ORAL TUMOURS

Dr B M Kalyanyama
Dept of oral surgery & oral pathology

1
 Definition

• Tumour originally means a

swelling.
• Swelling can either be a
neoplasmata, a hamartomata or the
result of infections.
• Tumour – neoplasmata (new
growth).
• The term tumour should be better
used in the concept of a neoplasm
(new formation or new growth). 2
• Neoplasm: it implies that there is an
abnormal type of growth which may be
evident not only in the intact animal
but also when the cells are grown in
culture.
• Neoplasms arise on any part in the oro-
facial region.
• Tumours (neoplasms) are either Benign
or malignant depending on their
properties and behaviour

3
Benign malignant

• 1. Grow slowly and expansively from 1. Grow faster and infiltrate within
surrounding
tissue
tissues which they originate
• 2. Do not cause metastases 2. Cause metastasis
far from original place

• 3. Grow to voluminous proportions 3. Usually larger in size

than benign
• 4. Do not endanger life unless too big to
inhibit vital functions 4. Life threatening due to
infiltration & spread by
metastasis

• 5. No microscopically visible difference 5. Tumor cells have different

from tissue of origin microscopic aspect and
other biochemical
and functional properties than the
cells of original tissue.

4
 Benign tumours

* No tendency of invading surrounding

tissues
* Excessive accumulation of cells
produces an expanding mass:
– Which may cause pressure atrophy
while others form fibrous capsule

5
– . Tumour becomes well circumscribed and
not intimately connected with surrounding
tissue except for those points of entry of
vascular supply.
– Capsule facilitates easy surgical excision;
do not recur following complete local
excision.
– That may cause obstruction:- tumour may
obstruct a natural passage e.g. bronchial
obstruction that may lead to atelectasis
and bronchopneumonia
6
* Due to encapsulation tumours are
usually round but shape depends on
surrounding structures.
• Ulceration and haemorrhage are rare.
* Microscopically – well differentiated,
cells are regular in size, staining and
shape. Scanty mitotic figure and if
present are of normal type.

7
 Malignant tumours

* Cells infiltrate and erode surrounding

tissue
* Normal cells are enveloped and
destroyed and the tumour edge
(therefore) becomes ill-defined.
* Complete surgical removal is difficult,
malignant cells often remain behind to
cause local recurrence.

8
* Spread by following areas/ planes
of least resistance e.g. canals etc.
• Carcinoma: refers to a malignant
tumour of epithelial cells.
• Sarcoma: refers to a malignant
tumour of connective tissue

9
* Local invasion and embolic spread of
tumour cells are the two
characteristics of malignant tumours
* Lack capsules because cells actively
infiltrate the adjacent tissues.
Sometimes a false capsule may form
due to an expansive growth.

10
* Have irregular outlines with diffusely
defined borders.
* Usually larger in size than benign
* Ulceration and haemorrhage are
common

11
An ulcer failing to heal within/after a few
weeks (10 days) of treatment should be
regarded as malignant until proved
other wise
* Tumours are undifferentiated or poorly
differentiated when the differentiation
is not so well developed, and
recognition of the tissue of origin is
often difficult or even impossible.
12
Poorly differentiated:
neoplastic cells are making
an attempt to resemble the
structure of those found
normally in the tissue
* High mitotic figures/activity

13
Anaplastic tumour = A tumour in which
there is no possibility to decide or
determine the tissue from which it
derives.
Anaplastic tumour derived from epithelial
or mesenchymal tissue is referred to as
anaplastic carcinoma or anaplastic
sarcoma respectively

14
 Complications

• Tissue destruction
• Haemorrhage due to erosion of
large vessels eg. lingual or
facial arteries etc, bleeding may
be fatal, a common finding that
should be treated effectively

15
• Mechanical obstruction
• Ulceration; Infection – secondary
infection
• Inhalation of food and saliva
• Suppuration – bronchopneumonia
is the commonest cause of death
in this condition.

16
• Starvation – ca. of mouth,
esophagus, stomach – failure to
eat.
• Pain and anxiety cause insomnia
(wasting)
• Anaemia – chronic blood loss,
malabsorption or bone marrow
replacement by cancer cells.

17
Spread of malignant tumours:

1.Direct invasion – infiltration of

surrounding tissues, also infiltration
along tissue planes and septa as in
cancer of the breast
2.Invasion of lymphatics
• Carcinoma and melanoma invade
lymphatic vessels at an early stage;
lymphatic permeation causes
regional lymphnode metastases
• Sarcoma invades lymphatics at a late
stage. 18
1.Invasion of blood vesels causes
haematogenic metastases
-- that is the commonest type of spread
in Sarcomas
-- that is responsible for death in most
cases
– Which limits the surgical and
radiotherapeutic treatment of cancer
NB: - Not every tumour cell that is
transported causes metastasis, cells
often are destroyed during transport. 19
 Causes of malignant tumours:

- Unknown but there are (modifying) factors:

* Exogenic cause :Tobacco in the form of:-
- Cigarette, pipe smoking, snuff.
- Reversed smoking may cause
cancer of the tongue on the dorsal
aspect
* Not carcinogenic but modify the tissue for cancer to
occur: chronic irritation eg Ndonya.
* Viral - Epstein barr virus (EBV) Burkitts and
nasopharyngeal carcinoma
– Cytomegalovirus (CMV) – Kaposi’s sarcoma
– Herpes Simplex type II - Cervical Carcinoma
– Varicella – zoster virus – No human Cancer
20
Tumour classification
• It is difficult to classify any condition of
unknown etiology
• No single classification is wholly
satisfactory.
• While some classifications are more useful
than others none is more correct than the
other. Tumours can be classified as:-
1. Connective tissue tumours
2. Epithelial tumours
3. Mixed tumours 21
 BENIGN EPITHELIAL TUMOURS
ODONTOGENIC TUMOURS

AMELOBLASTOMA:
• A true neoplasm of enamel orgarn tissue:
• Excluding Odontomas Ameloblastomas are
the commonest epithelial odontogenic
tumours
• Accounts for approximately 10% of all
tumours arising in the mandible and maxilla
• Median age at presentation is 35 years (range
4-92 yrs) with a peak in 3rd & 4th decades.
There is no gender predilection.
22
Pathogenesis:
• The tumour arises from an epithelium that is
endowed with the potentiality of odontogenesis
• It derives from epithelial rests closely
associated with development of teeth
• It can also derive from epithelium of epithelial
lining of the odontogenic cysts.
• Epithelial rests include: all rests of malassez,
remnants of dental lamina or enamel organ,
the basal layer of the oral epithelium

23
 Clinical features:

• Encountered in early childhood and adult life

• 80% of lesions occur in the mandible
involving mostly the molar, angle and ramus
regions
• Molar and canine regions are involved in the
maxilla
• Grows slowly, asymptomatically in early
stages.
• 35% of patients are completely asymptomatic
and are discovered during routine X-ray
examination
24
• When in the maxilla it may become
quite large before it is discovered –
nasal obstruction may be the first
symptom.
• On examination: It appears as a
gradually growing round swelling of the
buccal cortical plate – but
ameloblastoma can cause expansion of
lingual cortical plate unlike the
odontogenic cysts

25
* Bony hard, normal overlying mucosa in early
stages.
* Tumour continues to enlarge, bone gets
thinner and thinner leading to ping pong
rebounding and then more thinning will lead
to egg shell – cracking effect.
* Overlying mucosa still normal but later bone
is perforated and tumour may protrude into
oral cavity and the overlying mucosa may
ulcerate.

26
Progressive loosening and
sometimes displacement of
teeth .
* Due to mandibular canal
involvement, hyposthesia of
the lower lip may be present
(occasionally).
27
28
29
 Radiological Examination

• Closely trabeculated zones of osseous

destruction gives an appearance of a
multilocular cystic cavity.
• In most cases radiographic picture
shows the unilocular aspect common
in cysts.
• Bone often appears to be replaced by a
number of well-defined radiolucent
areas that give the lesion a honeycomb
or soap bubble configuration (common
in ameloblastomas).
30
• Displacement of teeth to the
periphery of the tumour and
resorption of roots are more
frequent in amoloblastomas
than in cysts
Confirm diagnosis with –
Tissue biopsy for histology
31
• All ameloblastomas are benign but
locally aggressive, will occasionally
metastasize, and a few have malignant
potential.
• Malignant Ameloblastoma may be
classified as metastasizing
amelobastoma or the more aggressive
Ameloblastic carcinoma.
• Ameloblastic carcinoma may arise either de novo or
as a transformation of benign amelobastoma. 32
• Six histopathologic subtypes are
recognized including follicular,
acanthomatous, plexiform, basal cell,
desmoplastic, and granular cell
variants.
• Most tumours show predominance of
one pattern but mixtures of different
patterns are commonly observed.
• These subtypes are of academic importance only
because no difference in their biologic behaviour 33
• WHO has reclassified ameloblastomas
into four types namely:
(i) solid/multicystic ameloblastomas
(ii) extraosseous/peripheral
amelobastomas
(iii) demoplastic ameloblastoma
(iv) unicystic ameloblastoma

34
SOLID/MULTICYSTIC AMELOBLASTOMA

• Present as locally aggressive tumours

that demonstrate inherent neoplastic
cellular proliferation.
• Are associated with high recurrence
rate following inadequate treatment
• Represent the most clinically
significant odontogenic tumours based
on potential morbidity and prevalence.

35
• When left untreated they
grow to extreme sizes
• Have 60-80% recurrence rate
when treated by enucleation
and curettage

36
• Neoplastic cells have been detected
several millimeters from the visible
radiographic margin of the tumour,
- therefore, resection including 1.5 to
2cms of normal margin (radical
resection or aggressive treatment)
that would give a 90% control rate is
recommended.
37
• Enucleation and curettage alone is
inadequate for definitive treatment of
solid ameloblastoma
• Resection is the gold standard and it
offers the most predictable recurrence-
free treatment for solid
ameloblastomas
• Segmental mandibular resection with
inferior alveolar nerve preservation
invites the risk of perineural recurrence38
• Maxillary ameloblastomas are rarer and
offer more problematic treatment than
mandibular tumours; because
surrounding anatomy is more complex
• Involvement of the maxillary sinus and
nasal cavity, infiltration of the orbit,
pterygomaxillary space and skull base
may occur in some patients with
recurrent or uncontrolled disease.
39
 UNICYSTIC AMELOBLASTOMAS

• 1ST by Robinson & Martinez in 1977

• Unicystic growth patterns are seen in
approx. 6% of ameloblastomas.
• Tend to occur in a younger population
(mean age 22.1 yrs)
• High percentage of the lesions are
associated with an impacted tooth.
• Present as well circumscribed,
unilocular periapical radiolucencies 40
• The lesion has a cystic architecture
with the typical ameloblastic changes
confined to the cyst-lining epithelium
• Since the ameloblastic characteristics
are usually confined to the lining of the
epithelial layers or it remains intramural
or mural (ie into the lumen of the cystic
cavity) proliferation, conservative
treatment such as enucleation and
curettage is adequate. 41
• However, transmural involvement of
the epithelium and bony invasion (an
aggressive biologic behavior of the
lesion) has been reported.
• Enucleation followed by application of
Carnoy’s solution is recommended in
the treatment of Unicystic
ameloblastoma

42
 EXTRAOSSEUS/PERIPHERAL
AMELOBLASTOMA
• It occurs exclusively in the gingiva
without bony involvement
• It accounts for 2-10% of all diagnosed
ameloblastomas
• Similar in appearance to basal cell
carcinoma – it has been suggested that
some lesions previously reported as
basal cell carcinoma of the gingival are
in fact peripheral ameloblastoma
43
• Present as painless, firm, exophytic
growths without gender predilection
and occurs in all age groups (mean age
of 52 yrs).
• 70% of the lesions occur in the
mandible, more commonly anterior to
the mental foramen.
• Treated by simple excision with
conservative margins, and rarely
recurs. 44
DESMOPLASTIC AMELOBLASTOMA
• Formation of fibrous connective tissue by proliferation of fibrobroblasts=desmoplasia

• Represnts between 1%and 12% of all

ameloblastomas
• Histologically characterized by
extensive stromal collagenization or
desmoplasia
• Immunohistochemically the
desmoplasia is thought to originate
from de novo synthesis of extracellular
matrix proteins 45
• Age incidence range: 18-70 years
(mean= 41.2yrs), mandible and maxilla
equally affected.
• Often present as asymptomatic slowly
enlarging bony or soft tissue mass in
the mandible or maxilla

46
• Unlike other types, radiographically it is
suggestive of fibro-osseous lesions
appearing as a poorly defined
radiolucent/radiopaque lesions (mixed
density), with or without loculations
• Treated by radical resection because
simple enucleation is associated with
high rates of local recurrence.

47
 Treatment of Amelobastoma

* The tumour is not radiosensitive, so

surgery is the treatment of choice
– Tumour enucleation especially in
unicystic amelobtastoma
– Complete resection of the affected
area of bone including a normal
margin of about1.5-2 cm outside the
appearance of periphery of the
tumour.
48
 –Recurrences occur following
incomplete surgical removal
–Follow the patient for up to 5
years
* Enucleation with curettage of
the surrounding bone may be
adequate for unicystic lesions.
49
Multicystic lesions – Radical
resection with or without
immediate reconstruction of
the defect with bone graft
OR,
* Resection of the lesion with
dentoalveolar structure
preserving the lower border
of the mandible. 50
The treatment is governed by :-
- the local invasiveness of the tumour
- the radiological appearance
- absence of metastases
- absence of invasion of the lower
border of the mandible
- possible perforation into the oral
cavity.

51
 THE ROLE OF RADIATION THERAPY ON
UNRESECTABLE OR LOCALLY ADVANCED
AMELOBLASTOMA

• Several authors have reported excellent local

control , either as definitive treatment or as a
postoperative adjuvant therapy for
microscopic residual disease.
• Radiotherapy may be recommended for a
patient with
positive margins
unresectable tumours
recurrent tumours involving the skull
base or vital neurological structures. 52
 ADENOMATOID ODONTOGENIC
TUMOUR.
- An uncommon histologic type of
odontogenic tumour
- Characterised by formation of ductlike
structures by the epithelial component
- Has uncertain histogenesis hence the lesion
is not known if it is a true neoplasm or not
- It is suggested to be either:-
- benign neoplasm
- harmatomatous
- odontogenic cyst ( eg, cystic compound
odontoma )
53
Clinical features
It accounts approx. 2-7% of all odontogenic
tumours
• Affects young patients during their 2nd
decade of life- adolescence ( age range: 3-
82yrs, with mean age of 18 yrs).
Females more affected than males at a ratio
of ( 2:1).
• Commonly located in the anterior maxilla
• Frequently occurs in the anterior part of the
jaws anterior to the canines in both jaws and
rarely distal to the premolars.
• 54
• 75% of cases are associated with an un
erupted tooth ( canine)
• Grows between 1.5-3 cm but may
reach 7cm big.
• An asymptomatic swelling, detected
during routine X-ray exam.
• The cyst formation may be related to
late disturbance in odontogenesis (ie
after odontogenesis has taken place.
• Maxilla:mandible ratio of 2:1
55
Radiological features:-
• A destructive lesion well or not well
circumscribed
• Resembles a Dentigerous cyst but it
extends further than the
cementoenamel junction.
• Unilocular radiolucence with
occasional foci of dense radiopacity .
• Often associated with the crown of an
impacted tooth
56
• Root resorpition rare but separation of
roots or displacement of adjacent teeth
is noted
Differential Diagnosis: Globulomaxillary
cyst, Dentigerous cyst.
Treatment: Conservative surgical
excision of the lesion
Recurrence is very rare following
complete excision

57
 PINDBORG TUMOUR
(Calcifying epithelial odontogenic tumour (CEOT)

• An uncommon epithelial odontogenic tumour

• First described by Pindborg in 1956.
• Thought to arise from stratum intermedium
of a normal dental germ.
• Benign but locally aggressive in nature
• Malignant transformation and metastatic
spread has been reported

58
Clinically
• Most of the tumours are intraosseous but a few
extraosseous (peripheral) CEOT have been reported.
• It grows asymptomatically and the mandible is more
affected than the maxilla at a ratio of 2:1
• The premolar – molar regions are the sites of
preference.
• The average age in men is 25 years and in women
approximately 50 years
• Histologically characterized by presence of sheets
and nests of polyhedral epithelial cells with
intercellular bridges, presence of amyloid and
calcifying deposits

59
The tumour has several different radiological
appearances.
* Diffuse or well circumscribed unilocular radiolucent
area.
* A combined pattern of radiolucency and radiopacity
with many small, irregular bony trabeculae
traversing the radiolucent area in many directions
producing a multilocular or honeycomb pattern.
* Scattered flecks of calcification throughout the
radiolucency – referred to as “driven snow”
appearance
* The lesion may appear totally radiolucent in
association with an impacted tooth – this mimics a
dentigerous cyst.
60
Differencial diagnosis:-
• Total radiolucency in association with
an impacted tooth – mimicks a
Dentigenours cyst.
• Combined pattern of radiolucency and
radiopacity with many small irregular
bony trabeculae traversing the
radiolucent area in many directions
producing a multilocular honeycomb
pattern.. – similar to Ameloblastoma.

61
Treatment:-
• True malignant behaviour is uncommon
• The tumour is not invasive so the
treatment ranges from enucleation to
radical resection
• Recurrences are reported, therefore, a
long term follow up of the cases is
indicated.
62
Extraosseous CEOT:
– Rare but occurs
– Mean occurring age of 35 years
– Both sexes equally affected
– Tumour affects mostly the gingiva
however the upper lip has been involved.
– Intraosseous and extraosseous lesions
are histologically identical

63
 CALCIFYING ODONTOGENIC CYST
(GORLIN CYST)

• First reported by Gorlin in 1962.

• Has some features of a cyst and many
characteristics of a solid neoplasm.
• The lesion may present/exist in three cystic variants.
TYPE 1 A: THE SIMPLE UNICYSTIC TYPE
– occurs at any age in life
– It may be intra or extra osseous
– The cyst wall is lined by low cuboidal or
squamous cells.
– Focal areas of stellate reticulum and “GHOST”
cells may be present as well as sparse amounts of
dentinoid.
64
• No any other hard tissue is found.
• Ghost cells - are pale eosinophilic, swollen
epithelial cells with lost nuclei but show a faint
outline of the cellular and nuclear membrane.
• Ghost cells are not pathognomonic for Ghorlin
cyst they are also found in
- Ameloblastoma
- Fibro – odontomas
- Complex and compound odontomas
- Craniopharyngiomas
- Carcinomas
65
TYPE 1B: THE ODONTOME PRODUCING TYPE:
– It can be either intraosseous or extraosseous
– Age indidence 10 – 29 years
– It is a unilocular cyst with similar epithelial lining
as in simple unicystic type (type 1A) but
– It exhibits formation of calcified tissues in the
cyst wall similar to those found in compound and
complex odontomas
– There is proliferation of tissue similar to an
ameloblastic fibroma which may be seen in the
cystwall and this may invade surrounding bone.

66
TYPE 1C: THE AMELOBLASTOMATOUS PROLIFERATING TYPE
An intraosseous lesion histologically presenting as
an ameloblastoma–like proliferations in the
connective tissue of the fibrous capsule as well as in
the lumen of the cyst.
TYPE II: NEOPLASM – LIKE LESION (DENTINOGENIC GHOST
CELL TUMOUR)
– Occurs late in life and consists of
ameloblastoma–like strands and islands of
odontogenic epithelium infiltrating into mature
connective tissue.
– Ghost cells are present with a varying amounts of
dentinoid and it is either extraosseous or
intraosseous

67
Radiologically:-
– Central intraosseous lesions appear radiolucent
and usually well circumscribed
– Radiolucency is scattered with calcified opacities
ranging from tiny flecks to large masses.
– Small lesions are more common findings than the
large ones which may be several centimeters in
diameter
Treatment:-
– Total surgical excision
– Recurrence may follow incomplete excision
– Malignant changes can occur

68
 NON – ODONTOGENIC TUMOURS

PIGMENTED CELLULAR NEVUS

(Pigmented Mole, Benign Melanotic Nevus)

– It is a tumour–like malformation occurring on the

skin and mucous membrane
– It is a superficial lesion composed of the so-called
nevus cells; hence the term “cellular” nevus.
– Occasionally it is seen in the oral cavity
– It can be Congenital or Developmental (acquired)

69
The acquired nevus is classified into five groups:-
1. Intradermal nevus
2. Junctional nevus
3. Compound nevus
4. Spindle cell or Epithelioid cell nevus
5. Blue (Jadassohn–Tieche) nevus
• Acquired nevi are extremely common appearing
about the 8th month of life
• They increase in number with age reaching their
peak in the late third decade of life.
• The number of nevi is genetically determined and
begin to decrease with increasing age.

70
skin
• The largest organ in
the body (2Sqm)
• Composed of 2 layers
–the epidermis and
dermis
• Other 2 layers – the
basement membrane
b/n the epidermis &
dermis and the
hypodermis/subcutis
beneath the dermis. 71
72
Intradermal nevus.
– The most common lesions of the skin in most
cases occurring in dozens scattered over the
body.
– The lesion is either smooth and flat or
elevated above the surface
– It can show brown pigmentation or not
– Rarely affects feet soles, palms of the hands
or the genitalia
73
Junctional nevus:
– The zone of demarcation is absent
– Histologically different but clinically similar to
Intradermal nevus
– The nevus cells contact and seem to blend into
the surface epithelilum
– The overlying epithelium is usually thin and
irregular and shows cells apparently crossing the
junction and growing into the connective tissue –
“The Abtrofung or Dropping off effect”.
– This lesion can undergo transformation to
malignant Melanoma.
74
Compound nevus:
• This is a lesion that is composed of two
elements
– an intradermal nevus and
– an overlying junctional nevus
• The lesion shows features of both the junctional
and intradermal nevus
• Nests of nevus cells are dropping off from the
epidermis, while large nests of nevus cells are
also present in the dermis

75
Spindle cell and/or Epithelioid cell nevus

• Mainly affects children; only 15%

appear in adults
• Histologically resembles malignant
melanoma in adults
• Rarely does this lesion show
clinically malignant features.
• Essentially the lesion is clinically
benign but histologically malignant.
76
–It is commonly composed of
pleomorphic cells of three types
namely: Spindle cells, Oval and
Epithelioid cells.
–There is both mononuclear and
multinucleated giant cells
–It doesn’t involve mucous
membrane surface including the
oral cavity
77
 The blue nevus

• It is a true mesodermal structure

composed of dermal
melanocytes. It rarely undergoes
malignant transformation
• It occurs mainly on the buttocks,
dorsum of feet and hands, the
face and occasionally on other
areas.

78
 Majority are present at birth or
appear in early childhood and
appear unchanged throughout
life.
 Lesions are smooth exhibiting
hairs growing from its surface
and vary in colour from brown to
blue or bluish black.
 It is known to occur in the oral
cavity.
79
Oral manifestations of pigmented cellular
nevus

• With the exception of the Spindle

or Epithelioid cell nevus ALL types
of acquired pigmented nevi
occasionally occur on the oral
mucosa
–Intradermal nevus 55%
–Blue nevus 36%
–Compound nevus 6%
–Junctional nevus 3%
80
• Intraoral nevi occur in all decades of
life except the first and are twice as
common in females as in males.
• It can occur at any site, but the hard
palate, buccal mucosa, lip and gingiva
dorminate.
• Most nevi appear as raised pigmented
lesions but a few appear as flat,
macular lesions.

81
Treatment:
–Surgical excision of pigmented
moles to be done if they:-
occur in areas which are irritated
by clothing such as the belt or
collar line,
 suddenly begin to increase in
size, deepen in colour or become
ulcerated. 82
– Surgical excision of all intraoral
pigmented nevi is recommended as a
prophylactic measure because of the
constant irritation of the mucosa in
nearly all intraoral sites occasioned
by eating, brushing etc.
– For junctional nevi close follow up
after treatment is required because
10% of all malignant melanomas are
believed to arise in this way.
83
 PAPILLOMA

• A benign papillomatous neoplasm

derived from epithelium (surface or
lining epithelium)
• The growth results into a warty
tumour or papilloma; and when in a
compact gland like the breast the
tumour is embedded in the tissue,
and is called an adenoma.
84
• Immunoperoxidase stains have
identified antigens of the human
papillomavirus (HPV) types 6 and 11 in
approximately 50% of cases of
squamous cell papilloma
• The lesion can occur on any epithelial
surface, some are sessile (broad base)
and others are pedunculated and may
be called polyps.
85
Clinical features:
– The tumour is made up of numerous
small finger-like projections resulting
into a lesion with a roughened,
verrucous or cauliflower-like surface.
– Well circumscribed, pedunculated
but occasionally sessile.
– Average size is less than 2 cm

86
 Intraorally the tumour affects
most commonly the tongue, lips,
buccal mucosa, gingiva and
palate particularly the area
adjacent to the uvula.
 Duration ranges from weeks to
10 years
 It affects all ages with no strong
sex predilection.
87
 Treatment of Papilloma

– Total surgical excision including the base

of the mucosa into which the pedicle or
stalk inserts.
– Surgical excision should never be
accomplished by an incision through the
pedicle.
– Recurrence if properly treated is rare
– No evidence that papillomas are
premalignant.

88
• Differential diagnosis include :
-Condyloma acuminatum
-Focal epithelial hyperplasia
-Intraoral verruca vulgaris
• Verruca vulgaris – Is a frequent tumour of the
skin analogous to the Oral papilloma. It is
thought to be caused by a virus called
Papilloma virus

89
 KERATOACANTHOMA
(Self healing carcinoma; Molluscum pseudocarcinomatosum;
Molluscum sebaceum; Verrucoma)

• This is a benign epithelial lesion

considered to be a low grade malignancy
orignating in the pilosebaceous glands.
• Clinically and histologically resembles
Squamous cell (Epidermoid) carcinoma. It
rarely progresses into an invasive SCC.

90
 Risk factors
• Chronic exposure to sunlight or UV light
• Fair skin, male, age 50years
• Exposure to radiation
• Immunosuppresion
• Long term scars (gasoline burn), chronic
ulcers, warts(human papillomavirus)
. Both genetic and viral factors
• Chemical carcinogens such as tar
91
Clinical features:
– Males are twice as often affected as
females.
– Common in elderly light-skinned
individuals with history of chronic sun
exposure.
– Age incidence is between 50 and 70 years
with a peak age incidence of 60 yrs. Rare
in young adults.

92
• Sites affected include: sun exposed areas
e.g. the face, neck, cheeks, nose, dorsum of
hands and forearms, scalp, ears and lower
legs especially in women.
• Both lips appear to be equally affected.
• It causes only minimal skin destruction but
a few are aggressive and can spread to
lymph nodes.

93
– The lesion is elevated, umbilicated or
crateriform with a depressed central
core or plug.
– It measures 1 – 2.5cm in diameter
– Most are painless, though some may be
itchy.
– Depending on site the lesion may
interfere with normal function of the
affected area.
94
• The lesion begins as a small firm,
round, skin-coloured or reddish papule
that rapidly progresses to dome-
shaped nodule with a smooth shinny
surface.
• A central crater of ulceration may
develop, or a keratin plug that may
project like a horn.
95
• After 4 to 8 weeks it attains the full size.
The lesion then remains static for 4 to 8
weeks and then it undergoes
spontaneous regression over the next 6
to 8 weeks period; there occurs
expulsion of the keratin core with
resorption of the mass.

96
• It leaves a residual scar if not excised.
• Tender and regional lymphadenopathy
may be present.
• Histology: The lesion consists of
hyperplastic squamous epithelium growing
into the underlying connective tissue. The
surface is covered by a thickened layer of
parakeratin or orthokeratin with central
plugging.

97
• Differential diagnosis: Squamous cell
carcinoma, Actinic keratosis, Basal cell
carcinoma, seborrhoeic keratosis.

98
 Surgery or Chemotherapy
Treatment:
. Wide surgical excision because of the
uncertainity of the nature of the lesion
from the clinical appearance.
. Prognosis is excellent following
complete excision
. In multiple lesions systemic retinoids
(isotretinoin), intralesional
methotrexate, 5-fluorouracil, bleomycin
and steroids, and topical imiquimoid
and 5-fluorouracil.
99
 Radiotherapy
• Keratoacanthomas are radiosensitive
and respond well to low doses of
radiation
• In patients with large tumoours
• In case of recurrence postoperative
• Laser and cryotherapy have been used
successfully in small tumours.

100
 MALIGNANT MELALNOMA

• This is a neoplasm of melanocytes.

• It is a more biologically unpredictable and
dangerous of all human neoplasms.
• It is the 3rd most common cancer of the skin,
however basal and squamous cell
carcinomas are more prevalent.
• The tumour accounts for 3% of all
malignancies but it accounts for over 83% of
all deaths in the United states (Tanzania – no
data).
101
* For many years it was believed that
many melanomas developed in
preexisting pigmented nevi, particularly
the junctional nevi.
* Some researchers comment that
junctional nevi are not histogenically
related to melanomas; and that:-
– The ones diagnosed as junctional nevi
were actually MELANOMAS in various
phases of growth.
102
• Melanoma develops into two phases of
growth.
• Radial growth is said to be the initial
phase of melanoma’s growth which
lasts for many years.
• During this phase the neoplastic
process is still confined to the
epidermis.

103
• Normal maturing epithelial cells are
shed together with neoplastic cells;
however, some neoplastic cells may
penetrate the basement membrane.
• Survival of these penetrating cells are
limited because they are being
destroyed by the host-cell immunity.

104
• Due to increased virulence of
neoplastic cells, decreased host-cell
response or a combination of both,
neoplastic cells survive and increase in
number to occupy the underlying
dermis.
• This now marks the beginning of
Vertical growth phase and metastases
is now possible to take place.

105
• Not all melanomas have both radial and
vertical growth phases; Nodular
melanoma has vertical growth only.
• The three types of melanomas (though
there are many), which account for
almost 90% of the tumour include:-
• Superficial spreading melanoma
• Nodular melanoma
• Lentigo maligna melanoma
106
Superficial spreading melanoma
• accounts for about 65% of cutaneous
melanomas
• It is the most common cutaneous
melanoma in Caucasians
• It exists in the Radial growth phase
• It is also termed as premalignant
melanosis or pagetoid melanoma in
situ
107
• Clinically it presents as:-
–a tan, brown, black or
admixed lesion on sun-
exposed skin especially the
back.
–Skin of the head and neck,
abdomen, chest and
extremities are affected
108
• This phase may last for months to
several years when it changes into
vertical growth phase marked by an
increase in
– size
– change in color
– nodularity and
– ulceration may occur

109
Lentigo maligma melanoma:
–It accounts for approximately
10% of cutaneous melanomas
–It exists in a radial – growth
phase which is known as lentigo
maligna or melanotic freckle of
Hutchinson.
–The lesion exists in this form for
years
110
Clinically it appears as
– a macular lesion on the malar skin of
middle – aged and elderly
Caucasians
– Occurs more in women than men.
– It also affects the eyes and mucous
membrane even parotid gland
although melanomas in this site are
usually metastatic to lymph nodes in
the parotid gland
111
Nodular melanoma:
– This accounts for 13% of cutaneous melanomas
– It exists in the vertical growth phase only
– Its features include a sharply demarcated nodule
with degrees of pigmentation ranging from pink
(Amelanotic melanoma) to black.
– Mostly it affects the back, head and neck skin of
men
– It affects both sexes equally in other cutaneous
sites.

112
 ORAL MANIFESTATIONS OF
MALIGNANT MELANOMA

• Malignant melanoma is rare in the oral

mucosa although epidemiologic data
show that the Oral mucosa is the most
common site for the lesion in
Japanese.
* Melanomas in blacks are seldom found
on the skin yet occur on mucous
membranes and on the plantar skin.

113
Primary oral melanoma affects males more
than females in the ratio of 2:1 of mostly
between 40 and 70 years.
The lesion favours the palate, maxillary
gingiva and alveolar ridge but also it can
occur in the buccal mucosa, mandibular
gingiva, tongue, lips and floor of the
mouth.

114
Clinically the lesion appears as
– a deeply pigmented area, at
times undergoing ulceration
and bleeding and
progressively increasing in
size.
– The lesion in the oral cavity
is preceded by focal
pigmentation several
months before its clinical
symptoms.
– Appearance of melanin
pigmentation in the mouth
and its increase in size and
depth of colour should be
viewed seriously.
Investigations:
– The majority of melanomas
are diagnosed by routine
light microscopy.
115
Treatment:
1. Surgical excision together with lymph nodes and
bone dissection if involved.
– Prophylactic lymphnode dissection should base on the
thickness of the lesion and its anatomic location.
– Lesions greater than 0.75cm in thickness and in the BANS
(back, arm, neck, scalp) sites have a greater tendency to
metastasize.
2. Cryosurgery, radiation, chemotherapy and
immunotherapy have been employed but none have
improved the prognosis of melanoma in the oral
cavity. The treatment of choice of oral melanoma
remains surgical excision

116
 BENIGN CONNECTIVE TISSUE
TUMOURS
• ODONTOGENIC MYXOMA:
(Odontogenic fibromyxoma or Myxofibroma)
• A benign tumour that arises from the
mesenchymal portion of the tooth germ, either
the dental papilla, the follicle or periodontal
ligaments.
• About 71% of myxomas occur in the heart, 41%
in the skin, 7% in the oral cavity.
• Incidence: 1-17.7% of all odontogenic tumours.

117
Clinical features:
– Most frequently the lesion occurs in the 2nd and
3rd decades of life and rarely before 10 years or
after 50 years of age.
– Both sexes are affected but probably females
more favoured.
– The mandible is more involved than maxilla.
– Sometimes the condyle or its neck are affected
– When central, the lesion infiltraes, expands and
may cause jawbone destruction.
– However, it is a slow growing tumour with or
without pain and it is not capsulated.
– In the maxilla the antrum is frequently involved
118
Radiological features:
– Features of mottled or honeycomb
appearance.
– May show a destructive expanding
radiolucency with occasional multilocular
pattern.
– Teeth displacement is common but root
resorption is rare

119
• Treatment:
– Surgical excision with cauterization.
– Big /advanced lesions: resection of bone together
with the tumour is indicated.
– Due to its nature of local invasion complete
surgical removal is sometimes difficult, a problem
complicated by the loose, gelatinous nature of the
tissue itself.
– The tumour is not radiosensitive.
– Prognosis – is good but it may reoccur (10-33%)
– Malignant form – Odontogenic myxosarcoma (it is
rare)

120
MYXOMA IN OTHER TISSUES
• Soft tissue myxoma is a relatively common
lesion of soft tissue occurring more
commonly in the heart.
• In the heart myxomas are located in either
the left or right atrium of the heart , about
86% occur in the left atrium.

121
• Myxoma may occur in soft tissues whereby the
lesion becomes deep seated e.g. in the
– Skin, subcutaneous tissues
– genitourinary tract, gastrointestinal tract
– liver, spleen or parotid gland
• Intra oral soft tissue myxoma is very rare, majority of
the oral cases may be a result of myxomatous
degeneration in fribrous tumours.
• Nerve sheath myxoma is a benign tumour arising
from perineural cells of peripheral nerves
characterized by occurrence of stellate cells in a
prominent mucoid matrix.
• Affects all ages and both sexes are equally affected

122
• Oral focal mucinosis or cutaneous myxoid
cyst develops because of a fibroblastic
overproduction of hyaluronic acid due to
unknown cause.

Treatment: Surgical excision

123
 CEMENTOMA (Peripheral Cemental Dysplasia)
(Periapical Osteofibroma, Osteofibrosis etc)

• The lesion cementoma develops by excessive

deposition of cementum around the root like in
hypercementosis
• The cause is not absolutely known but trauma (mild
chronic trauma or traumatogenic occlusion) has
been suggested.
• A lesion is diagnosed as cementoma when the
deposition of cementum is not present along the
general outline of the tooth root(s) and when there is
not a visible reason for its occurrence.
• Hypercementosis - is a diffuse thickening of the
cementum throughout the entire root length.
• Hypercementosis is related with a pulpless tooth as
a result of a low grade infection.
124
Two types of cementoma:
1. Cementoblastoma -this is an earlier stage of the true
cementoma.
2. True cementoma
Deposition of cementum takes place after the
formation of the roots. During the initial stages of
osteolytic process the lesion contains only soft
tissue – the cementoblastoma. In the next stage the
lesion undergoes calcification resulting into the true
cementoma. There is a gradual resorption with a
gradual increase of the tumour over a period of
years. The mature cementoma is mostly surrounded
by a connective tissue capsule.

125
Clinical features:
– Develops mostly without symptoms and often
discovered during routine x-ray exam.
– X-rays show irregular radiolucent area around the
apex of a vital tooth (before lesion has undergone
mineralization); a diagnosis of a granuloma could
be made at this stage . Later the center of the
radiolucent area becomes opaque whereby the
opacity is seen separated from the surrounding
bone and the root of the affected tooth by a
radiolucent zone
• Treatment: Surgical removal - enucleation.
126
 FIBROUS HISTIOCYTOMA
Subepidermal nodular fibrosis, Dermatofibroma,
Sclerosing haemangioma

• A benign, unencapsulated and often richly vascular

growth made up of histiocytes and collagen
producing fibroblast – like cells arranged in a
whorled or cartwheel pattern. Often the lesion
contains lipid–carrying macrophages.
• Occurs anywhere but most common in the dermis.
• The malignant counterpart is – malignant fibrous
histiocytoma.
• Fibrous histiocytoma of the oral cavity is rare. It
affects mostly children and young adults. Lips,
tongue and buccal mucosa are also affected.

127
• Oral and perioral lesions are uncommon, but when they
occur they favour the buccal mucosa and the vestibule.
• The oral lesion typically occurs in the middle aged and
older adults
• It presents as a painless submucosal nodule of few
millimeters to several centimeters.
• Deep seated lesions tend to be larger and most of them
cannot be easily moved about beneath the epithellium.
• The lesion is poorly demarcated from the surrounding
tissues and is separated from overlying mucosa by a
zone of fibrovascular connective tissue (grenz zone )

128
Treatment: Wide surgical excision
5-10% local reccurrence
Deeper and larger lesions have high rate of
recurrence
• Malignant fibrous histiocytoma is now
recognized as one of the more common
sarcomas of the soft tissues of the body. It is
subdived into 4 variants viz. fibrous, giant cell,
inflammatory (the most aggressive) and myxoid.
This is a rare tumour of the head and neck
region, there are reports of metastases, so it
should be treated very carefully and promptly.
129
 ANGIOMAS

• An angioma is a tumour, the cells of which

tend to form blood or lymph vessels.
*Capillary hemangiomas are composed of a
stroma containing many small capillary
blood vessels.
* Large cavernous hemangiomas
microscopically contain large
endothelium–lined vascular spaces
engorged with blood.
130
 HAEMANGIOMA (VASCULAR NEVUS)

• Haemangioma is a common lesion of

the vascular tissue. It is considered to
be hamartoma or developmental
vascular malformations rather than a
true neoplasm. It is seldom to have a
true haemangioma in the oral cavity.

131
• The tumour is characterized by
proliferation of blood vessels and
occurs more frequently in the head and
neck region than in other parts of the
body. The majority of oral lesions are
situated in soft tissues but also found
in muscle and bone. The vast majority
are present at birth or arise at an early
stage. A history of recent rapid growth
is not uncommon.
132
Haemangioma has been classified into
– capillary haemangioma
– cavernous haemangioma
– angioblastic or hypertrophic haemangioma
– racemose haemangioma
– diffuse systemic haemangioma
– metastisizing haemangioma
– nevus vinosus, or port-wine stain
– hereditary haemorrhagic telangiectasis
133
Clinical features
Oral manifestations
• The lesion may be found either extra-orally
on the face or intraorally and pain isn’t one
of the symptoms.
• Haemangioma appears as a dark reddish
blue or purple lesion, which is smooth and
soft. Frequently the lesions undergo
traumatization and ulceration with secondary
bacterial infection

134
Intramuscular haemangioma
• A rare lesion in the head and neck region
• It arises within normal skeletal muscle and
comprises less than 1% of all haemangiomas
Central haemangioma:
• Central haemangioma of the jaws occasionally
occur. These rare tumours are difficult to diagnose
because of their location.The tumour appears to be a
bone destructive lesion. Some central hemangiomas
present a honeycombed appearance on the x-ray,
sometimes with radiating spicules at the expanded
periphery forming a “sun burst” (or sun rays) as
seen in osteosarcoma.

135
• A hasty decision of doing surgical excision may lead to
death of the patient due to excessive blood loss. Needle
aspiration should be done before surgical opening of the
area.
• Other features which can enable you to reach the
diagnosis include:-
– Spontaneous bleeding into the oral cavity particularly
noticeable at night
– Loose, depressible teeth
– Honeycombed osteollytic lesions in the bone seen
on x-ray
– Aspirate if in doubt.

136
137
Histologic features
• The usual haemangioma is composed
of many small capillaries lined by a
single layer of endothelial cells
supported by a connective tissue
stroma, of varying density. It
resembles a young granulation tissue
and is nearly identical with some cases
of pyogenic granuloma.

138
 Juvenile Haemangioendothelioma: Is a
common lesion that occurs very early
in life.
It is characterized by an extremely
cellular pattern.
The lesion is thought to be an immature
stage of capillary haemangioma.
The lesion may develop into a simple
haemangioma or regress later.
139
• Cavernous haemangioma consists of
dilated blood sinuses with thin walls
each with endothelial linings. The
sinusoidal spaces are usually filled
with blood although it is occasionally
mixed with lymphatic vessels.

140
• Central cavernous haemangioma may
be caused by a foreign body. A piece
of steel penetrating the skin and
striking the cortical plate hard enough
may produce haemorrhage in the
cancellous portion with eventual
cavernous haemangioma formation.

141
Treatment:
1. Peripheral haemangioma:
(intramuscular)
• Small haemangiomas are surgically
excised.
Large ones are treated by the injection
of sclerosing solutions e.g. Alcohol
70% or Sodium chloride (30%) into and
around the mass.
142
• The injection is repeated 2 to 3 or 4
weeks after signs of inflammation has
subsided. Normally this is followed by
a reduction in size when now surgical
excision can be done. How? ligate,
open, electrocauterize the cavity wall.
• Many congenital haemangiomas may
undergo spontaneous regression at a
relatively early age.

143
2. Central haemangioma:
• External radiation of the lesion (with
1800 – 2200 rads).
- the osteolytic lesions of bone
disappear followed by normal bone
regeneration.
• Surgical excision – In large central
haemangioma partial resection of the
mandible may be done.
144
• A patient who presents with a loose
tooth or teeth and a history of
spontaneous gingival tissue bleeding
and whose x-rays reveal a radiolucent
area with irregular borders most likely
has central haemangioma.

145
 LYMPHANGIOMA

• Lymphangioma is a benign tumour of

lymphatic vessels. Rarely is the
tumour encountered. It is also of
questionable validity if this is a true
neoplasm or a hamartoma.
Etiology:
• Trauma – most frequent in the lips
• Congenital usually in the tongue or
cheek
146
• Following trauma lymphangioma may start
as a cracked lip which does not heal. New
lymphatic channels accompany the new
blood vessels that develop in injured tissues.
If for some reasons they are blocked,
lymphangiectasis and oedema takes place.
Interstitial fibrosis then follows, and the lips
become thickened because of the same solid
mass akin to elephantiasis, lip examination
may reveal obvious scars on both lips.
147
It is classified into
– Simple lymphangioma
– Cavernous lymphangioma
– Cellular or hypertrophic lymphangioma
– Diffuse systemic lymphangioma
– Cystic lymphangioma or Cystic hygroma

Clinical features:
• Majority of the cases are present at birth and
both sexes are equally affected involving the
head and neck.

148
Oral manifestations:
Intraoral lymphangioma most commonly
occurs on the tongue, but also on the
palate, buccal mucosa, gingiva and
lips.
• Superficial lesions appear papillary
having either the same colour of the
surrounding mucosa or of slightly
reddish colour.
149
• Deeper lesions appear as diffuse
nodules or masses without any
significant change in surface texture or
colour.
• Lymphangioma on the tongue causes
the tongue to enlarge hence the term
“macroglossia”; the anterior dorsum of
the tongue is the most frequently
affected

150
• The lesion usually presents with irregular
nodularity of the tongue surface, with gray
and pink projections. When these signs are
associated with macroglossia it is
pathognomonic of the lymphangioma.
• Lip involvement brings about enlargement of
the lip and it is referred to as “macrochelia”.
Cystic hygroma is a common and distinct
entity that is not manifested in the oral cavity
but occurs in the neck as a large, deep
seated, diffuse swelling.
151
– Lymphangioma of the alveolar ridge in
neonates presents as small blue-domed
fluid-filled lesions on the alveolar ridge.
– Its natural history is unknown – there is
spontaneous regression in some cases.
– Central lymphangioma of bone: These
Occasionally occur – (case reports)

152
Histology:
• The cavernous type is the most
common consisting of numerous
dilated lymphatics lined with
endothelial cells and containing lymph.
• Occasionally channels may be filled
with blood – a mixed
haemangiolymphangioma.

153
Treatment:
Surgery is the treatment of choice since
the lesion is more radioresistant and
insensitive to sclerosing agents than
the haemangioma. Spontaneous
regression is rare.
• Recurrence may follow surgery and
this tendency increases with increasing
age of the patients.
154
 NEUROLEMMOMA
Neurilemmoma, Perineural fibroblastoma, Schwannoma,
Neurimoma, Lemmoma).

• (Neurolemmoma is a rather common

benign neurogenic tumour of the
peripheral nervous system.
• The tumour is well encapsulated and the
cells of orign are thought to be Schwann
cells derived from the neural crest.
• Neurolemmoma slowly grows and can
exist for months to years without
producing symptoms.
155
• Neurologic symptoms tend to present late.
• Symptoms can be vague, and there is an
average interval of up to 5 years before
the diagnosis is established
• Cause is unknown, however, it can be
associated with von Recklinghausen
disease. In this case often there are
multiple tumours.

156
 Clinical features:

• Grows slowly and is usually of long period

by the time the patient comes to the clinic.
In some instances the tumour grows
rapidly.
• The tumour presents with cosmetic
deformity, a palpable mass, and/or
symptoms similar to a compressive
neuropathy
157
– The lesion occurs with some frequency in
patients having neurofibromatosis.
– No racial or sex predilection
– Affects people aged 20 -50, however, all
ages from infants (1 year) to the elderly
may be affected.
– Though neural in origin they grow
painlessly unless they cause pressure on
adjacent nerves rather than nerves from
which they originate.

158
– The presenting symptom is usually a
mobile mass along the axis of the nerve
from which it arises.
– Tenderness to palpation is often present.
– Secondary neurologic symptoms may
occur if tumour is large.

159
Oral manifestation:
• The head and neck are common sites for the
tumour but also oral and paraoral sites (tongue,
palate, floor of mouth, buccal mucosa, gingiva,
lips, vestibule, maxillary sinus, salivary glands,
retropharyngeal, nasopharyngeal and
retrotonsillar areas).
• It can occur as a central lesion, the mandible
(mandibular nerve) mainly involved than maxilla.

160
• The soft tissue lesion appears as a
single, circumscribed nodule of
varying size with no typical
features. So it can give rise to
several differential diagnoses:-
(fibroma, neurofibroma,
neurosarcoma, ganglion cyst, giant
cell tumour of tendon sheath,
lipoma)
161
• Central bone lesions: -There is bone
destruction with expansion of cortical
plates.
• Pain and paraesthesia may accompany
central lesions of bone
• The tumour can cause a functional deficit
due to local pressure on the nerve; and
malignant transformation has been reported.

162
Histologic features:
• The lesion consists of two types of tissue.
• Antoni type A is made up of cells with elongated
or spindle – shaped nuclei aligned to form a
characteristic palisading pattern.
• Antoni type B doesn’t show the palisading
pattern but shows a disorderly arrangement of
cells and fibres with areas of oedematous fluid.
• In most cases the tumour is encapsulated.

163
Treatment:
• Surgical excision
• When total excision is impossible a portion
of the tumour may be left behind without
dangers of recurrence for this is rare.
• Repeated incomplete surgical excision in
neurofibroma increases chances of
malignant transformation.
• When resection would lead to a significant
functional deficit, these benign lesions can
merely be observed.
164
 FIBROMA

• Fibroma is the most common connective tissue

tumour encountered in the oral cavity.
• The tumour is related to fibrous hyperplasia

Clinical features:
– An elevated lesion of normal colour with a smooth
surface. It can either be sessile and sometimes
pedunculated.
– The size of the tumour varies from small to several
centimeters in diameter.
165
 – The lesion is prone to trauma and ulceration
due to its projection above the surface.
– It is described as a well defined, slow
growing tumour affecting all ages but mostly
in the 3rd , 4th and 5th decades of life.
• Common sites of its occurrence include
the gingiva, buccal mucosa, tongue ,lips
and palate.
• On palpation the lesion is either soft and
spongy or firm.
166
Histologic features:
– The lesion consists of bundles of interlacing
collagenous fibers interspersed with varying numbers
of fibroblasts or fibrocytes and small blood vessels.
– In some fibromas there are areas of diffuse or focal
calcification or ossification, these lesions are those
found on the gingiva hence the term “peripheral
ossifying fibroma, ossifying fibroid epulis, peripheral
cementifying fibroma or peripheral odontogenic
fibroma.
• (Hypersplastic tissue – regresses following
withdrawal of stimulant while neoplastic tissue
never regresses) - this is controversial
167
Treatments:
• Conservative surgical excision
• Rarely recurs:
• These tumours arise not only from the
periosteum but also from the periodontal
membrane as well. During treatment
consider this.

168
 LIPOMA

• The lesion frequently occurs in the

subcutaneous tissues of the neck. Intraorally
the tumour is relatively rare.
• Lipoma is a benign, slow-growing tumour
composed of mature fat cells usually located
beneath the oral mucosa.
Clinical features:
• The tumour occurs on the tongue, floor of the
mouth, buccal mucosa, gingiva and mucobuccal
or labial folds.
• It is encountered in adults.

169
• The lesion is single or lobulated, painless and
attached by either a peduncle or has a sessile
base.
• The overlying epithelium is so thin that
superficial blood vessels are readily visible over
the surface. The lesion is soft to palpation.
• Only a slight elevation is noticed in deep seated
lesions, these are more diffuse and feel like fluid
(cystic- like).
• Intraosseous lipoma of the jaws have been
reported but difficult to justify from normal fatty
marrow
170
Lipo blastomatosis:
• A rare lesion and not a true neoplasm but a
continuation of the normal process of foetal fat
development carried into postnatal life.
Clinically - in infants:
• The lesion appears as a solitary or multiple soft-
tissue masses developing at various sites such
as the buttock, chest, axilla and neck.
• Benign in nature but recurs following incomplete
excision

171
Hibernoma – is rare and occurs in a few selected sites in
humans. Presumed to derive from multivacuolated fat
similar to brown fat of hibernating animals: Never found
in the oral cavity.
Histology:
• Mature fat cells with varying number of collagen strands
supporting small blood vessels. When this fibrous
connective tissue forms a more significant part of the
tumour, the term fibrolipoma is used.
Treatment:
• Surgical excision – Recurrences are uncommon

172
BENIGN TUMOURS OF MUSCLE TISSUE ORIGIN

LEIOMYOMA

The tumour arises from smooth

muscles and occurs on the skin,
subcutaneous tissues and oral cavity.
Due to lack of smooth muscles in the
oral cavity (except in blood vessel walls
and in circumvallate papillae of the
tongue) the tumour is uncommon in the
oral cavity.

173
 Clinical features:

• In most cases the lesion affects the

posterior portion of the tongue but the
palate, gingiva, lips, cheeks and
salivary glands may be involved.
• Mostly occurs in adults in their middle
decades of life
• The first decade of life may also be
affected.
174
• A slow growing painless lesion,
superficial and often pedunculated;
resembles normal mucosa in colour &
texture.
• Lesion doesn’t undergo ulceration
• Patient may complain of sore throat or
tumour in the throat.
• Central leiomyoma is extremely rare.
175
Histologic features:
• Composed of interlacing bundles of
smooth muscle fibers interspersed by
varying amounts of fibrous connective
tissues.
Treatment:
• Surgical excision – never recurs

176
 RHABDOMYOMA

• Rhabdomyoma is a benign tumour of

striated muscle origin.
• An extremely rare lesion.
• When it occurs it affects the tongue,
floor of the mouth, axilla, thoracic wall,
neck, larynx, pharynx, stomach, uterus,
vulva and vagina.

177
 Clinical features:

• affects patients in the 5th decade or

later in life at a male to female ratio of
2:1
• the lesion appears as a well
circumscribed lesion of long duration

178
• *FOETAL RHABDOMYOMA – is a very rare
tumour which occurs in children but may occur
also in adults.
• Intraoral lesions do occur.
Histologic features: Large round cells with
granular, eosinophilic cytoplasm with features of
cross striation.
Treatments:
• Surgical excision but may recur if not completely
excised

179
 OSTEOMA

• This is a benign bone tumour characterized by

proliferation of either the compact or concellous
bone usually in an endosteal or periosteal
sites.
• The lesion may occur as a peripheral or as a
very rare central tumour composed of
cortical bone or cancellous bone
respectively.
• Due to its unknown nature the tumour is
considered to be developmental.

180
• Multiple osteomas involving jaws, long
bones, and skull are characteristic of
Gardner’s syndrome.
• Gardner’s syndrome presents with:
• multiple osteomas, multiple polyps of
the large intestines, multiple
epidermoid cysts, desmoid (fibrous)
tumours of skin and impacted
supernumerary and permanent teeth.
181
 Clinical features:

• The periosteal tumour is asymptomatic

and appears as a solitary, hard,
smooth very slow growing,
circumscribed swelling of the skull and
jaw bones.
• Clinically, radiologically and
histologically the lesion resembles
exostoses thereby complicating the
diagnosis.
182
.Radiographically it presents a
radiopaque mass projecting from bone
surface or shows evidence of internal
trabecular stucture when composed of
cancellous bone.
Treatment;
• Surgical excision, rarely reccurs

183
 CHONDROMA

• Chondroma is a benign central tumour

composed of mature hyaline cartilage.
• The lesion is most common in the
bones of the hands and feet and rarely
occurs in the craniofacial complex.
• Chondroma tends to turn malignant
even after remaining benign for a long
time.

184
• Seldomnly the tumour affects
membraneous bones containing
vestigial cartilaginous remnants as the
case may be with mandible and maxilla.
• Secondary cartilage (one not related to
parts of the chondrocranium), is found
in the mandible in the body,mental
region, coronoid process and condyle.

185
• In the maxilla embryonic cartilage is found on the
lateral aspect near the malar process close to the
molar teeth, nasal septum and in the pre-maxillary
area.
Clinical features:
• Both sexes are affected and occur at any age but
usually before 50 years.
• Begins as a painless, slowly progressive swelling of
the jaw with loosening of the teeth.
• There may be ulceration of overlying mucosa.

186
Sites affected:
• Maxilla: anterior portion of maxilla (vestigial
cartilage rests do exist in this region particularly the
midline palatal to or between the central incisors.
• Mandible: The most part affected is posterior to the
cuspid tooth involving the body of mandible, the
coronoid or condylar processes
• Nasal septum and spine can be affected by the
lesion
Radiological features: An irregular radiolucent or
mottled area in the bone. Root resorption of
adjacent teeth is noted. Internal foci of calcification
may occur
187
Histologic features:
• Chondroma consists of mature hyaline
cartilage with small chonrocytes showing
either areas of calcification or of necrosis.
• It is difficult to differentiate chondroma from
chondrosarcoma histologically.
• Inspite of the innocent microscopic
appearance of many condromas, they
behave as low grade chondrosarcomas.

188
 Treatment :
The tumour is radioresistant.
To avoid the potential risk of
undertreating a malgnancy do wide
surgical excision with 1.5-2.0 cm
normal margin taking into
consideration its malignant
transformation behaviour.
• Prognosis is probably good.

189
 MIXED BENIGN TUMOURS
NEUROFIBROMA
• This is a tumour of nerve cells.
• The exact cells involved in the
development of the lesion is uncertain
but controversially it is thought to arise
from perineural cells with intermingled
neurites or axons.
• The tumour may arise from nerve
sheaths – endonerium,perineurium or
epineurium.
190
• The lesion most frequently involves the
skin or multiple form of the disease
called Neurofibromatosis or Von
Recklinghausen’s disease of skin
though it lacks systemic or hereditary
factors.
• Neurofibromatisis is common.

191
 NEUROFIBROMATOSIS
• Neurofibromatosis (or von Recklinghausen
disease) was first described in 1882 by the
German pathologist, Friedrich Daniel von
Recklinghausen.
• Neurofibromatosis (NF) type 1 also
known as von Recklinghausen disease)
is a genetically-inherited disorder.

192
• Neurofibromatosis is an autosomal
dominant disorder, which means only one
copy of the affected gene is needed for the
disorder to develop.
• Therefore, if only one parent has
neurofibromatosis, his or her children have
a 50% chance of developing the condition
as well.

193
• The nerve tissue develops tumours
(neurofibromas) that may be benign and
may cause serious damage by
compressing nerves and other tissues.
The disorder affects all neural crest cells
(Schwann cells, melanocytes, and
endoneurial fibroblasts).

194
Clinical features:
• No sex predilection
• Hereditary diseases, inherited as simple autosomal
dominant trait
• Incidence of 1 in 3000 births in general population
• There are two forms of lesions.
• Numerous sessile or pedunculated, elevated smooth
surfaced nodules of varying sizes scattered over the
skin surface mainly on the trunk, face and
extremities.

195
• Deeper, more diffuse lesions and proportionally
larger than the superficial nodules, these are
referred to as “ELEPHANTIASIS
NEUROMATOSA”. In many patients there are
asymmetric areas of cutaneous melanin
pigmentation – described as cafe-au-lait spots.
• axillary freckling is also common
• pigmentation and hirsutism suggests endocrine
disturbances.
• Loose overgrowth of thickened, pigmented skin
may hang in folds.

196
 Stopped here 17th April
• Cutaneous lesions may begin in infancy or in
childhood.
• The lesions may undergo malignant transformation
into sarcoma described as either fibrosarcoma,
spindle cell sarcoma or neurogenic sarcoma.
• Solitary neurofibromas rarely undergo malignant
transformation.
• Associated pathologic lesions include osseous
changes, mental disorders, congenital defects and
ocular disease.
• Cosmetically the patient is unsightly

197
Oral manifestations:
• Oral lesions occur in patients with von
Rocklinghausen’s disease.
• Oral lesions appear as discrete, non-ulcerated
nodules having normal mucosal colour occurring
on the buccal mucosa, palate, alveolar ridge
vestibule and tongue.
• Other cases present with diffuse masses involving
the palate, buccal tissues and alveolar ridges; also
having same colour as mucosa.
• Macroglossia may occur if the tongue in involved.

198
CENTRAL NEUROFIBROMA
• It has been reported affecting the mandible
associated with the mandibular nerve. There is
fusiform enlarged mandibular canal as seen on
x-rays. In these patients there is discomfort,
pain or paraesthesia .
Histologic features:
– Composed of proliferation of delicate spindle
cells with thin nuclei intermingled with neuritis in
an irregular pattern as well as delicate,
intertwining connective tissue fibrils.
– Cellular and myxoid patterns predominate.

199
• The diagnosis of NF1 is made if any two of
the following nine criteria are met:
• multiple small cutaneous neurofibromas
and a 'café au lait spot’.
• Two or more neurofibromas on or under
the skin, or one plexiform neurofibroma (a
large cluster of tumors involving multiple
nerves).

200
• neurofibromas form subcutaneous bumps
that are characteristic of the disease, and
increase in number with age.
• Freckling of the groin or the axilla (arm
pit).
• Café au lait spots (pigmented, light brown
macules located on nerves, with smooth
edged, "coast of California”birthmarks)
measuring 5 mm diameter in prepubertal
and >15 mm in postpubertal individuals. 201
• Skeletal abnormalities, such as sphenoid
dysplasia or thinning of the cortex of the
long bones (i.e. bones of the leg causing
bowing).
• Lisch nodules ( hamartomas of iris),
freckling in the iris.
• Tumors on the optic nerve, also known as
an optic glioma

202
• Other features include:
-Scoliosis with or without kyphosis
-Macrocephaly in 30–50% of the
pediatric population without any
hydrocephalus
-Epilepsy (seizures)
-Juvenile posterior lenticular opacity

203
Treatment of Neurofibromatosis
• Any lesion subject to obvious and continuous
trauma to be removed to avoid malignant
transformation.
• Any obvious increase in size or ulceration of a lesion
should be investigated and immediate complete
excision done.
• If sarcomatous transformation has taken place the
prognosis is poor as these sarcomas metastasize
early in the course of development; surgical
removal may be done.
• Multiple lesions, neither surgical nor radiotherapy is
of value due to multiplicity of the lesions.

204
 AMELOBLASTIC FIBROMA

• This is a tumour of mixed

connective and odontogenic
tissue origin, characterized by the
simultaneous proliferation of both
Epithelial and Mesenchymal
tissue without the formation of
enamel or dentin. It is a rare
mixed odontogenic tumour.

205
 Clinical features:

• It is most commonly found in

younger age groups, between 15
and 25 years of age.
• Males are more affected than
females.
• Clinically, the tumour, grows
slowly and painlessly, expanding
the jaw.
206
 Clinical features
• The lesion does not infiltrate
between trabeculae of bone.
• Grows by expansion with the
periphery of the lesion remaining
smooth with no complaints.
• Sometimes there is pain,
tenderness or mild swelling of the
jaw that alarms the patients to seek
treatment.
207
 Radiologic features:

– Similar to simple ameloblastoma

– It is unilocular or multilocular radiolucent
lesion having rather smooth outline with
sclerotic border
– It may be difficult to distinguish from a
unilocular ameloblastoma or dentigeruos
cyst, especially if there are unerupted
teeth.

208
 Histologic features
– The tumour can be distinguished from
ameloblastomas by the fact that both the
epithelial and mesenchymal components
are neoplastic, while in ameloblastomas
only the epithelium is neoplastic.
– The tumour consists of strands and
groups of epithelial cells in a connective
background and does not invade bone.
– Occasional myxomatous areas and foci of
predentine have been observed.

209
 Treatment:

– Because it doesn’t infiltrate the bone as

with simple ameloblastoma, it is more
readily separated from the bone.
– The treatment of choice is conservative
surgical removal;it can be “curetted” or
“peeled off” from its bony cavity.
– Recurrences may follow incomplete
removal.

210
 ODONTOGENIC FIBROMA

PERIPHERAL ODONTOGENIC FIBROMA

• A mesodermal tumour of odontogenic origin
rarely occurring believed to arise from
odontogenic epithelial rests in the periodontal
ligament or the attached gingiva itself..
Clinical features:
• No sex predilection and affects patients ranging
from 5 – 65 years
• Slow growing sessile,and nodular growth of
gingiva most often on the mandibular buccal or
lingual aspect lasting several years.

211
• The lesion is solid and firmly attached to
the gingiva
• Sometimes it arises between teeth with
occasional teeth displacement.
• Clinical differrential diagnosis includes
inflammatory gingival hyperplasia,
peripheral cemento-ossifying fibroma and
peripheral giant cell granuloma.

212
Histological features:
• Consists of an unencapsulated mass of
interwoven cellular fibrous connective tissue that
contains scattered nests or strands of
odontogenic epithelium.
• Calcified tissue may be present or not. Mature
fibrous connective tissue stroma is present
• Myxomatous changes may also be found in the
stroma
Treatment: Surgical excision, No recurrences
213
 CENTRAL ODONTOGENIC FIBROMA

• It is a very rare tumour; much about it unknown.

• Three basic concepts regarding the tumour:-
– Regarded as a lesion around the crown of an
unerupted tooth resembling a small dentigerous
cyst (in fact this is simply a hyperplastic dental
follicle and not a tumour.
– A lesion of fibrous connective tissue with
scattered islands of odontogenic epithelium
bearing some resemblance to the dental follicle
but because of the size it appears like a
neoplasm.
214
-- Described by WHO as a fibroblastic neoplasm
containing varying amounts of odontogenic
epithelium, calcified material similar to dysplastic
dentin or cementum-like material – except for
location it is histologically similar to superficial
odontogenic fibroma.
Clinical features:
• Affects mostly children and young adults although
older ones are also affected.
• Occurs predominatly in the mandible
• It grows asymptomatically except for the jaw
swelling.

215
Radiologic features:
• Expansile, multilocular radiolucency
similar to Ameloblastoma
• Treatment:
• Surgical excision – Recurrences are
unknown

216