Oral & Maxillofacial Surgery Fifth Year

1. Dr. Adel I. Abdelhady
BDS, MSC, (Egypt) PhD. (Egypt, USA)
Oral and Maxillofacial Surgery Dept.
College of Dentistry, Dammam University, KSA

2.  By the end of the lecture(s) Students should display a
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knowledge, information and understanding of :
1.Classification the odontogenic tumors
2.familiar with the different types of odontogenic tumor
according to its origin
3.Examine and diagnose patient’s complain from facial
swelling
4. Establish a Differential Diagnosis of the mandibular as will
as maxillary swelling
5. Differentiate between different types of tumor’s biological
behaviors and accordingly select the suitable management
technique (s)

3. Cementoblastoma
 This tumor typically occurs
around the roots of the lower
posterior teeth.
 Like virtually all odontogenic
tumors, it is benign but it
expands the jaw, causes pain and
requires surgical removal.
Radiographically it appears as a
ball of dense material attached to
the end of the root

5. (Central) Odontogenic Fibroma
Clinical Features
 Fewer than 50 cases have been reported in the
English literature.
 Patient Age: Patients have ranged in age from 980 years old with a mean of 40 years.
 Gender Predilection: Females, 7.4 : 1 in one study.
 Location: 60% Sixty percent occur in the maxilla
where most are located anterior to the first molar.
When in the mandible, approximately 50 % occur
in the posterior jaw.

6. Odontogenic Fibroma: Radiographic
Appearance
 The odontogenic fibroma usually appears as a well-
defined, unilocular radiolucency. It is often
associated with the apical area of an erupted tooth.
 Larger lesions are often multilocular.
 Many odontogenic fibromas have sclerotic borders.
root resorption is common.

8. Odontogenic Fibroma: Additional Features
 Small odontogenic fibromas are usually asymptomatic.
 The larger lesions may be associated with localized
bony expansion of the jaw or with the loosening of
adjacent teeth.

9. Odontogenic Fibroma: Histologic Features
 Some authors have described two separate types of
odontogenic fibromas.
 The simple odontogenic fibroma is composed
of stellate fibroblasts arranged in a whorled
pattern with fine collagen fibrils and a lot of
ground substance.
 Foci of odontogenic epithelium may or may not be
present.
 Occasionally, foci of dystrophic calcification may
be present.

10. Odontogenic Fibroma: Histological Features
 The WHO type odontogenic fibroma appears as a
fairly cellular fibrous connective tissue with collagen
fibers arranged in interlacing bundles.
 Odontogenic epithelium in the form of long strands or
isolated nests is present throughout the lesion.
 Calcifications composed of cementoid and/or
dentinoid may be present.

11. Odontogenic Fibroma: Treatment and
Prognosis
 The odontogenic fibroma is usually treated
by enucleation and curettage.
 There have been few recurrences, this the
prognosis is good.

13. Mixed Odontogenic Tumors
 Ameloblastic fibroma, ameloblastic fibrodentinoma,
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ameloblastic fibro-odontoma, odontoma
Both epithelial and mesenchymal cells
Mimic differentiation of developing tooth
Treatment – enucleation, thorough curettage with
extraction of impacted tooth
Ameloblastic fibrosarcomas – malignant, treat with
aggressive en bloc resection

14. Related Jaw Lesions
 Giant Cell Lesions
 Central giant cell
 Fibroosseous lesions
 Fibrous dysplasia
granuloma
 Ossifying fibroma
 Brown tumor
 Condensing Osteitis
 Aneurysmal bone cyst

15. Central Giant Cell Granuloma
 This is a neoplastic-like reactive proliferation of
the jaws that accounts for less than 7% of all
benign lesions of the jaws in tooth-bearing
areas.
 It commonly occurs in children and young
adults with a slight female predilection.
 The lesion is more common in the mandible
than maxilla underlying anterior or premolar
teeth. Expansile lesions can cause root
divergence or resorption.

16. Central Giant Cell Granuloma
 The clinical features:
 Vary according to the type of development the lesion
assumes. Lesions may be slow-growing and
asymptomatic or rapidly expanding with pain, facial
swelling and root resorption.
 The fast growing variants have a high rate of
recurrence.
 Because of the higher incidence of these lesions
among girls and women of child-bearing years,
hormonal influences have been suggested as
influential in their development.

17.  Intraosseous destructive lesions of the
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jaws
Far less common than peripheral giant
cell granuloma
10-30 yrs of age; Female > Male
Mandible > Maxilla; Ant. > Post.
Mandibular lesions frequently cross the
midline
Asymptomatic or painless expansion
Non-aggressive and aggressive lesions
Perforation of the cortical plates and
resorption of roots

18. Central Giant Cell Granuloma
 Neoplastic -like reactive proliferation
 Common in children and young adults
 Males > Females (hormonal?)
 Maxilla >Mandible
 Expansile lesions – root resorption
 Slow-growing – asymptomatic swelling
 Rapid-growing – pain, loose dentition (high rate of
recurrence)

19. Central Giant Cell Granuloma
 Radiographic findings
 Aggressive lesions show cortical perforation and root
 resorption
 Unilocular, multilocular radiolucencies
 Well-defined or irregular borders
 Histology
 Multinucleated giant cells, dispersed throughout a
fibrovascular stroma

20. Central Giant Cell Granuloma

21. Central Giant Cell Lesion
CGCL
 75% before the age of 30; female> male
 Anterior mandible to first molar; can cross the midline
 Non-aggressive vs aggressive:
 Aggressive lesions: larger on presentation, painful,
rapid growth, root resorption, cortical perforation,
younger patients
 Recurrence: 75% in aggressive lesions (11% in nonaggressive)
 Questionable minor histological differences

23. Central Giant Cell Granuloma
 Treatment
 Curettage, segmental resection
 Radiation – out of favor (risk of sarcoma)
 Intralesional steroids – younger patients, very
large lesions
 Individualized treatment depending on
characteristics and location of tumor

24. Brown tumors of
hyperparathyroidism
 Brown tumors are tumors of bone that arise in settings of
excess osteoclast activity, such as hyperparathyroidism and
consist of fibrous tissue, woven bone and supporting
vasculature, but no matrix. They are radiolucent on x-ray.
The osteoclasts consume the trabecular bone that
osteoblasts lay down and this front of reparative bone
deposition followed by additional resorption can expand
beyond the usual shape of the bone, involving the
periosteum thus causing bone pain. The characteristic
brown coloration results from hemosiderin deposition into
the osteolytic cysts. Also characteristic of giant cell tumors
of the bone.

25.  Brown tumor, an uncommon focal giant-cell lesion, arises
as a direct result of the effect of parathyroid hormone on
bone tissue in patients with hyperparathyroidism
 Laboratory evaluation revealed that the patient had
primary hyperparathyroidism, parathyroid hormone level
was 988 pg/ml (normal: 12 to 72).
 Other laboratory measurements were total serum calcium,
11.2 mg/dl (normal: 8.8 to 11.0); phosphorus, 2.0 mg/dl
(normal: 2.5 to 4.8); and alkaline phosphatase, 145 U/L
(normal: 32 to 104).
 Ultrasonography of the neck revealed an enlargement of
the lower left parathyroid gland (2.1 x 1.4 x 0.8 cm). The
finding of hyperparathyroidism confirmed the diagnosis of
brown tumor.

26. Brown Tumor
 Local manifestation of hyperparathyroidism
 Histologically identical to CGCG
 Serum calcium and phosphorus
 More likely in older patients

27. Cherubism
 Definition
 Genetic disorder characterized by
bilateral mandibular and maxillary
intraosseous fibrous swellings in
young individuals with autosomal
dominant inheritance.
Indistinguishable histologically
from central giant cell granuloma
 bilateral mandibular and maxillary
involvement
 young

28.  Histopathology
 Large number of osteoclast-like, multinucleated giant
cells
 Indistinguishable microscopically from central giant
cell granuloma
 sometimes more delicate fibrovascular stroma without
bone formation
 Differential Diagnosis
 Select up to 2 differential diagnoses to compare with
Cherubism
 Central Giant Cell Granuloma [Mandible and Maxilla]
 Primary Hyperparathyroidism
 Ossifying Fibroma

29. DD
 Large number of osteoclast-like, multinucleated giant
cells also in:
 central giant cell granuloma
 giant cell tumor (osteoclastoma)
 fibro-osseous lesions
 bone lesion of hyperparathyroidism
 aneurysmal bone cyst

30. Fibrous Dysplasia
 Monostotic vs. polystotic
 Monostotic
 More common in jaws
and cranium
 Polystotic
 McCune-Albright’s
syndrome
 Cutaneous pigmentation,
hyper-functioning
endocrine glands,
precocious puberty

31. Fibrous Dysplasia
 Painless expansile dysplastic process of
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osteoprogenitor connective tissue
Site :Maxilla most common
Does not typically cross midline (one bone)
Antrum obliterated, orbital floor involvement
(globe displacement)
Radiology : ground-glass appearance

32. Fibrous dysplasia
 Fibrous dysplasia is a condition in which normal
 medullary bone is replaced by an abnormal fibrous
 connective tissue proliferation in which new,
nonmaturing bone is formed.
 A genetic defect involving Gs-alpha proteins appears to
underlie this process.

33. Etiology and Pathogenesis.
 The nature of this condition has not been firmly
established.
 The name given to fibrous dysplasia was originally
intended to indicate that the condition represented a
dysplastic growth resulting from derange
mesenchymal cell activity or a defect in the control of
bone cell activity.
 This genetic alteration may ultimately affect the
proliferation and differentiation of fibroblasts/
osteoblasts that make up these lesions.

34. Clinical Features.
 This disease most commonly
 The most commonly
presents as an asymptomatic, slow
enlargement of the involved bone.
 Fibrous dysplasia may involve a
single bone or several bones
concomitantly.
 Monostotic fibrous dysplasia is the
designation used to describe the
process in one bone.
 Polyostotic fibrous dysplasia applies
to cases in which more than one
bone is involved. McCune-Albright
syndrome consists of polyostotic
fibrous dysplasia, cutaneous
melanotic pigmentations (cafe-aulait macules), and endocrine
abnormalities.
reported endocrine
disorder consists of
precocious sexual
development in girls.
Acromegaly,
hyperthyroidism,
hyperparathyroidism, and
hyperprolactinemia have
also been described

35. 
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Monostotic fibrous dysplasia is much more common
than the polyostotic form, accounting for as many as
80% of cases. Jaw involvement is common in this form
of the disease. Other bones that are commonly affected
are the ribs and femur.
Fibrous dysplasia occurs more often in the maxilla than
in the mandible
Maxillary lesions may extend to involve the maxillary
sinus, zygoma , sphenoid bone, and floor of the orbit.
This form of the disease, with involvement of several
adjacent bones, has been referred to as craniofacial
fibrous dysplasia.
The most common site of occurrence with mandibular
involvement is in the body portion.

36.  The slow, progressive enlargement of the affected
jaw is usually painless and typically presents as a
unilateral swelling.
 As the lesion grows, facial asymmetry becomes evident
and may be the initial presenting complaint.
 The dental arch is generally maintained, although
displacement of teeth, malocclusion, and interference
with tooth eruption may occasionally occur.
 Tooth mobility is not seen

38.  Age:
 This condition characteristically has its onset during
the first or second decade of life. Rarely, the lesion
presents later in life, although this may only reflect
the insidious, asymptomatic nature of fibrous
dysplasia.
 Gender :
 Monostotic fibrous dysplasia generally exhibits an
equal gender distribution, and the polyostotic form
tends to occur more commonly in females.

40.  Fibrous dysplasia has available radiographic appearance
 that ranges from a radiolucent lesion to a uniformly
radiopaque mass
 The classic lesion has been described as having a
radiopaque change that imparts a "ground glass" effect
 This characteristic image, which is most identifiable on
intraoral radiographs, is not, however, pathognomonic.
 Lesions of fibrous dysplasia may also present as
unilocular or multilocular radiolucencies, especially in
long bones.

41.  An important distinguishing feature of fibrous
dysplasia is the poorly defined radiographic and
clinical margins of the lesion. The process appears to
blend into the surrounding normal bone without
evidence of a circumscribed border.
 Laboratory values for patients with monostotic
fibrous dysplasia, specifically serum calcium,
phosphorus, and alkaline phosphatase, are usually
within normal
 However, these serum chemistry markers may be
altered in patients with McCune-Albright syndrome

42. Histopathology
 Fibrous dysplasia consists of a slight to moderate
cellular fibrous connective tissue stroma that
contains foci of irregularly shaped trabcculae of
immature bone
 A relatively constant ratio of fibrous tissue to bone
throughout a given lesion is characteristic.

43. Treatment and Prognosis
 Deferred, if possible until skeletal maturity
 Quarterly clinical and radiographic f/u
 If quiescent – contour excision (cosmesis or
function)
 Accelerated growth or disabling functional
impairment - surgical intervention

44. Treatment and Prognosis
 After a variable period of pre-pubertal
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growth, fibrous dysplasia characteristically stabilizes,
although a slow advance may be noted into adulthood.
Small lesions may therefore require no treatment other
than biopsy confirmation and periodic follow-up.
Large lesions that have caused cosmetic or functional
deformity may be treated by surgical recontouring.
This procedure is generally deferred until after stabilization
of the disease process.
En bloc resections for complete removal are impractical
and unnecessary, because the lesions arc relatively large
and poorly delineated.

45.  Malignant transformation is a rare complication of
 fibrous dysplasia {fewer than 1% of cases) that has
been described, usually in patients with the
polyostotic type.
 Many of the patients reported on were treated with
radiation therapy, suggesting a role for radiation
in the transformation process, although malignant
change has been documented in the absence of
radiation treatment.

46. Fibrous Dysplasia

48. Clinical Features
 Age: Ossifying fibroma is an uncommon lesion that tends
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to occur during the third and fourth decades of life
Sex :in women more than men. It is a slow-growing,
asymptomatic, and expansile lesion.
In the head and neck, ossifying fibroma may be seen in
the jaws and craniofacial bones.
Site: Lesions of the jaws characteristically arise in the
tooth-bearing regions, most often in the mandibular
premolar-molar area
The slow but persistent growth of the tumor may
ultimately produce expansion and thinning of the buccal
and lingual cortical plates, although perforation and
mucosal ulceration are rare
Most of these lesions are solitary

49.  Ossifying fibromas of the jaw are wellcircumscribed, slowly growing lesions. They are
often mentioned in the same differential diagnosis
as fibrous dysplasia, but it is important to make the
distinction because the former lends itself to ready
enucleation, while the latter can be admixed with
surrounding tissues, making surgery more
complicated.

52.  Patients generally present with a history of a painless
expansion of a tooth-bearing portion of the mandible.
Lesions of the maxilla are also encountered, but they
are less common.
 Radiographically, the lesions are typically 1 to 5 cm at
their greatest dimension. Well-defined areas of
osteolysis are noted radiographically, with varying
degrees of calcification and cortical thinning.
 These lesions can often be readily identified at the
time of surgery by noting the case with which they can
be separated from surrounding tissue.

53. radiographic features
 The most important
radiographic feature of
this lesion is the wellcircumscribed, sharply
defined border. Ossifying
fibroma otherwise present a
 variable appearance,
depending on the density of
 calcifications present.
 Lesions may be relatively
radiolucent because of evenly
dispersed, calcified new
bone.
 Lesions may also appear as
unilocular or multilocular
radiolucencies that bear a
resemblance to odontogenic
lesions.
 A mixed radiolucentradiopaque image is seen
when islands of tumor bone
are densely calcified.
 The roots of teeth may be
displaced and, less commonly
tooth resorption is seen.

54.  A variant of ossifying fibroma, juvenile (aggressive)
ossifying fibroma, has been described in children and
young adults .Most affected individuals are younger
than 15 years of age.
 This lesion most commonly involves the paranasal
sinuses and periorbital bones, where it may cause
exophthalmoses, proptosis , sinusitis, and nasal
symptoms.
 This rare tumor behaves in a more aggressive fashion
than does ossifying fibroma, and it may require more
extensive surgery when encountered.
 Microscopically, juvenile ossifying fibroma is highly
cellular and contains trabeculae or spheroids of new
bone.

55.  Cementifying fibroma, and cemento-ossifying
fibroma, are terms occasionally used when the bony
islands in these lesions have a round or spheroidal
shape.
 These tumors occur in similar age-groups and
locations, exhibit comparable clinical characteristics,
and have the same biologic behavior.
 They are, for all practical purposes, the same lesion as
ossifying fibroma.

57.  Other differential considerations are osteoblastoma,
focal cementoosseous dysplasia, and focal
osteomyelitis.
 Osteoblastoma is evident in a slightly younger agegroup and is often characterized by pain.
In addition, osseous trabeculae in these lesions are
rimmed by abundant plump osteoblasts, and a central
nidus may be evident.
 Periapical cemento-osseous dysplasia in posterior
teeth may appear radiographically similar and require
a biopsy to separate it from ossifying fibroma.
 Focal osteomyelitis is associated with a source of
inflammation and is possibly accompanied by pain
and swelling.

58. Treatment And Prognosis.
 Treatment of ossifying fibroma : is most often
accomplished by surgical removal using CURETTAGE
OR ENUCLEATION.
 The lesion can typically be separated easily from the
surrounding normal bone.
 Recurrence is described only rarely after removal.

59. Differential Diagnosis.
 The primary differential consideration
for fibrous dysplasia of the jaws is ossifying fibroma.
 As previously noted, clinical, radiographic, and
microscopic features must be considered together
in order to distinguish these processes.
 The well circumscribed ossifying fibroma as compared
with the diffuse fibrous dysplasia often serves as the
differentiating factor.

60.  Chronic osteomyelitis may occasionally mimic the
radiographic appearance of fibrous dysplasia.
 Inflammation, often mild, is present in osteomyelitis
and may be accompanied by symptoms that include
tenderness, pain, or drainage. The slowly progressive,
asymptomatic nature of fibrous dysplasia usually
allows differentiation from malignant tumors of bone.

61. Ossifying Fibroma
 True neoplasm of medullary jaws
 Elements of periodontal ligament
 Younger patients, premolar – mandible
 Frequently grow to expand jaw bone
 Radiology
 radiolucent lesion early, well-demarcated
 Progressive calcification (radiopaque – 6 yrs)

62. Ossifying Fibroma

63.  Distinguishing between
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 Historically, differentiating
ossifying fibroma and fibrous
dysplasia is the primary
diagnostic challenge.
Both lesions may exhibit similar 
clinical, radiographic, and
microscopic features.
The most helpful feature in
distinguishing the two is the well
circumscribed radiographic
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appearance of ossifying fibroma
and the ease with which it can be
separated from normal bone.
In most cases the well defined
appearance of ossifying fibroma
is evident radiographically.
the two lesions was based
primarily on histologic
criteria.
Fibrous dysplasia was
reported to contain only
woven bone, without
evidence of osteoblastic
rimming of bone.
The presence of more mature
lamellar bone was believed to
be characteristic of ossifying
fibroma

64. Types of Jaw Tumors and Primary Treatment Modalities