1 Tumors Tumors of of orofacial orofacial region region 08:16 2/125 Pseudotumors Pseudotumors of of orofacial orofacial region region True True tumors tumors of of orofacial orofacial region region Odontogenic Odontogenic tumors tumors Soft tissue and bone tumors Soft tissue and bone tumors Epitelial Epitelial tumors tumors Salivary Salivary gland gland tumors tumors 08:16 3/125 Pseudotumors Pseudotumors of of orofacial orofacial region region mostly mostly the the jaw jaw cysts cysts classified in several categories depending on histogenesis and etiology True cysts True cysts Odontogenic cysts ( Odontogenic cysts (arising arising from from the epithelium involved in the process of the epithelium involved in the process of teeth teeth development development) From the rest From the rests of of Malassez Malassez (periapical, residual cyst) (periapical, residual cyst) From From the he reduced reduced enamel epithelium ( enamel epithelium (dentigerous dentigerous, , eruption eruption, , paradent paradental al) From From dental dental lamina lamina (rests rests of of Serres Serres) (odontogenic keratocyst, lateral (odontogenic keratocyst, lateral periodontal cyst) periodontal cyst) Non Non-odontogenic odontogenic cysts cysts Developmental Developmental cyst cyst Pseudocysts seudocysts Post Post-traumatic bone cyst traumatic bone cyst Aneuryzmatická bone cyst Aneuryzmatická bone cyst 08:16 4/125 Odontogenic Odontogenic cysts cysts (cysts cysts derivated derivated from from rests rests of of Malassez Malassez) ) Rests Rests of of Malassez Malassez – rests rests of of Hertwig's Hertwig's Epithelial Root Sheath Epithelial Root Sheath Periapical Periapical cyst cyst (radicular radicular) Residual Residual cyst cyst 08:16 5/125 Periapical Periapical (radicular radicular) ) cyst cyst Located at the root tips of nonvital teeth Activation: necrosis of the pulp, advanced tooth caries, chronic pulpitis Remnants of Hertwig’s epithelial root sheath proliferate due to the inflammatory stimulus subsequent liquefaction necrosis in the center of these enlarged epithelial nests lined by nonkeratinising squamous epithelium may be thin and atrophic but mucous cells may be present inflammatory changes in the underlying connective tissue cholesterol clefts with adjacent giant cells hyaline Rushton bodies residual cyst is radicular cyst that is retained in jaws after removal of the associated tooth 08:16 6/125 Odontogenic Odontogenic cysts cysts (cysts cysts derivated derivated from from reduced reduced enamel enamel epithelium epithelium) Follicular Follicular (dentigerous dentigerous cyst cyst) Eruption Eruption cyst cyst
�� mostlymostly thethe jawjaw cystscysts� classified in several categories depending on histogenesis and etiology
�� True cystsTrue cysts�� Odontogenic cysts (Odontogenic cysts (arisingarising fromfrom the epithelium involved in the process of the epithelium involved in the process of teeth teeth developmentdevelopment))
� Located at the root tips of nonvital teeth� Activation: necrosis of the pulp, advanced tooth caries, chronic pulpitis� Remnants of Hertwig’s epithelial root sheath proliferate due to theinflammatory stimulus
� subsequent liquefaction necrosis in the center of these enlargedepithelial nests
� lined by nonkeratinising squamous epithelium� may be thin and atrophic but� mucous cells may be present� inflammatory changes in the underlyingconnective tissue
� cholesterol clefts with adjacent giant cells� hyaline Rushton bodies
� residual cyst is radicular cyst that isretained in jaws after removal of theassociated tooth
� Developmental cyst� surrounds the crown of an unerupted tooth and is attached to the neck of this tooth
� Usually associated with the maxillary canine or the mandibularthird molar tooth
� accumulation of fluid between the reduced enamel epitheliumand the crown surface or between the layers of the enamelepithelium itself
� no epithelial proliferation is needed to form this cyst
� thin epithelial lining - two to three cells thick� resembles the reduced enamel epithelium� mucus-producing cells as well as ciliated cells are more common
08:16 9/125
EruptionEruption cystcyst
� type of dentigerous cyst located in the gingival soft tissues
� overlying the crown of an erupting tooth
� appear as blue-stained blisters of the oral mucosa
� cyst rupturing with progressive eruption of the associated tooth
�� Soft Soft tissuetissue and bone and bone tumorstumors
08:16 17/125
OdontogenicOdontogenic tumorstumors
� group of lesions that arises from the odontogenic tissue. They developfrom the epithelial part of the tooth germ, the ectomesenchymal part, or from both.
� Tumor grows slowly; typical is locally aggressive behaviour, but do not metastasise� most common odontogenic tumour
� mandible (molars) 75%, 20-40y� Deformating the face, loosening of teeth� X-ray - as multilocular cyst� Rare metastatic – malignant ameloblastoma� polycystic amelobalstoma - unicystic ameloblastoma (younger patients)
� Histologically� anastomosing epithelial strands and fields or discrete epithelial islands� peripheral cells at the border with the adjacent fibrous stroma are columnar, withnuclei usually in the apical half of the cell body away from the basement membrane
� tumour infiltrates into the adjacent cancellous bone � spread into soft tissues is highly unusual
follicularfollicular type type –– tumor tumor islandsislands in in fibrousfibrous stromastromaplexiformplexiform type type –– formingforming netnet ((thethe farmerfarmer patternpattern))
4
08:16 19/125
OdontogenicOdontogenic tumorstumors
�� groupgroup ofof lesionslesions thatthat arisesarises fromfrom thethe odontogenicodontogenic tissuetissue. . TheyTheydevelopdevelop fromfrom thethe epithelialepithelial part part ofof thethe toothtooth germgerm, , thetheectomesenchymalectomesenchymal part, or part, or fromfrom bothboth. .
� benign, well circimscribed tumor, heavily mineralised cementummasses connected to the apical root
�� rarerare tumortumor
�� 2020--30 y 30 y patientspatients
�� molarsmolars a a premolarspremolars
�� painpain –– toothtooth isis vitalvital
� vascular, loose-textured fibrous tissue
� surrounds coarse trabeculae of basophilicmineralised material bordered by plump cellswith large but not atypical nuclei.
� Mitotic figures are rare
� Also, osteoclastic giant cells may be present
�� ThTh: : toothtooth extractionextraction
08:16 24/125
OdontogenicOdontogenic tumorstumors
� group of lesions that arises from the odontogenic tissue. They developfrom the epithelial part of the tooth germ, the ectomesenchymal part, or from both.
�� 70% 70% odontogenicodontogenic tumorstumors, , hamartomahamartoma�� thethe differenciationdifferenciation intointo dontoblastdontoblast and and ameloblastameloblast ((dentindentin and and enamelenamelproductionproduction) ) isis presentpresent
�� benignbenign processprocess�� 1010--20 y 20 y lifelife, , maxillamaxilla
�� HistologicallyHistologically::� Complex form
� well delineated mass of dental hard tissues in a irregular arrangement(dentin, enamel, cementum)
� stroma consists of mature fibrous connective tissue
�� CompoundCompound formform� malformation consisting of tiny teeth� may vary in number from only a few to numerous� do not resemble normal teeth� normal arrangement of centrally placed fibrovascular pulp tissue surroundedby dentin with enamel in the crown area and cementum in the root part.
08:16 26/125
OdontogenicOdontogenic tumorstumors
� group of lesions that arises from the odontogenic tissue. They developfrom the epithelial part of the tooth germ, the ectomesenchymal part, or from both.
�� nonneoplasticnonneoplastic intraosseousintraosseous lesionslesions thatthat replacereplace normalnormal bone and bone and consistconsist ofof cellularcellular fibrousfibrous connectiveconnective tissuetissue
�� youngyoung patientspatients, , swellingswelling a a painpain
�� osteoblastsosteoblasts a a osteoclastsosteoclastsactivationactivation + + cellularycellulary bone + bone + osteoidosteoid areasareas
7
08:16 37/125
GiantGiant cellcell lesionslesions
�� manymany lesionslesions ofof thethe mandiblemandible and and maxillamaxilla containcontain giantgiant cellcell tissuetissue
�� peripheralperipheral giantgiant cellcell granulomagranuloma�� extraossueousextraossueous nodulenodule in in jawsjaws�� fromfrom periosteumperiosteum and and periodontalperiodontalmembranemembrane
�� 3030--40 y 40 y womenwomen�� focalfocal prple prple nodulenodule on on thethe gigivagigiva
�� aneurysmalaneurysmal bone bone cystcyst�� vesselsvessels resemblingresembling hemangiomahemangioma�� 1010--20 y pacienti20 y pacienti
�� madiblamadibla –– ramusramus�� face face deformationdeformation / bone / bone fracturefracture
�� dif.dg.traumaticdif.dg.traumatic bone bone cystcyst
�� predilection for the face, handspredilection for the face, hands
�� solitarysolitary nodulenodule, fast growth, possible spontaneous regression, fast growth, possible spontaneous regression
�� solid papule with a central hollow, filled with keratinsolid papule with a central hollow, filled with keratin
�� central keratinization, hyperkeratosis seems embedded in the central keratinization, hyperkeratosis seems embedded in the epidermis, but bounded epidermis, but bounded by by normal epidermisnormal epidermis;; at the base of at the base of the the iinfiltrative growingnfiltrative growing may be presentmay be present, possibly mitotic activity but , possibly mitotic activity but no atypical mitoses, small abscesses in the epithelium, the no atypical mitoses, small abscesses in the epithelium, the inflammatory infiltrate inflammatory infiltrate
�� elderlyelderly
8
08:16 43/125
Epithelial tumorsEpithelial tumors
From squamous epitheliumFrom squamous epithelium�� BenignBenign
From glandular epitheliumFrom glandular epithelium�� Salivary gland tumorsSalivary gland tumors
08:16 44/125
PeutzPeutz--Jeghers syndromeJeghers syndrome
�� ADAD
�� formation of benign polyps in the gastrointestinalformation of benign polyps in the gastrointestinal -- hamarthamarthomashomas((risk risk intususcepcia!!) intususcepcia!!)
�� hyperpigmented maculae of the lips and mucosa hyperpigmented maculae of the lips and mucosa
From glandular epitheliumFrom glandular epithelium�� Salivary gland tumorsSalivary gland tumors
08:16 46/125
LeukoplakiaLeukoplakia
�� "white "white coatings at the mocous of oral cavitycoatings at the mocous of oral cavity, which can not be , which can not be wiped off and wiped off and classifiedclassified asas other disease"other disease"precancerprecancerosisosis!!smoking!, alcohol, chron.smoking!, alcohol, chron. candidosiscandidosis, HPV, EBV ..., HPV, EBV ...
homogeneoushomogeneous -- flat, uniform, white flat, uniform, white areasareasnonnon--homogeneoushomogeneous -- irregular, nodular irregular, nodular areasareas + erythroplakia+ erythroplakia
�� clinical diagnosis, has a characteristic histologic correlateclinical diagnosis, has a characteristic histologic correlateacanthosisacanthosis = thickening of the spinous layer of squamous = thickening of the spinous layer of squamous epitheliumepitheliumhhyperkeratosisyperkeratosis = thickening of the = thickening of the keratinkeratin layerlayeratrophyatrophy –– erythroplakiaerythroplakia
may lead tomay lead to�� dysplasia and CISdysplasia and CIS
�� mostly lower mostly lower liplip and tongueand tongue
�� ffirstirstlyly, the exophytic growth, slow , the exophytic growth, slow growth growth and and late late metastases metastases (in (in tonguetongue the the early early iningrowth growth into theinto the blood vessels and blood vessels and metastasis to the lungmetastasis to the lung can be foundcan be found) )
�� may exulcermay exulcerateate
�� The The endofytic formendofytic form does existdoes exist!!
08:16 48/125
Basal cell carcinomaBasal cell carcinoma
�� skin tumor (predominantly on the face) skin tumor (predominantly on the face) –– proliferation of the proliferation of the cells similar to the immature cells of the basal layer of the cells similar to the immature cells of the basal layer of the epidermis (but arises from hair follicule)epidermis (but arises from hair follicule)
�� variable histological featuresvariable histological features
�� grows predominantly endophytic, with the dermis infiltration, angrows predominantly endophytic, with the dermis infiltration, and d surface exulceration (ulcus rodens)surface exulceration (ulcus rodens)
�� without metastasis (semimalignant), locally destructive, with without metastasis (semimalignant), locally destructive, with relapses relapses –– the adequate surgical extirpation with the the adequate surgical extirpation with the histopathological examination of the borders is necessaryhistopathological examination of the borders is necessary
9
08:16 49/125
TumorsTumors ofof salivarysalivary glandsglands
�� relatively rare tumors with an incidence 1relatively rare tumors with an incidence 1--3/100.0003/100.000
�� AAffect ffect in in 70% 70% thethe major glands (parotid gland 70% major glands (parotid gland 70% -- benign, benign, sublingual 70%sublingual 70% -- malignant)malignant)
�� in in 30% 30% affectaffect small glandssmall glands
�� ductalductal and and myoepithelialmyoepithelial cellscells supportedsupported by by stromastroma withwithmucoidmucoid, , myxoidmyxoid or or chondroidchondroid appearanceappearance((myxochondroepitheliomamyxochondroepithelioma))
�� MyoepithelialMyoepithelial cellscells and and epithelialepithelial cellscells formform areasareas or or sheetssheets, , maymay bebe rarelyrarely cribriformcribriform or or tubulartubular
�� growinggrowing intointo capsulecapsule, , recurrencyrecurrency, , possiblepossible malignantmalignantvariant variant –– thethe biologicalbiological behaviourbehaviour isis difficultdifficult to to analyzeanalyze
08:16 52/125
MonomorphicMonomorphic adenomaadenoma
�� The group of benign tumors formed by proliferation of epithelialThe group of benign tumors formed by proliferation of epithelialcells of one type with a characteristic arrangementcells of one type with a characteristic arrangement
�� Properties similar to PA, less recidivismProperties similar to PA, less recidivism
babassocellulocellularar adenomaadenoma
�� nests of tumor cells separated by fibrous nests of tumor cells separated by fibrous stromastroma
�� in in thethe centre are centre are thethe cuboidalcuboidal cells resemblingcells resembling strat.basalestrat.basale ofof thetheepidermusepidermus
canalicularcanalicular adenomaadenoma
•• anastomoanastomosingsing sheetssheets forming the forming the canaliculescanalicules –– formedformed by a layer of by a layer of cylindricalcylindrical to to cuboidalcuboidal cellscells
•• myxomatmyxomatousous hypocellular stroma with dilated capillarieshypocellular stroma with dilated capillaries
� most common, form 4.8% of all salivary gland tumours, most commontypes of post-irradiation salivary gland tumours
� parotid, peak age incidence is in the fifth decade.
�� locally invasivelocally invasive growthgrowth, destructive, metastases, often quickly, painfully, destructive, metastases, often quickly, painfully
�� less malignant variantsless malignant variants –– recurrencyrecurrency
�� Well differentiated adenocarcinoma G1Well differentiated adenocarcinoma G1�� consists of squamous epithelial cells and mucusconsists of squamous epithelial cells and mucus--producing cellsproducing cells
�� cystic formations lined by mucincystic formations lined by mucin--producing cellsproducing cells
�� sheetssheets of squamousof squamous--epithelial cellsepithelial cells
�� More More commoncommon in in minor salivarysalivary glandsglands, , the palate is by far the most� peak age incidence is in the sixth decade (range 12-72 years) and thefemale to male ratio is 1.3
�� Slow growth, but painSlow growth, but painfulful and facial nerve palsyand facial nerve palsy� late appearance of recurrences, but ffrequent, metastases, worse requent, metastases, worse prognosisprognosis
�� Consists of cylindrical cavitConsists of cylindrical cavitiesies filled with hyaline masses and filled with hyaline masses and connectiveconnective tissuetissue with capillarieswith capillaries
�� MyoepitMyoepithhelelialial cellscells
08:16 58/125
AcinicAcinic cellcell carcinomacarcinoma
�� ArisesArises fromfrom acinicacinic cellcellss
�� ParotideParotide, women, women
�� LowLow--grade malignancgrade malignancyy, but often recurs, but often recurs
�� CellsCells:: mucinous, serous, seromucinmucinous, serous, seromucinousousin different structures (solid, mikrocystic, papillaryin different structures (solid, mikrocystic, papillary--cystic, cystic, follicular)follicular)Cells with abundant basophilic Cells with abundant basophilic granular cytoplasmgranular cytoplasmCells with Cells with vacuolatedvacuolated cytoplasmcytoplasmEosinophilic cells with Eosinophilic cells with centrally located centrally located nucleusnucleus
