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Oral Tumors
TUMORS OF THE ORAL CAVITY Tumor: is simply a swelling or lump. Neoplasm: is a new growth of tissues in which the multiplications of cells is uncontrolled or progressive. Hypertrophy: is an increase in cell size without an increase in cell number. It may be physiological (normal response to increased demands of a tissue) or pathological (gum hypertrophy in epileptics). Hyperplasia: is the increase in cell number without an increase in cell size. Also it may be physiological (breast during lactation or hypercementosis) or pathological (denture fissuratum, prostate in elderly males).

I. Classification of oral tumors I- According to tissue of origin: a- Odontogenic These are neoplasms arising from cells of the odontogenic apparatus. 1. Epithelial origin e.g, ameloblastoma, enameloma. 2. Mesenchymal origin e.g, odontogenic myxoma, cementoma.
3.

Mixed e.g, ameloblastic fibroma, compound and complex composite

odontome.

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b. Non-odontogenic These neoplasms may arise from surface or lining epithelium, or from various connective tissues. II. According to clinical behavior Benign tumors Slow growth Grow by expansion and pressure on the adjacent tissue. Usually has a fibrous capsule, and well separated from the surrounding tissues. Malignant tumors Rapid growth Grow by invasion and infiltration of the adjacent tissues. has no capsule and poorly demarcated from the surrounding tissues

Usually of large size. Usually of small size Never metastasize capsule and poorly Re c u r r e n c e i s ra r e Resemble the parent tissue (well differentiated) Show little cellular atypia and few mitosis No necrosis as no Commonly metastasize. Recurrence is often. Poor resemblance to the parent tissue (poorly differentiated) There is striking atypia and frequent mitosis Frequently . show central necrosis and invasive activity at the margins

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II. Examination and diagnosis of oral tumors I- History; this includes 1. Past and present medical history. 2. History of the lesion; which includes. a. Duration of the lesion. b. Change in size. c. Change in character. d. Symptoms associated with the lesion. II- Clinical examination
1. Size and shape of the lesion 2. The surface of the lesion: may be smooth, lobulated, irregular or ulcerated. It 3. The color of the lesion: e.g, bluish mass blanches on pressure may indicate

hemangioma.
4. The consistency of the lesionIt may be soft (lipoma), firm (fibroma), hard :

(pleomorphic adenoma) or bony hard (osteoma)

5. Presence of fluctuation: It is felt on palpation. It indicates fluid within the

mass.
6. Presence of pulsation: Palpation of a mass may reveal a palsatile quality

which indicates a large vascular component.

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7. Lymph node examination: Five characters of the nodes should be recorded:

Location Size. Tenderness (painful versus non painful). Degree of fixation (movable, matted, fixed) Consistency (hard or firm).

In malignant lesion L.N become enlarged and fixed in position. Classifications of Lymph nodes: A- Local lymph nodes (Pre-cervical L.N): Inner ring: includes Palatine tonsils. Pharyngeal tonsils. Lingual tonsils. Outer ring: includes Submental L.N. Submandibular .L.N. Buccal L.N. Pre-auricular L.N. Post-auricular L.N. Occipital L.N B- Regional nodes (Cervical L.N):

Superficial cervical L.N: related to E.J.V. Deep cervical: related to I.J.V. 1. Upper deep cervical: jugulo-digastric L.N. 2. Lower deep cervical: jugulo-omohyoid L.N. Anterior cervical: Pre-laryngeal and Pre-tracheal. Supraclavicular L.N.

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III. Radiographic Examination Characteristics of malignancies: 123456

ill defined borders with extensive bone destruction loss of lamina dura and widening of PDL space floating teeth in sarcomas, root resorption occurs invasion of maxillary sinus destruction of inferior alveolar canal cortex Plain radiograph: Indicate intra-bony lesions. C.T.: Indicate intra-bony lesions. M.R.I.: Indicate intra-bony lesions. Ultrasound Scintegraphy: denote distant metastasis. Sialography: assess S.G. tumors.

For lesion within or adjacent to the bone we may use:

IV. Laboratory investigations

Laboratory investigations are unnecessary in evaluation of oral lesions,

while biopsy yield more accurate results. V. Biopsy

Biopsy is the removal of tissue from a living individual for Value of biopsy: 1.
2.

micropscopic diagnostic examination. Proper and correct diagnosis. Determination of the degree of malignancy e.g., by Determination of the prognosis.

percentage of undifferentiated cells. 3.

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a. b. c.

Indications: Lesion not responds to ttt within 14 days. No apparent cause. If suspect malignancy. Types of biopsy: A) Excisional biopsy 1. It is the complete excision or removal of the lesion. 2. A margin of 2-3 mm of the surrounding normal tissues should be excised with the lesion to ensure its total removal.
3. Indications:

a.
b.

Small superficial lesion (1-2 cm in diameter). Well encapsulated tumors.

B) Incisional biopsy:
1.

It is the removal of a portion or sample from the edge of the lesion with Indications:

some normal tissue for identification of the lesion.

2.

Too large lesion. If the lesion nature is uncertain.

3.

Contraindications: Hemangioma. Malignant melanoma.

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4. Principle
a.

The sample is cut in a wedge shape. It is much better to

take a deep narrow biopsy rather than a broad shallow one.

b.

The biopsy should be taken from the edges of the lesion to

include some normal tissue.

c.

Avoid injection of local anesthetic directly into the tumor tissue

which may cause distortion of the tissues. Ring block or regional nerve block is recommended. d. Also avoid cauterization, areas of necrosis and/or impaction of

foreign bodies.
e.

The lesion should not be wiped with an antiseptic having

staining properties (iodine) because this will change the staining character of the tissues.
f.

The sample should be placed in 10% formalin solution in

a wide mouth bottle. C) Drill biopsy (intra-osseous biopsy)

1.

For obtaining samples from deeply seated lesions. Indication: intra osseous lesion

2.

D. Punch biopsy
1.

This is performed with a punch type forceps which punches or

bites out a portion of tissue.

2.

It is indicated in inaccessible areas (larynx and oropharynx).

E. Frozen section biopsy

1.

This is performed during surgery to attain immediate information.

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F. Curettage biopsy
1.

In this type, tissues removed from the depth of tooth socket after extraction

or from maxillary sinus using bone curette. G) Aspiration biopsy 1.

2.

It is the most valuable investigation for cystic and fluctuant lesions. A wide bore needle (18 gauge) attached to a 10 ml syringe is used. The

needle is inserted deeply into the lesion for aspiration of its contents. 3.

The results of aspiration may be: Air indicating maxillary sinus or traumatic bone cyst. Pus indicates an abscess or infected cyst. Yellowish (creamy white) inspissated material resembling pus

without its unpleasant smell denotes the presence of keratocyst. Straw-colored fluid containing cholesterol crystals indicates

periodontal or dentigerous cysts. Blood indicates vascular tumor or aneurysmal bone cyst. Mucinous fluids indicate ranula or mucocele.

H) Exfoliative oral cytology

1.

It is performed by scraping the lesion's surface repeatedly and

firmly by a spatula or tongue depressor. The cells obtained are smeared on a glass slide, fixed and stained, and microscopically examined. It is useful in poor surgical risk patients & in surface lesion when malignancy is suspected.

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I) Fine needle aspiration cytology (FNAC):

1.

A fine disposable needle of gauge 18-23 is used with 3-10 lcc

disposable plastic syringes. The needle is inserted into the lesion and moved in and out and laterally in three dimensional planes without being removed outside the lesion.
2.

Cells from the lesion will be collected inside the lumen of the needle. Then

the needle is withdrawn and the aspirate containing the cells is disposed on a glass slides. It is then spread, fixed, stained and examined microscopically. 3. 4. 5. Indications: S.G & L.N. Adv.: simple, atraumatic & cheap. Disadv: insufficient sample.

J. Unplanned biopsy:
1.

Indications: lesions discovered accidentally during tooth extraction.

K. Exploration biopsy: 1. 2. Surgical Exploration of internal lesion Indication: deep internal lesion

M. Brush cytology: 1. Special brush scraps the lesion 5-10 times to collect cells 2. Cells are fixed and stained on glass slide for microscopic examination 3. adv.: simple, quick & painless 4. Indications: suspicious superficial malignancy.

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1. ODONTOGENIC TUMORS These comprise those neoplasms that arise from any portion of the dental formative tissues. Classification of odontogenic tumors I . Epithelial Odontogenic Tumors

A. Benign 1. Soft tissue a. Simple Ameloblastoma. b. Calcifying Epithelial Odontogenic Tumor (Pindborg's Tumor). c. Squamous Odontogenic Tumor. 2. Hard tissue (with inductive changes) Enameloma (Enamel Pearl). 3. Mixed (with inductive changes) Adenomatoid Odontogenic Tumor. B. Malignant 1. Soft tissue a. Malignant Ameloblastoma. b. Ameloblastic Carcinoma (Carcinoma Ex Ameloblastoma). 2. Hard tissue (with inductive changes) No such lesion exists. 3. Mixed (with inductive changes). No such lesion exists. II. Mesenchymal Odontogenic Tumors A. Benign 1. Soft tissue a. Odontogenic Fibroma. b. Odontogenic Myxoma (Fibro-Myxoma).

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2. Hard tissue (with inductive changes) a . De n t i n o m a . b. True Cementoma (Benign Cementoblastoma). c. Periapical Cemental Dysplasia. d. Florid Cemento-Osseous Dysplasia (Gigantiform Cementoma). 3. Mixed (with inductive changes) Cementifying Fibroma. B. Malignant 1. Soft Odontogenic Fibrosarcoma 2 . Hard (with inductive changes) No such lesion exists. 3. Mixed (with inductive changes) No such lesion exists. III. Mixed Odontogenic Tumors A. Benign 1. Soft Ameloblastic Fibroma (FibroAmeloblastoma) 2 . Hard (with inductive changes) a. Compound Composite Odontome. b. Complex Composite Odontome. c. Dilated Odontome (Gestant Odontome; Dens In Dent). 3. Mixed (with inductive changes) a. Ameloblastic Fibro-Odontome. B. Malignant 1. Soft tissue Ameloblastic Fibrosarcoma 2. Hard tissue (with inductive changes) No such lesion exists.

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3. Mixed (with inductive changes) No such lesion exists.

2. NON-ODONTOGENIC TUMORS Classification

I. Epithelial A. Benign 1. Squamous Cell Papilloma 2. Keratoacanthoma B. Malignant 1. Squamous Cell Carcinoma II. Mesenchymal A. Benign 1. Fibrous Tissue Origin

Fibroma Fibromyxoma

2. Fat Cell Origin

Lipoma

3. Cartilage Forming Origin Chondroma 4. Bone Forming Origin

Osteoma Fibro-Osteoma Osteoid Osteoma Benign Osteoblastoma

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5. Muscle Tissue Origin

Granular Cell Myoblastoma Rhabdomyoma Leiomyoma

6. Nerve Sheath Origin Neurofibroma Neurilemmoma (Schwannoma)

Traumatic Neuroma (Amputation Neuroma)

7. Vascular Origin

Haemangioma
a.

Capillary Haemangioma. Cavernous Haemangioma hi. Venous

b.

Haemangioma

Lymphangioma
a. b.

Capillary Lymphangioma Cystic Hygroma

B. Malignant 1. Fibrous Tissue Origin Fibrosarcoma

2. Fat Cell Origin

Liposarcoma

3.Cartilage Forming Origin Chondrosarcoma

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4. Bone Forming Origin

Osteogenic Sarcoma Giant Cell Tumor Ewing's Sarcoma

5. Muscle Tissue Origin

Rhabdomyosarcoma Leiomyosarcom

6. Nerve Sheath Origin Neurofibrosarcoma 7. Vascular Origin Kaposi's Sarcoma

8. Haemopoeitic and Lymphoreticular Plasma Cell Myeloma Hodgkin's Lymphoma Burkitt's Lymphoma

9. Metastatic Carcinomas Cancer Lung Cancer Breast Cancer Prostate

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I. Pericoronal radiolucencies
1. Dentigerous cyst. 2. Primordial cyst. 3. Calycifying odontogenic cyst. 4. Ameloblastoma. 5. Unicystic ameloblastoma. 6. Adenomatoid odontogenic tumors. 7. Ameloblastic fibroma. 1. Simple ameloblastoma This is a benign locally invasive, soft epithelial odontogenic neoplasm. Incidence
1.

Simple ameloblastoma may occur at any age, but it most It occurs most frequently in the mandible mainly in the molar-

frequently occurs in the third to fifth decades of life.

2.

r amu s a re a. Histogenesis Simple ameloblastoma may arise from any odontogenic epithelium. The sources of its epithelium are:
1.Basal 2. 3.

layer of the surface epithelium of the oral mucosa.

T h e d e n t a l l a m i n a a n d i t s re m n an t s (epithelial rests of Serres). E n a m e l o r g a n s o f n o r m a l o r supernumerary teeth.

4.

Remnants of the epithelial root sheath of Hertwig (rests of

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Mallassez).
5.

Lining epithelium of follicular cysts (primordial or more commonly dentigerous cysts).

Clinical Features

Painless swelling unless secondarily infected. No facial disfigurement is noticed except when the tumor attains a large size. The growth commonly expands both lateral and lingual aspects of the mandible. The tumor does not usually perforate the cortical bone. Even when this bone is perforated, the tumor does not break through the periosteum unless the surface is traumatized.

Pathological Features

Ameloblastomas may be solid, micro-cystic or may contain one or more large cystic The partitions between the large cysts contain bone. Cystic ameloblastomas contain a clear or slightly turbid albuminous fluid

spaces.

with few or no cholesterol crystals. Radiographic Features

Large multilocular radiolucent area in the affected part of the jaw. Less commonly, unilocular radiolucent area.

Histopathological Features

In ameloblastomas, the epithelium takes the form of sheets and strands

bordered by cuboidal or tall columnar cells resembling those of the internalenamel epithelium.

The central parts of these epithelial masses may be composed of closely

packed polyhedral cells, or the cells may be arranged in a loose texture

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resembling the stellate reticulum of an enamel organ.

The fibrous stroma of an ameloblastoma varies both in quantity and in Follicular

cellularity.

In this variant, the tumor epithelium takes the form of more or less

discrete islands surrounded by a variable connective tissue stroma.

The epithelial masses consist of a c e n t r a l m a s s o f p o l y h e d r a l

l o o s e l y intercommunicating cells resembling the stellate reticulum, surrounded by a layer of cuboidal or columnar cells resembling cells of the internal enamel epithelium or preameloblasts.

Cyst formation is common within the epithelial islands. In cases of cyst formation, the several histological patterns may be seen Cystic Ameloblastoma Acanthomatous type: the presence of squamous metaplasia and

in or around the epithelial masses in follicular ameloblastomas are: 1.

2.

keratin.
3. Keratoameloblastoma: In most ameloblastomas keratinization is

absent or limited. If there is more extensive keratinization and the t u m o r i s t h e n r e f e r r e d t o a s a keratoameloblastorna.

4. Granular cell ameloblastoma: In some ameloblastomas the central

cells may show a remarkable granular change.

5. Juxta-epithelial hyalinization: In some tumors, the connective tissue

stroma around the epithelial masses undergoes a hyalinizing change.

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6. Basaloid type: Rarely, an ameloblastoma may show a basaloid

pattern.

Plexiform

In this variant, the tumour epithelium is arranged in the form of irregular The epithelial strands, just like the follicles of follicular ameloblastoma,

intercommunicating strands and cords rather than separate of discrete islands.

are bounded by a layer of columnar or cuboidal cells surrounding loosely intercommunicating cells similar to those of the stellate reticulum.

Cyst formation often occurs, but in this variant it is usually due to

stromal degeneration giving rise to stromal cysts. Unicystic Ameloblastoma

three histological variants of unicystic ameloblastoma have been In the first, a cyst epithelial lining may exhibit transformation to

described:
1.

one with cuboidal or columnar basal cells with hyperchromatic nuclei and subepithelial hyalinization.
2.

In the second variant, the cyst lining is similar to that of the first,

with a localized nodule arising from part of the lining and projecting into the cyst lumen.
3.

The third variety, sometimes referred to as mural

ameloblastoma, is formed of typical follicular or plexiform ameloblastoma growing in and infiltrating part of the wall of a cyst producing a mural projection into the cyst cavity.

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Behavior and Local Spread

1.

As the tumor grows, it causes resorption of some of the bone in its vicinity. The tumor spread into neighboring cancellous spaces without resorption of the bone surrounding these spaces. The absence of capsule gives the tumor its locally invasive nature. The tumor invades cancellous spaces and does not invade the Haversian canals of compact bone. Therefore, in the compact bone of the lower border of the mandible, the clinical and radiographic limit of the tumor is likely to be the true limit.

2.

3. 4.

Treatment of Ameloblastoma Treatment of ameloblastoma is usually surgical excision. 1. Marginal Resection

This is the treatment of choice in small, solid or multicystic A safety margin of about 1.5 cm of clinically uninvolved bone,

lesions.

all around the boundaries of the lesion should be included in the resection. 2. Segmental Resection

This is indicated with large tumors that have eroded the cortical bone and involved the periosteum and soft tissue. A safety margin of about 1.5 cm of clinically uninvolved bone, all around the boundaries of the lesion should be included in the resection.

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3. Curettage

This should not be used in the treatment of ameloblastoma because of the high risk of recurrence.

4. Radiotherapy

Has no place in the treatment of am el ob l a st om a b ec au se t h e t u m o r i s radioresistant.

2. ADENOMATOID ODONTOGENIC TUMOR Origin: arise from the enamel organ or its remnants. Clinically
1. Symptomless, well-defined swelling of the affected area of the jaw. 2. It usually occurs in the maxillary second incisor-canine region.

Frequently it is associated with an upper unerupted canine tooth. Radiographically

1. It presents as a well-defined radiolucent area frequently associated

with an unerupted t o o t h .
2. In most cases it appears like a dentigerous cyst but the

radiolucency appears to extend apically further than the cementenamel junction of the involved tooth. Treatment: enucleation or conservative surgical excision. 3. AMELOBLASTIC FIBROMA
1.

It is a benign mixed odontogenic tumor of soft tissues origin. lesion producing expansion of the affected area of the jaw.

2. Clinically: It is a slowly growing, painless, frequently asymptomatic

3.

Radiographically: it appears as a well defined radiolucent area

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Treatment: surgical excision.

II. Periapical radiolucencies

1. Radicular cyst. 2. Periapical scar. 3. Surgical defect.
4. Periapical cemento-osseous dysplasia.

5. Traumatic bone cyst.

6. Malignant tumors.

7. Dentigerous cyst.
8.

Dentoalveolar abscess. Periapical granuloma. Chronic suppurative osteomylities. Cementoblastoma (osteolytic stage). Cemento-ossyfing fibromas (osteolytic stage). 1. Radicular cyst

9. 10.
11. 12.

Differential diagnosis 1. Well defined radiolucency + untreated asymptomatic teeth + non vital pulp Radicular cyst.

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2. Teeth with endodontic treatment + asymptomatic, non enlarging radiolucency at the apex Periapical scar. 3. Endodontic treated teeth + asymptomatic radiolucency after root resection surgical defect.
4. Periapical radiolucency in the mandibular premolar molar region + vital

tooth Traumatic bone cyst as radicular cyst is occurred more common in the anterior region.

2. Periapical scar
1. Is a dense fibrous tissues and is situated at the apex of a pulpless tooth in

whish the root canal have been successfully filled. 2. It represents a previous periapical granuloma, cyst, or abscess. 3. Surgical defect Is an area that fails to fill in with osseous tissue after surgery. 4. Periapical cemento-osseous dysplasia Clinical features
1.

T h i s i s a d y s p l a s t i c d e v e l o p m e n t a l disturbance of cementum. It occurs around the apex of a tooth, usually a lower incisor. The condition is usually asymptomatic.

2. 3.

Radiographic examination: the radiographic picture varies with its histologic structure and stage of development. Four stages of development are usually described:

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a. Osteolytic stage:

This is the earliest stage which represents the immature cementoma composed of cellular element with no calcification. There is bone destruction wh ich app ears rad iograph ical ly as r ad io luc en cy similar to a granuloma or a radicular cyst.

b. Early cementoblastic stage:

Calcifications with the formation of initially discrete islands of

cementum occur in the fibrous tissue.

Radiographically, the lesion appears now as a radiolucent area

mottled or specked with areas of radiopacity. c. Late cementoblastic stage:

As

the lesion continues to develop, the initially discrete m a s s e s of

c e m e n t u m f u s e t o g e t h e r forming larger irregular masses of acellular cementum.

The

fused cementum masses appear radiologically as larger areas

of radiopacity within the radiolucent lesion. d. Mature stage: With gradual and c o n t i n u e d f o r m a t i o n o f c e m e n t u m , calcification of the whole lesion is almost complete, with remnants of the formative tissue surrounding the lesion. The lesion now appears as an irregular area of radiopacity with a thin radiolucent border around it. Treatment : No treatment of this lesion is required Differential diagnosis (for the osteolytic stage)
1. Teeth with vital pulp + mainly in the mandibular incisor region + older

patient Periapical cemento-osseous dysplasia.

2. Teeth with vital pulp + mainly in mandibular premolar molar region

+ young patient Traumatic bone cyst.

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5. Traumatic bone cyst Differential diagnosis The Traumatic bone cyst can be confused with median mandibular cyst but the median mandibular cyst causes a separation of the teeth while the Traumatic bone cyst does not.

6. Malignant tumors 1. Malignant tumor may appear as single periapical radiolucency as squamous cell carcinoma, chondosarcoma, fibrosarcoma. 2. Differential diagnosis is done by careful clinical examination and history of the lesion + Biopsy.

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III. Interradicular radiolucencies

1. Lateral radicular cyst. 2. Lateral developmental cyst. 3. Incisive canal cyst. 4. Median mandibular cyst. 5. Glogulomaxillary cyst.
6. Primordial cyst: may occur interradicularly in a region where a tooth failed

to develop. 7. Odontome. Odontome Benign mixed odontogenic tumors of hard tissues origin. Three types of odontomes are identified:
1.

Compound Composite Odontome: In which a large number of teeth

or denticles with normal arrangement of dental tissues (central pulp

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spa ce , su rro un de d b y dentine, which is covered by enamel in its coronal part and may be covered by cementum in its radicular part) are seen.
2.

Complex Composite Odontome: In which calcified dental

tissues (enamel, d e n t i n e a n d c e m e n t u m ) a r e s e e n scattered in a disorderly fashion without any special pattern.

3.

Dilated Odontome (Invaginated Odontome; Dens in Dent): i n

wh i c h t h e e n a m e l or gan becom es invaginating the dentine papilla, with the development of an enamel lined cavity within the dentine.

Clinically
1. 2.

Odontomes presenting themselves as local swellings. Odontomes are developmental malformations and are not The only danger encountered with these tumors is that they may attain

true neoplasms, as their growth is self limiting.

3.

a large size. Thus weakening the jaw or even causing pathological fracture. Radiologically
1.

They appear as a variable number of tooth-like structures in radiolucency.

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IV. Multilocular radiolucencies

1. Cyst: 1. 2. 3. 2. tumors: Ameloblastoma. Odontogenic myxoma. Central haemangioma of the bone. odontogenic keratocyst. Primordial cyst. Aneurysmal bone cyst.

Metastatic tumor to the jaws. 3. Others: 1- Central giant cell granuloma. 2- Giant cell lesion of hyperparathyroidism.

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1. Odontogenic Myxoma 1. 2. Origin: derived from odontogenic mesenchyme, this is a locally Clinical features :

invasive neoplasm It appears as slowly growing bony hard swelling of the asymptomatic Mandible > maxilla Female > male In dentated area it may extend interradicular areas

jaw frequently in place of a missing or unerupted tooth

3.

Radiographically: appear as large areas of multilocular radiolucency

with delicate or coarse trabeculations give the image of honeycomb or soap-bubble appearance. 4. 5. Histopathology : Stellate shaped cells in mucoid stroma No capsulation When the collagen fibers increased its called Myxofibroma Treatment: I. Surgical excision (local invasive & high recurrence)
1.

Enbloc Marginal resection Mainly for extensive, multilocular, ill-defined borders When > 1 cm of inferior border will be left after excision of lesion Segmental resection If less than 1 cm will be lift N.B.: Inferior alveolar nerve:
1.If

with 1 cm safety margin.

2.

not included within the lesion, it can be preserved with

deroofing of the canal and lateralization of canal during

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resection
2.If

included within the lesion, resection.

II. Reconstruction 6.

D.D from ameloblastoma is: The myxoma show fine trabeculation within the small lobules, Histopathology is the main way of differentiation.

whish are not present in ameloblastoma.

2. Central gaint cell granuloma

1. 2. 3.

Etiology: Intra-bony hemorrhage or inflammation. High recurrence rate. Common in young adults. Treatment:
1. 2.

Surgical resection. Recently calcitonine or interferon injection. 3. Gaint cell lesion of hyperparathyroidism

Characterized by
1. Increased 2. Increased 3. Multiple

serum alkaline phosphatase. serum parathrmone hormone.

lesions.

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of lamina dura. 4. Central Hemagnioma

Nature: It is a form of vascular malformations

found within bone. It is more located in the mandible, than maxilla. 1. Clinically: Patient complains of spontaneous

hemorrhage spurting in character around the necks of teeth. 2. facial asymmetry.

Slowly growing hard swelling ending in

Radiographically: soap bubble or honeycomb

radiolucency with displacement or resorption of related teeth.

Treatment: 1. Embolization of the feeder vessels to decrease the blood

flow to the lesion. 2. Embolization materials used include; autologous muscle,

gelfoam, steel coils and wisps of cotton, lyophilized dura and cyanacrylate. 3. Embolization should be followed with surgical removal of the

lesion within 24-48 hours. Differential diagnosis of multilocular radiolucencies

1.

If the lesion is present in the posterior part of the mandible + If the lesion is present in the posterior part of the mandible +

patient are over 30 years old + parasethesia of the lip ameloblastoma.

2.

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patient are over 30 years old + no parasethesia of the lip Multilocular cyst.
3.

If the lesion present in the posterior part of the mandible + patient

are between 10 - 30 years old + pain and parasethesia of the lip are rare Odontogenic myxoma.

V. Multiples Separate well defined radioluciencies

1. Basal cell nevus syndrome. 2. Multiple myeloma.

PLASMA CELL MYELOMAS (Plasmacytoma)

1. 2. 3.

Malignant non odontogenic tumor. They are a group of lesions characterized by excessive plasma cell-like Clinically Pain and anemia are the commonest features. Pathological fracture and cervical lymph node involvement are

aggregations.

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less common. 4.

In multiple myeloma, the laboratory findings show: Ele va te d se ru m glob ul in lead in g to reversed Raised total serum proteins. Elevated erythrocyte sedimentation rate (ESR). Lymphocytosis and anemia of variable degrees. Bence-Jones protein in urine. Radiographically: Multiple myeloma shows punched out lesions of varying size Treatment: Multiple myeloma is treated by chemotherapy and it has a poor

albumin/globulin ratio (A: G ratio).

5.

without any peripheral reaction. 6.

prognosis. D.D of multiples Separate well defined radioluciencies

1. 2.

The multiple R.L lesion of MM are usually smaller and more numerous. Laboratory findings show el evat ed serum gl obul in l eadi ng t o

reversed albumin/globulin ratio (A: G ratio) and the presence of Bence-Jones protein in urine MM.

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VI. Mixed radiolucent radiopaque lesion not necessarily contacting teeth

1. Focal cementoossous dysplasia.
2. Cementoossifying fibroma.

3. Osteogenic sarcoma. 4. Chondroma. 5. Chondrosarcoma. 1. Osteogenic sarcoma Clinically:

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Rapidly growing, firm swelling leading to facial deformity, with pain. Followed by loosening of related teeth, toothache, bleeding. In maxillary lesions nasal obstruction may follow. In mandibular lesions, paraesthesia of the lower lip is a

common finding. Radiographically: bone-producing lesion penetrates through the cortex, lifts up the periosteum producing the typical "sun-ray" appearance. Treatment: radical resection. D.D
1. Differential Diagnosis with Chondrosarcoma and chondroma:

Chondrosarcoma and chondroma affect mainly an older age patient and more often in the anterior maxilla.

2. Differential Diagnosis with Cementoossifying fibroma Cementoossifying fibroma appears as circular, well defined marginated, and not have the sunburst appearance. 2. CHONDROMA
1.

It is a rare tumor that develops from cartilagenous rests that result

from incomplete absorption of Meckel's cartilage or in the symphysis from remnants of the accessory symphyseal cartilages.
2.

Clinically: It is slowly growing, painless, and usually appears as a Treatment: surgical excision. 3. CHONDROSARCOMA

radiolucent or mottled lesion in radiographs.

3.

1.

Clinically Symptomatic tumors, and pain, becoming severe and persistent.

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2.

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Radiographically : Large lesion characterized by:

Irregular or circular radiolucencies. Granular or lobular radiopaque areas of calcification.

3.

T r e a t m e n t : r a d i c a l su rgi cal resection.

VII. Mixed radiolucent radiopaque lesion associated with teeth

1. Periapical cementoosseous dysplasia (intermediate stage). 2. Cementoossifying fibroma. 3. Odontome (intermediate stage). 4. Adenomatoid odontogenic tumor. 5. Calcying odontogenic cyst. 6. Ameloblastic fibroodontome. 7. Calcifying epithelial odontogenic tumor.

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1. Periapical cementoosseous dysplasia (intermediate stage). 1. D.D of PCOD with Osteoblastic carcinoma, chondosarcoma, and osteogenic sarcoma:

Slowly growing tumors + smooth, well defined fibroosseus lesion PCOD. Rapidly growing tumors + irregular, ill defined fibroosseus lesion Osteoblastic carcinoma, chondosarcoma, and osteogenic sarcoma.

2. D.D OF PCOD with odontome:

Odontome is usually located above the crown of unerupted tooth, sometimes between the teeth and rarely in the periapices.

3. D.D of PCOD with Cementoossifying fibroma: It is a difficult differentiation because the two lesions occur at the apex of a vital tooth + they are round with well defined border.

The differentiation between them is very important because cementoossifying fibroma need excision while the PCOD need only removal.

PCOD Common lesion occur mainly in the lower incisors region Female > male occur in patient over 30 years old rarely to attain a diameter of more than 1 cm rarely produce mandibular expansion multiple lesion

cementoossifying fibroma uncommon lesion occur mainly in the lower premolar molar region male > female occur in patient under 30 years old frequently attain a diameter of more than 1 cm frequently produce mandibular expansion single lesion

2. Cementoossifying fibroma

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1. 2.

Benign mesenchymal tumor (Mixed tissues) Clinical features: It presents itself as a painless swelling usually in Radiographically : radiolucent area which g r a d u a l l y b e c o m e s Treatment: surgical excision.

the premolar- molar area of the mandible.

3.

r a d i o p a q u e a s t h e cementum-like tissue is laid down.

4.

3. AMELOBLASTIC FIBRO-ODONTOME 1. Benign mixed odontogenic tumor. 2. This is a rare neoplasm having the histological features of ameloblastic fibroma but showing inductive changes leading to the formation of hard dental tissues (enamel and dentine). 3. Radiographically: it is characterized by the presence of multiple small radiopaque masses in a radiolucent lesion. 4. Generally this tumor behaves as ameloblastoma and should be similarly managed. 4. CALCIFYING EPITHELIAL ODONTOGENIC TUMOR (Pindborg's Tumor)
1.

Origin: It is a rare lesion characterized by development of intra-

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epithelial structures that calcify and become extruded into the surrounding stroma.
2.

Clinical features: slowly growing, painless swelling, often in the area of a non-erupted tooth. Radiographic features: m u l t i l o c u l a r r a d i o l u c e n c y c o n t a i n i n g r a d i o p a q u e a r e a s related to the crown of the associated unerupted tooth. The treatment: wide surgical excision.

3.

4.

Differential Diagnosis of pericoronal Mixed radiolucent radiopaque lesion associated with teeth Age Odontome First & second complex decade of life Jaws Mandible > maxilla Region Molar region Additional features

Odontome First & second compound decade of life

Maxilla > mandible

Anterior region

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First & second AOT decade of life

Maxilla > mandible

Anterior region On aspiration, it gives a thick, granular, yellow fluid (Keratin) while the aspiration of odontome is unproductive. 52 % associated with

75 % occur COC 47 % occur in patient under 31 years old Mandible > maxilla anterior to the first molar

Third decade CEOT of life

Mandible > maxilla Molar region

unerupted tooth & does not often produce large, dense masses of calcified tissues.

VIII. Solitary radiolucemcies with ragged and poorly defined borders

1. Squamous cell carcinoma. 2. Malignant minor salivary gland. 3. Osteogenic sarcoma osteolytic types. 4. Chondrosarcoma. 5. Fibrosarcoma.
6. Fibrous dyplasia. 7. Metastatic tumor to the jaw.

79940460.doc 91 8. Ewing's sarcoma. 9. Burkitt's lymphomas. 10. Chronic alveolar abscess. 11. Chronic osteomylities. 12. Osteoradionecrosis.

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1. SQUAMOUS CELL CARCINOMA MALIGNANT NON-ODONTOGENIC TUMORS 1. Incidence

1.

Age: Usually above middle age between 50-70 years, but in Egypt it

usually affects a younger age group from about 30 years of age.

2.

Sex: Males are more commonly affected that females in about 3:1 ratio.

2. Etiology The etiology of Sq C.Ca is unknown, but the following risk factors may be considered as predisposing factors:

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A. Tobacco abuse. B. Alcohol abuse or heavy use. C. Combined risk of heavy alcohol and tobacco use. D. Viral infection (HSV, HPV). E. Sunlight exposure. F. Poor condition of the dentition. a. Sharp edges of carious teeth. b. Sharp denture clasps. G. Betel leaf chewing especially in Indian and Tobacco chewing in the Sudan. H. Syphilis. I. Malnutrition a. Iron deficiency anemia (Plummer Vinson syndrome). b. Hypovitaminosis: Vitamins A and B complex.

3. Diagnosis Diagnostic Clinical Features: Relatively chronic history. Indurated margin of the ulcer. Resistant to improvement by local treatment. Presence of enlarged stony hard cervical lymph nodes. Special Investigations to Confirm the Diagnosis 1. Biopsy: This is the most important investigation 2. X-ray: This is of little importance as the lesion is mainly a soft tissue

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lesion. 4. PRE-CANCEROUS LESIONS IN THE ORAL CAVITY (Reading) 1. Leukoplakia: this means a white patch. The buccal mucosa is the most commonly affected part. 2. Erythroplakia: means red patch, red plaques or well defined red patches with tiny areas of ulcerations. 3. Tr aum at ic de nt al u lc er s: May occur anywhere on the oral mucosa usually against sharp edges of broken teeth. 4. Erosive lichen planus: The common sites are the cheek and lateral border of the tongue. Solitary or multiple lesions appear as superficial ulcers surrounded by white lines or plaque.

5. Histopathology 1.Carcinoma in situ: Non-invasive carcinoma is a lesion in which the whole thickness of epithelium shows histologic and cytologic features of epithelial dysplasia, but the basement membrane is intact and there is no invasion of the underlying connective tissue. 2.Invasive carcinoma: When strands and islands of dysplastic epithelial cells break through the basement membrane and invade the underlying connective tissue. 6. Subdivision of Sq C Ca: Degree of differentiation:
1.

Well Differentiated: The neoplastic cells show the criteria of

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malignancy but their origin can still be recognized.

2.

Moderately Differentiated: When the tumor cells show a

moderate degree of differentiation as evidenced by some areas of cell nests and epithelial pearls.
3.

Poorly Differentiated: the tumor shows very few or no cell nests and

epithelial pearls. 7. Spread of Oral Carcinoma

1.

Local spread: The lesion increases in size by direct local infiltration Lymphatic spread. Blood borne metastasis: Is rare and late in the course of the disease.

and invasion of the neighboring tissues. 2.

3.

Spread to the lung usually follows.

8. Clinical Features Signs and Symptoms: Early:

1.The p a t i e n t ' s f i r s t c o m p l a i n t m a y b e t h e appearance of the lymph in

the neck indicating that metastatic spread to cervical lymph nodes has already occurred.
2.The patient may first notice a white spot, a sore or swelling in the mouth.

Late:
1. P ai n du e to sec on da ry inf ecti on or involvement of nerves in the

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region.
2. Excessive salivation which may be blood stained. 3. Dysphagia. 4. Ankyloglossia in case of cancer tongue and floor of the mouth. 5. Deviation of the tip of the tongue towards the affected side on protrusion.

9. Clinical appearance Carcinoma may take the form of: a. An ulcer: It is the most common type; it is characterized by being hard with indurated base and raised everted edges. a. b. A nodule: Usually hard below the mucosa without signs and A chronic fissure: usually on top of leukoplakia, not responding symptoms of acute infection. to treatment; ulceration may occur in the fissure. b. Papillary form: Appears as a soft warty growth that may be extensive. e. Atrophic mass: It produces a small hard mass.

10. Clinico-Pathological Types of Squamous Cell Carcinoma (Reading)

1.

Exophytic "Cauliflower-like or papillary": It grows slowly on the surface to the outside with minimal invasion or infiltration of underlying tissues. It metastasizes late in its course to the regional lymph nodes. Prognosis is good. Endophytic "Ulcerative or infiltrative": It grows rapidly and rapidly infiltrates the underlying tissues. Rapid metastasis to lymph nodes, prognosis is poor.

2.

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3.

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Verrucous: It is markedly exophytic and shows a low degree of malignancy. It affects just the surface mucosa. It erodes rather than invades the underlying tissues. It does not metastasize to lymph nodes, prognosis is excellent.

11. Sites of Occurrence

1.

Lips: the vermilion border and labial mucosa. The vermilion border of the

lower lip is more commonly affected than the upper lip as it is more exposed to the ultraviolet rays of the sun. 2.
3.

Buccal Mucosa Gums "Gingiva and Alveolar Mucosa": this usually occurs in the premolar Tongue: It is the most commonly affected site with squamous cell carcinoma in

and molar regions, more often in the lower jaw.

4.

the oral cavity. T h e i m p o r t a n t s y m p t o m i s persistent dysphagia and sore throat. Neoplastic involvement of the lingual nerve or nerves is responsible for the pain referred to the ear on the affected side in case of cancer tongue or floor of the mouth.
5.

Floor of the Mouth: Usually starts in the anterior segment at the

midline lateral to or involving the frenum. The first symptom is sometimes an induration that is felt with the tip of the tongue.
6. 7.

Palate: Relatively rare. It is a disease of elderly men. Retromolar Region: It is the most serious site as it is hidden and usually

diagnosed at a later stage. It spreads to the pharynx, cheek, mandible and maxilla. It may cause trismus due to invasion of muscles of mastication. 12. Treatment of Oral Carcinoma: In the end of the chapter.

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2. Osteogenic sarcoma osteolytic types Clinically:

Rapidly growing, firm swelling leading to facial deformity, with pain. Followed by loosening of related teeth, toothache, bleeding. In maxillary lesions nasal obstruction may follow. In mandibular lesions, paraesthesia of the lower lip is a

common finding. Radiographically: bone-producing lesion penetrates through the cortex, lifts up the periosteum producing the typical "sun-ray" appearance. Treatment: radical resection. 3. CHONDROSARCOMA Clinically

Symptomatic tumors, and pain, becoming severe and persistent.

Radiographically : Large lesion characterized by:

Irregular or circular radiolucencies. Granular or lobular radiopaque areas of calcification.

T r e a t m e n t : r a d i c a l su r g i c al resection. 4. FIBROSARCOMA Clinically : Pain, swelling and disfigurement of the face are the usual symptoms. Treatment: radical surgical excision. Differential diagnosis of solitary radiolucemcies with ragged and poorly defined borders

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1. The D.D of this lesion is very difficult as the clinical features of the entire lesion are the same. 2. For that the D.D depend mainly on the patient age and the location of the lesion and some additional features. 3. Patients age: SCC occur in older patients. Chondrsarcoma and OS occur in young patients. 4. Location of the lesion: SCC and OS occur in the mandible more than the maxilla.

Chondrsarcoma occurs in the maxilla more than the mandible.

5. Additional features: If the patient had a history of tobacco smoking and alcohol consumption + rapid growth swelling SCC.

Sun-ray appearance in the radiograph OS.

IX. Solitary cyst like radiolucencies not necessarily contacting teeth

1. Residual cyst.
2. Traumatic bone cyst.

3. Primordial cyst.

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4. Odontogenic keratocyst. 5. Unicystic ameloblastoma. 6. Giant cell lesion. 7. Focal cementoosseous dysplasia. 8. Incisive canal cyst. 9. Midpalatine cyst. 10.Ossifying fibroma. 11.Benign non odontogenic tumors. 1. Odontogenic keratocyst Differential diagnosis 1.Should be differentiated from: Residual cyst, Traumatic bone cyst and Primordial cyst.
2.By aspiration:

Amber colored fluid Residual cyst or Primordial cyst.

Cheesy, thick and yellow material Odontogenic keratocyst. Air or non productive aspiration Traumatic bone cyst. 3. By presence or absence of the tooth: If the tooth fail to develop Primordial cyst. If the tooth was extracted and the cyst was associated with it Residual cyst. 2. Giant cell lesion (Osteoclastoma) 1. 2. Malignant non odontogenic tumors. The skeletal location of giant cell tumor is similar to that of

osteogenic sarcoma; 50% of cases occur near the knee or the upper end of the tibia. True giant cell tumors of the jaws are rather rare.

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3.

Radiographically: large, oval, radiolucent lesion. 3. Focal cementoosseous dysplasia 1. Asymptomatic, focal, and radiolucent in the early lesion, radiopaque in the mature lesion, or mixed radiolucent-radiopaque with well to poorly defined border. 4. Incisive canal cyst and Midpalatine cyst.

Differential diagnosis 1. Should be differentiated from: mucoepidermoid tumor (low grade) and lipoma. 2. For mucoepidermoid tumor (low grade):

Occur mainly in the lateral aspect of the palate near the anterior palatine foramen.

On aspiration give viscous, clear, sticky fluid not an amber colored fluid. 4. For lipoma: differentiated from cyst by aspiration. 5. Incisive canal cyst can be easily differentiated from midpalatine cyst Incisive present in the canal above the palatine papillae while midpalatine cyst present in the midline of the palate posterior to the papillae. 5. Ossifying fibroma 1. It is a true benign non odontogenic neoplasm of skeletal fibrous ti ssue . 2. Clinically: slow growing tumor that causes early displacement of the teeth involves in the region.

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3. Radiographically: the lesion appears as an a r e a o f r a d i o l u c e n c y s p e c k l e d w i t h radiopacities. 4. Treatment: surgical excision. 5. Differential diagnosis: from periapical and focal cementoosseous dysplasia in that it occur in younger patients, most often in the premolar molar region of the mandible. 6. Benign non odontogenic tumors 1. Benign non odontogenic tumors are rarely observed within the jaws 2. As examples: lipoma, salivary gland adenoma, amputation neuroma, neurofibroma, neurilemmoma (shwannoma), leiomyoma, rhabomyoma, fibroma, and myxoma. 3. Because their growth is slow, they appear as well defined radiolucency of varying shape. I. LIPOMA
1. This is a neoplasm of adipose tissue. 2. Clinically: it presents as a soft, smooth, rounded or lobulated

mass.
3. Treatment: surgical excision.

II. TRAUMATIC OR AMPUTATION NEUROMA 1. It is common in the region of the mental foramen. 2. The lesion is n o t a tr u e n eop l asm an d ap p ears as a b u l b o u s e n l a r g e m e n t a t t h e e n d o f traumatized nerves.

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3. Treatment: surgical removal. III. NEUROFIBROMA 1. This is a tumor of nerve sheath origin. 2. Clinically: It is a painless mandibular swelling together with skin and subcutaneous manifestations of multiple neurofibromatosis (von Reklinghausen's d i s e a s e of t h e s k i n ) . 3. Treatment: surgical excision. IV. NEURILEMMOMA 1. It is a benign tumor that arises from the sheath of nerve endings and most probably from the Schwann cells of the nerve sheath. 2. Clinically: round, ovoid or fusiform swellings. 3. Treatment: surgical excision. V. LEIOMYOMA 1. These are tumors of smooth muscle. 2. They are very rare tumors in the oral cavity. When they occur in the oral cavity, they usually occur in the tongue, where they may arise from the smooth muscle coats of blood vessels. 3. Treatment: surgical excision. VI. RHABOMYOMA 1. These are tumors of striated muscle. 2. They too are very rare in the oral cavity, and they also occur most commonly in the tongue.

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3. Treatment: surgical excision. VII. FIBROMA

1.

Central fibroma is a rare lesion, occurs in the mandible more than the maxilla. It could be of odontogenic or nonodontogenic origin. Clinically: It is a well-circumscribed pedunculated or sessile slowly growing lesions covered by smooth normal epithelium. Treatment: surgical excision. VIII. FIBROMYXOMA

2.

3.

1. It is a very rare tumor of osteogenic origin. The mandible is more

affected than the maxilla.

2. Clinically: I t i s a p a i n l e s s m a n d i b u l a r s w e l l i n g . 3. Radiographically: large multilocular radiolucent shadow which may

exhibit a honey-comb appearance in a few areas and may be mistaken for an ameloblastoma.
4. Treatment: surgical excision with a good safety margin to avoid

recurrence.

X. Mesenchymal non odontogenic tumor (Sarcoma)

1. Fibrosarcoma

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2.

Neurofibrosarcoma 3. Chondrosarcoma
4. Osteogenic Sarcoma 5. Giant Cell Tumor
6. 7.

Rhabdomyosarcoma Ewing's Sarcoma

8. Plasma Cell Myeloma 9. Burkitt's Lymphoma 10. Hodgkin's Lymphoma 11. Kaposi's Sarcoma NEUROFIBROSARCOMA

T h i s t u m o r r e se m b l e s c l i ni c al l y an d radiographically the picture of

fibrosarcoma.

Treatment and prognosis follow the same lines as those of fibrosarcoma.

GIANT CELL TUMOR (Osteoclastoma) 1. 2. The skeletal location of giant cell tumor is similar to that of Radiographically: large, eccentric, oval, radiolucent destructive

osteogenic sarcoma. True giant cell tumors of the jaws are rather rare. lesion, producing cortical erosion and thinning, and expanding the bone contours. RHABDOMYOSARCOMA
1.

This is a rare tumor that usually occurs in children below 10

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years of age. It has the characteristics of rapid growth with nodal and lung metastases.
2.

Treatment consists of radical excision of the affected part with

radiotherapy as the tumor is radioresponsive. EWING'S SARCOMA (Round Cell Sarcoma)

1. 2.

It is a highly destructive lesion. Marrow endothelial cells or undifferentiated cells of t h e r e t i c u l o Jaw involvement is usually a part of a generalized disease. Clinically: The mandible is more affected than the maxilla. Intermittent pain and rapidly growing swelling. Low grade fever, malaise and leucocytosis are not uncommon. R a d i o g r a p h i c a l l y : i r r e g u l a r b o n e destruction is seen; there is

e n d o t h e l i a l s y s t e m a r e considered to be the origin.

3. 4. 5.

subperiosteal bone deposition giving the radiographic l a y e r i n g k n o w n a s t h e o n i o n - s k i n appearance.

6.

Treatment: combined chemotherapy and radiotherapy h av e b ee n

u se d .

BURKITT'S LYMPHOMA
1.

It is a lesion that differs from other malignancies in several ways: Its occurrence is linked to a viral exposure (Epstein Barr

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virus EBV).

It is associated with a chromosomal abnormality. It is considered the fastest growing human malignancy. Immunologically, the tumor appears to be of B-cell origin The tumor has two epidemiologic patterns, namely endemic and Clinically: Endemic Burkitt's lymphoma is a pediatric disease occurring

nonendemic forms.
2.

in patients between 6-9 years of age. The most common site of presentation is the face with the mandible being primarily affected by a rapidly growing destructive bony lesion causing loosening of the teeth. U s u a l l y t h e r e i s n o a s s o c i a t e d lymphadenopathy.

Nonendemic form: the most common site of presentation is the Radiographically: small areas of bone resorption are seen as an

abdomen with the head and neck region affected in about 5% of the cases.
3.

early sign and they later coalesce to form larger areas of bone destruction.
4.

Treatment: Chemotherapy.

NON-HODGKIN'S LYMPHOMA
1.

Clinically: It occurred more common in the molar and ascending

ramus area of the mandible. Loosening of teeth is common and may be an early manifestation.
2.

Radiographic features: Is not pathognomonic representing an osteolytic

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lesion of invasive character.

3.

Treatment: the condition is extremely radiosensitive it has a very

poor prognosis as it recurs rapidly. HODGKIN'S LYMPHOMA

1.

Clinically: Pain is variable. Associated lymphadenopathy or

disseminated disease may be present. Constitutional symptoms may occur.

2.

Radiographically: the presence of osteolytic lesions, sclerotic lesions or a

mixture of both pictures can be seen.

3.

Treatment: chemotherapy. KAPOSI'S SARCOMA

1.

Clinical Features: Multiple skin lesions on the extremities, face, sometimes

the oral cavity and many visceral organs. They appear as reddish or brownish red nodules which vary in size and are usually tender or painful.

XI. Fibro-osseous diseases

1. Ossifying fibroma. 2. Osteoblastoma. 3. Osteoma. 4. Tori-extosis.

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5. Cemento-osseous dysplasia. Periapical cemental dysplasia. Focal cemento-osseoua dysplasia. Florid cemento-osseoua dysplasia. Ossifying fibroma 1. It is a true benign non odontogenic neoplasm of skeletal fibrous ti ssue . 2. Clinically: slow growing tumor that causes early displacement of the teeth involves in the region. It causes varying degrees of facial deformity which is usually the main complaint of these patients. 3. Radiographically: the lesion appears as an a r e a o f r a d i o l u c e n c y s p e c k l e d w i t h radiopacities of varying densities depending on the degree of calcification present. 4. Treatment: surgical excision.

BENIGN OSTEOBLASTOMA 1. It is a benign non odontogenic neoplasm. 2. Clinically: The lesion is usually central and pain and swelling of relatively short duration are the main features.

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3. Radiographically: it is a well defined radiolucency with some evidence of new bone formation. 4. Treatment: surgical excision. OSTEOMA
1. It is a benign non odontogenic neoplasm. 2. It could be peripheral (periosteal) or central ( endost eal ) and m ay be

multiple.
3. Radiographically: it appears as well defined radiopacities. 4. Treatment: surgical excision.

Periapical cemento-osseous dysplasia Clinical features

4. 5.

Benign mesenchymal odontogenic tumors. T h i s i s a d y s p l a s t i c d e v e l o p m e n t a l disturbance of cementum. It occurs around the apex of a tooth, usually a lower incisor. The condition is usually asymptomatic.

6. 7.

Radiographic examination: the radiographic picture varies with its histologic structure and stage of development.

Four stages of development are usually described: c. Osteolytic stage:

This is the earliest stage which represents the immature cementoma composed of a cellular element with no calcification.

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There is bone destruction wh ich app ears rad iograph ical ly as r ad io luc en cy similar to a granuloma or a radicular cyst.

d. Early cementoblastic stage:

Calcifications with the formation of initially discrete islands of

cementum occur in the fibrous tissue.

Radiographically, the lesion appears now as a radiolucent area

mottled or specked with areas of radiopacity. d. Late cementoblastic stage:

As

the lesion continues to develop, the initially discrete m a s s e s of

c e m e n t u m f u s e t o g e t h e r forming larger irregular masses of acellular cementum.

The

fused cementum masses appear radiologically as larger areas

of radiopacity within the radiolucent lesion. e. Mature stage:

With

gradual and c o n t i n u e d f o r m a t i o n o f c e m e n t u m ,

calcification of the whole lesion is almost complete, with remnants of the formative tissue surrounding the lesion.
The

lesion now appears as an irregular area of radiopacity

with a thin radiolucent border around it. Treatment: No treatment of this lesion is required.

FLORID CEMENTO-OSSEOUS DYSPLASIA (Gigantiform Cementoma; Familial Multiple Cementoma)

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1. 2.

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Benign mesenchymal odontogenic tumors Clinical features: It is a developmental dysplastic condition

c ha ra ct er iz ed by mult ip le, lob ul ated, bilaterally symmetrical lesions in several parts of the jaws.
3.

Radiographically: it appears as d en se ra d i op aq u e m as se s with Treatment: local excision. EXOSTOSIS (TORI)

1.

no radiolucent border around them.

4.

These are developmental non-neoplastic outgrowths appearing around the midline of the palate (torus palatinus) more frequently than the lingual surface of the mandible (torus mandibularis). Tre at me nt: if ne ce ssar y for pr osthet ic purposes, is excision.

2.

XII. Soft tissues tumors

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1. Papilloma 2. Pyogenic granuloma 3. Pregnancy tumors 4. Peripheral giant cell granuloma 5. lipoma 6. Hemangioma

Pyogenic granuloma

Nature: It is a reactive tumor of granulation tissue caused by trauma and

infection and generally involves the gingiva.

Clinically: It appears as a soft, red to purple pedunculated or sessile mass

with a lobulated, granular surface that may ulcerate.

Treatment: Surgical excision by electrosurgery is recommended with

removal of the offending agent such as an adjacent infected tooth or calculus.

SQUAMOUS CELL PAPILLOMA

1. 2. 3.

Benign non odontogenic tumor. This is a benign neoplasm of skin and mucous membrane. Clinically: the lesion appears as a sessile or pedunculated cauliflowerlike raised lesion which may or may not be keratinized Treatment: surgical excision.

4.

Pregnancy tumor (Granuloma Gravidarum)

Nature: It is an exaggerated form of pyogenic granuloma that develops

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in som e pregnant wom en.

Cause: increase in estrogen and progesterone during pregnancy and nutritional deficiency and poor oral hygiene are responsible for this condition.

Clinically: The color of the tumors is deep red to purple whish fades on compression; after delivery, it may regress partially or completely disappear.

Treatment: Surgical excision by electrosurgery is recommended without removal of the adjacent teeth.

Peripheral giant cell graunloma (PGCG)

Nature: This lesion derives its name from the histological finding of

large number of multinucleated giant cells.

Clinically It occurs only on attached gingiva. The premolars and molars region in the a n d i b l e is th e fa v o r e d m

1. 2.

lo c a tio n . 3. I t a r is es fro m th eperiodontal ligament or alveolar periosteum as a result

of irritation or trauma. 4. The lesion can erode the underlying alveolar bone and often induces a cup-

shaped bone defect.

Treatment:

Surgical excision and removal of local irritants (calculus or Hemangioma

adjacent teeth). The base of the tumor should be cauterized after surgery.

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Nature: It is a benign tumor of vascular origin, most frequently found

intraorally in the lip, tongue, buccal mucosa and palate.

Clinically Superficial lesions usually have a typical blue or red appearance.

1.

Application of pressure will cause blanching of the lesion. 2. The capillary type has small endothelial-lined vessels. It occurs in the

mouth and face to be known as port-wine stain. 3. The cavernous type has large endothelial-lined vessels with tendency to

invades soft tissues or erode the adjoining bony structures by pressure.

Treatment 1. 2. Surgical excision after ligation of the main feeding For high flow or large lesions, selective embolization vessels which determined by angiograms (arteriography). by striated muscles or silicone pellets to occlude the feeding vessels. 3. Injection of sclerosing solution such as 1% sodium

tetradecyl sulfate (sotradecol) or sodium morrhuate to provoke inflammatory response with subsequent fibrosis and obliteration of vascular channels. 4. 5. Cryotherapy is indicated for small to moderate sized Radiotherapy may be used in large hemangiomas to superficial lesion especially in poor risk patients. produce sclerosis of the feeding vessels and fibrosis of the tumor. Excision, then, can be made with elecroscalpel. 6. Co2 or Nd: YAG laser can be used successfully for its ability to penetrate soft tissues to 1-cm depth resulting in deep photocoagulation.

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XIII. Masses in the neck

1. Salivary gland tumors. 2. Salivary gland inflammation. 3. Epidermois and dermoid cyst. 4. Thyroglossal duct cyst. 5. Branchial cleft cyst.

XIV. Lesion of the lip

1. Mucocele. 2. Minor salivary gland tumors. 3. Minor salivary gland calculus. 4. Nasolagial cyst. 5. Lipoma. 6. Fibroma. 7. Squamous cell papillom. 8. Hemangioma. 9. Lymphangioma. LIPOMA 1. Benign non odontogenic tumor.
2. This is a neoplasm of adipose tissue that rarely occurs in the oral

cavity. It may be seen on the cheek lip or sometimes the palate

3. Clinically: it presents as a soft, smooth, rounded or lobulated

mass.
4. Treatment: surgical excision.

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FIBROMA
1. 2.

Benign non odontogenic tumor. Central fibroma is a rare lesion, occurs in the mandible more than the maxilla. It could be of odontogenic or nonodontogenic origin. Clinically: It is a well-circumscribed pedunculated or sessile slowly growing lesions covered by smooth normal epithelium. Treatment: surgical excision. SQUAMOUS CELL PAPILLOMA

3.

4.

5. 6. 7.

Benign non odontogenic tumor. This is a benign neoplasm of skin and mucous membrane. Clinically: the lesion appears as a sessile or pedunculated cauliflowerlike raised lesion which may or may not be keratinized Treatment: surgical excision. HAEMANGIOMA

8.

1. Benign non odontogenic tumor. 2. Clinically: Solitary, multiple or diffuse lesions may occur, and the lesion may occur centrally within bone. Central lesions are slowly growing, and pulsations may be elicited over the tumor. 3. Radiographically: central haemangiomas present as multilocular circumscribed honeycomb radiolucencies. 4. Treatment: surgical excision after tying of the feeding vessels. Cryosurgery has also been advocated.

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LYMPHANGIOMA 1. Benign non odontogenic tumor. 2. This is similar to haemangioma both clinically and radiographically. 3. They are commonly occurring in the tongue leading to macroglossia. 4. Clinically: Superficially located lesions appear papillary and of the same color or slightly more reddish than the surrounding mucosa; deeper lesions appear a s d i f f u se n od u l es wi t h n o s i g n i f i c a n t difference in surface color or texture. 5. Treatment: surgical excision after tying of the feeding vessels. Cryosurgery has also been advocated.

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XV. Tumors affecting the tongue

I. Benign tumors 1. Vascular in origin: Hemangioma. Lymphangioma. 2. Neural in origin: Neurolemmoma. Neurofibroma. 3. Muscular in origin: Lieomyoma. Rhabomyoma. 4. Fibrous in origin: Fibroma. 5. Salivary gland: Canalicular adenoma. Basal cell adenoma. II. Malignant tumors 1. Epithelial in origin: Squamous cell carcinoma. 2. Mesenchymal in origin:

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Rhabomyosarcoma. Neurofibrosarcoma.

III. Cyst 1. Thyroglossal duct cyst. 2. Demoid & epidermoid cyst. 3. Mucous extravasation or retention cyst.

XVI. Midline Lesion

1. Nasoplatine cyst: Incisive canal cyst. Nasopalatine canal cyst. 2. Fissural cyst :

Median mandibular cyst. Median Palatine cyst. Median alveolar cyst.

Epstein pearls. 3. Demoid cyst. 4. Epidermoid cyst. 5. Thyroglossal duct cyst.

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XVII. Palatal swelling

I. Benign Tumors 1. Nerve in origin: Neurolemmoma. Neurofibroma. 2. Vascular in origin: Hemangioma. Lymphangioma. 3. Muscle in origin: Rhabomyoma. 4. Osseous in origin: Osteoma. Torous palatinous. II. Malignant tumors 1. Epithelial in origin: Squamous cell carcinoma. 2. Mesenchymal in origin: Rhabdosarcoma. Kaposis sarcoma.

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III. Salivary gland 1. Benign tumors: Plemorphic adenoma. Basal cell adenoma. 2. Malignant tumors: Adenocystic carcinoma. Mucoepidermoid carcinoma. IV. Cyst 1. Non odontogenic fissural cyst: Nosopalatine cyst. Median palatine cyst. Globlomaxillary cyst. 2. Odontogenic cyst enlarge to expand palatal bone: Keratocyst. Dentigerous cyst. Inflammatory developemental cyst. V. Benign odontogenic tumors causes expansion palataly 1. Epithelial in origin:

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Ameloblastoma. Adenomatoid odontogenic tumors. Calcifying epithelial odontogenic tumors. Squamous odontogenic tumors.

2. Mesenchymal in origin: Odontogenic fiboma. Odontogenic myxoma. 3. Mixed: Ameloblastic fibroma. SQUAMOUS ODONTOGENIC TUMOR
1.

Clinical features: slowly growing, painless swelling of small size and loose teeth. Radiographically: it appears as radiolucent lesion related to the roots of the teeth and sometimes associated with an impacted tooth. Treatment: conservative surgical excision. ODONTOGENIC FIBROMA

2.

3.

1.

This is a benign fibrous neoplasm with islands of entrapped inactive Radiographically: i t u s u a l l y a p p e a r s a s a u n i l o c u l a r Treatment: is by wide surgical excision. There is little tendency to

odontogenic epithelial cells denoting its odontogenic origin.

2.

radiolucency.
3.

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recur. AMELOBLASTIC FIBROMA

1.

It is a slowly growing, painless, lesion producing expansion of the affected area of the jaw. Radiographically: it appears as a well defined radiolucent area with a regular outline. Treatment: surgical excision. VI. Malignants odontogenic tumors causes expansion palataly

2.

3.

1. Epithelial in origin: Malignant Ameloblastoma. Ameloblastic carcinoma. 2. Mesenchymal in origin: Ameloblastic fibrosarcoma MALIGNANT AMELOBLASTOMA 1. Clinical features : It presents itself as a painful swelling of rapid progression. 2. Radiographicaly: appears as an irregularly outlined radiolucent area with manifestations of bone destruction. AMELOBLASTIC CARCINOMA 1. In these cases a squamous cell carcinoma may have arisen from areas of squamous metaplasia in a pre-existing ameloblastoma. AMELOBLASTIC FIBROSARCOMA (Ameloblastic Sarcoma)

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It is similar to ameloblastic fibroma in which the mesodermal component shows malignant features of a sarcoma.

Treatment modalities for malignancies

I. Aim of the treatment 1. Curing of the malignant lesion. 2. Reconstruction of the surgical defect. 3. Rehabilitation of the patient to have an acceptable life with no pain or deformity. II. Factors affecting type of treatment: 1. 2. 3. 4.
5.

History of the lesion Clinical examination Diagnostic aids(biopsy & imaging) Decision making & treatment planning Reconstruction and rehabilitation and psychotherapy

III. Lines of treatment 1. Surgery: (TWO PHASE) PHASE I This includes excision of the tumor with safety margins of 1-3 cm of

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adjacent normal tissues and radical neck dissection of the lymph nodes. PHASE II Reconstruction and rehabilitation of either soft tissue or bone or both 2. Neck dissection.

3. Radiotherapy .

It may be used as a primary line of treatment for small

lesions, especially if it is inaccessible sites. Also it is used post surgical to kill any residual tumor cells at the margins of excision. 4. Chemotherapy.

Its chief role in treatment is palliative. Effect: kill malignant cell and stop their metabolism. Side effect: affect normal body cells To decrease side effect: 1. 2. their toxicity Injection into the artery feeding the tumor Use multiple chemical agents to decrease

5. Combined chemotherapy and Radiotherapy.

Combinations of radiotherapy and/or chemotherapy with

surgery increase the long-term efficacy of surgery alone in certain cases. These combinations still remain the most effective means of

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treating a patient with oral cancer.

Surgical operative procedure of oral tumors

2. Technique 1. It is the local removal of the pathologic tissue by means of Curettage or enucleation

vigorous scraping. 2. After the gross lesion is removed a margin of normal bone should be

removed using a scraping motion with large round surgical bur. 3. recurrence. Uses 1. This technique is used successfully for benign encapsulated tumors The bony bed of the tumor can be treated with cryotherapy,

electrocautery or chemical cautery to kill remnants of the tumor cells and reduce

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with no tendency of recurrence. For example it may be used for odontoma, ameloblastic fibroma, and ossifying fibroma. 2. It is used successfully also for oral benign soft tissue lesions such as

fibromas, pyogenic granuloma, peripheral giant cell granuloma and papilloma Curettage: Scrapping of bone after excision of the lesion to remove any remnants

to reduce recurrence rate. E.g.: CGCG

2- Enbloc marginal resection (Block excision) Technique 1. This is a surgical procedure in which the entire tumor is removed intact with a rim (1 cm) of the surrounding uninvolved bone without disruption of the continuity of the jaw. Uses 1. It is frequently advocated for the treatment of

aggressive odontogenic tumors (e.g, ameloblastoma) when there is at least 1 cm of uninvolved bone closer to the inferior border of the mandible. 2. It is either done through inraoral or extraoral approaches.

The intraoral approach is used with lesions affecting the tooth-bearing portion while the extraoral approach is used with lesions of the ramus or when immediate reconstruction is planned.

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3- Segmental resection Technique 1. In this technique the lesion is removed with 1-2 cm of uninvolved bone distal and proximal to it with continuity defect or disruption of the jaw including inferior border of the mandible. Uses 1. myxoma. 2. Either partial (hemimandiblelloectomy) or total (full It is indicated in large aggressive tumor with less than 1 cm

of uninvolved bone at the inferior border, for example ameloblastoma and

mandiblelloectomy).

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4- Composite resection Technique 1. I t i s t h e r e s e c t i o n o f t u m o r w i t h t h e i n v o l v e d j a w (Hemimandibulectomy or hemimaxillectomy) and adjacent soft tissues and regional lymph nodes. Uses
1.

It is used most commonly for malignant lesions (Carcinoma and sarcoma).

Technique of Marginal resection (I.O Block excision)

1. 2. 3. 4.

It's block excision via I.O incision only. G.A. Intra-oral incision extends 1 cm beyond the lesion is performed. Bone is cut using surgical bur not reaching inferior border of the

mandible.
5.

Bone block and overlying soft tissue are removed as one segment.

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Suturing.

Technique of hemimandibulectomy (Block excision I.O and E.O)

1. It's block excision via I.O and E.O incisions. 2. G.A. 3. Intra-oral incision extends 1 cm beyond the lesion is performed. 4. Bone is cut using surgical bur extending toward inferior border of the

mandible.
5. Intermaxillary fixation is performed to fix mandibular position. 6. E.O submandibular incision. 7. Dissection of soft tissue, legation and cut the facial artery. 8. Complete bony cuts at inferior border of the mandible. 9. Bone block and overlying soft tissue are removed as one segment. 10. Suturing both I.O and E.O. in layers.

Technique

Delayed reconstruction 1 stage: Resection and reconstruction plate 2nd stage after 6 months bone reconstruction is done
st

Immediate reconstruction Tumor resection + reconstruction plate + grafting are done in the same surgery one stage surgery

Advantages

* Follow up for 6 m clinically and

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radiographically to ensure absence of recurrence. Disadvantages * risk of infection need 2nd surgery * Any recurrence removal of the graft * risk of infection

Neck Dissection
Management of cervical lymph nodes after surgical TTT of the 1ry malignant tumors According to staging: I) Stage I & II:

Where N0 no lymph node involvement (clinically and by all diagnostic

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methods).

We have to perform Supra-Omo-Hyoid neck dissection (as the diagnosis may be false).

In Supra-Omo-Hyoid neck dissection, the following lymph nodes are removed:

1. Submental and submandibular LN.

2. Upper Jugular L.N. 3. Middle Jugular L.N. 1. 2. Advantages: Diagnostic. Prophylactic.

2) Stage III:

Where T3 N0 M0 & T1. 2. 3 N1 M0 RADICAL NECK DISSECTION (commando

operation): 1. L.N is done. In which removal of all ipsilateral and affected

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Groups extended from inferior border of

the mandible to the clavicle and from the lateral border of the sternomastoid, sternohyoid, hyoid bone and contralateral anterior belly of djgastric medially till the anterior border of the trapezious. 3.

Structures sacrificed: All lymph nodes:

Superficial and deep cervical. Jugulo-digastric. Jugulo-omohyoid Paratracheal. Supraclavicular.

Muscles:

Platysma, anterior and posterior belly of digastric. Sternomastoid. Omohyoid, stylo-hyoid and part of trapezious.

Nerves: Cervical branch of facial nerve. Supra-clavicular. Spinal accessory.

Glands:

Submandibular SG. Lobe of parotid.

Veins:

Internal jugular.

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External jugular. 4. Preservedstructures:

Carotid sheath. Sympathetic plexus. Vagus. Mandible if remained. Trapezious.

MODIFIED RADICAL NECK DISSECTION:

1. The Americans tried to preserve 3 important structures and so

classified it into 3 types: 2. Type I: preservation of spinal accessory nerve. 3. Type II: preservation of spinal accessory + sternomastoid.
4. Type III: preservation of spinal accessory + sternomastoid + internal

jugular vein.
5. Advantages:

* Avoid dropping shoulder after removal of spinal accessory nerve which supplies trapezious. * Avoid de-innervations atrophy of sternomastoid if preserved.

4) Stage IV: Where T4 NO MO & T1, 2, 3 N1 MO Same as stage III.

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5 ) S t a g e V:

Where To, 1,2,3,4 N2, 3 M1 palliative treatments:

1. 2. 3.

Radiotherapy. Chemotherapy. Nerve amputation.

Radiotherapy
Source of radiation. 1. Teletherapy: from machine to target e.g.: gamma ray or X- ray. Used for treatment of 1ry tumor, postoperative radiation and can't used in inaccessible area. 2. Brachytherapy (interstitial therapy): by injection of radioactive source inside

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the target e.g. Radium. Used in inaccessible area as the base of the tongue. Indication of Radiotherapy
1. Curative treatment: in radiosensitive lesions (O 2 content)

In stage I, II. Specially if surge can not be done as in:

a. Old or Debilitated patients. b. Hemophilic patient or with contraindications to surgery.

c. Inaccessible area.

d. Patient with history of apnea with G.A. 2. Combined with surgery: In stage I, II, III and IV

Either before surgery debulking of tumor. After surgery to ensure damage of any cancer cells left

behind at the surgical site and in lymph nodes. 3. Palliative treatment: in stage IV with metastasis desensitization of ulcer. Contraindications: Pregnancy. Children not to affect bone growth.

In intra-bony lesion due to O2 level.

Mode of action of radiotherapy:

Indirect effects: As radiotherapy ionization of H2O molecules inside the cells Free radicals destroy cells and DNA. Direct effects: by effect directly on tumor cells thermal damage & DNA damage.

Response of tumors to radiotherapy: Depends on oxygen contents.

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Radio sensitive: as lymphoma. Radio responsive (intermediate): as squamous cell carcinoma. Radio, resistant: as bony tumors due to J, 02 level. Skin burns and mucositis. ms fibrosis S.G atrophy and xerostomia. Rampant caries.

Side effects of radiotherapy on tissues:

Osteoradionecrosis. Pre-irradiation care:

Proper oral hygiene. Prophylactic extraction.

Post-irradiation care: Proper oral hygiene. Topical fluoride application to avoid radiation caries.

Factors affecting surgical excision of benign tumors

1. Histopathological diagnosis. 2. Biological behavior of the tumor:

Expansion & Size: Sessile, pedunculated, superficial or deep.

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Invasion: E.g. ameloblastoma.

Tendency for recurrence. Malignant transformation e.g. polymorphic adenoma, leukoplakia. 3. Site of the tumor.

Classification of benign tumors according to anatomical location (For treatment purposes)

1. Soft tissue tumors arising from Labial, Buccal mucosa, floor of the

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mouth & tongue :

Examples Mucosal lesions Sqamous cell papilloma, Fibroepithelial polyp Pedunculated lesion: Ring block L.A. Elliptical V-shape incision with small safety margin. Undermining. Suturing. Sessile lesion: Ring block L.A. Elliptical V-shape incision with safety margin. Small size lesion Undermining & suturing. In large size lesion we do: 2 parallel relaxing incisions to the defect or Z- plasty incision Or Vshape bridge flap become Y after suturing. Submucosal lesions Fibroma, lipoma,...etc L.A. Mucosal incision over the lesion. Blunt dissection to expose the underlying l e s i o n . Grasp the lesion by Allis forceps. Surgical Excision. suturing

Management

2. Soft tissue of the hard palate:

Non-invasive e.g. fibroma, lipoma. Invasive e.g. pleomorptic adenoma

L.A or field block. Surgical excision of the lesion with L.A or field block. Surgical excision of the lesion. Pack the palate with iodoform or vaselinized
gauze supported figure of 8 suture or clear acrylic p a l a t a l s t e n t . safety margin 5mm-10mm.

Curettage. Cauterization: electrical or

chemical.

Pack the palate with iodoform or

vaselinized gauze supported figure of 8 suture or clear acrylic palatal scent.

3. Soft tissue of the alveolus (gingival, alveolar mucosa, PL & periosteum)

Gingiva or alveolar mucosa Gingival polyp, or pyogenic granuloma Pedunculated Sessile P.L or Periostium Peripheral giant cell granuloma

Examples

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After proper scaling,

Chlorhexidine M.W and periotherapy.

Proper scaling,

Chlorhexidin with M.W and periotherapy L.A. Surgical excision. Tooth should be extracted Alveolotomy for adjacent bone. Curettage cauterization. Packing healing by 2ry intension.

L.A. Surgical excision. Proper curettage. Cauterization by

Electrosurgery or Chemical cauterization using Carnoy's solution or phenol followed by alcohol.

Surgical excision.
Management

Exposed bone is packed

by iodoform, vaselinized gauze or periopack to heal by 2ry epithalization.

Packing

4. Central tumors of the jaws:

Non-Odontogenic Non-invasive Central fibroma. Odontoma. Odontogenic

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Central giant cell granuloma Invasive Myxoma

Odontogenic fibroma Ameloblastoma, Odontogenic myxoma

Central fibroma L.A Surgical flap. Bone removal. Grasp the lesion by Allis forceps and complete surgical excision of the lesion. suturing

CGCG L.A Surgical flap. Bone removal. Enucleation of the lesion. Curettage of the lesion using bone curette to remove any remnant. Cauterization. suturing

Management

Ameloblastorna, myxoma small size Block excision (I.O): Excision with 1 cm safety margin. Marginal resection: 1. Excision of the lesion while leaving inf. Border of the md. Intact. 2. Technique: oI.O incision. o Excision with safety margin of bone and overlying mucosa. o Suturing. Large size Block excision (E.O + I.O) Segmental resection, hemimandibulectomy or hemimaxillectomy. Resection: I.O + E.0 incisions are done. F ollow ed by recons truction a. Delayed. b. Immediate.

Management

RECONSTRUCTION OF JAWS AFTER REMOVAL OF ORAL TUMORS

1. Osseous

defects may occur after removal of oral tumors. These defects

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may range from loss of alveolar bone to loss of major portions of the jaw.
2. Frequently,

surgical removal of a lesion involves removal of a portion of

the alveolus. In these cases the patient need ridge augmentation. This augmentation can be in the form of bone grafts, synthetic bone grafts, or a combination of these materials.
3. Defects

of the maxilla that not excessive could be closed with available

soft tissues of the buccal mucosa and palate. While very large defects or defects in patients who are poor surgical risks may require prosthetic obliteration in which a partial or complete denture extends into the maxillary sinus or nasal cavities.
4. In

general, benign tumors of jaws are reconstructed immediately,

whereas malignancies are reconstructed later.

5.

The delay in reconstruction after the surgical removal of a malignancy is performed for several reasons:

Radiation whish used after surgery may affect the survival of bone

grafts.

The soft tissue deficits result after removal of the malignancy requires

soft tissues reconstruction before osseous reconstruction.

A very important reason is the recurrence of the malignancy that

may require further surgery.

6.

When delayed reconstruction is decided consideration should be

given to maintaining the residual mandibular fragments in their normal anatomic relationship with intermaxillary fixation, external pin fixation, splints or internal fixation.