radio-graphical description of benign tumors of jaw

1. Benign tumors of
jaw
MODERATED BY:
DR. SUNITA GUPTA
DR. SHALINI
DR. DEEPMALA
DR. VIPUL
DR. ANSHUM
By:
VARUN SURYA
1

2. The term " benign " implies mild
and non-progressive
A benign tumor is a tumor that
lacks all three of the malignant
properties of a cancer.
Thus, by definition, a benign
tumor does not grow in an
unlimited , aggressive manner,
does not invade surrounding
tissues , and does not
2

3. Features Benign tumor Malignant tumor
Periphery Smooth, well defined,
Encapsulated,
corticated
Ill defined border, lack
of cortication , absence
of encapsulation
Surrounding tissue Compressed Invaded
Size Usually small Often larger
Growth rate Slow Rapid
Spread Direct extension Metastasis
Location Specific anatomic site Anywhere
Internal structure RO , RL , mixed Radiolucent
Effect on surrounding Resorb teeth root ,
displace teeth in a
bodily fashion without
causing loose teeth
Destroy supporting
alveolar bone so that
teeth may appear
floating in space
3

4. Benign tumors represent a new uncoordinated
growth
Benign tumors are slow-growing and spread by
direct extension and not by metastases.
They tend to resemble the tissue of origin
histologically.
It is thought that benign tumors have unlimited
growth potential.
Often hamartomas are included in the category of
benign tumors.
However, hamartomas are overgrowths of
disorganized
normal tissue that have a limited growth
potential
For example, an odontoma is a hamartoma of 4

5. Clinical Features
Benign tumors typically have an insidious onset
and
grow slowly.
These tumors usually are painless ,do not
metastasize, and are not life threatening
unless they
interfere with a vital organ by direct extension.
Benign tumors are usually detected clinically by
enlargement of the jaws or are found during a
radiographic examination.
5

6. Radiologic features
LOCATION
Many tumors have a specific anatomic predilection
odontogenic
lesions
occur in the alveolar
processes
Above the inferior alveolar nerve
canal, where tooth formation
occurs
Vascular and
neural lesions
may originate inside the
mandibular canal, arising from
the Neurovascular tissues
Cartilaginous
tumors
occur in jaw locations where
residual cartilaginous cells lie, such
as around the mandibular condyle.
6

7. PERIPHERY AND SHAPE
Benign tumors enlarge slowly by formation of additional
internal tissue.
Because of this, the radiographic borders of benign
tumors appear relatively smooth, well defined, and
sometimes corticated.
If the tumor produces a calcified product-for
example, abnormal tooth material or abnormal bone-
the most mature part of the tumor will be in the
central region with the most immature aspect at the
periphery.
This sometimes results in a radiolucent band of soft
tissue or capsule at the periphery where the calcified
product has not yet formed; this band separates the
more mature internal
radiopaque portion from the surrounding normal
bone. 7

8. INTERNAL STRUCTURE
It may be completely radiolucent or radiopaque
or maybe a mixture of radiolucent and
radiopaque tissues.
If the lesion contains radiopaque elements,
these structures usually represent either
residual bone or a calcified material that is
being produced by the tumor.
For instance curved septa that are
characteristic in ameloblastoma represent
residual bone trapped inside the tumor that has
remodeled into curved septa.
The ameloblastoma does not produce bone.
.
8

9. EFFECTS ON SURROUNDING STRUCTURES
a benign tumor exerts pressure on neighboring
structures, resulting in the displacement of teeth or
bony cortices.
If the growth is slow enough, there will be adequate
time for the outer cortex to remodel in response to the
pressure,resulting in an appearance that the cortex has
been displaced by the tumor .
This is caused by simultaneous resorption of bone
along the inner surface (endosteal) of the cortex and
deposition of bone along the outer cortical surface by
the periosteum
Through this remodeling process, the cortex
maintains its integrity and resists perforation.
Benign tumors may also cause bodily
displacement of near by teeth .
9

10. The roots of teeth maybe resorbed by either benign
or malignant tumors, but root resorption more
commonly is associated with benign processes.
The benign tumors especially likely to resorb
roots are ameloblastomas, ossifying fibromas, and
central giant cell granulomas.
Benign tumors tend to resorb the adjacent root
Surfaces in a smooth fashion.
When root resorption is associated with malignant
tumors, the resorption is usually in smaller
quantities causing thinning of the root into a
"spiked" shape.
10

11. 11

12. 12

13. Benign tumors
The benign neoplasias are separated into two
major
groups: odontogenic tumors and non-
odontogenic
tumors.
ODONTOGENIC
TUMORS
Odontogenic tumors arise from the tissues of the
odontogenic apparatus
According to (WHO),
13

14. 1). Odontogenic epithelium
(i). Ameloblastoma
(ii). Squamous odontogenic tumor
(iii).Calcifying epithelial
odontogenic tumor (Pindborg’s tumor)
(iv).Clear cell odontogenic tumor
2). Odontogenic epithelium with odontogenic
ectomesenchyme
(i). Ameloblastic fibroma
(ii). Ameloblastic fibro dentinoma and
ameloblastic fibro odontoma
(iii). Odontoameloblastoma
(iv). Adenomatoid OdontogenicTumor
(v). Calclifying odontogenic cyst
(vi). Complex odontoma
(vii). Compound odontoma
14

15. 3). Odontogenic ectomesenchyme
(i). Odontogenic fibroma
(ii). Myxoma / Odontogenic myxofibroma
(iii).Benign cementoblastoma
( True Cementoblastoma)
15

16. Odontogenic
epithelial tumors
16

17. AMELOBLASTOMA
Synonyms
Adamantinoma , adamantoblastoma, and
epithelial odontoma
Definition
A true neoplasm of enamel organ type which
doesn’t undergo differentiation to the point of
enamel formation.
robinson Defined it as
A tumor that is -Unicentric,
non functional,
intermittent in growth,
anatomically benign
and clinically persistent
17

18. 18

19. Clinical features
Age - 20 to 40yrs
Site - mandible > maxilla
slow growing, painless, bony expansion
initially Tennis ball like consistency
“Egg shell” like cracking
Jaw bone enlargement & parasthesia
19

20. Radiographic Features
Location. Most (80%) develop in the
molar-ramus region of the mandible, but they
may
extend to the symphyseal area.
Periphery. is usually well defined
and frequently delineated by a cortical border.
The
border is often curved and in small lesions the
border
and shape may be indistinguishable from a cyst
The periphery of lesions in the maxilla is usually-
more ill defined.
20

21. 21

22. Internal structure. The internal structure varies
from totally radiolucent to mixed with the
presence of bony septa creating internal
compartments.
These septa are usually coarse and curved and
originate from normal bone that has been
trapped
within the tumor.
Because this tumor frequently has internal cystic
components, these septa are often remodeled
into curved shapes providing a honeycomb
(numerous small compartments or loculations) or
soap bubble (larger compartments of variable
size)patterns .
Generally the loculations are larger in the 22

23. 23

24. Egg shell
24

25. Effects on surrounding structures. There is
pronounced tendency for ameloblastomas to cause
extensive root resorption . Tooth displacement is
common.
Because a common point of origin is occlusal
to a tooth, some teeth may be displaced apically.
An occlusal radiograph may demonstrate cyst like
expan-
sion and thinning of an adjacent cortical plate,
leaving
a thin "egg-shell" of bone .
Actual perforation of bone into the surrounding
soft tissues or anatomic spaces is a late feature of
ameloblastoma
Unicystic types of ameloblastoma may cause
extreme expansion of the mandibular ramus
25

26. Differential Diagnosis
The odontogenic keratocyst may contain curved
septa but usually the keratocyst tends to grow
along the bone without marked expansion,
which is Characteristic of ameloblastomas.
26

27. Giant cell granulomas generally occur anterior to
the molars, occur in a younger age group, and
have more granular and ill defined septa
27

28. Odontogenic myxomas may have similar
appearing septa; however , there are usually one or
two thin, sharp, straight septa, characteristic
of the myxoma.
Even the presence of one such septum may
indicate a myxoma. Also myxomas are not as
expansile as ameloblastomas and tend to grow
along the bone.
28

29. The septa in ossifying fibroma are usually
wide, granular, and ill defined. Also, look for
the presence of small irregular trabeculae.
29

30. Treatment
The most common treatment is surgical resection. If
the ameloblastoma is relatively small , it may be
removed
completely by an intraoral approach and larger
lesions
May require resection of the jaw.
The maxilla is usually treated more aggressively
because of the tendency of ameloblastoma to
invade adjacent vital structures.
Radiation therapy may be used for inoperable
tumors,
Especially those in the posterior maxilla.
30

31. CALCIFYING EPITHELIUM ODONTOGENIC
TUMOR
( Pindborg’s tumor )
Definition:
It is a locally aggressive tumor consist of sheets &
strands of polyhedral cells in fibrous stroma with
no inflammatory component & are often
accompanied by spherical calcifications & amyloid
staining hyaline deposits.
Origin -Rest of dental lamina
-Reduced enamel epithelium
1% of all odontogenic tumor
31

32. Clinical features
CEOT
Central Peripheral
(intraosseous) (extraosseous)
age - 40yrs site - anterior gingiva
site - 2/3rd of appears as superficial
lesions in mandible soft tissue swelling
slow growing. of gingiva in a tooth
painless mass. bearing area or
edentulous area
of jaw
32

33. Radiographic features:
Location. mandible
most develop in the premolar-molar area, with
a
52% association with an unerupted or impacted
tooth.
Periphery. The border may have a well-defined
cyst like
cortex. In some tumors the boundary maybe
irregular
and ill defined
Internal structure. The internal aspect may
appear unilocular or multilocular with numerous
scattered,
radiopaque foci of varying size and density. 33

34. 34

35. most characteristic and diagnostic finding is the
appearance of radiopacities close to the crown of the
embedded tooth
35

36. 36

37. Effects on surrounding structures. may displace
a developing tooth or prevent its eruption.
Associated expansion of the jaw with maintenance
of a cortical boundary may also occur.
Differential Diagnosis
Lesions with completely radiolucent internal
structure
may mimic dentigerous cysts or even
ameloblastomas
Other lesions with radiopaque foci, including
ade-
nomatoid odontogenic tumor, ameloblastic
fibro-
odontoma, and calcifying odontogenic cyst , may
have 37

38. Treatment
The treatment of the CEOT is more conservative
than
the ameloblastoma , with local resection
38

39. MIXED TUMORS
(OF ODONTOGENIC
EPITHELIUM AND
ODONTOGENIC
ECTOMESENCHYME)
39

40. ODONTOMA
Most common type of odontogenic tumor
Definition:
a tumor that is radiographically and histologically
characterized by the production of mature enamel,
dentin, cementum,and pulp tissue.
Clinical features:
Age- 10 to 20yrs
Site - Maxilla > mandible
Slow growing , hard , painless mass
40

41. GARDNER’S Syndrome is associated with it
(a). Multiple odontomas
(b). Multiple osteomas
(c ). Intestinal polyps
(d). Epidermoid cyst
(e). Dermoid tumor(fibrous)
2 Types
(1). Complex
(2). Compound
41

42. Features Compound complex
location anterior maxilla in
association with the
crown of an unerupted
canine.
mandibular first and
second molar area.
Internal structure number of toothlike
structures or denticles
that look like deformed
teeth
irregular mass of
calcified tissue
Frequency More Less common
Sex predilection M=F More in female
42

43. Radiographic Features
Location.
compound odontomas (62%) occur in the anterior
maxilla in association with the crown of an
unerupted canine.
70%of complex odontomas are found in the
mandibular first and second molar area.
Periphery. The borders of odontomas are
well defined and may be smooth or irregular.
These lesions have a cortical border and
immediately inside and adjacent to the cortical
border is a soft tissue capsule.
43

44. Internal structure. The contents of these
lesions are largely radiopaque.
Compound odontomas have a number of
toothlike structures or denticles that look like
deformed teeth
Complex odontomas contain an irregular mass of
calcified tissue
Effects on surrounding structures. Odontomas
,can interfere with the normal eruption of
teeth. Most odontomas (70%) are associated
with abnormalities such as impaction,
malpositioning, diastema, aplasia, malformation,
and devitalization of adjacent teeth.
Large complex odontomas may cause expansion of
the
44

45. Complex odontoma
45

46. Compound odontoma
46

47. treatment
Complex and compound odontomas are usually
Removed by simple excision. They do not recur and are
not locally invasive
47

48. AMELOBLASTIC FIBROMA
Synonyms
Soft odontoma, soft mixed odontoma, mixed
odonto genic tumor, fibroadamantoblastoma,and
granular cell
Ameloblasticfibroma
defination
Ameloblastic fibromas are benign, mixed
odontogenic
tumors. They are characterized by neoplastic
prolifera-
tion of maturing and early functional
ameloblasts,as
well as the primitive mesenchymal components of
the 48

49. Clinical features:
Age- 5 to 20yrs
Site - Maxilla > mandible
Sex- no sex predilection
They usually produce a painless,slow-growing
expan-
sion, and displacement of the involved teeth
Radiographic Features
Location. in the premolar-molar area of the
mandible
Periphery. The borders of an ameloblastic-fibroma
are
well defined and often corticated in a manner
similar
49

50. 50

51. 51

52. 52

53. Internal structure. An ameloblastic fibroma is
more commonly unilocular (totally radiolucent)
Effects on surrounding structures. If the lesion
is large,
there may be expansion with an intact cortical
plate.
The associated tooth or teeth may be inhibited
from
normal eruption or may be displaced in an
apical
direction.
53

54. Differential Diagnosis
Ameloblastoma—however ,the ameloblastic
fibroma occurs at an earlier age and the septa in
an ameloblastoma are more defined and coarse.
In fact the septa in ameloblastic fibroma are
infrequent and often very fine.
Giant cell granulomas --may appear multilocular,
but these tumors usually have an epicenter anterior
to the first molar and the septa are
characteristically granular and ill defined.
Odontogenic myxomas-- can appear multilocu-
lar but usually a few sharp straight septa can be
identi-
fied, which are not characteristic of
ameloblastic
fibromas and myxomas usually occur in an older
age 54

55. Treatment. Ameloblastic fibromas are benign, and
the
rate of recurrence is low. A conservative
surgical
approach,including enucleation and mechanical
curet
tage of the surrounding bone,
55

56. AMELOBLASTIC FIBRO-ODONTOMA
Definition
An ameloblastic fibro-odontoma is a mixed tumor
with
all the elements of an ameloblastic fibroma but
with
Scattered collections of enamel and dentine
Clinical Features.The clinical features are
similar
to odontomas, often associated with a missing
tooth
or tooth that has failed to erupt.
This tumor appears during the same age as
odontomas and ameloblastic fibromas with no
particular sex predilection. 56

57. Radiographic Features
Location-posterior aspect of the mandible. The
epicenter of the lesion is usually occlusal to a
developing tooth or toward the alveolar crest.
Periphery. This tumor is usually well defined and
some-
times corticated.
Internal structure. The internal structure is
mixed, with the majority of the lesion being
radiolucent. Small lesions may appear as enlarged
follicles with only one or two small,discrete
radiopacities. Larger lesions may have a more
extensive calcified internal structure
57

58. Differential Diagnosis
Differentiation from a developing odontoma may
be difficult, but generally these tumors have a
greater soft tissue component (radiolucent) than
an odontoma
A complex odontoma, which shares a
common location, usually has one mass of
disorganized
tissue in the center, whereas the ameloblastic
fibro-
odontoma will usually have multiple scattered
mature
small pieces of dental hard tissue
Treatment
Usually conservative enucleation is used 58

59. 59

60. ADENOMATOID ODONTOGENIC TUMOR
Synonyms ,
Adenoameloblastoma and ameloblastic adenomatoid
tumor
Definition
Adenomatoid odontogenic tumors are uncommon,
Nonaggressive tumors of odontogenic epithelium
Clinical features
Age - younger patient (10 to 19yrs).
Sex - female
Site - anterior portion of the jaw
maxilla > mandible
Asymptomatic, painless, slow growing.
large lesions causes expansion of bone.
60

61. Both central and peripheral tumors occur. The
central tumors are divided into the follicular
type (those associated with the crown of an
embedded tooth) and the extra- follicular type
(those with no embedded tooth).
Radiographic Features
Location. At least 75% occur in the maxilla
The incisor canine-premolar region, especially the
canine region
Periphery. The usual radiographic appearance is a
well-
defined corticated or sclerotic border.
Internal structure. Radiographically,
radiopacities develop in about two thirds of cases
61

62. Effects on surrounding structures. As the
tumor enlarges, adjacent teeth are displaced.
Root resorption is rare. This lesion also may inhibit
eruption of an involved tooth. Although some
expansion of the jaw may occur, the outer cortex is
maintained.
Differential Diagnosis
If the attachment of the radiolucent lesion is
more apical than the cementoenamel junction,
a follicular cyst can be discounted.
The ameloblastic fibro-odontoma and the
calcifying epithelial odontogenic tumor occur more
commonly in the posterior mandible.
62

63. Pebble –like calcification
63

64. Treatment
Conservative surgical excision is adequate because
the
tumor is not locally invasive,is well
encapsulated,and
is separated easily from the bone
64

65. MESENCHYMAL TUMORS
(ODONTOGENIC ECTOMESENCHYME)
65

66. ODONTOGENIC MYXOMA
Synonyms
Myxoma, myxofibroma, and fibromyxoma
Definition
Odontogenic myxomas are uncommon,
accounting
for only 3% to 6% of odontogenic tumors. They
are benign, intraosseous neoplasms that arise from
odon-
togenic ectomesenchyme and resemble the
mesenchy-
mal portion of the dental papilla
66

67. Clinical features
Age - 10 to 30yrs.
Sex – female
The tumor grows slowly and may or may not
cause pain.
Eventually it causes swelling and May grow
quite large if left untreated
67

68. Radiographic Features
Location- mandible , the premolar and molar areas
Periphery--The lesion usually is well defined, and it
may
have a corticated margin but most often is
poorly
defined, especially in the maxilla
Internal structure. majority have a mixed
radiolucent-radiopaque internal pattern.
Residual bone trapped within the tumor will
remodel
into curved and straight, course or fine septa.The
pres-
ence of these septa gives the tumor a
multilocular appearance. 68

69. 69

70. 70

71. The majority of the septa are curved and course,
but the finding of one or two of these straight
septa will help in the identification of this tumor
Effects on surrounding structures. When
growing in a tooth-bearing area, it displaces and
loosens teeth,
but rarely causes resorption of teeth. The lesional so
frequently scallops between the roots. of
adjacent teeth similar to a simple bone cyst. This
tumor has a tendency to grow along the involved
bone without the same amount of expansion seen
with other benign tumors.
71

72. Differential Diagnosis
Include ameloblastomas, central giant cell
granulomas, and central hemangiomas.
The finding of characteristic thin, straight septa
with less-than-expected bone expansion is very
useful in the differential.
Careful inspection of this area of expansion will
reveal a thin but intact outer cortex that would not
be seen in osteogenic sarcoma
Treatment
by resection with a generous amount of
surrounding bone to ensure removal of
myxomatous tumor that infiltrates the adjacent
marrow spaces.
72

73. BENIGN CEMENTOBLASTOMA
Synonyms
Cementoblastoma and true cementoma
Definition
Benign cementoblastomas are slow-growing ,
mesenchymal neoplasms composed principally of
cementum
Clinical Features
Age - 12 to 65
Sex - females
The tumor usually is a solitary lesion that is
slow-growing but that may eventually displace
teeth.
The involved tooth is vital and often painful.
The pain seems to vary from patient to patient
and can be relieved by anti-inflammatory drugs.73

74. Radiographic Features
Location. mandible (78%) -premolar or first
molar(90%).
Periphery. The lesion is a well-defined radiopacity
with
a cortical border and then a well-defined
radiolucent
band just inside the cortical border
Internal structure. mixed radiolucent-
radiopaque lesions in which the majority of the
internal structure is radiopaque.
wheel spoke pattern
The density of the cemental mass usually
obscures the outline of the enveloped root.
This central radiopaque mass as mentioned is
surrounded by a radiolucent band indicating that the
tumor is maturing from the central aspect to 74

75. 75

76. Effects on surrounding structures.
If large enough, this tumor can cause expansion of
the mandible but with an intact outer cortex.
Differential Diagnosis
the radiolucent band around the benign
cementoblastoma is usually better defined
and more uniform than with cemental dysplasia.
Also, in the first molar region the
cementoblastoma has a more rounded shape
than cemental dysplasia.
Treatment
Benign cementoblastomas are apparently self-
limiting
and rarely recur after enucleation. Simple
excision
and extraction of the associated tooth are 76

77. CENTRAL ODONTOGENIC FIBROMA
Synonyms
Simple odontogenic fibroma and odontogenic
fibroma
(World Health Organization [WHO] type)
Definition
Central odontogenic fibromas are rare neoplasms
that
Sometimes are divided into two types according to
his-
tologic appearance:
simple type contains mature fibrous tissue with
sparsely scattered odontogenic epithelial rests;
WHO type, which is more cellular,
77

78. Clinical Features
Age - 11 and 39 years
Sex – females
patients may be asymptomatic or may have swelling
and mobility of the teeth.
Radiographic Features
Location. mandible, molar-premolar region.
They are also prevalent in the maxilla anterior to the
first molar.
Periphery. The periphery usually is well defined,
Internal structure. Smaller lesions usually are unilocu-
lar, and larger lesions have a multilocular pattern. The
internal septa may be fine and straight, as in odonto-
genic myxomas,or it maybe granular, resembling those
Seen in giant cell granulomas. 78

79. Effects on surrounding structures. A central
odontogenic fibroma may cause expansion with
maintenance of a thin cortical boundary or on
occasion can grow along the bone with minimum
expansion similar to an odontogenic myxoma.
Tooth displacement is common, and root resorption
has been reported.
Differential Diagnosis
Desmoplastic fibromas are more aggressive and
tend to break through the peripheral cortex and
invade surrounding soft tissue
79

80. NON
ODONTOGENIC
TUMORS
80

81. BENIGN TUMORS OF NEURAL ORIGIN
NEURILEMOMA
Synonym
Schwannoma
Definition
A central neurilemoma is a tumor of neuro-
ectodermal
origin, arising from the Schwann cells that make up
the
inner layer covering the peripheral nerves.
Clinical Features
Age – second and third decades
Sex – equal frequency
81

82. The usual complaint is a swelling.
Pain, when present, usually develops at the
Site of the tumor; if paresthesia occurs,it is felt
anterior
to the tumor.
Radiographic Features
Location. mandible, most often located within
an expanded inferior alveolar nerve canal posterior
to the mental foramen
Periphery. In keeping with its slow growth rate,
the
margins of this tumor are well defined and usually
cor-
ticated as it expands the cortical walls of the
inferior 82

83. 83

84. Internal structure. The internal structure is
uniformly
radiolucent. When lesions have a scalloping
outline,
this may give a false impression of a
multilocular
pattern.
Effects on surrounding structures. If the tumor
reaches either the mandibular foramen or mental
foramen, it can cause enlargement of the foramen.
Expansion of the inferior alveolar canal is slow
and thus the outer cortex of the 'canal is
maintained and the expansion of the canal is usually
localized with a definite epicenter unless the lesion
is large.
84

85. Treatment
Excision is usually the treatment of
choice
85

86. NEUROFIBROMA
Synonym
Neurinoma
Definition
Neurofibromas are moderately firm, benign,
well-
circumscribed tumors caused by proliferation
of
Schwann cells in a disorderly pattern that
includes
portions of nerve fibers, such as peripheral
nerves,
Axons ,and connective tissue of the sheath of
Schwann.
As neurofibromas grow, they incorporate axons.86

87. Clinical Features
The central lesion of a neurofibroma maybe the
same
as the multiple lesions that develop in von
Reckling-
hausen's disease.
Neurofibromas can occur at any age but usually are
found in young patients.
Neurofibromas associated with the mandibular
nerve may produce pain or paresthesia.
Neurofibromas also may expand and perforate the
cortex; causing swelling that is hard or firm to
palpation.
87

88. Radiographic Features
Location. in the mandibular canal, in the
cancellous bone, and below the periosteum.
Periphery.. the margins of the radiolucency in
neurofibromas usually are sharply defined and
may be corticated.
However, despite the benign nature and slow
growth of the neurofibroma, some of these lesions
have indistinct margins.
Internal structure. The tumors usually appear
unilo-
cular but on occasion may have a
multilocular appearance.
Effects on surrounding structures. A
neurofibroma of the inferior dental nerve shows a 88

89. 89

90. Differential Diagnosis
Differentiation from other types of neural lesions
may
not be possible.
This tumor can be differentiated from
Vascular lesions because the expansion of the
canal is
in a fusiform shape,'whereas vascular lesions
enlarge
the whole canal and alter its path.
Treatment
Solitary central lesions that have been excised
seldom
recur. However, it is wise to re-examine the area
peri- 90

91. NEUROFIBROMATOSIS
Synonym
von Reckling-hausen'sdisease
Definition
Neurofibromatosis is a syndrome consisting
of cafe au-lait spots on the skin, multiple
peripheral nerve tumors, and a variety of
other dysplastic abnormalities of the skin,
nervous system, bones, endocrine organs,
and blood vessels
The two major classifications are
NF-1, a generalized form,
NF-2, a central form.
Oral lesion may occur as part of NF-1 or
may be solitary and are called segmental or
forme fruste manifestations
91

92. Clinical Features
Neurofibromatosis is one of the most common
genetic
Diseases.
The peripheral nerve tumors are of two types,
schwannomas and neurofibromas. Most
manifestations are appear gradually during
childhood & adult life. Cafe-au-Iait spots become
larger and more numer-
ous with age; most patients eventually have
more than six spots larger than 1.5 cm in
diameter.
92

93. Radiographic features
The radiographic changes in the jaws with
neurofibroatosis can be characteristic. These
changes include
1. enlargement of the coronoid notch in
either or both the horizontal and vertical
dimensions
2. an obtuse angle between the body and
the ramus
3. deformity of the condylar head
4. lengthening of the condylar neck
5. lateral bowing and thinning of the ramus
6. enlargement of the mandibular canal &
mental and mandibular foramina and an
increased incidence of branched mandibular93

94. 94

95. Treatment
Most patients live a normal life with Jew or no
symp toms. Small cutaneous and subcutaneous
neurofibro-
mas can be removed if they are painful, but
large
plexiform neurofibromas should be left alone.
Malignant conversion of these lesions has occurred
in rare cases.
95

96. MESODERMAL TUMORS
OSTEOMA
Definition
Osteomas can form from membranous bones of the
Skull and face.
The cause of the slowly growing osteoma is obscure, but
the tumor may arise from cartilage or embryonal
periosteum
It is not clearwhether osteomas are benign neoplasms or
hamartomas
Structurally, osteomas can be divided into three-
types: composed of compact bone (ivory),
composed of cancellous bone,
composed of a combination of compact and cancellous
bone. 96

97. 97

98. 98

99. Clinical Features
Age – above 40 years
Sex – Cortical type = men
cancellous type= women
Radiographic Features
Location. mandible -posterior aspect -lingual side of
the ramus or on the inferior mandibular border
below the molars
Internal structure. Osteomas composed solely of
compact bone are uniformly radiopaque; those con-
taining cancellous bone show evidence of internal tra-
becular structure.
Effects on surrounding structures. Large lesions can
dis-
place adjacent soft tissues , such as muscles , and
cause
dysfunction. 99

100. Treatment
Unless the osteoma interferes with normal function
or
presents a cosmetic problem, this lesion may
not
require treatment. In such casesthe osteoma should
be
kept under observation.
Resection of osteoma sis possible and maybe
difficult if the osteoma is of the cortical (ivory) type.
100

101. CENTRAL HEMANGIOMA
Definition
A hemangioma is a proliferation of blood vessels
creating a mass that resembles a neoplasm , although in
many cases it is actually a hamartoma
Clinical Features
Age – first decade
Sex – female
Enlargement is slow , producing a non-tender
expansion of the jaw that occurs over several
months or years.
The swelling may or may not be painful, is not
tender, and usually is bony hard.
Pain, if present, usually of throbbing type
101

102. Some tumors may be compressible or pulsate, and
a bruit may be detected on auscultation
Anesthesia of the skin supplied by the mental
nerve
May occur.
The lesion may cause loosening and migration of
teeth in the affected area.
Bleeding may occur from the gingiva around the
neck of the affected teeth.
These teeth may demonstrate rebound mobility;
that
is,when depressed into their sockets,they rebound
to
their original position within several minutes
because
of the pressure of the vascular network around
the 102

103. Hemangioma are associated with following
Syndrome—Syndrome features
Rendu-osler-
weber-syndrome
multiple telangi-ectasias ,occasional GI tract &
CNS involvement
Sturge-weber-
dimtri syndrome
Port-wine stain, leptomeningeal angiomas
Kasabach –
merritt syndrome
Thrombocytopenic purpura associated with
hemangiomas , consumptive coagulpathy ,
microangiopathic hemolysis , intralesional
fibrinolysis
Maffucci
syndrome
Hemangiomas of mucous membrane ,
dyschondroplasia
Von hippel-
lindau syndrome
Hemangiomas of cerebellum , or retina, cyst of
viscera
Klippel –
trenaunay weber
syndrome
Port-wine stain & angiomas of extremities
103

104. Radiographic Features
Locotion. Mandible , posterior body and ramus
and within the inferior alveolar canal.
Periphery. In some instances the periphery is
well
defined and corticated, and in other cases it maybe
ill
defined and even simulate the appearance of a
malig-
nant tumor
The formation of linear spicules of bone ema-
nating from the surface of the bone in a sunray-
like
appearance can occur when the hemangioma
breaks 104

105. 105

106. Internal structure. When there is residual
bone
trapped around the blood vessels ,the result
maybe a
multilocular appearance.
Small radiolucent locules may resemble enlarged
marrow spaces surrounded by coarse, dense
,and well-defined trabeculae .
These internal trabeculae may produce a
honeycomb pattern composed of small circular
radiolucent spaces
that represent blood vessels oriented in the same
direc-
tion of the x-ray beam.
106

107. When the inferior alveolar canal
is involved, the whole canal is increased in width
and
often the normal path of the canal is altered into
a
serpiginous shape
Some lesions may be totally radiolucent.
When the hemangioma involves soft tissue the
formation of phleboliths (small areas of
calcification or concretions found in a vein with
slow blood
flow) may occur within surrounding soft tissues
They develop from thrombi that become
organized and mineralized and consist of calcium
phosphate 107

108. 108

109. Effects on surrounding structures. The roots of
teeth in the region of the vascular lesion often are
resorbed or displaced.
When the lesion involves the inferior alveolar
nerve canal, the canal can be enlarged along its
entire length and its shape may be changed to a
serpiginous path. The mandibular and mental
foramen may be enlarged. Hemangiomas can
influence the growth of bone and teeth.
The involved bone may be enlarged and have
coarse, internal trabeculae.
Also, developing teeth may be larger and erupt
earlier when in an intimate relationship with a
hemangioma
109

110. 110

111. Differential Diagnosis
Hemangiomas should be considered in the
differential
Diagnosis of multilocular lesions involving the
body of
the ramus and body of the mandible.
Demonstration
of involvement of the inferior alveolar canal is
an
important indicator of a vascular lesion.
Treatment should be treated without delay,
because trauma that disrupts the integrity of
the
Affected jaw may result in lethal exsanguination
.Specifi-
cally, embolization (introduction of inert 111

112. ARTERIOVENOUS FISTULA
Synonyms
A-V defect, A-V shunt, A-V aneurysm, and
A-V
malformation
Definition
An arteriovenous (A-V) fistula, an uncommon lesion
, is
a direct communication between an artery and a
vein
that bypasses the intervening capillary bed.
It usually results from trauma .
The head and neck are the most common
sites.
112

113. Clinical Features
vary considerably, depending on the extent of
bone or soft tissue involvement.
The lesion may expand bone, and a mass may be
present in the Extraosseous soft tissue.
The soft tissue swelling may have a purple
discoloration. Palpation or auscultation of the
swelling may reveal a pulse.
On the other hand,
neither the bone nor the soft tissue maybe
expanded,
and no pulse maybe clinically apparent.
Aspiration produces blood.
Recognition of the hemorrhagic nature of these
lesions is of utmost importance, because extraction
of an associated tooth may be immediately
followed by life-threatening bleeding. 113

114. Radiographic Features
Location.- ramus and retromolar area of the mandible
and involve the mandibular canal.
Periphery.The margins usually are well defined and
corticated.
Internal structure. A tortuous path of an enlarged
vessel in bone may give a multilocular appearance.
Otherwise the lesion is radiolucent.
Effects on surrounding structures. Both central
lesions
and those in adjacent soft tissue can erode bone, result-
ing in well-defined (cystlike) lesions in the bone.
Changes in the inferior alveolar canal may occur, as
described in hemangiomas.
114

115. 115

116. Treatment
An A-V aneurysmis treated surgically.
116

117. REFERENCES
1. SHAFER’S ORAL PATHOLOGY
2. NEVILLE ORAL PATHOLOGY
3. ORAL radiology – white & pharoah
4. burket’s ORAL medicine
117

118. 118