field after removal of lesion.
Application of surgical dressing at
the
region of removal of the lesion
3 months after the surgical procedure
35. Leukoplakia
Leukoplakia of buccal mucosa posterior
to commissure of lip
Demarcation of incision for surgical excision
of leukoplakia
37. Incisional Biopsy
• Incisional biopsy involves removal of only a portion of a relatively
more extensive lesion, so that histo-pathological examination may be
performed and a diagnosis made.
• Indications of incisional biopsy:
- Lesion is larger than 1 or 2 cm.
- There is suspicion that the lesion is malignant.
38. The incisional biopsy technique involves the
following
• After local anesthesia, a wedge-shaped portion of the most
representative part of the lesion is removed, usually from the
periphery of the lesion, extending into normal tissue as well
42. Extensive palatal swelling which is an indication
for incisional biopsy
Administration of local anesthesia in normal
tissues
surrounding lesion
43. • Surgical field after wedge-shaped excision of tissue
Wedge-shaped incision for removal of part of lesion Surgical field after wedge-shaped excision of tissue
45. Fine-Needle Aspiration
• A useful method for evaluating subcutaneous or more deeply
situated mass lesions,
• FNA requires specialized training. This type of procedure is most
widely used in determining the nature of salivary gland or neck
masses.
46. Aspiration Biopsy
• Aspiration biopsy is indicated in cases where lesions are not
accessible for histopathological examination, e.g., tumors of the
parotid gland, lymph nodes, cysts, etc.
• It is performed using a trocar needle or fine needle (21-gauge to 23-
gauge) adapted to a glass syringe or plastic disposable syringe .
• The aspirated material is smeared on a glass slide.
47. Aspiration Biopsy
• Then immersed in Hoffman solution (95% ethyl alcohol solution and
5% ether solution) in equal parts or it is fixed with hair spray.
• Cytological examination is then performed.
• A histological examination may be performed if a specimen is sucked
into the needle tip, usually with a trocar needle, and expressed onto a
glass slide.
50. Frozen Section
• Diagnosis may influence immediate surgical management.
• Lesion is not accessible or the patient not amenable to preoperative
biopsy
• Preoperative biopsy attempted but was not successful
• Staging of malignant neoplasms
• Assessing the adequacy of excision
51. Attention to:
• Surgical pathologist should confirm the following conditions are met:
- No risk of compromising the tissue specimen.
- High probability of rendering the correct diagnosis.
- Little risk of conveying incorrect diagnostic information.
Then and only then should the frozen section examination proceed
52. Specimen Care
• The tissue specimen removed with biopsy is placed in a vial
containing an aqueous solution of 10% formalin (4% formaldehyde)
and sent to the laboratory, along with the biopsy data sheet
containing all the necessary clinical
information. The pathology laboratory
will send the dentist the pathology
report that includes a histological
description and diagnosis.
53. Exfoliative Cytology
• This method is to be used as an additional aid to, and not a substitute
for, biopsy, mainly providing bacteriological information.
• The reason for this is that it is considered unreliable due to lack of
pathologist expertise in the field of exfoliative cytology. Individual
cells are examined, rather than the lesion as a whole, which
represents a drawback.
• The lesion is scraped using a cement spatula or tongue depressor. The
superficial cells scraped from the area are smeared evenly on a glass slide.
The fixation procedure that follows is the same as that for aspiration
biopsy, after which the cells are stained.
54. Tolouidine Blue Staining
• This method is used most often to indicate the most appropriate
biopsy location, even though it does not indicate tumors present
under normal epithelium.
• A 1% tolouidine blue staining solution is applied to the epithelial
surface, whereupon rinsing with a 1% acetic acid solution leaves no
stain on normal epithelial surfaces or benign erythematous lesions.
• On the contrary, the stain remains on the surface of premalignant
and malignant erythematous lesions.
• Benign lesions usually have well-defined stain margins, whereas
premalignant or malignant lesions have more diffuse margins.
Editor's Notes
Excisional Biopsy Excisional biopsy is typically used to manage clinically benign lesions that are < 2 cm in diameter. An excisional biopsy is defined as a diagnostic surgical procedure in which all clinically abnormal tissue is removed for microscop- ic analysis. Excision of a small but poten- tially malignant lesion (eg, squamous cell carcinoma with a primary tumor [T], regional nodes [N], and metastasis [M] staging of T1N0M0) may be appropriate in settings in which the surgeon performing the biopsy is also responsible for final treat- ment. With rare exceptions, an excisional biopsy should not be performed on a suspected malignant lesion unless the per- forming clinician is involved in definitive treatment. Otherwise, the surface mucosa may be completely healed by the time the patient is referred to the oncologist, obscuring the extent of the original lesion and unnecessarily hindering definitive treatment planning.
Specimen orientation is recommended whenever a clinician suspects that a neo- plastic process may have recurrent or malignant potential, including conditions such as epithelial dysplasia or pleomorphic adenoma. This can be accomplished by careful identification of the anatomic mar- gins of the biopsy specimen with suture(s), an accompanying sketch of the specimen, and its orientation to the surrounding tis- sues or both. Such anatomic orientation of the tissue sample allows the pathologist to properly subdivide and process the speci- men so that the adequacy of excision can be assessed at all surgical margins. The terms negative or clear margins are used when the surgical margins appear free from tumor involvement. When tumor is transected or lies immediately adjacent to the surgical margin without evidence of a capsule, proper specimen orientation per- mits the location of the positive margin(s) to be determined as precisely as possible. With this information the surgeon can then plan the most conservative surgical approach that will also accomplish the pri- mary goal of therapy: complete removal of residual neoplastic tissue.
Incisional Biopsy Incisional biopsy is generally indicated for large lesions (> 2 cm) and those that could represent unencapsulated or potentially malignant neoplasms. By definition an incisional biopsy is a diagnostic surgical procedure in which a sample or portion of a lesion is removed for histopathologic review, leav- ing the remainder of the lesion at the biop- sy site. In cases of suspected malignancy, an incisional biopsy is usually the procedure of choice unless the clinician performing the biopsy will also be involved in defini- tive treatment of the cancer
Fine-Needle Aspiration Fine-needle aspi- ration (FNA) is a useful method for evalu- ating subcutaneous or more deeply situated mass lesions, although obtaining a diagnos- tic sample and interpreting the results accu- rately requires specialized training. This type of procedure is most widely used in determining the nature of salivary gland or neck masses. Currently FNA is available in most large urban areas throughout the United States, usually in conjunction with tertiary care medical centers.
Exfoliative Cytology Exfoliative cytol- ogy is a relatively inexpensive noninva- sive technique that may be used to pro- vide additional information related to lesions of surface origin. The utility of this technique in the diagnosis of condi- tions such as candidiasis, herpesvirus (herpes simplex virus, human her- pesviruses 1 and 2) infections, and pem- phigus vulgaris is well documented.
More recently a modified form of cytologic sampling that employs an oral brush instrument to collect epithelial cells followed by automated histopathologic evaluation has been introduced to den- tistry. Suggested advantages include improved sampling of all epithelial layers and increased sensitivity and specificity in the detection of precancerous and cancer- ous lesions versus results with routine exfoliative cytology. This new technique does not provide a definitive diagnosis, however, and cannot be used as a substi- tute for scalpel biopsy and routine histopathologic examination (see below). Therefore, in a clinical setting where the index of suspicion for possible precancer- ous or cancerous change is high, such as the high-risk areas for oral cancer (ie, ven- trolateral tongue, floor of mouth, tonsillar pillars, soft palate), or in a patient with sig- nificant risk factors (ie, heavy smoking, heavy alcohol use, or both), use of brush cytology would not be recommended due to the inherent delay in definitive diagno- sis of the lesional tissue and any subse- quent treatment. In cases in which a per- sistent mucosal lesion is identified but the index of suspicion is low, the brush cytol- ogy technique may be useful in excluding the presence of precancerous or malignant
epithelial changes. For such innocuous lesions, a finding of abnormal cells could trigger scalpel biopsy (and definitive diag- nosis) before the surgical procedure might otherwise have been deemed necessary.