odontgnic myxoma

is one type of odentogenic tumor , slow growing , and with a

potential for aggressive behavior .
what characterized it that there is no lining will show in the
radiograph so it looks more nastier , myxoma is a benign lesion , but
what characterize it that it dont have will delineated borders , so
when doing surgery we have to be aggressive as we treated
ameloblastoma i.e. resection . because it can infiltrate where you
can't see neither radiographically nor clinically
occur commonly in the posterior mandible , rarely on posterior
maxilla
May cause displacement or root resorption of teeth

one of the main characteristic feature of cancer that it always penetrate the
basement membrane , so when you see a lesion with no boundaries you will think
it's sinister and nasty

if you werent aggressive and did just curettage it might recurrence in

a matter of fact its consider as a persistent lesion because the
lesion was not completely removed

 radiographic feature
- lesion of mixed density,
- multilocular or unilocular
- step leader pattern
treatment :- resection with 1 cm safety margin .

calcified odontogenic tumor " Pindborg tumor"

it's a very rare tumor very unlikely to phase in your entire life , only
200 cases were reported worldwide .
mixed radiopaque radio lucent lesion associated with an impacted
tooth
ct scan coronal cut showing mid facial bone , obliterated left sinus
with mixed lesion
treatment it resection with 1 cm margin

adenomatoid odontogenic tumor

 it a hemartoma , it was previously called adenoameloblastoma , in

the anterior maxilla associated with a tooth " canine "
it resemble amelobalstoma histologicaly but it acts differently , the
lesion will grow till reach to a certain limit then stop growing so they
classified it as hemartoma not a tumor
treatment :- enucleation with removing the associated tooth .

fibro osseous disease

in the previous lectures we talked about a lot of lesions whats

combine them that the cell which form those lesions where
odotognic in origin . Today we will be talking about lesions found in
the maxilla facial area but the cell which respond for there
formation is apparently not from an odentogenic source .
so if it's not from odentogenic source you can find it anywhere in the
body , so its non odontogenic can tumor that might come in the
maxillofacial area
in this disease there will be some sort of abnormity resulting in
replacement of the osteoblast with fibroblast ,That will start laying
fibrous tissue . ossified cementum like lesions can be found , and
the lesion might ossified completely into complete hard tissue not
necessarily bone
there is three sub group for this disease

fibro-osseous
disaeas

fibrous
dysplasia

cementosseous
dysplasia

Fibro-osseous
neoplasm

fibrous dysplasia

Theres big controversy about it , some consider it as a tumor that

should be excised ,while others consider it as hemartoma .
most likely it's hemartoatous
generally asymptomatic
maxilla appears to be affected more than mandible
and female seems to be affected more than males
period of activity and quiescent , it resemble cherubism in this
action

there is two type of it :-

- polystotic
-mono stotic

 in case of maxillofacial area it's consider as monostotic if happens in

mandible alone , or poly stotic if it happens in maxillofacial bone and
anywhere else .
Albright syndrome characterized by
polyostatic fibrous dysplasia
hyper pigmentations(caf-au-lait spots)

if it was polystotic and associated with other findings

precocious puberty in female
it is consider as a syndrome which is called
endocrine problem , and in male there
Albright syndrome .

will be thyroid problem

In craniofacial fibrous dysplasia we are concerned about the vital

structure in that area i.e. optic nerve mainly ,in this case we must
open surgically and do decompression around the optic nerve.

it has ground glass appearance radiographically

there is a type of imaging called bone scan to show the activity of the
bone over the body , the inject the patient with a tracer in then take
radionucluar image to see where it's more absorbed the tracer name is
Technetium-99m .

in the jaw area of this patient theres three

dark spots meaning that
those are highly active .
theres two dark spots in the patient
abdominal area representing the
kidneys , because the kidney is a highly
active organ same goes for
brain and heart some in nuclear imaging
those are showed dark
Treatment of this lesion with such a
behavior is to intervene in the quiescent
phase , because this kind of lesion is
highly vascularized so if we decided to do
a surgery the patient might lose high amount of blood resulting in
his death !!
the treatment of choice is shaping or shaping or sculpting, same as
cherubism but if it caused compression of the optic nerve we must
open and decompress the nerve .
some says that the lesion might have sarcomatous changes we
should remove it by excision.
and some claims that this lesion from the beginning is a low grade
osteosarcoma and should be removed completely .
cemento osseuos dysplsia
has four types : Periapical :- the lesion is most commonly found in the
mandible anterior mainly , like small target lesion around
the apices of teeth , and teeth will be vital so the lesion is
not inflammatory in origin.
Florid :- if the patient was followed up then this lesion i.e.
periapical may ossified , or coherence with the lesion next
door to become florid cemento osseous dysplasia " florid
= Diffused

 focal cemento osseos dysplsia:- commonly founded in

the edentulous area e.g. when you extract a lower right
six and youve founded a radiolucency and took a biopsy
and turn out to be focal cemento osseous dysplasia not a
radicular cyst according to histology .
Familial Gigantiform Cementoma : it's (familial) inherited ,autosomal
dominant , affect more than one quadrant of teeth , anterior mandible.
the etiology is unknown some theory says it's because of trauma
happened to the corresponded teeth lead to the formation of the
lesion around the apices of those teeth .
females predominate
afro - American has the highest incident

treatment :- if it was asymptomatic then no treatment we just

follow up,
if the lesion was infected , we should give antibiotics and
deal with it .

Florid cemento osseous dysplasia

 Fibro-osseous neoplasm
ossifying fibroma :

the well known example of

fibro-osseous neoplasm , its
tumor with well demarcated
bordered ,mixed
radiolucency found mainly
below the root of lower first
molar

Females > Male

It might be Peripheral(Outside
bone) or Central (inside bone)
treatment is surgical to enucleate the lesion
juvenile aggressive ossifying fibroma :
it happens in an earlier age below 15 years old
it's more aggressive it can easily expand and need to be dealt
with aggressively
mainly happened in the rest of the body

osteoblastoma and osteoid lesion

osteoblastoma tumor happened in the rest of the body it might

happened in the maxillofacial area but it's very unlikely
what is very peculiar about it is pain
if the lesion was > 2 cm it is called osteoblastoma , < 2cm it is
called osteiod osteoma they share the same histology
DD :- ossifying fibroma , fibrous dyspsia and osteo sarcoma

 Tx :- conservative surgical excision

chondroma

benign tumor of cartilage it need to be dealt with very consciously

Painless slowly growing swelling which may result in mucosal
ulceration
we need to deal with it as low grade chondro sarcoma like fibrous
dysplasia
the patient should be closely followed up
treatment is localized surgical excision

osteoma
is a benign tumor of bone
asymptomatic radio opacity
periferal osteama or endoosteol osteoma
What's important to us in Osteoma is what is called Gardner's
Syndrome,where there will be multiple osteomas, Intestinal polyps,
fibromas of skin, epidermal cyst ,impacted teeth, and odontomas.
so we send him to a GI specialist to do endoscopy to find multiple
intestinal polyps ,the findings in the maxillofacial won't harm him but
what is consider fetal is the intestinal polyps
synovial chondramatosis
happens in the capsule around
the TMJ
small particles inside synovial
membrane
pain and swelling , and sounds
lose of occlusion& posterior
open bite
treatment open the capsule and
clean it

 Osteochndroma
benign lesion containing bone and
cartilage
on MRI it appears as extraneous
appendages toward the TMJ.
It's usually more radiopaque than
the surrounding mandible
very unlikely to see

general role in medicine we treat the biology not the histology ; so if a

patient came to you and he have growing a lesion with the histological
report said nothing to worry you should trust what you see and interfere.
The lesion happens in children and start to eat the bone , when you take
a biopsy and send to histopathology they will come back with very benign
tumor they will say leave this tumor it's very benign and will do nothing
,so if you treat the lesion as the histopathologiest has recommended the
patient will lose the mandible and the maxilla , but if you treat the biology
you need to be very aggressive to remove that lesion before it's eat the
whole maxilomandibuilar area.
vascular malformation
if the patient came to the clinic and we want to do an excisional biopsy
the first thing to do is aspiration to rule out any vascular mal formation .
vascular malformation is very unlikely to happens ,but if it happened once
the patient might lose his life
it's a developmental lesion it will be present since the patient were
born ,and it will get bigger and bigger as the patient is growing
it may affect soft tissue and bone
Central vascular malformation :- it happens inside the bone
very rare but it's well documented entity

 It's divided into :

High flow Vascular malformation

Low flow Vascular malformation

the High flow Vascular malformation is more dangerous

Slowly growing expansile lesion of the jaw asymptomatic and if it's
high it may be associated with bruit "the sound of blood pumping "
which mean that theres pulse.
Appears as irregular poor defined soap-bubble type lesion
Cause resorption of root of the teeth why because it's high flow ,
and it's ill-defined because it's invading the area with pressure

angiogram :- is an imaging
modality for the blood vessel , the
intervenisional radiologist will
inject all the blood vessel that
might supply that area ,in the
maxillofacial area the Dr will inject
the facial blood vessel
it will give us that theres a
large vessel due to
embryological problem that
supply the radio lucent lesion
the treatment in high flow is embolization to occlude the vessel
that supply the area by special material and it's done by the
intervenional radiologist and it's very dangerous procedure.
so the lesion that was supplied by the vessel be blood free , then the
maxillofacial surgeon will intervene and enucleate and clean the area now
why is this because although we occlude the vessel and the area now is
dry but the body has the ability to form collateral vessels .
so one of the treatment option is just to occlude the area while the better
option is enucleate the lesion after the embolization and to put a bone
graft so that the space will be close so if collateral vessel occurred it will
not have a room to cause vascular mal formation .

 paget disease
more common in men , it resemble fibrous dysplasia because it has
stages
one of the clinical scenarios that the patient came to your clinic
complaining that his hat wont fit his head anymore or as to dentist
his denture, headache and symptoms due to vascular and nerves
compressions
panoramic radiograph you will find the cotton wool appearance

Resorption of bone will occur, then the area will be highly vasculrised, afterwards
there will be sclerosing phase

around the teeth there will be hyper cementosis so when extracting

the tooth it should be made surgically
how to diagnosis the patient
he will have high serum alkaline phsphotase because of the bone
resorption
treatment of paget disease

treatment to prevent bone resorption , the hormone that is in responsible

of replacement of the lost bone is 1} calciotonine for inhibition of bone
resorption that occur in the first stage
2} or bisphisphonate to inhibit bone resorption

those patient will die mainly because of left side heart failure
because the bone resorption is taking place all over the body and it's
being replaced by blood, so the heart now is obligated to pump heart
to the bone all over the body ending by having heart failure

 and the lesion might transform to cancer osteo sarcoma

one of the difficulties that during the second stage there will be high
blood supply in the body, so if we tried to do surgery in this area we
may face tremendous bleeding and the patient may die !!

Done by the one and only :- mohammad fayeq elwir