Oral Path I Combined PDF

January 6, 2005
Dr. Childers (lec & appendix)

ORAL PATHOLOGY
BLOOMS TAXONOMY OF EDUCATIONAL OBJECTIVES

Blooms Triangle- aim to be at the top of the triangle
Making evaluative judgments is why they call you doctor
Knowledge- remembering something previously encountered
Comprehension- Understanding of material being communicated, w/o necessarily
relating it to other material
Application- the use of abstractions in particular and concrete situations
Analysis- Breaking down communication into its parts so that organization of ideas is
clear
Synthesis- putting elements into a whole
Evaluation- judging the value of materials and methods for a given purpose
DIFFERENTIAL DIAGNOSIS
5 Steps in developing a Differential Diagnosis
o Describe the Lesion (soft tissue and radiographic lesions)
o Consider the anatomic location
o Consider the patient history
o Consider the pathologic processes
o Best 3 differential diagnoses
Use this method, using exact vocabulary
Must know certain factors that help you make a decision
DESCRIBE THE LESION
Describing the Soft Tissue Lesion SIZE- centimeters
SHAPE- must give to dimensions
O SURFACE CONTOUR
~ Papule- solid, raised lesion < 5mm in diameter (around the size of a pimple)
~ Nodule- Solid, raised lesion > 5mm in diameter (bigger than papule)
Must take into consideration how it attaches to mucosa
- Polypoid (resembles polyp in gross feature
- Pedunculated (stalk attachment)
- Sessile (broad base of attachment)
- May need to manipulate tissue for clear description
~ Macule- Focal area of color change which is not elevated or depressed
Non palpable, no mass to it, just a color change
Purpura (hemorrhage to skin), Vascular
Pigmented
~ Plaque- Lesion that is slightly elevated and is fiat on its surface
Wipeable or not
Smooth or papillary (growth exhibiting numerous surface projections )
~ Ulcer- loss of epithelium covering & often some CT; often appears depressed or excavated
st
Can be 2 lesion i.e. vesicle (blister) 1 roof destroyed by mastication ulcer
Vesicle- superficial blister 5mm in diameter, usually filled w/ clear fluid
Bulla- large blister >5mm in diameter (a big vesicle)
Describing the Soft Tissue Lesion SHAPE- (contd)
o BORDERS~ Symmetrical
~ Serpiginous- snake like, scalloped
~ Iris
~ Sharp, rolled
~ Ill defined- is it well circumscribed or invading surrounding areas
~ Polygonal
~ Oval Round
COLOR
Brown
o Purple
o Red
o Black
o Pink
o Normal
o Blue
o White
o Note the lip has 3 distinct parts to it, the Border, vermillion and
LOCATION
o precise anatomic location may influence final diagnosis
o Distribution- Number
~ Solitary
~ Multiple
o Arrangement
~ Grouped
Alveolar mucosa
Gingival mucosa
~ Disseminated
o Surface vs. Deep
PALPATION
o Consistency- Soft, firm, hard, fluctuant, board
o Tenderness
o Mobility
o Temperature
Some Descriptive Examples of Soft Tissue Lesions
o
mucosa
LEFT: Size- use something as a standard, i.e. size of tooth, to estimate size of findings
~ Understand the order of magnitude
o Lesions w/ same general look, color and texture, but the location of the lesion are different
~ The dorsal midline of tongue picture is candidiasis
~ The lateral lesion is cancer (note- cancer rarely appears on the dorsal midline of the
tongue)
Will describe the soft tissue lesions in more detail next semester
Describing Radiographic Lesion
SIZE
o Centimeters
o Anatomic boundries may be used
o Pic of young patient, lesion around developing tooth
~ 2 cm, well circumscribed, encompassing developing tooth
~ Note its making calcified product on the mesial portion of
the crown (must decide whether its making calcified
product or its residual bone)
~ Note delay in eruption of tooth, 1st molar hasnt erupted
~ Extends from the 2nd primary molar to the distal of the 1st molar
o
SHAPE
O RELATION TO TEETH
~ Periapical (around the apex), pericoronal (around the crown)
Impacted tooth
Erupted tooth
Root resorption or spiking
Displacement
~ Alveolar, interradicular
~ PDL, lamina dura
O BORDERS
~ Well demarcated
~ Poorly defined or ragged
o LOCULATIONS~ Unilocular Radiolucent radiolucent lesion (resembling soap bubble, or tennis racket) having a single
compartment
Must consider location- pericoronal, periapical, other location
~ Multilocular Radiolucent radiolucent lesion having several or many compartments
Soap bubble, Tennis racket
o CORTEX
~ Cortex is the outer portion of area
~ Thickened
~ Expanded
~ Eroded, thinned
O UNIQUE FEATURES
o Diagram
~ 1- well circumscribed
~ 2- Well defined but not corticated (no white line)
~ 6- scalloped edge
~ 8- by apex
~ 11- mimicking periodontal disease
DENSITY
o Radiolucent
~ Poorly defined or ragged borders
~ Multifocal or generalized
o Radioopaque- is it calcified
~ Well demarcated or Poorly demarcated
~ Multifocal
Describing Radiographic Lesion
DENSITY (contd)
o Mixed Radiolucent/Radioopaque
~ Well demarcated
~ Poorly demarcated
~ Multifocal
o Unique Radiographic Appearance
~ Ground glass- its fine trabeculation, gives smokey
appearance
i.e. smoke screen, glass, like you put on shower door
~ Cotton wool- assoc w/ disease in England, we would call cotton ball
~ Sunburst
~ Onion skin- multilayer
o Soft tissue Radioopaque
~ Calcification
NUMBER
Solitary
Multifocal
ANATOMIC LOCATION
o May influence the final diagnosis
Define type of imaging
o Include copies of images
o
o
ANATOMIC SITE
Site
o Gingival
o Floor of mouth
o Lip
o Buccal Mucosa
o Tongue
Tissues
o Epithelium
o Fibrous
o Vascular
o Neural
o
o
o
o
o
o
o
o
Palate
Neck
Maxilla
Mandible
Salivary gland
Bone
Odontogenic
Hematopoietic
PATIENT HISTORY
Age, gender, race, occupation
Duration and Onset
Relationship to
o Habits, meds, heat, cold
o Pregnancy, travel, season
o Previous treatment
Oral Symptoms
Constitutional symptoms
PATHOLOGIC PROCESS
Metabolic- altered metabolism
Inflammatory/Infectious
o Related to repair or reaction to injury
o Infectious- viral, bacterial, mycotic
Neoplastic
o An abnormal mass of tissue w/ uncoordinated growth and
removal of stimulus does not stop growth
Developmentalo An error of morphogenesis, chromosomes, or genes
****KNOW THE DEFINITION OF A NEOPLASM****
Characteristics of Benign and Malignant Neoplasms
Neoplastic vs. Noneoplastic- will influence treatment plan
RECONCILIATION
Reconcile the information
Best 3 as differential Diagnosis
o Plan treatment
o Biopsy, aspirate, culture, cytology, antibiotics, lab studies
o Referral
PATIENT TREATMENT RECORD
SOAP note
A- is where you come up w/ your DDs (differential diagnosis)
CLINCIAL DIFFERENTIAL DIAGNOSIS

Each disease process may have more than one clinical presentation
Each clinical presentation may represent more than one disease process
Evaluate each patient individually, based upon your clinical judgment as to the weighted value of each feature
For more details, the practitioner is referred to a textbook of oral pathology
1-13-06- Dr. Childers

Lec 2 & Txt Ch. 14 pp. 534-552
BONE PATHOLOGY
~
We will discuss Bone Diseases That Effect the Jaws

o Many of these diseases are inherited
o Generally disease that effect the teeth and other epidermal structures i.e. hair are generally autosomal
dominant, but there are exceptions
we are learning that many of the diseases have different types of inheritance
may have both recessive and dominant inheritance
also may have spontaneous mutations
Osteogenesis Imperfecta
Inheritance
o Autosomal Dominant, Autosomal Recessive, Spontaneous mutations
o All effect collagen maturation
Clinical Features
o Fragile bones (fractures at birth), Bone deformities, Joint Hyperextensibility
o Blue sclera
o Hypoacusis- hearing impairment
o Patients have lots of problems
Radiographic Features
o Osteopenia- Decreased calcification or density of bone
Bowing, Angulation, Deformity of Long Bones

Multiple Fractures
o Bone w/ thin cortex, fine trabeculation, and Diffuse osteoporosis
o Wormian Bones- tiny small bones found at serrated borders of sutures b/w the cranial bones
Oral Features
o Teeth look clinically and radiographically identical to dentinogenesis imperfecta
~ Osteogenesis imperfecta affects bones and teeth
~ Dentinogenesis imperfecta only affects teeth
o Opalescent Teeth- dont have transparent, translucent porcelain look
~ Teeth have a blue-brown translucence
~ Change coming from the effect of the dentin, not a problem w/ enamel, similar
to tetracycline stain
~ Opalescent look ranges from mild to severe in different types
o Both primary and permanent dentitions involved
o Often have complete pulpal obliteration
~ Takes a bit to realize that there is no pulp
~ Some forms have extremely large pulps, but obliteration more common
o Often have a lot of dental caries
o Often Class III malocclusion
~ Caused by maxillary hypoplasia
o Florid Cemento-osseous dysplasia
~ On rare occasion xrays show multifocal RL, mixed RL or
RO that
resemble those seen in florid COD
Osteogenesis Imperfecta (contd)
Types of Osteogenesis Imperfecta
o Type I
~ Autosomal Dominant Inheritance
~ Most common, mildest
~ Blue sclera, bone fractures, hearing loss, hypermobile joints, bruising
o Type II
~ Autosomal Dominant, Autosomal Recessive, Sporadic
~ Most Severe
~ Still borne or early death
~ Bleu sclera, extreme bone fragility, fractures during delivery
o Type III
~ Autosomal Dominant, Autosomal Recessive
~ Most severe beyond perinatal (around time of birth, shortly before or after) age
~ Severe bone fragility, normal to blue sclera fades w/ age, lax ligaments, hearing loss
~ 1/3 survive to adulthood, most die in childhood from cardiopulmonary complications
o Type IV
~ Autosomal Dominant
~ Mild to moderately severe bone fragility, normal to blue sclera, less fractures after puberty
o Opalescent teeth may be present in all types
Histopathological Features
o Attenuated bone (thin, weakened)
o Minimal matrix
o Immature woven bone, does not transform to lamellar bone
Treatment and Prognosis
o Bone fracture management
o Teeth often show attrition
o Overall disability depends on severity of disease
o
o
Osteopetrosis
Osteo= Bone
Petrosis= petrified hard (Note- Osteosclerosis does not equal osteopetrosis)
Aka Albers-Schonberg Disease and Marble Bone Disease

Rare disease of osteoclastic defect (More rare than osteogenesis imperfecta)
o Bone not resorbed b/c osteoclasts do not function normally
Infantile osteopetrosis
o Ranges from malignant intermediate transient (return to normalcy)
o Autosomal recessive
o Increased Bone Density Marrow failure, frequent fractures
o Narrowing of skull foramina compression of cranial nerves
~ Results in blindness, deafness, facial paralysis
o Delayed tooth eruption
~ Osteomyelitis of jaw common complication of tooth extraction
~ Roots of teeth difficult to visualize b/c of density of surrounding bone
Adult Osteopetrosis
o Usually benign- less severe
o Autosomal dominant
o Axial skeleton has significant sclerosis, whereas long bones have little or no defects
o Increased radiopacity of medullary portions of jaw bone
o 40% Asymptomatic, but in symptomatic bone pain frequent
Cleidocranial Dysplasia
Aka cleidocranial dysostosis (old name), b/c little portion of the clavicle formed
Inheritance
o Autosomal Dominant and Spontaneous Mutation
o Defect of Osteoblastic differentiation
Clinical and Radiographical Features
o Hypoplasia (under development), Malformation, or absence of clavicles
~ Patient has no clavicles so patient can touch shoulder
o Short stature, Large heads, frontal bossing (big forehead),
o Ocular hypertelorism (wide spread eyes), Depressed nasal bridge
o Open skull sutures, wormian bones
Oral Features
o Increased prevalence of cleft palate
o Retained deciduous teeth
o Unerupted permanent and supernumery teeth
~ Note- can have supernumery teeth w/o this syndrome
~ Tooth eruptions not fully understood- hypothesized to
cementum development, but controversial
o Narrow ascending mandibular ramus, Mandible has coarse
trabeculations w/ areas of increased density, pointed coronoid process, thin zygomatic arch
o May develop class III malocclusion
Treatment
o None for skull, clavicular and bone anomalies
o For dental problems- preferred treatment to extract primary and supernumerary teeth
Focal Osteoporotic Marrow Defect

Defect in bone marrow, aka hematopoetic bone defect
o Normally, hematopoetic marrow not found in jaws, marrow is just fibro-fatty, not making RBCs
o In these patients they have hematopoetic marrow, they are making rbc
Not a true Neoplasm
o May be aberrant bone regeneration following extraction
o Persistent fetal marrow
o Marrow hyperplasia to meet increased demand for rbcs
Clinical Features
o Always asymptomatic, rare disease
o 75% adult females
related to
70% posterior mandible, usually edentulous area

No expansion
o Hematopoetic cells in radiograph
o X-ray shows subtle change of trabeculation
~ Periapical view shows ill defined borders and fine trabeculation
o Panoramic view ay appear radiolucent and well defined
o Incidental findings
o Usually several mm to cm
Histological Features
o Normocellular hematopoietic marraow
o megacaryocytes and blood cells, the only way you would be able to see this is by biopsy
Treatment and prognosiso Bx-dx, once diagnosis established, not further treatment is needed, prognosis excellent
Idiopathic Osteosclerosis
Idiopathic- unknown cause
Osteo-bone
Sclerosis- Increase in calcified material
Definition
o Focal increased radiodensity that is of unknown cause and cannot be attributed to any
inflammatory, dysplastic, neoplastic, or systemic disorder
~ Not response to inflammation- note how both premolars look normal
~ Generally assoc w/ teeth that dont have anything wrong w/ them
~ Notice area of sclerosis under mandibular premolars
o Fairly common, most dont need biopsy
o If Lesions at periapical region of nonvital, carious, or inflamed pulp it is probably
condesing osteitis or chronic sclerosing osteomyelitis
~ Note- -itis" usually deals w/ inflammation, which is not idiopathic
Clinical features
o 5% prevalence (this is a common disorder)
o Slightly higher in Blacks and Asians
st
nd
o Arise late 1 or early 2 decade
o Static or slow increase in size (sclerotic area stabilizes once patient reaches full maturity)
~ May have slow increase in density to 4th decade
o Asymptomatic, they do not cause pain, or an increase in size of bone
o More common in mandible (90%)
~ 1st molar area, premolar, 2nd molar
o Usually one, but may be multiple
o Aka bone scar (she doesnt like that name), dense bone island, bone eburnation, bone whorl, enostosis, focal
periapical osteopetrosis
o Well defined, rounded or elliptical radiodense area
~ Usually uniform density
o No radiolucent rim (no capsule)
o 3mm 2 cm
o Often assoc w/ a root apex
Histopathologic Features
o Dense lamellar bone
Diagnosis
o Not usually biopsied (If you biopsy, you will just get vital bone)
~ Only considered if assoc w/ symptoms or significant cortical expansion
o Diagnosis based on history, clinical features and radiographic findings
o Must make differential as to whether it needs biopsy or not
o Differentiation from condensing osteitis difficult but absence of deep restorations or caries, a periapical RO
assoc w/ vital tooth is most likely idiopathic osteosclerosis
o
o

o If discovered during adolescence, take periodic
until area stabilizes
o After that no treatment indicated
Description of radiograph
o 1cm, radioopacity in lower left mandible, well
radiographs
circumscribed
Massive Osteolysis
Rare disease of unknown cause, aka hemangiomatosis of bone
Destruction of bone (disappearing density) replaced by vascular proliferation followed by fibrous fill
Clinical Features
o Children and young adults
o 50% report trauma preceded diagnosis
o Usually in mandible (when there is maxillofacial involvement)
~ Similar lesions seen in other bones i.e. pelvis, humeral head and shaft, and axial skeleton
o Signs and Symptoms- Mobile teeth, pain, malocclusion, deviated mandible, facial asymmetry, sleep apnea,
pathologic fracture of mandible
o Radiolucent foci of varying size w/ poorly defined borders
o Loss of lamina dura, thinning of cortex
o Gradually coalesce enlarge and involve cortical bone portions of involved bone disappear
o Nonspecific vascular proliferation w/ inflammation
o In later stages tissue from area of bone loss I more collagenized
o Variable clinical course, variable treatment
o Radiation most successful but failures occur, and patient at risk for postradiation sarcoma
Pagets Disease of Bone

Characterized by abnormal resorption and deposition of bone
o Tend to think of skeleton as static, but it is dynamic, it is always laying down and breaking down
o Patients turnover is out of sink, more laying down than breaking down
o Patients get thickened and enlarged bones, affect entire body
o Note bones are not stronger, b/c its defective bone
Clinical Features
o Common in Britain and US, rare in Africa and Asia
o Occurs more in males, usually over 40 y.o.
o Usually polyostotic (affect more than one bone)
~ Usually occurs in more than one bone, especially skull
o Bone pain and osteoarthritic changes
o Lumbar vertebrae, pelvis, skull, femur most commonly
affected bones
o Thickened, enlarged, weakened bones
~ Bowing of long bones
~ Enlargement of skull circumference
o Unexpected elevation in serum alkaline phosphatase levels
Oral Features
o Jaw involvement (17%)
o Diastema forms
~ start to have space b/w teeth (recall that this may occur in periodontal
disease as
well, so must distinguish)
o Denture wont fit (usually bone resorbs under denture)
o More frequent in maxilla than mandible
o Mouth protrudes, enlargement of middle 1/3 of face
~ Normally maxilla has slight concavity

Pagets Disease of Bone contd
o Must take radiograph to determine if its soft (i.e. hypergingiva) or
hard tissue (bone
enlargement in Pagets)
o Decreased radiodensity w/ patch sclerosis
~ Cotton wool
~ pic- skull enlargement, notice abnormal texture of skull, has
cotton wool
appearance, cloudy finger like projections
o Hypercementosis- cementum enlarged around each tooth (can occur w/o pagets)
Diagnosis
o Elevated serum alkaline phosphatase (so elevated that its off the
charts, very high,
this is major diagnostic feature)
~ but normal calcium and phosphorus
o Combined with clinical and radiographic findings
o Pagets goes thru phases- in biopsy~ increase in osteoblastic and osteoclastic cells
~ ncreased activity than expected in patient this age, causing reversal lines
o Chronic and progressive
o Dont really have cure, just treat the symptoms
~ Bone pain w/ analgesics
~ Serum alkaline phosphatase w/ parathyroid hormone
antagonist
~ Make denture bigger
o This is metabolic disease- so removing bone wont cure it, the bone
wont heal
well
Complications
o Extractions must consider hypercementosis
o AV shunts, oral surgery during active phase may result in extensive hemorrhage
o Poor healing
o Osteosarcoma develops 1% (b/c of all this activity)- aggressive and assoc w/ poor prognosis
Central Giant Cell Granuloma (or lesion)
Central- within the bone (Note- periphery- is outside bone, in gingiva when discussing jaws)
Non neoplastic lesion
Common disease of unknown cause
It is not a granuloma, just and old misnomer
Clinical Features
o Seen in young persons,
~ 60% under 30
~ Can occur in all ages (2-80 y.o.)
o Mandible > Maxilla
~ May cross midline in mandible
~ Usually anterior to 1st molar
o Usually asymptomatic but may have expansion, pain, paresthesia, ulceration
o Non aggressive lesions- No symptoms, Slow growth, no perforations or root absorption
o Aggressive lesions- Pain and recurrence, Rapid growth, cortical perforation, root resorption
o Benign fibrosseous lesion may mimic odontogenic lesion
~ i.e. if this lesion was in 18 yr old in posterior mandible it would look like an odontogenic lesion due to 3rd
molar
Central Giant Cell Granuloma (or lesion) contd
Left Pic- Well defined radio lucent area, notice thinnes of cortex of mandible
Right Pic - Buccal and lingual expansion, w/ multiple loculations
o Radiolucent
o Unilocular or multilocular
o Well defined borders, but noncorticated
o Notice shift is impacted tooth
o This looks like an odontogenic lesion (neoplasm) , but its
benign fibroseous lesion
o May be assoc w/ aneurysmal bone cyst, central odontogenic fibroma
o Microscopically we see multinucleated giant cells in a background
ovoid cells cells
~ May show hemosiderin deposits
~ Looks like brown tumors of hyperparathyroidism
~ Pathologist would diagnose Central Giant Cell Granuloma
hyperparathyroid cells b/c from microscope
cant differentiate
~ Doc must do a serum test for hyperparathyroid- test Ca levels
o Must rule out multifocal lesions (more than one lesion, in more
quadrant), which suggests cherubism
o Microscopically different than odontogenic lesion (odontogenic
have giant cells)
o Usually treated by thorough curettage (scraping)
o Recurrence 15-20% (high)
o Alternative treatment~ Corticosteroids, calcitonin, interferon
~ Sometimes injected w/ cortocosteroids to let them shrink a little bit than perform
surgery
o The more aggressive the treatment the lower the recurrence rate, but surgeon must
choose balance
o More difficult to treat once it breaks thru cortex of mandible
o pic of excision, showing that disorder can be very aggressive
Different than giant cell tumor,
o which is lesion of the long bone, more aggressive, may become malignant
o
o
Cherubism
Inheritance
o Autosomal Dominant w/ high penetrance variable expressivity
Clinical Features
o Usually manifest b/w 2-5 y.o.
~ Progresses till puberty, stabilizes, regresses
o Cherublike face
o Upturned eyes
o Usually bilateral symmetrical enlargement of posterior mandible
angle and ascending rami
~ In maxilla involvement occurs in tuberosity areas
not, its a
of spindle to
rule out
pathologist
than one
lesion wont
including
Eventually they are self limiting and will shrink a bit

Tooth displacement and failure to erupt
o Multilocular, expansile, bilateral radiolucent areas
~ Virtually diagnostic
o Rarely unilocular
o Rarely other bones
Syndrome Association
o Ramon, Jaffe- Campanacci, Noonan-like
o Multinucleated giant cells in a vascular, fibrous stroma
~ May show eosinophilic cuffing
o These look the same microscopically as Central Giant Cell Granuloma, but occur in
more than one quadrant
Diagnosis and Treatment
o Look at age, radiograph, biopsy, family, and location, to determine Dx of Cherubism
o Natural history is unpredictable
o May regress after puberty
o Optimal therapy unknown (surgery vs. observation)
o Rare disease
o
o
Simple Bone Cyst

Benign, empty or fluid filled cavity w/in bone, w/o an epithelial lining
o Tends to be empty
o Not a true cyst- b/c doesnt have a epithelium lining, filled w/ fluid
Causes and Pathogenesis
o Trauma-hemorrhage theory- trauma to bone that is insufficient to cause a fracture results in intraosseous
hematoma if it doesnt repair it may liquefy resulting in a cystic defect
o aka traumatic bone cyst,
~ implies trauma, while there isnt always a history of trauma
Clinical Features
o Occurs in almost every bone, most common in long bones
o More common in mandible, esp premolar and molar areas
o Most frequent b/w 10-20 y.o.
o Rare under 5 yrs or over 35 y.o.
o Usually asymptomatic
~ 20% have painless swelling
Simple Bone Cyst (contd)
o Well delinieated radiolucent area
~ May be focally ill definied
~ Cyst in jaw like water balloon
o 1 -10 cm
o May scalloping b/w teeth roots
o Vital teeth, generally do not show root resorption
o Less commonly expansile
o May occur in association w/ cemento-osseous dysplasia and other BFOL
o Lined by thin fibrovascular connective tissue (not epithelium)
Diagnosis
o Bx - Dx
o Before a surgeon will biopsy a bony lesion
~ Must always aspirate b/c there may be a hemangioma (vascular lesion) in bone, if
not present you get a serous fluid, not bloody
o
o
~ Simple bone cyst tend to be empty

~ Biopsy gives scant tissue
~ But going to biopsy, helps stimulate healing
Requires clinical/pathological/radiographic correlation
No Ray, No say - must give pathologist a pic of x-ray for them to make diagnosis
~ Need clinical, pathologic, and radiographic correlation
Aneurysmal Bone Cyst

Aneurysmal- vascular lesion
Intraosseous accumulation of blood filled spaces (hemorrhagic extravasation)
o May have giant cell granuloma like areas
o Sinisoidal, large spaces filled w/ vascular tissue (not a hemangioma)
Cinical Features
o Occurs in long bones and verterbrae
o Rare in jaws
o Wide age range, mean approx 20 y.o.
~ Commonly in posterior part of jaw
o Rapidly growing swelling
o May move teeth
o Pain reported, but paresthesia, compressibility and crepitus are rarely seen
o Unilocular or multilocular radiolucent area
o Cortical expansion and thiining
o Borders may be well or poorly defined
o May have small radioopaque foci
o Sinusoidal spaces filled w/ flood
o Cellular fibrous CT
o Multinucleated giant cells and osteoid
o May be associated w/ central giant cel granuloma or other BFOL
Aneurysmal Bone Cyst (contd)
Diagnosis and Treatment
o May do small biopsy- may have giant cells, but this can happen in a lot of diseases esp around the edges
~ Important to correlate, clinical radiograph and pathologic features
~ Recall- disease can have as many diseases as he pleases
o Currettage or enucleation
~ Dark venous blood wells up
~ Tissue is like blood soaked sponge
o Variable recurrence rate
Pic 1- lateral obliqe film, notice how inferior border has expanded, its
radiolucent,
ill defined w/ a thin cortex
Pic 2- radiolucent, multilocular, extending from posterior body up the ramus,
expanding
mandible (notice cortex close to tooth), displacing impatcted bone cyst
(notice
occlusal view of mandibular 3rd molar)
o Differential- giant cell granuloma rule out hyperparathyroidism,
cherusim
Slide 40
From appendix- please refer to it, we didnt go over all of it
Slide 41
Differential- Simple bone cyst, central giant cell granuloma (crosses midline),
Review remaining slides

Quiz next week including picture
Oral Pathology
Dr. Childers- Lec 3, chap 14 (pp.553-
1-20-2006
FIBRO-OSSEOUS LESIONS
Classifications are important b/c there are usually reasons that diseases are grouped together
Fibro-osseous Lesions
Classification of diverse processes that have:
o Normal bone replaced by fibrous tissue w/ calcified tissue production
It is not a specific diagnosis
Histologically they often look the same, but radiographically they are different
o Important to get radiograph w/ biopsy (no ray no say)
o Need both pieces of info to make diagnosis
Developmental, reactive, dysplastic, neoplastic processes
o Prognosis for various processes w/in this classification are different, must be able to distinguish
Fibrous Dysplasia
Very common
Developmental process (not neoplastic), usually starts in kids
o Sporadic condition from postzygotic mutation in GNAS 1 gene
Tumorlike condition, characterized by replacement of normal bone by an

excessive
proliferation of cellular fibrous connective tissue mixed w/ bony trabeculae
Types of Fibrous Dysplasia
st
o One of 1 thing to be determined is how many bones are involved:
~ Monostotic Fibrous Dysplasia Limited to a single bone
If mutation occurs postnatal life, mutated cells are essentially
confined to
one site fibrous dysplasia affectss single bone
80-85% of all cases, jawxs most commonly affected site
~ Polyostotic Fibrous Dysplasia Affects many bones and may be associated w/ cutaneous and endocrine abnormalities
If mutation occurs in undifferentiated stem cells in early embryologic life osteoblasts,
melanocytes and endocrine cells will carry and express that mutated gene
If mutation occurs during later period (once skeletal progenitor cells developed), multiple bone
lesions of fibrous dysplasia w/o cutaneous and endocrine problems
~ Craniofacial Fibro Dysplasia
Affects bone in the face and cranium
Behaves like monostotic, eventhough if may affect multiple bones adjacent to maxilla
I.e. - if infection in maxilla and zygoma it is not polyostotic, its craniofacial
Clinical Features
o Painless swelling of affected area
o Growth generally slow
nd
o Usually diagnosed in 2 decade
~ Often 1st diagnosed by dentist, often begins in jaws
o Occurs in Males = Females
o Maxilla > Mandible
Fibrous Dysplasia
o Ovoid or Fusiform- (football shaped) growth
~ As opposed to a neoplasm, oseofibroma (?)
which has
centriphical growth (sphere)
~ Shape of lesion impacts treatment
o Borders are not well demarcated
o Cortex is expanded
o Cortex is often lesional bone
~ Its not eroded, its become lesion
~ Smooth clear border cortex become lesion
~ Treat this with a shave- b/c its not a neoplasm that needs to be completely removed, note this wont cure
it
o Ground Glass aka smoke screen aka orange peel finely granular trabeculations
~ Must know what normal bone looks like to identify this
~ Pic- Look under 1st molar and b/w 1st molar and 2nd premolar its not
normal
o Narrow PDL space and ill defined lamina dura
o Pic- Axial CT- note you have cortex on one side, and lesion on other, get a
feel for
altered trabeculations
o Lesional bone w/ smoke screen appearance
o Pic- Maxillary lesion- to the right of septum, note these lesions have a little
bit of
cortex all around (remember thats not hard and fast rule)
Polyostotoic Fibrous Dysplasia
o More serious
o Rare involvement of 2 or more bones
o May be in conjunction w/ cutaneous and
endocrineabnormalities
o Jaffe-Lichtenstein syndrome
~ Caf au lait pigmentation- brown spots (macules)
Coast of Main- rough, rocky coast; irregular borders, typical for

fibrous dysplasia
Coast of California- smooth borders, more common in disorders
neurofibromatosis
McCune-Albright Syndrome
~ Caf au lait pigmentation
~ Assoc w/ syndromes like endocrinopathies
Precoclous sexual development- patients develop early
Pituitary adenoma
hyperthyroid
Usually dominated by symptoms related to long bone lesions
~ Hockey stick deformity- leg length discrepancy may
involvement hockey stick shaped lesional bone; enlarged,
Go thru different stages where they appear differently at
lesion
polyostic
like
resultfrom femur
but not normal
differenttimes of
Fibrous Dysplasia (contd)

Histological Features
o Chinese character trabeculations
~ Loosely arranged fibrous stroma (background), w/ small oddly shaped trabeculations
~ Trabeculae are not connected to one another
o Monotonous pattern through out lesion
o No osteoblastic rimming
o Dont make diagnosis just on slide, need radiograph and clinical
o Fuse directly to adjacent normal bone, so no capsule or line of demarcation is present
Treatment
o Excision usually not possible
o Early treatment may induce growth
o Cosmetic reduction shave down
o 25-50%
o Radiation therapy is contraindicated
~ it may induce osteosarcoma, which is rarely reported as a complication of fibrous dysplasia
Prognosis
o Osteosacrcoma rarely reported
Cemento-osseous Dysplasia (COD)
COD aka Osseous dysplasia
Occurs only in the jaws (in tooth bearing areas)
o Most common fibrous osseous lesion
o Theorized to arise from PDL (a unique structure of the jaw), or a defect in extraligamenterary bone remodeling
due to local factors or a possible underlying hormonal imbalance
Classification (consider it a spectrum of disease)
o Focal Cemento-osseous Dysplasia
~ Clinical Features
Single site involvement
90% females- avg 38 y.o.
Usually caucasian
Asymptomatic
Posterior mandible dominant site
Lesions usually < 1.5cm
~ Radiographic Features
Varies from radiolucent to radiopaque w/ radiolucent rim
- Mostly mixed RL/RO pattern
Borders are well defined but irregular
Lesions occur in edentulous and dentulous areas

Focal lesion may represent early florid lesion
- Cant distinguish from florid by radiograph alone
Goes thru stages
- 3rd pic shows early stage on right side of molar (?)
- 4th pic- left side of molar may be further along note calcification inside

Classification (contd)
o Periapical Cemento-osseous Dysplasia~ Clinical Features
Periapical region of anterior mandible, usually multiple lesions
- Kind of b/w focal and florid, often the beginning of florid
Usually Females (10-14:1)
Middle ages (Diagnosed 30-50y.o.)
- Almost never under 20
Usually Black (70%)
Teeth are almost always vital (alive), and rarely have restorations
- Note vitality test are not 100%
- You havent helped your patient if you do endodontic therapy and they dont need it
Patient is Asymptomatic
Application- No caries, middle aged black women, and you notice this on radiograph, a light should
go off; keep an eye on it
Early Lesions- Well circumscribed radiolucent area at apex of vital
mandibular
incisor teeth
Looks like periapical granuloma or periapical cyst
- Over time, lesion coalesce to for linear area
encompassing apices of several teeth
Later Lesions
- Mixed radiolucent and radiopaque
Mature Lesions
- Circumscribed, dense calcification surrounded by a
radiolucent
rim
- Usually Asymptomatic
- PDL intact, not enlarged
- Not fused to tooth
- Seldom greater than 1cm diameter
- Self limiting growth
- Does not expand cortex
~ Differential- Periapical Pathology
solitary, unilocular, well circumscribed, radiolucency at base of
anterior
tooth, most dentist think pulpal pathology
- But may be beginning of periapical COD
Must distinguish, are they symptomatic, do they fit the
demographic
it, watch it
You dont treat periapical COD
o Florid Cemento-osseous Dysplasia~ Clinical Features
Multifocal involvement
- More than one quandrant and sextant
involved,
not limited to anterior mandible
Lesions come in all sizes and shapes,
- Can be lumpy, or smooth
May be symmetrical

Classification
o Florid Cemento-osseous Dysplasia~ Clinical Features (contd)
Usually asymptomatic but may have painful
sequestra or
expansion
- Sequestra- A piece of necrotic tissue, usually
bone, that
has become separated from the surrounding
healthy
tissue
- Symptomatic- pain, swelling, little portions
of bone
come to surface
- Often have inflammatory component, seems like inflammation fires up disease process
90% Black Female, Middle age to elderly
Same pattern of maturation as focal COD and periapical COD (radiolucent mixed radiopaque
w/ radiolucent rim)
More sharply defined radiolucent areas may represent simple bone cysts
- Bone cyst may need treatment as well as Florid COD
Lesions found in dentulous and edentulous areas
Pics- same
patient in 2 different times

COD Histopathologic Features
o All 3 patterns are similar
o Tissue consists of fragments of cellular mesenchymal tissue composed of spindle-shaped fibroblasts and
collagen fibers w/ numerous small blood vesseW
o Fibrous Connective tissue w/ woven bone, lamellar bone and cementum
~ Mature lesions have mineralized product that looks like ginger root- more bulbous
o In final stage individual trabeculae fuse and form lobular masses composed of sheets or fused globules
COD Diagnosis
o Focal COD~ Usually needs biopsy
~ Surgical findings of gritty tissue that does not separate easily from adjacent
bone
o Periapical COD or Florid COD
~ Cinical and radiographic evidence
~ May not necessitate a biopsy
COD Treatment
o Since its not a neoplasm, it doesnt just shell out (come out easy), lesion comes out gritty
~ Ossifying fibroma, on contrary is a neoplasm and will shell out easily
o May not require treatment
o
o
o
o
~ Root canal will not help- lesion wont heal

During predominately radiolucent phase lesions cause few problems
Once significant sclerosis present- lesions tend to be hypovascular and prone to necrosis w/ minimal
provocation
~ Best treatment is regular recall w/ prophlaxis and reinforcement of good home hygiene
Can cause complications
~ Difficult extractions
~ Ridges dont do well under dentures
Symptomatic patients difficult to treat
~ Inflammatory component is like a chronic osteomelitis involving dysplastic bone and cementum
~ Antibiotics may not be effective
~ Sequestration of sclerotic cementum like masses occurs slowy and is followd by healing
~ Saucerization of dead bone may speed healing
Prognosis for COD is good
Simple bone cyst may need biopsy for diagnosis
~ Simple bone cysts often do not heal as rapidly as those in younger patients w/o COD
Familial Gigantiform Cementoma

Rare
Autotosmal Disorder, patient has big sclerotic masses in jaws
o Disorder of gnathic bone that ultimately leads to the formation of massive sclerotic masses of disorganized
mineralized material
Clincal Features
st
th
o Begins to manifest in 1 decade and continues till 5 decade
~ Rapid and expansive growth in adolescence
o Both maxilla and mandible affected in multiple sites
o Progresses to facial deformity and may have sequestra formation
~ Gnathic enlargement in most patients results in significant facial deformity
o Teeth may be impacted, displaced and malocclusion may result
o In final stage, affected bone is very sensitive to inflammatory stimuli and becomes necrotic w/ minimal
provocation (similar to COD)
~ May have elevated alkaline phosphatase, anemia and adenomas of the uterus
o Begin as radiolucent areas and progress to dense sclerotic masses w/ a radiolucent rim
o Initially similar to cemento-osseous dysplasia
o As lesion progresses, affected sites replace much of normal bone w/in involved quadrant and devlop mixed
RL/RO pattern
o Same as cemento-osseous dysplasia (Ginger-root, bulbous appearance)
Treatment
o Best recontoured during sclerotic phase
~ Before this phase, dyspastic tissue rapidly regrows
Establish a Differential Diagnosis
unilocular radioopacity, 2cm, well circumscribed, at apex of mandibular

premolar,
Note PDL in check
Chart from Neville appendix radiopacities well demarcated borders
Pic- occlusal view- ground glass, radioopacity, had fibrous dysplasia
Note this is not cotton wool- cotton wool is usually only seen w/
pagets disease
Fusiform- has ovoid like appearance
Occlusal view gives a lot of information, must take x-rays at

different views to get full understaning
Chart from appendix- Poorly demarcated borders

Must learn to understand differential
Cemento-osseous dysplasia- can be well or poorly defined, sometimes disorders fall in more than one category
Must describe what you see, develop a well developed differential diagnosis, and even if you are wrong, there is no
malpractice here
o i.e. have unilocular well defined, lesion at apex of non vital tooth you may do a root canal, but if you find out
that is not the problem, you are not at fault, take biopsy, it may be metastatic prostate cancer but you
werent at fault for doing root canal, thats why differential is important
Chart- Ground glass
Panoramic picture
Multifocal, well demarcated, mixed lesions, 2-3cm,
Differential- Florid Cementoosteus Dysplasa(2 quadrants)
Note- panoramic radiographs are difficult to use as diagnosis in

anterior region, familial gigantiform cementoma, pagets
Chart- Radiopacities- Multifocal or Generalized

Pic- crop of panoramic
Mixed, well demarcated, 2-3cm, body of mandible
Dysplasia- cemento-osseus dysplasia, pagets, familial gigantiform cementoma

Chart- mixed radiolucent/radioopaque lesions- well demarcated border
Pic- crop of panaromic pic
Well circumscribed, radiolucent, 2-3cm, periapical region
Diferential - Central Giant cell granuloma, simple bone cyst, aneurismal, periapical pulpal
pathology
Chart unilocular radiolucencies, other locations

Pic- panoramic
Multifocal, well demarcated, radiolucent and mixed lesion (notice

anterior region)
Differential- Florid cemento osteos dysplasia, pagets, cherubism (maybe), familial gigantiform
Chart- mixed RL/RO multifocal or generalized

Chart- unique radiographic appearance- cotton wool
Oral Pathology - Dr. Childers

Lecture 4, Chap 14 (pp. 563-574)
1-27-2006
FIBRO-OSSEOUS LESIONS of the JAW
Ossifying Fibroma
Aka Cementifying Fibroma, or Cemento-Ossifying Fibroma
True osteogenic neoplasm of fibrous connective tissue and calcified product
o Must keep in mind if its metabolic, neoplastic, developmental, etc
o Origin is odontogenic or from PDL
Clinical Features
rd
th
o Wide age range most 3 and 4 decades
o Occurs more in females than males
~ Premolar and molar
o Small tumors asymptomatic
~ May grow large causing facial asymmetry
~ Rarely assoc w/ pain and paresthesia
o Surgically separates easily from surrounding bone (different than COD which is gritty)
~ There is a plane of separation, it is shelled out
~ Well circumscribed
o Can present similar to focal cemento-osseous dysplasia
o Well defined and unilocular
o May have sclerotic borders
~ may be very thin borders if lesion has been there for a long time
o Radiolucent, mixed, or radiopaque
~ Rarely large radiopaque w/ thin radiolucent rim that is usually end stage focal cemento-osseous
dysplasia
o This is centriphical (sphere) growth, like a snowball
~ Unlike fibrous dysplasia that grows like fusiform (football)
o May cause movement or resorption of teeth, or root divergence
o May bow cortex downward-
~ Doesnt erode thru cortex, and cortex doesnt become lesional bone (like fibrous dysplasia) it just pushes
thru bone (bow)
o Well demarcated from surrounding bone
~ Grossly submitted as one mass or a few large pieces
o Fibrous connective tissue w/ mineralized material
~ Variants of bone (hard tissue portion resembling trabeculae of
osteoid and
bone; and basophilic, poorly cellular spherules resemble
cementum)
o Osteoid and osteoblatic rimming are usually present
o Variations in types of mineralized material help distinguish from
fibrous
dysplasia
o Goes thru stages
~ May start of radiolucent, calcified material may be microscopic, then becomes more circumscribed
o Gross Specimen
~ Looks like cut potato
~ Shelled out
Ossifying Fibroma contd

Treatment and Prognosiso Enucleation (removal of lesion) usually possible due to circumscribed borders of lesion
o Rare recurrence
o No evidence of malignant transformation
Juvenile Ossifying Fibroma
Aka Juvenile Active Ossifying Fibroma and Juvenile Aggressive Ossifying Fibroma
Variant of ossifying fibroma
o Differs from conventional ossifying fibroma on the basis of patient:
~ Age (younger patient)
~ Site
~ Clinical behavior (more aggressive)
o 2 forms- Trabecular and Psammonatoid
Clinical Features
o Slow growth
o Wide Age range
~ Trabecular mean age 11
~ Psammoma mean age 22
o More common in Maxilla
o May show expansion
o May impinge and extend into adjacent anatomic structures
~ Orbit, Nasal Cavity, Cranium
~ Psammoma variant also seen in orbital, frontal and Paranasal sinuses
o Younger patients may have more aggressive growth
~ Slow growth typically, but can be very aggressive and grow
o Circumscribed radiolucent area, may contain radioopacities
o Sinus lesions may appear as cloudy
o Part of panoramic pic- radiolucent/mixed well circumscribed,
(pushing superior cortex into coronoid process, and expanding
has pushed developing tooth, approx
5 cm
o CT Scan- mixed, expanding buccal cortex and a bit of the lingual,
well circumscribed
o Nonencapsulated but well demarcated
o Fibrous CT stroma
fast
expansile
inferior cortex),
Trabecular calcifications- are strands of osteoid lined by osteoblasts and osteoclasts

Psammamatoid calcifications- are concentric rings of calcified material w/ brush borders
Treatment
o Smaller lesions may be locally excised
o Larger lesions may need to resection
o Must be treated aggressively
Prognosis
o Recurrence 30-58%
o Malignant transformation not reported
Osteoma
Benign tumor of craniofacial skeleton
o Pretty common lesion, rare in other bones
o This is a neoplasm (controversial)
~ Somewhat like a tori, but tori arent neoplastic
Clinical Features
o Found in young adults
o In Jaws- Arise on surface of bone or in medullary bone
~ Periosteal osteoma- on surface of bone as polypoid or sessile mass
On mandible or maxilla, may reach large size facial deformity
~ Endosteal osteoma- w/in medullary bone**
o Often asymptomatic, solitary lesions
o Most located in lingual side of body of mandible posterior to premolars, or on the Condyle
o Slow growing
o May involve condyle
~ Result in change of occlusion, facial swelling, pain, limited
opening,
deviation of midline of chin twd unaffected side
Associated with Gardeners Syndrome
o Not every patient w/ osteoma will have gardeners syndrome
o Must rule out Gardner Syndrome
o Radiopaque
o Circumscribed sclerotic mass
o May have trabeculation
o Small endosteal osteomas hard to differentiate from foci of sclertotic bone representeing end stage of
inflammatory process (i.e. condensing osteitis) or non-inflammatory process (i.e. idiopathic osteosclerosis)
o Dense, Vital bone, May be:
~ compact bone- normal appearing dense bone w/ minimal marrow tissue
~ cancellous bone- trabeculae of bone and fibrofatty marrow
o prominent osteoblastic activity
Treatment
o Conservative surgical exicision vs. periodic observation
o Condylar osteoma usually removed surgically
~ Must be treated if you needed removable prosthesis
Prognosis
o Dont regularly recur
o No reported malignant transformation
o
o
Gardeners Syndrome
Rare Autosomal Dominant Disorder
o Chromosome 5
o Part of familial colorectal polyposis
o Gardeners is familial- once one family member has it they check other family members
Clinical Features
nd
o Colonic polyps arise in 2 decade
~ Adenomas transform into adenocarcinoma

~ malignant or premalignant polyps in colon
Gardeners Syndrome
Clinical Features (contd)
o Oral manifesetations
~ Osteomas- arise in puberty
Most commonly invove skull, paranasal sinuses, and mandible
In mandibular angles- often assoc w/ facial deformity
Osteomas seen before symptoms of bvowel polyps
3-6 osseous lesions
Osteomas are histologically the compact type cant microscopically differentiate from solitary
osteoma
~ Supernumerary teeth (not as common as cleidocranial dysplasia)
~ Impacted teeth
o Other manifestations
~ Epidemoid cyst
~ Desmoid tumors
~ Thyroid Carcinoma
~ Other- involve skin, soft tissues, retina, skeletal system
Treatment
o Colectomy- remove colon to prevent future growth of tumors
~ High rate of malignant transformations 50-100%
o Dentists are a part of diagnosis
Differential
o Kuteigers syndrome- also has polyps in colon but they are benign
Osteoblastoma and Osteoid Osteoma
OSTEOBLASTOMA- benign neoplasm of bone that arises from osteoblasts
o resemble cementoblatoma, but not fused to root of tooth
o Clincal Features
~ Rare in jaw
~ Slightly higher occurrence in mandible (in posterior regions)
~ Slightly higher occurrence in males
~ Usually < 20y.o.
~ 2 -4 cm
~ Painful- not well relieved by aspirin
o Radiographic Features
~ Well defined or ill defined radiolucent area w/ patchy radiopaque foci
~ Mixed RL/RO
o Histopathologic Featurs
~ Prominent reversal lines in calcified product
~ Calcified material surround by osteoblasts and osteoclasts
Have a lot of ostoblasts
~ Prominent vascularity
o Aggressive Osteoblastoma~ Tends to be larger than osteoblastoma
~ Epithelioid osteoblasts seen histologically
~ May resemeble osteosarcoma- which are very aggressive
Osteoblastoma and Osteoid Osteoma contd
OSTEOID OSTEOMA- related to osteoma
o Clinical Features
~ Distinguished from osteoblastoma by size (looks like osteoblastoma, but smaller)
~ Rare in jaws
~ Focus of peripheral nerves, produce prostaglandins
~ Patients have nocturnal pain

Often relieved by aspirin b/c lesion causes release or prostaglandins (which is relieved by aspirn)
~ Histologically similar to osteoblastoma
~ Well circumscribed RL defect
~ Small radiopaque nidus giving a targetoid appearance
Nidus is a point of calcification
~ May have sclerotic rim
~ Usually < 1 cm (note- osteoblastoma >2cm)
Cementoblastoma
True odontogenic neoplasm
Arises from cementoblasts
o Better classified as odontogenic than bone
o Probably classified as an odontogentic lesion, but
radiographicallyseems like a benign ___???
Clinical Features
o Rare
~ Almost always near mandibular 1st permanent molar (50%) (premolar-molar region 90%)
o Children and young adults
o Pain and Swelling
o Radiopaque mass fused to tooth root
o Surrounded by a thin radiolucent rim
~ Soft tissue halo around it
o Outline of root is obscured by lesion
~ Lesion so attached to root that it is obliterated
o Tooth is usually vital
st
o Pic- Notice radiolucent soft tissue halo, at the mandibular 1 molar
~ Notice how distal root is obliterated/obscured by lesion
o Resembles osteoblastoma
~ Sheets of trabeculae w/ prominent reversal lines
o Distinguished by fusion to tooth root
o Cementoblasts on outer covering of root
o Multinucleated Giant cells
o Noncalcified matrix around periphery
Treatment/Prognosis
o Surgical extraction of tooth and lesion
~ It is a neoplasm- the entire thin needs to be removed
o If completely removed they dont recur
Chondroma
Benign neoplasm of hyaline cartilage
Found in jaws, more commonly in hands and feet
Easily misdiagnosed, often asarcoma (microscopically and histologically)
o Have aggressive microscopic appearance
Clinical Features
rd
th
o Arise in 3 and 4 decades
o Usually found in condyle or anterior maxilla
o Painless, slow growing tumors
o May move teeth and resorb roots
Radiographic
o Mixed Radiolucent area w/ radiopaque center
o Solitary site
Syndrome Assoc
~ Ollier disease: multiple, unilateral lesions
~ Maffucci syndrome: skeletal chondromatosis, soft tissue angiomas
o Mass of mature hyaline cartilage
o May mimic chondrosarcoma
Treatment
o Typically tumor removed completely
o
Chondromyxoid Fibroma
Very rare, benign neoplasm
Found also in long bones
Clinical Features
o Wide age range 10-67 years (mean 30yrs)
o Occurs more in Mandible
o Pain and swelling noted
o Circumscribe Radiolucent area
o Sclertoic or scalloped borders
o 1-6.5cm
o Lobules of cartilage (chondroid), myxoid material, and fibrous material
~ Myxoid is a gelatin like material clinically; microscopically it has an abundance in glycose aminoglycans
(ground substance)
o Spindle and pleomorphic cells
Treatment
o Conservatively by curettage
~ Curretage- scoop out
~ Opposed to resection where you cut on each side
o Recurrence common in long bones, rare in jaws
Synovial Chondromatosis (quickly reviewed in lecture)
Nonneoplastic joint disease of unknown cause
More common in long bone, but can found in jaw (in condyle)
Clinical Features
o Nonneoplastic arthropathy characterized by metaplastic development of cartilaginous nodules w/in the
synovial membrane
o 3 Stages~ foci of metaplastic cartilage arises in synovial lining
~ foci grow and detach- cartilage material in synovial membrane and joint
~ loose bodies in joint- cartilage material found only in joint
o Middle aged patients
o Females > Males
o Joint selling, pain, crepitus, limited opening
~ Aka Joint mice- little pieces of cartilage that get in joint, painful, causing swelling
o Loose bodies- rounded, irregularly shaped, and variably sized radiopaque structures in fregion of joint
o Irregular head of condyle head, irregularity of joint space, widened joint space
o Nodules of cartilage w/in synovieum and lie losse in joint space
Treatment
o Pieces of loose cartilage removed by scope
o Prognosis good w/ low frequency of recurrence
Desmoplastic Fibroma (quickly reviewed in lecture)
Bony counterpart of soft tissue fibromatosis

Clinical Features
o Growth of fibrous CT in bone
o <30 y.o. (mean 14yrs)
o Primarily in Molar-angle-ramus area of mandible
o Painless swelling
o Locally aggressive
o Usually unilocular, but can be multilocular
o Margins well or ill defined
o Expansile
o Thinned Cortex
o Fibroblasts and Collagen
o Usually treated determined by location, but typically they are excised
Pic
2 cm, well circumscribed radiolucent spherical lesion, mesial to root of
nd
2 molar which is supererupted w/ large carius lesion
Differential- periapical cyst or granuloma, simple cyst, focal ossifying dysplasia
Chart- Unilocular radiolucencies- other locations
Central ossifying fibroma
Cemento osseous dysplasia
Central giant cell granuloma
Odontogenic keratocyst
Central ossifying fibroma
These are other choices that the previous radiograph may have been
Pic- 2 molars
Radiolucent lesion, approx 2cm, ill defined borders, at apex of
mandibular 1st and 2nd molars
Differential- central giant cell granuloma, early phase of cementodysplasia, osteosarcoma
Chart- radiolucencies- poorly defined or ragged borders
o Periapical cyst or granuloma
o Osteosarcoma
o Ewings sarcoma
o Hematopoietic bone marrow defect
o Simple Bone cyst
o Massive osteolysis
osseous
Pic- segment of panoramic radiograph

1cm Radioopaque, well circumscribed, lesion at inferior border of
mandible, below the 1st and 2nd mandibular molars,
nd
rd
Differential- osteoma, hard to come up w/ 2 and 3 for this pic
Chart- radiopacities- well demarcated borders
Pic- Periapical radiographs
Multilobular Spherical radioopacity approx 7 mm b/w
roots of mandibular CI,
o Note- multilobular used w/ radiopacities, whereas
are radiolucent (like soapbubbles)
Note- impacted tooth
Differential- possible rudimentary supernumery teeth
(not well formed, malformed teeth, ovoid with a little
radiolocular
bit of a taper), gardners, cleidocranial dysplasia

Chart- radiopacities- multifocal or generalized
o Florid cemento-osseous dysplasia
o Idiopathic osteosclerosis
o Pagets disease of bone
o Polyostotic fibrous dysplasia
o Osteopetetrosis
Pic- Segment of panaroamic radiograph

Well circumscribed mixed lesion, approx 2-3 cm, radiolucent halo
capsule, inferior to 2nd premolar and 1st molar, obliterating root
Radiolucent
Differential- cementoblastoma, ossifying fibroma, as a reach you
may periapical COD,
Chart- mixed RL/RO well demarcated borders
o Developing tooth
o Cemento-osseous dysplasia
o Ossifiying fibroma
o Calcifying odontogenic cyst
o Osteoblastoma/osteiod odontoma
o cementoblastoma
Oral Pathology I
Dr. Childers Lec 5 Chap 14 pp. 574-583
-
2-3-2006
MALIGNANT FIBRO-OSSEOUS LESIONS

They are deadly, sneaky
In dental office diagnosis often delayed from 6mo - 1 yr must think of it to diagnose it
Osteosarcoma
Mesenchymal malignancy that is bone producing, making malignant bone
Clinical Features
o Extragnathic Osteosarcoma (outside jaw, i.e. long bones tibia)
~ Bimodal age peak- get very young patients and older patients
Age 10-20- complain of knee pain (sneaky b/c can be thought to be due
to growth)
Over age 50 years- In jaws its mostly in adults
o Rare in jaws (usually in long bones)
o Mean age 33 years old
~ Wide age range but most 3rd and 4th decades (older than extragnathic occurrence)
o Males > Females
o Maxilla = Mandible
~ Inferior portion of maxilla (alveolar ridge, sinus floor, palate)
~ Posterior body and horizontal ramus of mandible
o Pain, loose teeth- mimics periodontal disease and caries
o Paresthesia- numbness, or altered sensation in nerve distribution; (key in thinking about this)
o Nasal Obstruction, Slow growing
o Difficult to diagnose b/c clinical and radiographic hard to point out
~ Changes are subtle, you must think of it
o Vary from dense sclerosis mixed radiolucent
o Ill defined borders
o Root resorption
o Root Spiking- teeth become conical and spiked
~ Malignancy gets into PDL, easier coarse to travel then bone
~ Malignancy whips around root and replaces it
Symmetrical widening of PDL and movement of teeth

Bone formation above CEJ (Good clue for malignancy)
~ In perio you get bone resporption, and its not easy to grow back, bone doesnt regenerate once perio
treated
~ In xray where bone is above CEJ this should be red light, dont think its good b/c they dont have perio
problem
~ Note- normal bone grows up to 2mm below CEJ
o Pic- Note widening PDL, movement of the teeth (must get history to confirm)
~ Alveolar bone b/w molars is high (subtle), it looks a bit more
radiopaque, but hard to see
o Sun ray or Sunburst appearance on occlusal radiograph
~ Only in about 25% of cases, Is very subtle
~ Almost looks like cotton wool- so Pagets
may be a
differential, but recall Pagets is usually
bilateral,
where this is on one side
Osteosarcoma
o Malignant mesenchymal cells producing bone
o Considerable histologic variability
Treatment
o Surgical excision w/ neoadjuvant or adjuvant
(pre or post op) chemotherapy
o This is view of specimen of excised jaw
~ Notice sunburst appearance (usually on occlusal, but get this view since this is no longer attached to
patients)
Prognosis
o Local recurrence may cause death w/in 2 yrs
~ Recurrence assoc more frequently w/ maxillary tumors
~ Metastases asso c w/ mandibular tumors
o Metastasis usually to lungs and brain
o Survival 30-50%
Subclassifications of Osteosarcoma
O PERIPHERAL (JUXTACORTICAL ) OSTEOSARCOMA
~ Oseteosarcoma that originates on the surface of the cortex and does not involve the intramedullary bone
Generally osteosarcoma starts in bone, but sometimes they start on surface
~ Parosteal (outside)
Pedunculated nodule attached to the cortex
No elevation of periostum, no new bone formation
Good prognosis if treated adequately
~ Periosteal- (under periosteum)
Sessile nodule under the periosteum
Elevated eriosteum w/ new bone formation
Fair prognosis if treated adequately
O POSTIRRADIATION BONE SARCOMA
~ Sarcoma arising in a bone that has been previously irradiated
Secondary to radiation, i.e. patient w/ squamous cell carcinoma
~ Develops 3-14 years after radiation
~ Correlates with radiation dose
0.2% w/ 7000cGy vs. 0% for less than 1000cGy
~ Oteosarcoma most common type, then fibrosarcoma, chondrosarcoma
~ Histology and prognosis same as for de novo
o
o
Chondrosarcoma
Mesenchymal malignancy that is cartilage producing Malginancy of cartilage
o Closely related to osteosarcoma, clinically you distinguish (both in clinical differential)

Clinical Features
th
o Usually older patient- Peak age 7 decade
~ Wide age range (Mean age 41.6 yrs)
~ 20% under 20 yrs
o Painless mass or swelling (note pain w/ osteosarcoma)
o Separation or loose teeth
o Possible nasal obstruction, congestion, epistaxis, visual loss
Chondrosarcoma
o Note- same as patient on clinical pic
o Very subtle on radiograph
o Poorly defined borders
o Radiolucent but may have mixed appearance or opaque
~ More commonly RL than osteosarcaoma
~ Variable amt of radiopaque foci, caused by calcification of cartilage matrix
~ May be multilocular radiolucent and mimic benign process
o May have sunburst appearance
o Symmetric widening of PDL Space
o Rarifaction loss of trabeculation seen in palate of pic
o Panogram not as good b/c loose detail on midline
o Cartilage matrix
o Cells may show varying degrees of maturation
o May infiltrate b/w osseous trabeculae
o Grade Correlates w/ growth and prognosis (dont need to know too much detail)
~ Grade I- Well differentiated, subtle variations from normal cartilage, most common
~ Grade II- Increased cellularity and pleomorphism
~ Grade III- Poorly differentiated, rare
~ Variants Clear cell chondrosarcoma- abundant clear cytoplasm
Dedifferentiated chondrosarcoma
Prognosis
o Related to size, location and grade
~ Location influences resection
o Radical surgical excision
~ Adjunctive radiation and chemotherapy
o Recurrence is often late
o Treated a bit differently than osteosarcoma
o Generally do better than osteosarcoma
Sub classification of Chondrosarcoma
O MESENCHYMAL CHONDROSARCOMA
~ Small differentiated cells that dont make alot of cartilage (poorly differentiated sarcoma)
~ Aggressive but Rare
~ Clinical Features Jaws Common
nd
rd
2 or 3 decade
Swelling and pain
~ Radiographic Features Circumscribed radiolucent area
Stippled opacities
~ Histopathologic Features
Small, undifferentiated mesenchymal cells
Foci of well differentiated cartilage

~ Treatment/Treatment
Surgical excision w/ wide margins
Recurrence common but may be late, 10 year survival 28%
Ewings Sarcoma
Neuroectodermal malignancy t(11;22)
o `Some features of neurons of features of ectodermal cells
Clinical Features
o Rare in jaws
nd
o Peak in 2 decade
~ 80% less than 20y.o.
o Slight male predominance
o Majority white, rare in Blacks
o Painful swelling
o Fever, leuckocytosis, elevated ESR (erythrocyte sedimentation rate)
o Paresthesia (numbness), loose teeth
o Tumor penetrates thru cortex Soft tissue mass over bone
o Clinical Differential- Chondrosarcoma, osteosarcoma, ewings sarcoma
o Ill defined, radiolucent area
o May or may not have cortical destruction or expansion
o Onsionskin (layering appearance)~ Lesion breaks thru periosteum it spreads body reacts body regenerates
another layer of periosteum lesion spreads and breaks thru cycle continues
~ Problem w/ onionskin also occurs in garays osteomalytitis, which is rxn to
non vital 1st molar in real young patient but this is just an infection not a
malignancy
o Pic - Occlusal view- lingual has sunburst like appearance, on buccal it has an
onionskin like appearance
Histolopathologic Features
o Small round cells
o May contain glycogen
o Immunohistochemical studies show CD99 rxn
o Gene studies for transolocation
Metastatic Tumors to the Jaws

Most common is metastatic carcinoma
o Breast, Lung, Prostate
st
o Kidney (renal cell carcinoma)- famous for showing up 1 as a metastatis
~ Often people dont know they have renal cell carcinoma
see metastasis (this also happens in thyroid)
o Hematogenous spread- spread thru blood (as opposed to
lymph)
Clinical Features
o Older Patients, children rare
o Pain, swelling, loose teeth, mass, paraesthesia (Numb-chin
until they
spread thru
Syndrome)
Metastatic Tumors to the Jaws

Clinical Features
o Non healing extraction site
~ A clue is the paraesthesia that you get w/ osteosarcoma and chondrosarcoma, except that it affects the
chin; if patient comes in complaining of this and pain, an extraction wont help
~ Patients will have a non healing extraction site
~ If you threw out the tissue instead of biopsy you wouldnt know the problem
They mimic a lot of things
o Usually radiolucent
o Ill defined
o Mimic periapical lesion- May have unilocular well circumscribed radiolucency w/ big
restorations
~ Give RCT and it doesnt heal, must think of something else
o Also may mimic periodontitis
o May resemble primary site
o Correlation w/ medical history and clinical evaluation
o May be treated by excision or radiation
o Poor prognosis
~ Patient stage IV
o 5 year survival rare
o
Osteosarcoma w/ altered trabeculations

Ill defined borders
Tricky b/c supereruption looks like it is due to non opposing tooth
Axial ct
Well circumscribed, expansile, RO
Altered trabeculation more solid and dense than normal medullary bone (try to find
area of comparison to normal bone)
Notice tooth movement
Large RO thats pushing teeth around is reason for worry, but cant tell from this one
image if its benign or malignant
Differential- Osteosarcoma, Juvenile ossifying fibroma (these 1st 2 are often hard to
distinguish), ewings sarcoma, osteoblastoma
RCT therapy, apicoectomy done (removed apex), post and cord w/ apical seal
Ill defined borders (radiolucency clear, but surrounding area not as clear), radiolucent, 23cm, periapical to the lateral mandibular incisor
This is a metastatic lesion

Endo wants us to make a differential
This is not pulpal
Differential- Pulpal, periapical granuloma, radicular cyst, metastatic tumor
Oral Pathology- Dr. Childers

Lecture 6 & Text Ch.15 pp. 589-610
2-10-2006
ODONTOGENIC CYSTS
Odontogenic Cysts and Tumors Odontogenic cysts- encountered relatively commonly in dental practice
Odontogenic tumors- uncommon lesions
Important topic- definite Board Questions; not very controversial, pretty straight forward, generally are rare, but
show up in jaws, so dentists are one to find
Odontogenic Cysts
Epithelium lined cysts in bone
o Cyst- pathologic cavity lined by epithelium that may or may not be filled w/ fluid or epithelium
o Almost unique to the jaws
o Epithelium derived from odontogenic epithelium
World Health Organization (WHO) Classification
o Developmental Cysts of unknown cause
o Inflammatory Cysts due to inflammation
o There are several type of classifications
Pic shows all odontogenic cysts in one
Dentigerous Cyst
Most common type of developmental odontogenic cyst (you will see this)
Formed by the separation of the follicle from the developing crown of an unerupted tooth
Primarily Developmental, but can get an inflammatory component
o i.e. if partially erupted, bacteria can get in
Clincial Features
o Cyst attached to tooth at the CEJ
~ as crown developments, follicle is attached right at CEJ
~ this is distinguishing factor from other cysts i.e. follicle lower down on root
~ cant have this cyst in erupted tooth, b/c once tooth erupted follicle goes away
May involve any unerupted tooth

~ Most common mandibular 3rd molars
rd
Also incl. max canines, max 3 molars, mand
2nd premolars
~ Rare in decidous teeth
~ Rare in supernumerary or odontoma
~ May be expansile
~ May become infected and be assoc w/ pain and
swelling
Usually from partially erupted tooth or by extension from a periapical lesion of adjacent tooth
o Patient Type
~ Discovered frequently in patients 10-30 y.o.
~ Slight male predilection
~ Prevalence higher for whites than for Blacks
o Paradental cyst- assoc w/ periocoronitis and sometimes w/ enamel pearl
~ assoc w/ buccal aspect (where you get enamel pearl), its not necessarily around same area as dentigerous
cyst
Dentigerous Cyst contd
o Unilocular Radiolucency assoc w/ crown of impacted tooth
~ May appear multilocular if large (rare)
o Well defined, Sclerotic border (white line indicative of slow growth, allows bone to recalcify)
~ An infected cyst may show ill-defined borders
o Cyst-to-Crown Relationship
~ Central- Tooth crown may be in center of RL area
~ Lateral- cysts grows laterally along root surface and partially surrounds crown
rd
assoc w/ mesioangular impacted mandibular 3 molars that are partially erupted
~ Circumferential- crown and significant portionof root appears to lie w/in the cyst
~ or may extend down root
o Cyst may displace teeth and/or resorb roots of adjacent erupted teeth
o Dentigerous cyst vs. enlarged follicle
~ May be difficult to distinguish hyperplastic dental follicle
from typical
small dentigerous cyst
~ Normal space for follicle is about 2-3 mm
~ so it is dentigerious when it is larger than this 3-4mm
~ when space enlarged we call it a cyst
o Pic- Solitary unilocular, radiolucency, look how cyst locks in at CEJ (that area should make you think
dentigerous cyst),
o Radiographic Differential: Odontogenic keratocyst, unilocular ameloblasts
o Nonkeratinized squamous epithelium
o Fibrous CT
o Odontogenic (epithelial) rests present w/in fibrous wall
o Inflamed cysts~ inflammatory cells
~ varying amts of hyperplasia
~ more definite squamous features
o Rarely includes mucous cells, sebaceous cells or ciliated cells
o Gross
~ Nodular thickening on luminal surface must be examined
microscopically to rule out presence of early neoplastic change
o Recurrence rare if completely remove
o Treatment~ Completely remove cyst and unerupted tooth
Notice pic- when you take it out, you have this sac
o
~ To preserve tooth, partially remove cyst wall ortho treatment to assist eruption
~ Marsupialization- for lager cysts; permits decompression of cyst excised later w/ less extensive
surgical process
o Rare transformation to
~ ameloblastoma (lining undergoes neoplastic transforamation)
~ squamous cell carcinoma (may arise in lining of dentigerous cyst)
~ intraosseous mucoepidermoid carcinomas (from mucous cells in lining)
o Must inform patients that there is a small risk of transformation, and should be followed radiographically
~ i.e. older patient w/ impacted tooth cyst epithelium may change
Eruption Cysts
Soft tissue counter part to dentigerous cyst
Result of separation of dental follicle from crown of erupting tooth that is w/in the soft tissues overlying the alveolar
bone
Clinical Features
o Soft, often translucent swelling of gingival mucosa over the crown
of an
erupting tooth
~ Erupting tooth does break thru, and swelling occurs in mouth
~ Sometimes can be cut, and tooth would come thru
o Usually < 10 y.o.
st
o Most common: 1 molars and maxillary incisors
o Eruption Hematoma
~ Cyst may be filled w/ blood
~ Cyst may appear blue to purplish-brown color
o Can look like abscess clinically, but when you take a radiograph and see there is
no pus, and tooth is coming thru, you know its an eruption cyst
o Usually in children
~ May be in 3rd molars, but not typically, b/c even if cyst occurs its not due to
3rd molar trying to erupt
o Usually only roof of cyst
o Oral mucosa on one side
o Stratified squamous lining on the other
o Underlying lamina propria shows variable inflammatory cell infiltrate
o May rupture spontaneously
o May be unroofed surgically (simple incision)
o Tooth usually erupts
Odontogenic Keratocyst
Some other classifications of Odontogenic cysts are: Odontogenic keratocysts and all others
Biologically behaves differently than all other cysts
This is an important odotogenic cysts
Primordial Cyst- missing tooth and get cyst in its place, no longer called this
Arises from dental lamina (that strand of epithelia that connects bell and
developing tooth to surface)
o In some patients when it does not completely dissolve, it can cause
trouble
o These cysts can occur all thru the bone
Benign neoplastic cyst
o Some may say that its not developmental, rather its neoplastic
o It is an aggressive cyst
Odontogenic Keratocyst contd
Clinical Features
o Can occur in any age range, most 10-40 y.o.
o Slight male predominance
o Mandible- 60-80% of cases
~ Posterior body and ramus
~ Note- Can occur anywhere in jaw
o May be small and asymptomatic or large w/ pain, swelling and
infection
o Tend to grow anterior-posterior without expansion
~ i.e. growing up ramus
~ Differential- dentigerous and radicular cysts of comparable size are usually assoc w/ expansion
o Sometimes assoc w/ impacted tooth, sometimes not
o Sometimes can be assoc w/ only soft tissue
o They are assoc w/ syndrome: Nevoid basal cell carcinoma
(Gorlin)
syndrome
~ Most patients w/ syndrome have this cyst
~ Not all patients w/ this cyst have this syndrome
~ If patient has more the one odontogenic kerocyst, you think
of syndrome
o Has been reported as peripheral
o Those occurring in anterior midline maxillary region can mimic nasopalatine duct cysts
~ This subset of keratocysts usually occurs in older individuals 70 y.o.
Radiographic
o Well defined radiolucent area w/ corticated borders
o Multilocular radiolucency or unilocular
o May encompass crown of unerupted tooth 25-40%
~ If unilocular, RL encompassing crown dentingerous cyst
should be
in differential
o May resorb roots
~ (less common than noted w/ dentigerous and radicular cyst)
o Radiographic Differential- dentigerous cyst, radicular cyst, residual cyst, lateral periodontal cyst, fibroosseous
lesion (depending on location)
Histopathologic Features***
o Diagnosis of odontogenic keratocyst is based on histopathologic features
o Epithelial lining of stratified squamous epithelium, 6-8 cells thick
o Inconspicuous rete ridges
~ Basal area smooth b/c of loss of rete ridges
o Luminal surface is
~ Corrugated (wavy)
~ Parakeratin (still has nuclei)
o Hyperchromatic and palisaded basal cell layer
~ Palisated = nuclei line up like a picket fence
o Satellite cysts aka daughter cysts, goes along w/ dental
lamina, can take out major cyst and see other smaller cysts
o Inflammation may obscure diagnostic features
o May be filled w/ transudate or keratinaceous debris
o General pathologist- often dont know difference b/w
odontogenic keratocyst and dentigerous cyst
Odontogenic Keratocyst contd
Treatment
o Aspiration
o Enucleation and curettage
~ Surgeons will aspirate anytime they go into bony lesion
~ Pic of aspiration is not a blood lesion (usually get some red
~ Curettage is a little controversial- most surgeons will take a bone bur and pull out lesions; with lesions in
maxilla this is more difficult
~ Complete removal of the cyst in one piece is often difficult b/c of thin, friable nature of the cyst wall
o Must refer for evaluation to rule out syndrome
Prognosis
o High recurrence rate (5-62%)
o Must follow patient long term form recurrence
~ Many recurrence after 10 yrs later
o Rarely do the turn to squamous cell carcinoma
Orthokeratinized Odontogenic Cyst

Not a specific clinic diagnosis
Clinical and Radiographic Features
o Young adults
o Males > Females
o Usually unilocular
o Usually in a dentigerous relationship
rd
o Often involve unerupted 3 molar
o Range from 1-7 cm
o Differential- Dentigerous cyst
~ Have no clinical or radiographic features that differentiate them from an inflammatory or developmental
odontogenic cyst
~ Behave like a dentigerous cyst- it doesnt recur; usually around impacted tooth
o No nuclei keratin
o Epithelial lining (stratified squamous) w/ orthokeratinized luminal surface
o Basal area not palisaded
~ Dont confuse w/ odontogenic keratocyst*
o Recurrence rare
Nevoid Basal Cell Carcinoma Syndrome
Autosomal dominant w/ high penetrance and variable expressivity
Mutation in PTCH (patched), a tumor suppressor gene
Clinical Features
o Multiple basal cell carcinomas of the skin (Nevi = a lot)
~ Earlier age- puberty or 2nd-3rd decades
~ Non-sun exposed skin and midface
~ Blacks have fewer BCC
o Odontogenic keratocysts
~ Multiple cysts
~ Young age
~ Most patients who have OKC dont have syndrome, but most
have syndrome have OKC
o Palmar and plantar pits (on palms)
o Calcified falx cerebri
o Intracranial calcification
o Enlarged head circumference (frontal and temporoparietal bossing)
~ Mild ocular hypertelorism
~ Mild mandibular prognathism
o Rib and vertebral anomalies- i.e. spina bifida, kyphoscoliosis
o Ovarian fibroma, medulloblastoma, meningioma, cardiac fibroma,
patients who
rhabdomyoma
Same as isolated orthodontic keratocyst

Basal cell tumors cannot be distinguished from ordinary basal cell carcinomas
o Most manifestations not life threatening
o Prognosis generally depends on the behavior of the skin tumors (BCC most serious)
o The odontogenic keratocyst are treated by enucleation (the same ase as isolated ones)
~ But in may patients cysts will continue to develop resulting in
varying degrees of jaw deformity from multiple cyst
operations
If patient has syndrome and its a spontaneous mutation they must be
checked b/c they may have more serious lesions
Differential- OKC should come to mind w/ this radiograph, also cherubism
should come to mind
o
o
Gingival Cyst of the Newborn

Arise from remnants of the dental lamina
Small, superficial, keratin-filled cysts found on alveolar mucosa of infants
Similar inclusion cysts,
o Eptsteins pearls- found in midline of palate (from fusion)
o Bohns nodules found- remnants of salivary gland formation, seen
bilaterally
Clinical Features
o Common; up to of all new borns
o 2-3mm, white, papules on alveolar ridge of neonates
o Often multiple
Gingival Cyst of the Newborn contd
Clinical Features contd
o See along alveolar ridge b/c thats where dental lamina is
o Tiny white filled cystic area, They look like little rice grain
o They dont require treatment
o Parakeratinized epithelial lining filled w/ keratinaceous debris
o No treatment indicated
o Spontaneous involution
~ burst and heal w/ no real problem
o Lesions rarely seen after 3 months of age
Gingival Cyst of the Adult
Arises from dental lamina (rest of Serres)
Soft tissue counterpart to lateral periodontal cyst
Clinical Features
o Mandibular cuspid and premolar area (60-70% of time)
~ Maxillary cysts usually found in incisor, canine & PM area
th
th
o 5 and 6 decade
o Almost always on facial gingival or alveolar mucosa
o Painless, dome shaped nodule < 0.5cm in diameter
o Blue or gray
o Superficial to the periosteum
~ Superficial to periosteum- These are not
radiograph
~ When patient comes in w/ swelling on
cyst must take radiograph to
in bone- seen from
determine if its bony

May have some cupping of bone that is
apparent when cyst excised
~ If significant bone missing, its arguably a lateral periodontal cyst that eroded the cortical bone, not a
gingival cyst originating in mucosa
o Similar to lateral periodontal cyst
o Thin epithelial lining w or w/o focal plaques containing clear cells
o Clear cells are glycogen rich, representing the dental lamina
o Simple excision, Rare recurrence, Prognosis excellent
o
Lateral Periodontal Cyst (Botryoid Odontogenic Cyst)

Arises from dental lamina, uncommon developmental odontogenic cyst
Intrabony counterpart of Gingival Cyst of the Adult
o Gingival cyst of adult related is just soft tissue
o Lateral periodontal cyst is part of bone
Differential- odontogenic keratocyst, simple bone cyst, central giant cell
o Note- can have a pulpal origin lesion on lateral of root b/c there are lateral
bit rare)
Lateral Periodontal Cyst (Botryoid Odontogenic Cyst) contd
Clinical Features
o Occurs along the lateral surface of a tooth root
th
th
o 5 to 7 decade (Rare before age 30)
o 75% in mandibular premolar/cuspid/lateral incisor area
~ Should not think of this when RL around impacted tooth, in ramus or near molar
~ In maxilla, cysts appear around same region
o Well circumscribed
o Radiolucent
o Lateral to root of vital teeth
o Less than 1.0cm
o Botryoid odontogenic cyst- may appear multilocular
~ Polycystic appearance; grape like cluster of small individual cyst
Histopathlogic Features
o Thin epithelial lining w/ focal nodular thickenings and clear cells
~ Only 1-3 cells thick in most area
o Conservative enucleation
o May preserve adjacent teeth
o Bone comes out as cyst, does not recur
o Botryoid variant may recur
~ Botryoid- is the multilocular variant of lateral perio cyst
~ Microscopically they are the same except for one this is multilocular
~ They also have a slight higher % of occurring
Calcifying Odontogenic Cyst (COC)
Has features of both a cyst and a neoplasm
Can also occur w/ other odontogenic tumors
Variants
o Intraosseous (central)
o Extraosseous (peripheral)
granuloma
canals (is a
Cystic
Solid
o Odontogenic ghost cell tumors
Can have a lot of different features but can be lumped together b/c they dont know that much about it
May be associated w/ other odontogenic tumors, commonly odontomas (20%)
o Adenomatoid odontogenic tumors and ameloblastomas have also been associated w/ COC
Clinical Features
o Predominantly introsseous
~ But 13-30% appear as peripheral (extraosseous)
o Maxilla = mandible
o Incisor and cuspid area 65% of cases
o Wide age range (mean 33 yrs)
~ COC assoc w/ odontomas tend to occur in younger patients (mean 17 y.o.)
~ Neoplastic variants appear in older patients
Calcifying Odontogenic Cyst (COC) contd
o Calcifications may be microscopic and not show up radiographically
o Central Lesions (Intraosseous)
~ Well Defined
~ Unilocular (occasionally appear multilocular) Radiolucency
Radiopaque or mixed appearance from calcifications w/in
radiolucency
~ Assoc w/ unerupted tooth 30% (most often a canine)
~ Usually 2-4 cm
~ Root resorption and divergence
Notice pic- pushed impacted tooth (bicuspid) out of way
~ Bottom Radiograph
RO mass above missing CI, unerupted tooth, tooth
pushed out
of way
Mixed dentition of young patient, this isnt supernumery
teeth, just
looks jumble b/c lesion is pushing teeth out of way
o Peripheral Lesions (Extraosseous)
~ If its peripheral it would be cyst just on gingival
~ Sessile or pedunculated gingival mass w/ no distinctive
clinical
feature
~ Can resemble common gingival fibromas, gingival cysts or
peripheral
giant cell granulomas
~ Notice pic- subtle lesion, slight expansion of palate
o Cystic structure 86-98% of cases
o Cyst lined by odontogenic epithelium
~ Basal layer resemble ameloblasts
~ Suprabasal layer resembles ameloblastoma
o Ghost cells~ Altered epithelial cells characterized by loss of
nuclei w/ preservation
of basic cell outline
~ cant see nucleus, but see shadow of it, nucleus
obscured by contents
of cytoplasm
o Calcified material, dentinoid material
o 20% assoc w/ odontoma
o Neoplastic (Solid) structures 2-16% of cases
~ Solid ones seem to act more aggressively
~ Peripheral cases are more often solid
~ Palisaded basal layer (like in OKC) and central stellate
reticulum resemble
ameloblastoma
o
o
~ Ghost cells and dentinoid differentiate COC from ameloblastoma

Treatment/Prognosis
o Simple enucleation
o Central lesions low recurrence rate, Peripheral lesions rarely recur
o When occur w/ another tumors, prognosis same as for the other tumor
o May have malignant features- Odontogenic ghost cell carcinoma
~ Recurrence common, 5 yrs survival 73%
Glandular Odontogenic Cyst
Rare developmenta cyst w/ salivary features
No place in clinical differential b/c its rare
Clinical Features
o They are very aggressive, push teeth around, expand mandible, cross
midline
o Middle aged adults- avg 49 y.o.
o Mandible 85% of cases
o Predilection for anterior midline
o May grow large (from <1cm to most of the jaw)
o May present w/ pain or paresthesia
~ Assoc w/ large cyst
~ Small cyst asymptomatic
o Multilocular radiolucency w/ well defined sclerotic rim
~ May be unilocular
o Cyst lined by squamous epithelium
o Luminal cells are cuboidal to columnar (May have cilia)
o May have mucous cells and mucous pools w/ mucicarminophilic material
o Glandular b/c they have mucous cells in them
o Epithelium lining has undergone change to become glandular epithelium
o May form plaques or thickenings
o Enucleation or curettage
o Tends to recur
Buccal Bifurcation Cyst

rd
Similar to paradental cyst- which usually occur distal or buccal of partially erupted mandibular 3 molars w/ a
history of pericoronitis
Uncommon inflammatory odontogenic cyst go in and try to clean out
Clinical Features
o Children 5-11 y.o.
st
o Buccal aspect of mandibular 1 permanent molar (May be bilateral)
~ When tooth erupts an inflammatory response may occur in surrounding follicular tissues that stimulates
cyst formation
st
o Tenderness assoc w/ erupting mandibular 1 molar
o Pushes roots to lingual, causing tipping
o May have swelling and pus
o Pocket formation of buccal aspect of molar (detected thru probing)
o Well circumscribed unilocular radiolucent area near buccal furcation (1-2cm)
o Occlusal view shows roots tipped to lingual
o May show proliferative periostitis
o Nonspecific inflamed cyst, prominent chronic inflammatory cell infiltrate
o Well circumscribed enucleation of the cyst w/o extraction of the tooth
o Usually complete healing w/ normalization of probing depths and evidence of bone fill w/in 1 yr
Odontogenic Carcinoma
Almost evey odontogenic cyst or tumor has been described to give rise to odontogenic carcinoma
o Rare but does occur
Typically in older patients
rd
Can mimic odontogenic teeth (thats why we like to extract impacted 3 molar especially w/ cyst around it)
May arise de novo or from an odontogenic cyst or tumor
o Residual periapical cyst, dentigerous cyst, lateral periodontal cyst, odontogenic keratocyst, orthokeratinized
odontogenic cyst
o Also may arise in an ameloblastoma or from the epithelial lining of odontogenic cysts
Clinical Features
o More common in older patients
~ Mean age 57 -61 y.o.
o Males > Females
o Pain and swelling
o May be asymptomatic
~ Diagnosis made only after microscopic examination of a presumed odontogenic cyst
o Mimics any odotogenic cyst
o May have ill defined borders
o Most carcinomas arising in cysts have been well differentiated squamous cell carcinomas
o Varies w/ size and location
o 5 yrs survival about 50%
o Often resemble squamous cell carcinoma- must rule out metastatic squamous cell carcinoma before accept as
odontogenic carcinoma
WHO CLASSIFICATION OF ODONTOGENIC CYSTS

Developmental Cysts
o Dentigerous Cyst
o Eruption Cyst
o Odontogenic Keratocyst
o Orthokeratinized Odontogenic Cyst
o Gingival (Alveolar) Cyst of the Newborn
o Gingival Cyst of the Adult
o Lateral Periodonal Cyst
o Calcifying Odontogenic Cyst
o Glandular Odontogenic Cyst
Inflammatory Cyst
o Periapical (radicular) Cyst
o Residual Periapical (radicular) Cyst
o Buccal Bifurcation Cyst
3-17-2006 Oral Pathology I Dr. Childers

Lec 8- Ch. 15 (pp. 610 619)
ODONTOGENIC TUMORS
Odontogenic Tumors
Diverse group of lesions histologically and clinically
WHO Classification of Odontogenic Tumors
o Tumors of odontogenic epitheliumo Tumors of odontogenic ectomesenchyme
o Mixed odontogenic tumors- composed of odontogenic epithelium and
ectomesenchymal elements
~ Dental hard tissue may or may not be formed in these lesions
o Note these are histologic classifications, you cant classify this way clinically
~ Need to make clinical differential as well
Know odontogenesis (development of tooth)
o Review histology of tooth development
o i.e. Reduced enamel epithelium where inner and outer
epithelium come together and collapse
Odontogenic Tumors are very uncommon
o Odontoma- more common, probably will see in practice
o Ameloblastoma- most common after odontoma
o Other types of odontogenic tumors are more rare, but you must
know
TUMORS OF ODONTOGENIC EPITHELIUM
AMELOBLASTOMA
Most important and common clinically significant odontogenic
tumor
NB- Odontoma is most common, but not as clinically significant
o You must treat it, but it wont kill or disfigure patient
Theoretically may arise from:
o Rests of dental lamina
o Developing enamel organ
o Epithelial lining of an odontogenic cyst
o Basal cells of the oral mucosa
Slow growing, locally invasive tumors that run a benign course in most cases
3 Different Clinicoradiographic Situations:
o Conventional solid or multicystic- 86%
o Unicystic- 13%
o Peripheral (extraosseous)- 1% (outside the bone, a nodule on the gingival)
AMELOBLASTOMA
Conventional Solid or Multicystic Ameloblastoma
Most common type of ameloblastoma
Solid or Multicystic
Benign tumor
Clinical Features
rd
th
o Wide age range- 3 7 decades
o Males = Females
o Some studies show higher prevalence in blacks
o 85% posterior mandible, molar ascending ramus area
o 15% maxilla, posterior
~ More clinically significant
~ Harder to treat
o Painless swelling
~ May be small and evident only in radiograph or grotesquely
~ Pain and paresthesia are uncommon
~ Notice in floor of mouth there is lingual expansion, need to
Note- tori typically bilateral on mandible
~ 5cm buccal and lingual expansion (mass) in posterior portion of
including the tuberosity
Area buccal to bicuspids is where tooth was extracted
o Multilocular radiolucent lesion typically
~ Soap bubble appearance- when loculations are large
~ Honeycombed appearance- when loculations are small
o May be unilocular- resemble any type of cystic lesion
o Buccal and lingual expansion common
~ Recall odontogenic keratocyst will have a large
extending to posterior portion of mandible w/o
helps w/ differential
o Root resorption
o Tooth displacement
o May encompass an impacted tooth
Desmoplastic ameloblastoma
o Radiographically resembles a fibro-osseous lesion
o Mixed RL and RO appearance
~ Does not have typical multilocular RL appearance
o It can be radio-opaque
o Usually occurs in anterior regions of jaws esp maxilla
Example- Radiolucent, multilocular well circumscribed, about 2cm b/w the roots
canine and premolar, with some tooth displacement
~ Differential- lateral periodontal cyst, ameloblastoma, odontogenic
central giant cell granuloma
Conventional Solid or Multicystic Ameloblastoma
o
large
take an x-ray
maxilla
tooth
lesion
expansion
of conventional
of the
keratocyst,
Microscopic patterns have little prognostic value

~ Follicular common
Islands of epithelium resemble enamel organ epithelium in
CT, looks
similar to stellate reticulum
Peripheral single layer of tall columnar ameloblast-like cells
w/
reversed polarity (nuclei are at apical end of cell)
~ Plexiform- common
Long, anastomosing cords or larger sheets of odontogenic epithelium, bounded by ameloblast like
cells
~ Acanthomatous- extensive squamous metaplasia assoc w/ keratin formation occurs
May be confused w/ squamous cell carcinoma or squamous odontogenic tumor
~ Granular Cell- abundant cytoplasm filled w/ eosinophilic granules that resemble lysosomes
Seen in young patients and clinically aggressive tumors
~ Desmoplastic- islands& cords of odontogenic epithelium in dense collagenized stroma
~ Basal Cell Pattern- least common
Nests of uniform basaloid cells
Similar to basal cell carcinoma of skin histopathologically
o More aggressive treatment, lower recurrence rates
o Curettage- 50-90% recur
~ Conventional ameloblastoma tends to infiltrate b/w intact cancellous bone
trabeculae at periphery of the lesion b4 bone resorption becomes
radiographically evident
~ Margin of tumor often extends beyond its apparent radiographic or clinical
margin
~ Curettage often leave small island of tumor w/in bone recurs
o Marginal resection 15% recur
~ Should be at least 1cm past radiographic limits of the tumor
o Maxillary tumors more difficult and dangerous, may infiltrate vital structures
o May rarely transform to malignancy
o
Unicystic Ameloblastoma
10-15% of all ameloblastoma
Unique clinical, radiographic, pathologic and prognostic features
Clinical Features
nd
o Younger patients 50% in 2 decade
o 90% in mandible, usually posterior
o Often asymptomatic, but large lesions can cause painful swelling
o Often resembles odontogenic cyst
rd
o Often circumscribed RL around crown of unerupted 3 molar (resemble dentigerous cyst)
o Other tumors appear as sharply defined RL areas and are
considered primordial, radicular, or residual based on
relationship to teeth
o May have scalloped margina
o Sometimes not assoc w/ impacted tooth
Unicystic Ameloblastoma
o Ameloblastoma may not be suspected until microscopic
examination
o Luminal- confined to cystic lining (luminal surface)
~ Fibrous cyst wall w/ a lining that consists totally or partially of ameloblastic epithelium
~ Basal layer of cells / hyperchromatic nuclei w/ reverse polarity and basilar cytoplasmic vacuolization
Intraluminal- nodules project into lumen

~ Nodules may be relatively small or largely fill cystic lumen
~ Sometimes nodule exhibits plexiform pattern seen in conventional ameloblastoma
o Mural- infiltratres the fibrous wall
o Diagnosis of unicystic ameloblastoma is made only after microscopic examination, b/c clinical and
radiographic findings suggest that lesion is an odontogenic cyst
o Enucleation or curettage suffice for luminal and intraluminal lesions
~ Mural lesions treatment is controversial- resection or radiographic observation
o Recurrence rate 10-20%
o
Peripheral Ameloblastoma
1% of ameloblastoma
Probably arises from rests of dental lamina beneath the oral mucosa or from basal epithelial cells of surface
epithelium
Clinical Features
o Nonspecific gingival nodule
~ nonulcerated sessile or pedunculated gingival or alveolar mucosal lesion
o Painless
o Wide age range, avg 52y.o.
o Most commonly found on posterior gingival and alveolar mucosa
o Somewhat more common in mandibular areas
o No bone involvement but may have some cupping
o Same features as the intraosseous form of the tumor
o Ameloblastic epithelium
o Plexifom or follicular patterns most common
o May be confused w/ a peripheral odontogenic fibroma microscopically esp if a prominent epithelial component
is present
o Innocuous (harmless) clinical behavior
o Local surgical excision
o Recurrence 15-20%- further excision almost always results in a cure
Missed lecture- notes from book, pwr point, and audio complete, except skipped audio on histo slides
explanation
3-24-2006 Oral Pathology Dr. Childers Lec 9 (text, lecture, and pwr point notes)
ODONTOGENIC TUMORS contd (same pwr pt as lec 8)
TUMORS OF ODONTOGENIC EPITHELIUM
Malignant Ameloblastoma and Ameloblastic Carcinoma
Rare, less than 1%, but can be deadly so you must know
Malignant ameloblastoma- looks histologically just like conventional ameloblastoma but it metastasizes (i.e. to
lung)
o Ameloblatoma that metastasizes
Ameloblastic carcinoma- cytologically malignant ameloblastoma
o More aggressive lesion
o When you look at slide it looks like malignancy
o Looking invasive is not the distinguishing characteristic b/c conventional ameloblastoma is invasive
o Cytologic features of malignancy include- Hyperchromatic nuclei, undifferentiated cells, abnormal and high #
of mtitotic figures
Clinical Features
o More commonly in elderly, but also happens in kids
o Wide age range 4-75 y.o.
o Time to transformation 1-30yrs, avg 10 yrs
~ Sometimes its not transformation, but it starts off malignant, sometimes it never goes thru benign phase
o Lung metastasis most common
~ Cervical lymph nodes 2nd most common site for metastasis
o Malignant Ameloblastoma appears same as
conventional
~ Malignant ameloblastoma is not predictable
b/c radiographically and histologically it
looks like conventional
o Ameloblastic Carcinoma may show ill defined
borders and cortical destruction
~ Histologically and radiographically looks
different than conventional
o Malignant ameloblstoma- appears same as conventional
o Ameloblastic carcinoma- cytologic features of malignancy
~ Mitotic figures
~ Increased nuclear to cytoplasmic ratio
~ Nuclear hyperchromatism
~ Necrosis
~ Dystrophic areas of calcification
o Poor prognosis, Few cases for analysis
o Patients with metastasis about 50% survival
o Ameloblastic carcinoma locally destructive
~ Uniformly aggressive clinical course w/ perforations of cotical plates of jaw and extensions of tumor into
soft tissue
Clear Cell Odontogenic Carcinoma

Rare, discovered in 1985, 20 examples reported to date
Clinical Features
o Most patients over 50 years
o Both maxilla and mandible reported
o May have pain or be asymptomatic
o Unilocular or multilocular radiolucent lesion
o Boders may be ill defined or irregular
o Epithelial cells with clear (eosinophilic) cytoplasm
o Histologically you see clear cells (cytoplasm transparent on histology), but you have features of carcinoma and
around periphery have odontogenic features
o This is a histologic diagnosis, it will not be in clinical differential
o May be difficult to distinguish from intraosseous mucoepidermoid carcinoma w/ prominent clear cell
component
~ Note- mucin stains for clear cell odontogenic carcinoma are negative
o Metastasis may occur (pulmonary or lymphatic)
o Most require fairly radical surgery
Adenomatoid OdontogenicTumor (AOT)

3-7% of odontogenic tumors
o More common,
Tumor- think of solid instead of cystic
Odontogenic
Adenomatoid- -oid means like so its gland-like
o Has specific clinical correlation which should make you think of this
o Start to think of this when you see ducts
Controversial whether its ectomesenchymal or epithelial
o Considered here to be odontogenic epithelium
o WHO considered to be mixed odontogenic epithelium and ectomesenchymal
Clinical Feature
o 10-19 yrs (66%)
~ Note- Clinically narrow age range
o Maxilla (anterior) more common than mandible 2:1
o Females more common than males 2:1
~ Note- specific clinical picture that should make you
o Relatively small: < 3cm
o Rarely peripheral- small sessile masses on the facial gingiva
~ Clinically cant be differentiate from gingival fibrous lesions
o Often asymptomatic~ Discovered on routine xray or when tooth not erupted
think of AOT
of the maxilla
o
o
o
75% pericoronal (must have unerupted tooth), mostly maxillary cuspid

Larger lesions cause a painless expansion of bone
So if you have an impacted cuspid in a female under 20 w/ RL over crown of it think AOT, also in differential
will be dentigerous cyst and OKC
Adenomatoid OdontogenicTumor (AOT) contd

o 75% circumscribed, unilocular RL involving crown of unerupted tooth
o Periocoraonal radiolucent enlargement of follicular space
o Can be radiolucent or mixed
~ Can have small calcifications so it may go into your mixed
differential
~ A pericoronal mixed RL and RO, solitary unilocular lesion,
o May extend down root from CEJ (helps distinguish from dentigerous cyst)
o Less often b/w roots of erupted tooth (not crown of unerupted tooth)
o Description of pic- unilocular mixed lesion, approx 2cm b/w the maxillary
lateral incisor
and cuspid, displacing teeth will possibility of root resorption
~ Differential- remember its mixed, so there is not much, ossifying fibroma, adenomatoid odontogenic
tumor, periapical osseous dysplasia
o Differnetial for RL Dentigerous Cyst
~ Max impacted canine w/ RL around it, differential = AOT and dentigerous cyst
~ But usually a dentigerous cyst comes right in CEJ
~ So if it slips down apically to CEJ in this specific patient type (young girl) you may want to put AOT
first, even though dentigerous cyst is more common
o Well defined w/, Thick capsule
o Tubular or Ductlike structures
o Small calcifications
o Narrow, anastomosing cords of epithelium in an eosinophilic loosely arranged matrix at
periphery of tumor adjacent to the capsule
Tretatment and Prognosis
o Completely benign
o Enucleation
~ usually shell out b/c its encapsulated, but usually have to take tooth out
o Recurrence rare to never
Calcifying Epithelial Odontogenic Tumor (Pindborg Tumor)
Rare, less than 1%
Clinical Features
o Wide age range, mostly 30-50 yrs
o 66% in mandible, posterior
o Painless, Slow growing swelling
o Rarely peripheral (peripheral variance is even more rare)
~ Appears as nonspecific, sessile gingival masses, most often on anterior gingiva
o Unilocular or multilocular (more often)
o Often margins scalloped (from lytic defect)
o Radiolucent or Mixed typically
~ May contain calcified structures of varying size and density
~ Driven snow (snow storm) appearance
~ But may also say RO
o May be well circumscribed or not well circumscribed (pic is well circumscribed)
rd
o Assoc w/ impacted tooth (mandibular 3 molar)
~ Calcifications w/in tumor most prominent around crown of impacted tooth
Calcifying Epithelial Odontogenic Tumor (Pindborg Tumor)- contd
Epithelial cells may have nuclear pleomorphism

~ b/c of nuclear pleomorphism thay have been misdiagnosed as cancer
o Areas of amorphous, eosinophili, hyalinized (Amyloid-like) material
o Concentric ring Calcifications (Liesegang rings)
~ Caused by calcifications w/in amyloid like material
o Several variations:
~ Clear cell variant- clear cells significant portion of epithelial
o Conservative local excision- resection includes a narrow rim of surrounding bone
o Lesions is posterior mandible treated more aggressively
o Recurrence around 15% (curettage has highest rate of recurrence)
o
component
Squamous Odontogenic Tumor

Rare
Arise from neoplastic transformation of dental lamina or perhaps epithelial rests of Malassez
Appears to originate w/in lateral portion of PDL of an erupted tooth
o Important b/c it can mimic periodontal disease
o Looks similar radiographically
Clinical Features
o Wide age range 8-74 yrs, avg age 38 yrs
o Randomly distributed thru out alveolar process, w/ no site of predilection
o Painless or mildly painful swelling
o Assoc w/ tooth mobility
o May be asymptomatic (lesions detected during routine radiograph)
o Multiple lesions in one patient have been reported
o Rarely peripheral
o Non specific triangular RL area lateral to root
o May mimic periodontal bone loss
o Somewhat ill defined borders or may show a well-defined sclerotic border
o Small lesions < 1.5 cm
o Bland, squamous epithelium
o Microscystic vacuolization and individual cell keartinizations w/in epithelial
islands
o Small microcysts
o Conservative local excision or curettage
o Rarely recurs
o Maxillary tumors may be somewhat more aggressive than mandibular, w/ greater tendency to invade adjacent
structures (probably from porous nature of maxillary bone)
4-7-2006 - Oral Pathology I

Dr. Childers Lec 10, Ch. 15 (pp. 627-637)
ODONTOGENIC TUMORS -contd from lec 8&9
MIXED ODONTOGENIC TUMORS
Ameloblastic Fibroma
Note ameloblastic fibroma is rare, usually not in differential before ameloblastoma, but note age difference
(ameloblastoma avg age 33 yrs old)
Clinical Features
o True mixed Neoplasm
~ Epithelial and mesenchymal tissues are both neoplastic
~ It is less aggressive, more emphasis on fibroma not ameloblastoma
o Young patients mostly (dont have all permanent teeth)
~ Parents reports as missing permanent teeth
~ Occasionally in middle-aged patient
o Males slightly > occurrence than females
o 70% posterior mandible
o Small lesions asymptomatic
o Large lesions may be expansile
o Peripheral never reported
o Multilocular or unilocular radiolucent lesion
o Well defined borders, may be sclerotic
o 75% unerupted tooth
st
o Notice unerupted manidibular 1 molar (notice difference b/w that and normal
unerupted developing maxillary 2nd molar)
st
o Unilocular RL well circumscribed lesion that displaced permanent 1 molar
inferiorly
o Solid tumor often encapsulated
~ Solid, soft tissue mass w/ a smooth outer surface
o Mesenchymal stroma resembles dental papilla
~ This is not fibrous connective tissue, this is a stroma, that is neoplastic
~ It is a mesenchymal background (part of the tumor)
~ Consists of plump stellate and ovoid cells in a loose matrix
o Odontogenic epithelium w/in stroma has 2 patterns:
~ Long narrow cords of odontogenic epithelium in anastomosing (connecting) arrangements
~ Islands of ameloblastic epithelium resemble follicular stage of developing enamel organ
Treatment and prognosis
o Conservative excision initially, more aggressive if recurrence
Considerable recurrence rate

Ameloblastic fibrosarcoma~ When they frequently recur, they become more irritated and may transform to malignancy
~ They also may become malignant denovo
~ the epithelial stays the same, but the mesenchymal portion transforms to malignant
~ If found they will take a significant, aggressive resection and reconstruction
MIXED ODONTOGENIC TUMORS contd
o
o
Ameloblastic Fibroma contd
Multilocular well circumscribed radiolucent (or mixed) lesion, 1-2cm, located b/w 1st
and 2nd mandibular premolars, displacing roots of teeth
Tissues Present- Bone, neural, vascular, odontogenic
Differentialo Note- if you say mixed, you cant say OKC
o Radiolucent- odontogenic keratocyst, ameloblastic fibroma, lateral periodontal cyst
Multilocular mixed radiolucent/radioopaque (or radiolucent), lesion starting distal to
mandibular 2nd premolar extending up the body of the ramus, displacing the
developing 1st molar inferiorly
Differential- OKC, ameloblastic fibroma, dentigerous cyst
Ameloblastic Fibro-Odontoma
Odontoma- benign tumor of odontogenesis
o Haphazard arranged of enamel, dentin and pulp; it has calcified material (usually dentin)
Ameloblastic Fibro-Odontoma and Odontoma are separate entities, but once thought to be the same
o Ameloblastic Fibro-odontoma- a true neoplasm, may show progressive growth, considerable deformity and
bone destruction
o Odonotma- developmental anomaly, not a neoplasm
Clinical Features
o Average age 10 y.o.
o Posterior Maxilla and Mandible
st
o Often discovered at failure of 1 molar to erupt
o Usually asymptomatic or Large lesions may cause painless swelling
o Unilocular or rarely multilocular radiolucent lesion
o Well defined borders
o Variable amount of calcification (dentin and enamel)
~ Appear as small radioopacities or a solid mass
o Often includes unerupted tooth
o Presentation varies: Completely RL largely calcified w/ radiolucent
rim
o Microscopically identical to ameloblastic fibroma but w/ enamel or
dentin
formation
~ Ameloblastic epithelium
~ Mesenchymal stroma
o Calcified enamel and/or dentin
~ The more calcified areas may appear as rudimentary small teeth
~ If you see calcifications on xray put Ameloblastic fibro-odontoma higher on differential
o Ameloblastic fibro-dentinoma- calcifying component only of dentin matrix and dentinoid material
MIXED ODONTOGENIC TUMORS contd
Ameloblastic Fibro-Odontoma (contd)

o Conservative curettage
o Recurrence unusual
o Less aggressive, Rare to see malignant transformation (Ameloblastic Sarcoma)
Solitary well circumscribed mixed radiolucency at root of primary cuspid

Differential- ameloblastic fibro-odontoma, odontoma, ossifying fibroma (remember to
think about benign fibro-osseous lesion)
Ameloblastic Fibrosarcoma
Malignant counterpart of ameloblastic fibroma
o Very serious, very aggressive disease
o Patient usually has history of multiple recurrence of ameloblastic fibroma
o But may arise de novo
Clinical Features
o Males > Females Young patients- avg. 28.5 y.o.
o 80% mandible
o Pain and rapid growth
o Suggest Malignancy
~ Ill defined borders
~ Radiolucent
~ Destructive
o Ameloblastic epithelium typically benign but scanty
o Mesenchymal portion is cellular w/ hyperchromatism,
mitoses
~ Its soft tissue, not epithelium that is malignant (not you
recognize histology, just understand it)
o Radical surgical excision
Odontoma
Most common odontogenic tumor
They are a developmental anomaly (harmatoma), not a true neoplasm
Hamartoma- A focal malformation that resembles a neoplasm, grossly and even
microscopically, but results from faulty development in an organ; composed of an
abnormal mixture of tissue elements normally present in that site, and are not likely to
in compression of adjacent tissue (in contrast to a neoplasm)
Primarily made of enamel and dentin w/ variable amt of pulp and cementum
Odontoma
2 Types:
o Compound Odontoma- composed of multiple small toothlike structures
~ More frequently diagnosed
~ Differential- is supernumary tooth, depending on person looking at it
o Complex Odontoma- conglomerate mass of enamel and dentin
~ No anatomic resemblance to tooth, except maybe same density
o Know classifications for board questions (shes not too hung up on)
pleomorphism and
dont have to
result
Clinical Features
st
nd
o Young patient- detected in 1 and 2 decade
o Asymptomatic- detected in routine radiograph or when taken b/c tooth failed to develop
o Usually small and < size of tooth
~ When large may cause expansion
o Assocw/ unerupted tooth or often found b/w roots of erupted teeth
o Compound (tooth-like) more common in anterior maxilla
o Complex (haphazard) more common in posterior jaw
o Rarely may be peripheral~ Peripheral odontoma analogous to tooth erupting
o Compound Odontomas- Toothlike structures w/ a thin radiolucent halo
o Complex Odontomas- Radioopaque mass w/ thin radiolucent halo
o Radiolucent halo- analogous to tooth follicle around developing tooth
o Developing Odontoma- may show little calcification and appear as circumscribed radiolucent lesion
o Pic
~ Solitary, unilocular, mixed radiolucent area thats overlying midroot of the 1st premolar
~ Differential- ossifying fibroma, ameloblastic fibro-odontoma, odontoma
Differential short b/c not a lot of lesions making product
o Varying arrangement of enamel matrix, dentin, pulp in a fibrous stroma:
~ Developing odontomas structures that resemble tooth germs are present
~ Complex- mostly tubular dentin enclosing hollow structures that contained
enamel, w/ a thin layer of cementum around periphery
o May have ghost cells- in 20% of complex odontomas
o Dentigerous cyst- may arise from epithelial lining of fibrious capsule of complex
odontoma
o Simple local excision
o Do not recur- they are just haphazard mistake of odontogenesis
Calcifying mass w/ RL rim overlying crown of unerupted 1st molar
Differential- ossifying fibroma, ameloblastic fibro-odontoma, odontoma, calcifying
odontogenic cyst (better than saying ossifying fibroma b/c it was pericoronal, in the
follicular space of developing tooth)
o Recall- calcifiying odontogenic cyst often occurs w/ odontoma
TUMORS OF ODONTOGENIC ECTOMESENCHYME

Central Odontogenic Fibroma
Uncommon and controversial
Clinical Features
o Wide age range, avg 40 y.o.
o Females > Males (2.2:1)
o 33% assoc w/ unerupted tooth
st
o In maxilla- most lesions occur anterior to 1 molar
st
o In mandible- most lesions occur posterior to 1 molar
o Small lesions asymptomatic
o Larger lesions expansile and loosen teeth
o This is in radio-opaque and radio lucent list
o Smaller lesions- Well defined, Unilocular radiolucent
~ Often assoc w/ periradicular area of tooth
o Larger lesions-Well defined, multilocular radiolucent
May have radiopaque flecks

Root resorption and divergence
o Simple Type~ Fibroblasts, collagen, scanty epithelium
~ Occasional foci of dystrophic calcification may be present
o WHO type- more complex pattern
~ Fibroblasts, collagen, abundant epithelium
o Small calcifications
o May have giant cell granuloma like component
o Few recurrences
o
o
Peripheral Odontogenic Fibroma

Soft tissue counter part of central odontogenic fibroma
Clinical Features
o Slow growing, firm, Sessile gingival mass (Bump on the gums)
~ Cant clinically differentiate from common fibrous gingival lesions
~ Wouldnt put so much on clinical differential (but know that bump occurs)
o Doesnt involve underlying bone
o Nomal overlying mucosa
o 0.5 to 1.5 cm
o Often facial mandibular gingival
nd
th
o Wide age range- 2 7 decade
o Take xray to make sure not a lesion in bone
o Similar to WHO type central odontogenic fibroma
o Local surgical excision
o Recurrence reported
Enlargement of dental papilla
Granular Cell Odontogenic Tumor
Rare
Similar to central odontogenic fibroma, except for fibrous stroma you have granules
Clinical Features
o Adults
o Premolar, molar region
o May be asymptomatic or painless expansion
Radiographic Feaatures
o Well defined radiolucent area
o Unilocular or multilocular
o May have small calcifications
o Background filled w/ eosinophilic granular cells
~ Anytime you have granules you need to know what it represents
mitochondria and lysosomes look granular under light microscope
o Filled w/ lysosomes
o Narrow cords or small island of odontogenic epithelium scattered among granular cells
o May have small cementum-like or dystrophic calcifications
o Curettage is adequate
o Recurrence not reported
This is less common, wouldnt be in clinical differential
Odontogenic Myxoma
Arise from ectomesenchyme
Myxoma- A benign neoplasm derived from CT, that resemble primitive mesenchymal tissue
A neoplasm
Clinical Features
o Wide age range- avg. 25-30 y.o.
o Larger lesion painless expansion
o May show rapid growth, may be aggressive
o Unilocular or multilocular radiolucency
~ Multilocular (aka Tennis racket) appearance may look like hemangioma in bone
(surgeons must aspirate when they go in)
o Displace or resorb tooth root
o Margins often irregular or scalloped
o May be poorly defined
o Loose, myoid stroma,
o More collagenized variants may be called:
~ Fibromyxoma or Myxofibroma
o Curettage or resection
~ Myxoid tissue has gelatinous texture, sometimes hard to incise
o 25% recurrence rate
Differential- Can now consider OKC, ameloblastic fibroma and odontogenic myxoma
4-14-2006 Dr. Farquharson

Lec Notes (incl handout) & some notes from text Ch. 2
Oral Pathology I
DEVELOPMENTAL DISTURBANCES
Developmental Alterations in the Number of Teeth
HYPODONTIA
o Anodontia- lack of total tooth development
o Hypodontia- Congenital absence of some teeth from dental arch
~ Oligodontia- sub division of hypodontia, lack of development of > 6 teeth
~ Pseudohypodontia- clinically absent teeth, developed but impacted
o Cause~ Dental lamina obstruction or disruption during early stage of embryogenesis
Inappropriate amount of dental lamina developed (too much or too little)
Environmental influence- dental lamina sensitive, damage b4 tooth formation can result in
hypodontia, examples:
- Trauma, Infection, chemotherapeutic meds, endocrine disturbances
o Associated Syndromes include:
~ Ectodermal dysplasia- which can result in:
Conical teeth, Hypodontial, Anodontia
o Clinical Presentation
~ Uncommon in deciduous dentition
~ In permanent dentition most common 3rd molars then 2nd Premolars and lateral incisors
o Tx- orthodontics, prosthodontics
SUPERNUMERARY TEETH (HYPERDONTIA)

o Hyperdontia- development of increased # of teeth, additional teeth are termed supernumerary
o Supernumary teeth- may have normal morphology but tend to be smaller than normal
~ Mesiodens- in anterior location (usually maxillary)
~ Distomolar or distodens- accessory 4th molar
~ Paramolars- in posterior region, lingual or buccal to molar tooth
o Cause- by increased activity of the dental lamina
o Associateed Syndromes include:
~ Gardners syndrome
~ Cleidocranial dysostosis
o many times diagnosed radiographically
~ More frequent in permanent dentition
~ Most common sites:
Extra molar than premolar (Dr. Farquharson in lecture)
*Maxillary incisors maxillary 4th molars and mandibular 4th molars, PM, canines, and lateral
incisors (text p. 71)
~ Variable eruption 75% in anterior fail to erupt
Tx- surgical removal and orthodontics
NATAL TEETH
o Natal teeth- teeth present (erupted) in newborns
o Neonatal teeth- are teeth that erupt 1 month after birth
o May be predeciduous supernumerary and require extraction, but most are prematurely erupted deciduous (not
supernumerary)
Eruption Defects
ECTOPIC LOCALIZATION, ERUPTION
o Dental Transposition- normal teeth erupt in inappropriate position
o Eruption of a normal tooth into another location in the dental arch
o Ectopic - Normal structure that occurs in wrong place; canine erupts in incisior area
o Patient has TMJ and occlusion issues
o Seen in incisors, canines and 1st molars
o Tx-surgical-orthodontic
ANKYLOSIS
o The cessation of eruption after emergence, occurs from an anatomic fusion of tooth cementum or dentin w/
alveolar bone
~ Appears clinically as an eruption defect, frequently followed by irregular occlusion.
~ It is characterized by occlusion surface retention of the affected teeth, at a level at least 1mm or more
cervical to the adjacent teeth
o Cause- local trauma or metabolic factors or genetics
o Affects primary and permanent molars.
o Radiograph shows break of periodontal membrane continuity
~ Doesnt usually erupt completely, doesnt develop PDL locked in bone
o Tx- surgical removal if becomes symptomatic
Developmental Alterations in Size of Teeth

MICRODONTIA
o Teeth that appear smaller in size compared to normal
~ X-chromosome -responsible for size and shape of teeth
o females>males
o Generalized microdontia
~ Rare and is associated (caused by) with congenital hypopituitarism
o Localized microdontia
~ More common and is frequently followed by hypodontia
~ Common in permanent teeth
~ seen in upper laterals and third molars shapes conical or pegged
o Associated syndromes
~ Ectodermal dysplasia, Trisomy 21, Dleft lip and palate
o Tx- composites/porcelain crowns
MACRODONTIA
o Teeth that appears larger than the normal
o Generalized macrodontia
~ Seen in pituitary gigantism (from hyperpituitarism)
~ Giganitism - effects growth prior to closure of epiphyseal plate
o Associated syndromes
~ Cranialfacial dysostosis
~ Sturge-Weber
Clinical Presentation
~ Seen in lower third molars, second premolars and upper central incisors
~ Morphology is rounded edges and can cause crowding
o Tx- restorations
Developmental Alterations in Shape of Teeth
o
GEMINATION
o Attempt of single tooth bud to divide, resulting in the formation of two partially or completely independent
crowns with a shared root
~ Has normal amt of teeth (when you count double crown tooth as one)
~ Pulp chamber and root canal are usually common to both elements
o Genetic factors involved are probably similar to those affecting the dental lamina in cases of hypodontia
o Males = Females in prevalence
o Occurs in upper and lower incisors
o Tx- composite, crown or extraction
FUSION
o Union of 2 discrete tooth buds, resulting in formation of a tooth with an anomalous shape
~ Fusion leads to a reduced number of teeth (when dbl crown counted as one tooth)
o Cause by local factors affecting interdental lamina persistence during dental organ development
o seen in anterior teeth
~ when counting # fused tooth as one, you will have less teeth than normal
o Tx- composites, crowns or extraction
CONCRESCENCE
o Fusion in which formed teeth are joined only along the line of cementum
o Occurs before or after teeth erupt
o Cause- probably due to dislocation of tooth germs during formation
o In upper second and third molars and only on radiographs
o Usually asymptomatic and only important if extractions will be done
DILACERATION
o Extensive bend in the root or the cervical area of the affected teeth
o Cause- disruption of the Hertwig epithelial root sheath due to eccentric dislocation of the already formed
crown in relation to the developing adjacent soft tissue
o 3% of the successors in cases of traumatized primary teeth
~ Curved due to environment
o Often in anterior teeth and could be a problem for extractions
o Tx- none if asymptomatic
DENS INVAGINATUS (DENS IN DENTE)

o Clinical Presentation- Prominent lingual cusp and a centrally located pit
o Cause- early invagination of enamel epithelium into dental papilla of underlying tooth germ
~ Dental papilla forms the pulp (tooth forms w/in developing pulp)
o Seen in permanent teeth upper lateral incisors
o Increased risk for caries in lingual pit
o May effect restorations:
~ affects endodontic therapy if obstructing pulp
~ may cause pulpal exposure of little tooth
o Tx- Preventative filings of the pit
Developmental Alterations in Shape of Teeth

DENS EVAGINATUS
o Clinical Presentation- Elevated, tuberculated appearance on occlusal surface of affected teeth
o
o
o
o
o
~ Contain enamel, dentin and pulp

Cause- Focal hyperplasia of ectomesenchyme of the primitive dental papilla
~ Due to genetics
Seen frequently in the Asian population affecting premolars and molars
Complication pulp may extend into the tubercula (cusp), increased risk of pulp exposures
Tx- occlusal reduction of cusp to stimulate secondary dentin or prevent occlusal trauma
~ Endodontic Therapy
Note- Talon cusp is denevaginatus of anterior tooth (usually maxillary or central incisors)
ENAMEL PEARLS
o Ectopic enamel- presence of enamel in usual location (mainly tooth root)
o Ectopic nodular deposits of enamel at roots of involved teeth.
~ Can be extra or intra dental
~ Hemispheric structures may consist entirely of enamel or contain some underlying dentin
o Cause unknown.
~ Arise from local activity of the Hertwigs epithelial root sheath remnants
o Seen frequently in Asian and Eskimo populations and on permanent upper molars at furcation
o Can only be detected on radiograph or gross inspection. Usually contains enamel and dentin
o Tx- none
TAURODONTISM
o Enlargement of body and pulp chamber of a multirooted tooth w/ apical displacement of the pulpal floor and
bifurcations of the roots
~ Defect usually found in multirooted teeth.
~ Characterized by prolonged crown and more apically root furcation,
~ Resulting in the creation of enlarged pulp chambers with increased occlusal-apical length.
o 3 types based on degree of apical displacement of pulpal floor
~ Hypotaurodontism- mild
~ Mesotaurodontism- moderate
~ Hypertaurodontism- severe
o Cause - Local factors and failure of Hertwigs epithelial root sheath to invaginate below crown at the proper
time during dental development
o Associated Syndromes:
~ Amelogenesis imperfecta type IV
~ Ectodermal dysplasia,
~ Downs and Klinefelter syndrome
o Affects permanent 1 and 2 molars and can only be diagnosed on radiograph
o Tx- none
Enamel Defects
Enamel hypoplasia-pits, grooves and lines in the whole enamel surface or in certain areas.
o Cause- infection, environmental or genetics during development or by hypoparathyroidism
Amelogenesis imperfecta also produces enamel defects
Possible reduction of the enamel thickness
Tx- conservative esthetic restorations or prosthetic rehabilitation
Enamel Defects
AMELOGENESIS IMPERFECTA
o Isolated defects of the enamel resulting exclusively from genetic factors
o Cause- genetic factors during enamel formation phase.
~ Defect in the enamel matrix proteins amelogenin and enamelin on X and Y chromosome
~ Affects all teeth primary and permanent
~ Can have a coloration issue, a snow capping issue, no enamel at all
~ Increase chance of caries b/c no enamel protecting

~ Always generalized, if its localized its just enamel hypoplasia
4 Types:
~ Type I (Hypoplastic)
Autosomal Dominant[AD]
Inadequate deposition of enamel matrix
Reduced enamel thickness on surface of teeth. Does not develop properly
Pitted and smooth patterns
~ Type II (Hypomature)
Enamel does not mature
Enamel matrix is laid down appropriately but there is defect in maturation of enamels crystal
structure
Teeth are normal in shape but have mottled, opaque white-brown-yellow discoloration
The enamel is softer than normal and tips from underlying dentin
Pigmented and snow capped
~ Type III (Hypocalcified)
Reduced hardening of enamel
Enamel matrix laid down appropriately but no significant mineralization occurs
Appropriate shape on eruption but enamel is soft and easily lost becomes stained brown to balck
and exhibits rapid calculus apposition
Mineralized
~ Type IV Hypomature-Hypoplastic
Exhibits hypoplasia in combination w/ hypomaturation
Taurodontism
Tx- crowns
Dentin Defects
Dentinogenesis Imperfecta-AD
o Genetic disorder affecting dentin collagen esp phase of tissue differentiation and organic matrix
o Cause- Defect in collagen
o Type I- assoc w/ Osteogenesis Imperfecta chromosome 7 and 17
o Type II- chromosome 4
~ affects all teeth primary and permanent
appears amber translucent/opalescent
~ radiograph shows obliteration of pulp chambers and root canals
o Tx- prosthetic rehabilitation
Dentin Defects
Dentin Dysplasia
o 2 types:
~ Type I- radicular dysplasia- extreme short roots- obliterated pulp; no roots
~ Type II- coronal dysplasia- complete obliteration of pulp, thistle roots and pulp stones; small thin roots
w/ large crowns
o Cause- Epithelial invagination of dental organ cells into the dental papilla
~ Producing ectopic formation of dentine
o Tx- prosthetic rehabilitation
Odontodysplasia
o Severe dental defect involving all dental tissues of both ectodermal and mesodermal origin
o Cause- unknown, suggested that defect is related to a vascular deficiency
o Affects primary and permanent dentition.
o Seen more in the maxilla and involving an entire arch
~ Typically process affects a focal area of dentition
~ Involvement of more than 2 quadrants rare
~ Teeth eruption is delayed and painful, occasionally teeth fail to erupt

~ Small irregular crowns that are yellow to brown, often w/ very rough surface
~ Caries assoc w/ periapical inflammatory lesions
Radiograph shows:
~ ghost teeth appearance (teeth dont form fully)
Extremely thin enamel and dentin surround an enlarged radiolucent pulp
~ Short roots
~ Wide pulp canals
~ Open apices
-Tx- surgical removal and prosthetic rehabilitation
Odontomas
Odontogenic hamartomas tumor containing dental calcified tissues
o Hamartoma- development of tissue in normal area but having abnormal presentation
Cause- unknown. Malformation of dental tissues and their formative elements
Most common odontogenic tumor lesion.
Diagnosed by radiograph
Two types:
o Complex odontoma- dont look like teeth; histologically only have enamel and dentin
~ Seen in premolar/molar region
o Compound odontoma- look like teeth; histologically have enamel, dentin and pulp
~ Seen in anterior maxilla
Prevents the eruption of adjacent permanent teeth
Tx- surgical removal and orthodontic therapy
Staining
Intrinsic staining- thru medication or trauma, or congenital issue
o Mottling a form of instrinsic staining
~ Due to excess amt of flouride w/in enamel and dentin (Flourosis)
Extrinsic staining- thru bacteria, tobacco
Cleft Lip/Palate
Males > Females
Bifid uvula- is form of clef palate
Bifid tongue- slight form of cleft lip
Ankyloglossia
Tongue tie- developmental malformation in which tongue is abnormally fixed to floor of mouth or lingual aspect of
the gingiva, due to a short and malpositioned lingual frenulum
Malformation may cause partial or complete immobility of the tongue
Tx- surgical clipping of the frenulum in severe cases
Low Frenum attachment
o Can cause recession that can lead to periodontal disease
o Various syndromes associated (did not mention)
Congenital lip pits and Double Lip
Also assoc w/ various syndrome
Fordyce Granules
Ecotopic sebacacous glands- there is not treatment but should recognize and not confuse w/ conditions like measles
(not seen in US)
Exostoses
extended growth of alveolar bone on buccal, normal bone growth, no need to operate dentures needed
Hypercementosis
Often assoc w/ pagets disease; over growth of cementum
Roots are bulbous, appear larger than normal on radiograph
Can also be assoc w/ cementoblastoma (an odontogenic tumor)
Usually asymptomatic
Facial Hemiatrophy
Parry-Romberg syndrome is a degenerative disorder characterized by atrophic changes of the deeper
structures(e.g. fat, muscle, cartilage and bone) involving one side of the face
Facial asymmetry due to some type of trauma or developmental
o of face normal, other small
o of tongue normal, other small
o Progresses
Cause unknown
Clinical Presentation
o Starts in childhood and seen in girls more than boys
o Side of face affected is atrophied skin is wrinkled, shriveled and shows hypo or hyperpigmentation
o Hypoplasia of maxilla, mandible, delayed eruption and malocclusion may occur
o Atrophic process progresses slowly for some years then stabilizes
Diagnoses is based on clinical finding.
DDx- Scleroderma, Facial hemihypertrophy and Lipodystrophy
Tx- plastic reconstruction and orthodontic therapy
4-21-2006- Dr. Fryer

See Operative Text for additional info
Oral Pathology I
THE PATHOLOGY OF DENTAL CARIES

Various Pathologies of Teeth
Inflammatory Response- like general pathology, inflammation is a major
contributing factor
Trauma
o Attrition wearing of away
o Erosion
o Abrasion
Caries- acid demineralization by bacteria
o White spots, brown spots
Introduction
Most common disease of the Oral Cavity
o Periodontal disease (PDD)
o Dental caries
PDD and caries are perhaps the most expensive infections that most individuals have to contend w/ during a
lifetime
Definition of Caries
Caries- infection microbiological disease of teeth that results in localized dissolution and destruction of the calcified
tissues
Dissolution, destruction = cavitation
Cavitations or holes: signs of bacterial infection
Treatment directed twd identification and management of the underlying disease
Wholes or cavitation could be decay or erosion
o Decay- you will get a catch or stick
o Is it sticky or just narrow
Want to remove caries and determine what patient is doing that allows them to be
susceptible to decay
Have a systematic approach
Caries Risk Factors
Prehistoric
Caries and diet
Model developed in 1960s
Overlap of the circles

o Plaque, Tooth, Diet (3 outer circles)
o Caries (w/in overlapping of circles)
o Surrounding circles- Time, Flouride, Immune System, Saliva
o Outer most circle- education, socioeconomic status, income, knowledge, attitude, behavior
How are caries risk increased or decreased?
Hypothesis Concerning Caries Etiology

Non specific Plaque Hypothesis- universal presence of potential pathogens in plaque and assumes all
accumulations of plaque are cariogenic
Specific Plaque Hypothesis- Accumulation of plaque is not always associated w/ disease
o Aimed at elimination of specific patho-organisms, not removal or all plaque
o Only a limited # of organisms can produce a carious response
How should treatment be directed?
o In theory if we know what bacteria causes decay we should be able to go in and attack them
o Antibacterial Agent- chlorhexadine (anti plaque), fluoride
o Homeostatic environment- There are also organisms that off set environment
Etiologic Agents of Carious Lesions (Plaque, bacteria) Plaque and Bacteria most significant- TEST ??
Plaque and Bacteria
o Bacteria
~ Streptococcus mutans (initiation)
~ Lactobacilli (progression)
~ Sites- TEST ??
Enamel s. mutans
Dentin s. mutans, lactobacillus
Root actinomyces
~ Environment of demineralization pH<5.5 and aneorobic
o Bacteria by products
o Accumulation is highly organized and ordered
o Review in text how plaque accumulates
o Survival dependant upon ability to adhere (recetoprs and sticky matrix coherence)
Sucrose: frequency vs quantity (frequency is most important0
Flouride
o Active enamel carious lesion- spreads
o Arrested enamel carious lesion- caused by remineralization w/ fluoride
~ Note root better
Tooth Alignment
o Malalignment can contribute to caries problems by providing sheltered areas for plaque retention
o Defective margins also a concern
~ It traps food
Roles of Saliva
o After __ comes the pellicle
o Produces salivary pellicle
~ Where fluoride exchange happens
~ Review the Pellicle
~ After prophy you should wait for pellicle to reform so fluoride has place to exchange (a few minutes)
o Antimicrobial
o Clears bacteria and carbohydrates; buffers acid
o Contains Ca/Phosphate/fluoride
o Lubricates oral mucosa
o Mediates taste acuity
Pathophysiology of carious lesion

Common Sites of Development
o Pits and Fissures- most common
~ Grooves help shelter bacteria
o Proximal Enamel
~ Gingival area around the contact, 2nd most common
o Root surface
o Root and Proximal surface have more exposure to washing process of saliva
Diagram Test ?? notice how enamel rods run
o Tooth view is buccal-lingual direction shows various progression of lesions
Spread of Caries- Pits and fissures
o Enamel- base of triangle at DEJ
o Dentin base of triangle at DEJ
Spread of Caries- Smooth Surface (i.e. interproximal lesions)
o Enamel- base of triangle at surface
o Dentin base of triangle at surface? (dbl check)
Location of Decayo Caries more frequent in distal of tooth as well as in mandibular teeth
o Chart of Frequency
~ Common on distal of 1st molar surface of tooth
~ Common in mandibular in molars
Demineralization
Dissolution
Progression in Enamel
o Variable
~ pH 3-4: enamel etched, rough
~ pH 5- surface intact, subsurface mineral lost (porous)
Caries Risk Assessment
Incipient caries
o Smooth surface opaque lesion located cervically
Advanced Caries
o Rampant caries/Milk bottle syndrome
o Multiple lesions
Arrested Caries
o Darker (remineralized)
o Commonly on interproximal surfaces at contact areas
High Risk Patients
o Orthodontic patients are high risk patients
Root Caries Etiology
Demineralization critical pH = 6.7
Lesion progression and mineral loss 2.5x greater than enamel
Rapidly develops; slower thereafter
Gingival recession
Darkening of surface assoc w/ remineralization
When doing Class V restoration make sure you get aacces to gingival floor to avoid an open margin
Watch out for patients who had radiology therapy
Listen to Lecture after break (about 1hr)
Morphology of Enamel Caries and Progression of Decay
Over period of time
Must manage lesions
General Presentation
o Pit and fissure: inverted V (enamel < DEJ)
o Smooth surf (prox): V shape (enamel > DEJ)
o Root Surface: U-shaped in cross section, progresses more rapidly

Cross Section of Occlusal Caries
Histopathology of Caries
Diagnosis and Prevention of Caries
Diagnosis- visual and tactile
Criteria for visual examination of caries
o No or slight change in enamel translucency after prolonged air drying (>5sec)
o Opacity or discoloration hardly visible on the wet surface, but distinctly visible after air drying
o Opacity or discoloration distinctly visible w/o air drying
o Localized enamel breakdown in opaque or discolored enamel and/or grayish discoloration from the underlying
dentin
o Cavitation in opaque or discolored enamel
exposing the
dentin
Criteria for histologic examination of fissure caries
o No enamel demineralization or a narrow
surface zone
of opacity (edge phenomenon)
o Enamel demineralization limited to the outer
half of the
enamel layer
o Demineralization involving b/w half of enamel and outer 1/3 of dentin
o Demineralization involving the middle 1/3 of dentin
o Demineralization involving the pulpal 1/3 of dentin
Histology of Pulpal response to caries
Reversible pulpitits
Irreversible pulpitis
o Acute
o Chronic
Histology of Dentinal Response to Caries
Pathologic secondary dentin
Physiologic secondary dentin

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January 6, 2005

Dr. Childers (lec & appendix)

BLOOMS TAXONOMY OF EDUCATIONAL OBJECTIVES

Characteristics of Benign and Malignant Neoplasms

Neoplastic vs. Noneoplastic- will influence treatment plan

CLINCIAL DIFFERENTIAL DIAGNOSIS

1-13-06- Dr. Childers

We will discuss Bone Diseases That Effect the Jaws

Bowing, Angulation, Deformity of Long Bones

Petrosis= petrified hard (Note- Osteosclerosis does not equal osteopetrosis)

Aka Albers-Schonberg Disease and Marble Bone Disease

Focal Osteoporotic Marrow Defect

70% posterior mandible, usually edentulous area

Treatment and Prognosis

Pagets Disease of Bone

~ Normally maxilla has slight concavity

Eventually they are self limiting and will shrink a bit

Simple Bone Cyst

~ Simple bone cyst tend to be empty

Aneurysmal Bone Cyst

Review remaining slides

Tumorlike condition, characterized by replacement of normal bone by an

Coast of Main- rough, rocky coast; irregular borders, typical for

Fibrous Dysplasia (contd)

Lesions occur in edentulous and dentulous areas

Cemento-osseous Dysplasia (COD)

Cemento-osseous Dysplasia (COD)

patient in 2 different times

~ Root canal will not help- lesion wont heal

Familial Gigantiform Cementoma

unilocular radioopacity, 2cm, well circumscribed, at apex of mandibular

Pic- occlusal view- ground glass, radioopacity, had fibrous dysplasia

Fusiform- has ovoid like appearance

Occlusal view gives a lot of information, must take x-rays at

Chart from appendix- Poorly demarcated borders

Multifocal, well demarcated, mixed lesions, 2-3cm,

Differential- Florid Cementoosteus Dysplasa(2 quadrants)

Note- panoramic radiographs are difficult to use as diagnosis in

Chart- Radiopacities- Multifocal or Generalized

Mixed, well demarcated, 2-3cm, body of mandible

Dysplasia- cemento-osseus dysplasia, pagets, familial gigantiform cementoma

Pic- crop of panaromic pic

Well circumscribed, radiolucent, 2-3cm, periapical region

Chart unilocular radiolucencies, other locations

Multifocal, well demarcated, radiolucent and mixed lesion (notice

Chart- mixed RL/RO multifocal or generalized

Oral Pathology - Dr. Childers

Ossifying Fibroma contd

Trabecular calcifications- are strands of osteoid lined by osteoblasts and osteoclasts

~ Adenomas transform into adenocarcinoma

~ Patients have nocturnal pain

Bony counterpart of soft tissue fibromatosis

Pic- segment of panoramic radiograph

bit of a taper), gardners, cleidocranial dysplasia

Pic- Segment of panaroamic radiograph

MALIGNANT FIBRO-OSSEOUS LESIONS

Symmetrical widening of PDL and movement of teeth

o Closely related to osteosarcoma, clinically you distinguish (both in clinical differential)

Foci of well differentiated cartilage

Metastatic Tumors to the Jaws

Metastatic Tumors to the Jaws

Osteosarcoma w/ altered trabeculations