Benign tumors of oral cavity sonal

Benign Soft Tissue Tumors
of the Oral Cavity
Dr. Sonal Aggarwal
M.D.S.
Oral & Maxillofacial Pathology & Microbiology

 The dentist has a vital role in the diagnosis and
treatment of these lesions.
 Although the dentist might not see all the types of
benign oral tumors, it is important to be familiar about
them so as to manage them whenever necessary.
WHY,,,>>

What is a tumor?
The tumor, by definition is simply a swelling of
the tissue; in the strict sense, the word does not
imply a neoplastic process.
Many of the lesions to be discussed now are
called tumors only because they are manifested
as swellings; they are in no way actually related
to true neoplasms.

A neoplasm can be defined as an abnormal mass of
tissue, the growth of which exceeds and is
uncoordinated with that of the normal tissues and
persists in the same excessive manner after cessation
of the stimuli which evoked the change.
(Willis 1952).

Difference between a Benign and malignant tumor?
Benign Tumor
It is a locally controlled growth or
lesion, generally encapsulated,
which does not produce
metastases, and therefore not
endangering life.
Malignant Tumor
It is an independent uncoordinated
new growth of tissue which is
potentially capable of unlimited
proliferation and which does not
regress after removal of the stimulus
which produced the lesion.

Benign tumors of the Oral Cavity -
Classification
Tumors of Epithelial Tissue
origin.
a.
Tumors of Connective Tissue
origin.
b.
Tumors of Muscle Tissue
origin.
c.
Tumors of Nerve Tissue origin.
d.

Benign Tumors
of Epithelial
Tissue origin

Squamous Papilloma
 It is an exophytic growth made up of numerous,small finger like
projections which result in a roughened surface.
 The HPV(Human Papilloma Virus) types 6 and 11, commonly
associated with squamous papillomas,
 The exact mode of transmission is unknown. Virulence is low.
Benign Tumors of Epithelial Tissue origin
Papilloma

Papilloma
 It is the fourth most common oral mucosal mass and is found in 4 of
every 1,000 and accounts for 3–4% of all biopsied oral soft tissue
lesions.
 The squamous papilloma occurs with equal frequency in both men and
women.
 It is seen at any age and probably caused by the Human Papilloma
Virus.
 It is diagnosed most often in persons 30 to 50 years of age.
 Sites of predilection include the tongue, lips, and soft palate, but any
oral surface may be affected.
 This lesion is the most common of the soft tissue masses arising from
the soft palate.
CLINICAL FEATURES

Papilloma
The squamous papilloma is a soft, well
circumscribed,painless, usually
pedunculated, exophytic nodule with
numerous fingerlike surface projections that
impart a “cauliflower” or wartlike
appearance.
CLINICAL FEATURES
Projections may be pointed or blunted
,and the lesion may be white, slightly red,
or normal in color, depending on the
amount of surface keratinization.

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HISTOPATHOLOGIC FEATURES
1. Proliferation of keratinized stratified
squamous epithelium arrayed in finger-
like projections with fibrovascular
connective tissue cores.
2. The connective tissue cores may show
inflammatory changes, depending on
the amount of trauma sustained by the
lesion.
3. The keratin layer is thickened in lesions
with a whiter clinical appearance, and
the epithelium typically shows a normal
maturation pattern.
Papilloma

TREATMENT AND PROGNOSIS
1. Conservative surgical excision, including the base of the lesion, is
adequate treatment for the oral squamous papilloma, and recurrence
is unlikely.
2. Adult-onset lesions are typically less aggressive and tend to be single.
3. In rare instances, squamous cell carcinoma will develop in long-
standing laryngeal papillomatosis, sometimes in a smoker or a patient
with a history of irradiation to the larynx.
Papilloma

VERRUCA VULGARIS
(Common wart)

 Verruca vulgaris is a benign, virus-induced, focal
hyperplasia of stratified squamous epithelium.
 Verruca vulgaris is contagious and can spread to other
parts of a person’s skin or mucous membranes by way
of autoinoculation.
 It infrequently develops on oral mucosa but is extremely
common on the skin.
 The associated viruses in verruca are the subtypes HPV-
2, HPV-4, HPV-6 ,and HPV-40.
Verruca Vulgaris

 Frequently discovered in children, but occasional
lesions may arise even into middle age.
 Presents as pointed or verruciform surface
projections, a very narrow stalk, appears white due
to considerable surface keratin, and presents as
multiple or clustered individual lesions.
 It enlarges rapidly to its maximum size, seldom
achieving more than 5 mm in greatest diameter.
 Enlarges rapidly to its maximum size (usually <5
mm), and the size remains constant for months or
years thereafter unless the lesion is irritated.
 Multiple or clustered lesions are common.
Verruca Vulgaris
► On occasion, extreme accumulation of compact
keratin may result in a hard surface projection
several millimeters in height, termed a cutaneous
horn or keratin horn.

HISTOPATHOLOGICAL FEATURES
 Characterized by a proliferation of
hyperkeratotic stratified
squamous epithelium arranged
into finger-like or pointed
projections with connective tissue
cores.
 Chronic inflammatory cells often
infiltrate the supporting
connective tissue.
 Elongated rete ridges tend to
converge toward the center of
the lesion, producing a “cupping”
effect.
Verruca Vulgaris

A prominent granular cell layer
(hypergranulosis) exhibits
coarse, clumped keratohyaline
granules.
Abundant koilocytes are often seen in the
superficial spinous layer.
Verruca Vulgaris

1. Oral lesions are usually surgically excised, or
they may be destroyed by a laser, cryotherapy,
or electrosurgery.
2. Cryotherapy induces a subepithelial blister that
lifts the infected epithelium from the
underlying connective tissue, allowing it to
slough away.
3. Without treatment, verrucae do not transform
into malignancy, and two thirds will disappear
spontaneously within 2 years.
Verruca Vulgaris

 A nevus is defined as a congenital, developmental tumor like malformation
of the skin or mucous membrane that contains melanin pigment.
 In the skin it is called as the “common mole”.
 This lesion is composed of so-called nevus cells.
Pigmented cellular Nevus

PATHOGENESIS
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 Proliferation of melanocytes occurs in benign nevi.
 The dendritic melanocyte is located in the basal layer of skin and
produces melanin.
 Melanin pigments in melanosomes are transferred to
keratinocytes.

PATHOGENESIS
 The synthesis of melanin (melanogenesis)
occurs in melanocytes through cascade of
biochemical and enzymatic reactions.
 Stage I and II comprise immature,
unmelanized premelanosomes, structural
proteins, as well as melanin synthesizing
enzymes transported from other organelles to
immature, non-pigmented Stage II
premelanosomes.
 Melanin deposition begins at Stage III
melanosomes and the organelle is fully
melanized by mature Stage IV melanosomes.

Intradermal nevus
Junctional nevus
Compound nevus
Juvenile melanoma
Blue nevus
THE FOLLOWING ARE THE DIFFERENT TYPES OF NEVI THAT
ARE RECOGNIZED NOW,

Proliferation of
benign neoplastic
melanocytes along
the epithelial-
mesenchymal
junction
Migration of these
cells into the
mesenchymal
compartment
(compound nevi)
Loss of the junctional
component of the
nevus, so that all
remaining
nevomelanocytes are
located within the
subepithelial
compartment
(intramucosal nevi)
Most nevi originate as basal
layer melanocytes that
proliferate in the lower strata
of the epithelium along the
junction with the connective
tissue, and are therefore
termed JUNCTIONAL NEVI.
Later, the nevocytes
(melanocytes) drop
off into the
connective tissue to
form theques and
islands, a feature that
labels them as
COMPOUND NEVI.
Their eventual fate is to
leave the surface epithelium
entirely, whereby all the
clusters of nevus cells reside
in the dermis or submucosa
as intradermal or
INTRAMUCOSAL NEVI.

Junctional nevus

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Compound nevus

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Intradermal nevus

Pigmented nevi of all types, except the juvenile melanoma,
occasionally occur on the oral mucosa.
They are well circumscribed lesions and may occur at any site
intra-orally but are more commonly seen in the anterior gingiva,
lips and palate.
Treatment is surgical excision.

BLUE NEVUS
(DERMAL MELANOCYTOMA; JADASSOHN- TIECHE NEVUS)
 Blue nevi are a subset of melanocytic
proliferations containing cells reminiscent
of the embryonal neural crest–derived
dendritic melanocytic precursors.
 Its an uncommon, benign proliferation of
dermal melanocytes, usually deep within
subepithelial connective tissue.
 Two types of blue nevus are recognized:
1) Common blue nevus
2) The cellular nevus
 Common blue nevus is the second most
frequent melanocytic nevus in the mouth.

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The blue colour of this melanin producing lesion can be
explained by TYNDALL EFFECT.

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 Histopathologically, the
common blue nevus
consists of a collection of
elongated , slender
melanocytes with
branching dendritic
extensions & numerous
melanin globules.
These cells are located deep within the dermis or lamina propria &
usually align themselves parallel to the surface epithelium.

1. Impossible to attempt to eradicate all such lesions.
2. The congenital nevi have a great risk for transformation to malignant
melanoma.
3. Surgical excision of all intraoral pigmented nevi is recommended as a
prophylactic measure because of the constant chronic irritation of the
mucosa in nearly all intraoral sites occasioned by eating,
toothbrushing, etc.
Pigmented Nevus

Benign Tumors
of Connective
Tissue origin

Fibroma
Irritation fibroma, focal fibrous hyperplasia

Benign Tumors of Connective Tissue origin
Fibroma
 It is the most common benign soft tissue tumor occurring in the
oral cavity.
 It is a reactive hyperplasia of fibrous connective tissue in response
to local irritation or trauma.
 It appears as an elevated lesion of normal color with a smooth
surface and a sessile or pedunculated base.
 The tumor maybe small or in some cases up to several centimeters in
diameter.

Clinical
Features
It is always a well defined, slow growing lesion.
It occurs in any age , but is more common in the third,
fourth or fifth decade of life.
Females are affected twice as frequently as males. (2:1)
It is most frequenly seen in the buccal mucosa, gingiva,
tongue, lips and palate and is firm on palpation.
A smooth-surfaced pink nodule that is similar in color
to the surrounding mucosa.
They range in size from tiny lesions that are only a couple
of millimeters in diameter to large masses (majority 1.5cm
or less in diameter).
Fibroma

1. A nodular mass of fibrous connective tissue covered by stratified
squamous epithelium.
2. Frequently appears stretched and shows shortening and flattening
of the rete pegs.
Fibroma
1. 2.

3. The fibroma consists of bundles of interlacing collagenous fibers
interspersed with varying numbers of fibroblasts or fibrocytes and
small blood vessels.
4. The collagen bundles may be arranged in a radiating, circular, or
haphazard fashion.
Fibroma
3.
4.

 The irritation fibroma is treated by conservative
surgical excision; recurrence is extremely rare.
 Other benign or malignant tumors may mimic the
clinical appearance of a fibroma.
 Hence, it is important to submit the excised tissue
for microscopic examination.
Fibroma

Central Ossifying Fibroma
of Bone

Benign Tumors of Connective Tissue origin -
Central Ossifying Fibroma of Bone
 This tumor occurs as a central
tumor of bone and is a
separate entity from the
fibrous dysplasia and other
fibro-osseous lesions of the
bone.
 It occurs at any age, but is
more common in young
adults.
 Either jaw may be involved,
but more common in the
mandible.

 The lesion is slow growing, and
generally asymptomatic until
the growth produces a
noticeable swelling and mild
deformity.
 Displacement of teeth may be
an early feature.
 X-ray examination presents an
extremely variable appearance
depending upon it’s stage of
development.

 In the early stages the lesion
appears as a radiolucent area
with no internal radiopacities
and as the tumor matures
there is increasing calcification
and the radiolucent area
becomes a uniform
radiopaque mass.

 However in all the stages the
X-ray shows that the lesion is
always well demarcated from
surrounding bone, in contrast
to the fibrous dysplasia.
 The lesion should be excised
conservatively and recurrence
is rare.

Clinical Features
 The giant cell fibroma is typically
an asymptomatic sessile or
pedunculated nodule,
 Usually less than 1 cm in size
 Surface of the mass often appears
papillary.
 A slight female predilection
 Mandibular gingiva is affected
twice as often as the maxillary
gingiva.
 The tongue and palate also are
common sites.
Giant Cell Fibroma

Histopathologic Features
 An unencapsulated mass of vascular fibrous connective tissue, which is usually
loosely arranged.
 Frequently, the surface of the lesion is pebbly.
 The covering epithelium often is thin and atrophic.
 The rete ridges may appear narrow and elongated.
Giant Cell Fibroma

THESE
CELLS
MAY
CONTAIN
SEVERAL
NUCLEI.
Giant Cell Fibroma
numerous large, stellate
fibroblasts within the
superficial connective tissue

Treatment & prognosis
 Conservative excisional biopsy is curative, and its
findings are diagnostic.
 Recurrence is rare.
Giant Cell Fibroma

PERIPHERAL OSSIFYING FIBROMA
(OSSIFYING FIBROID EPULIS; PERIPHERAL FIBROMA WITH CALCIFICATION;
CALCIFYING FIBROBLASTIC GRANULOMA)

 The peripheral ossifying fibroma is a relatively common
gingival growth that is considered to be reactive
rather than neoplastic in nature.
 Some peripheral ossifying fibromas are thought to
develop initially as pyogenic granulomas that
undergo fibrous maturation and subsequent
calcification.
Peripheral Ossifying Fibroma

Clinical Features
 Can occur at any age, although it appears to be somewhat more
common in children and young adults.
 A predilection for occurrence in females by a ratio ranging from 2 : 1
to 3 : 2.
 The peripheral ossifying fibroma occurs exclusively on the gingiva .
 It appears as a nodular mass, either pedunculated or sessile, that
usually emanates from the interdental papilla.
 The color ranges from red to pink , and the surface is frequently but
not always ulcerated.
 Slight predilection for the maxillary arch incisor-cuspid region

RED ULCERATED MASS OF THE
GINGIVA. SUCH ULCERATED
LESIONS ARE EASILY MISTAKEN
FOR A PYOGENIC GRANULOMA.
Pink, nonulcerated mass arising from
the maxillary gingiva.

Histopathologic Features
The surface of the peripheral
ossifying fibroma exhibits either
an intact or, more frequently, an
ulcerated layer of stratified
squamous epithelium.
It can be described as a fibrous
proliferation associated with the
formation of a mineralized
product.
If the epithelium is ulcerated the
surface is covered by a
fibrinopurulent membrane with a
subjacent zone of granulation tissue.

Sometimes, the fibroblastic proliferation and
associated mineralization is only a small
component of a larger mass that resembles a
fibroma or pyogenic granuloma.
The deeper fibroblastic component often is
cellular, especially in areas of
mineralization.

Usually, the bone is woven and trabecular in type, although
older lesions may demonstrate
mature lamellar bone. Trabeculae of unmineralized osteoid
are not unusual.
The type of mineralized component is variable and
may consist of bone. cementum- like material, or
dystrophic calcifications.

Treatment and Prognosis
 The treatment of choice for the peripheral
ossifying fibroma is local surgical
excision with submission of the specimen
for histopathologic examination.
 The mass should be excised down to
periosteum because recurrence is
more likely if the base of the lesion is
allowed to remain.
 In addition the adjacent teeth should be
thoroughly scaled to eliminate any
possible irritants.

Lipoma
 Benign tumor composed of mature adipocytes with uniform nuclei
identical to the cells of normal adult fat.

Lipoma
 The lipoma is a benign tumor of fat.
 It is a relatively rare intraoral tumor, although it occurs more
frequently in the subcutaneous tissues of the neck.
 It is a benign, slow growing tumor composed of mature fat cells.
 The cells of lipoma differ metabolically from normal fat cells
though they are histologically similar.
 While most lesions are developmental anomalies, those which
occur in the maxillofacial region usually arise late in life and are
presumed to be neoplasms of adipocytes, occasionally associated
with trauma.

 Usually found in adults.
 The tumor occurs in the tongue, floor of the mouth, buccal
mucosa, gingiva, and mucobuccal folds.
 Typically, the tumor is asymptomatic and often has been noted for many
months or years before diagnosis.
 Most are less than 3 cm in size, but occasional lesions can become much
larger.
 Although a subtle or more obvious yellow hue often is detected
clinically, deeper examples may appear pink.
 Morphologically intraoral lipomas can be classified as diffuse form
affecting the deeper tissues, and a superficial & encapsulated form.
Lipoma
Clinical features

 Lesions in deeper tissues produce only
a slight surface elevation which tend to
be more diffuse than the superficial
type of lipoma.
 The lipoma is yellowish and soft on
palpation.
 Epithelium is usually thin and the
superficial blood vessels are readily
visible over the surface.
 When palpated, the diffuse form feels
like fluid, sometimes leading to a
mistaken diagnosis of ‘cyst’.
Lipoma

 Superficial form appears as a single or lobulated, sessile or
pedunculated, painless lesion.
 It presents as a yellowish surface discoloration and well
encapsulated.
 It is freely movable beneath the mucosa.
Lipoma

Lipoma
Histologicfeatures The tumor is usually well
circumscribed and may
demonstrate a thin fibrous
capsule.
A distinct lobular
arrangement of the
cells often is seen.

Benign Tumors of Connective Tissue origin Lipoma
Mature
adipocytes and a
lobular pattern
are distinctly
visible.

1. Fibrolipoma
2. Angiolipoma
3. Spindle Cell/
Pleomorphic
Lipoma
4. Myxolipoma
5. Lipoblastoma
6. Myolipoma
7. Hibernoma
8. Chondroid
Lipoma
Histological Types of Lipomas
1. 2.
3. 4.
6.

Treatment & Prognosis
 Lipomas: Benign and do not metastasize
•Not treated with any forms of chemotherapy nor radiation.
•Observation for small asymptomatic lipomas
 Surgery: Marginal excision for symptomatic, large or
deep lesions
 Local recurrence:
•Risk depends on size and location of lipoma
•Rarely occurs for subcutaneous tumors
•Intramuscular tumors--up to 20% local recurrence rate.

Myxoma
 It is the tumor of the soft tissues and is made up of tissue resembling
primitive mesenchyme.
 A heterogenous group of soft tissue tumors which have a common
histologic appearance of abundant myxoid ground substance,
composed of mucopolysaccharides, mainly hyaluronic acid.
 The lesion is benign and does not metastasize, although it frequently
infiltrates adjacent tissues.
 Most of them are deep seated lesions and are very rare intraorally.

Clinical Features
 Rare tumor: 1 case per 1 million people
 Age: any; Adults 40 to 60 years old
 Sites: Thigh, Gluteus, Upper Arm
 Slowly growing mass•Painless
 Size usually 5 to 10 cm
 Multiple tumors (rare; 5% of patients)
 Associated with fibrous dysplasia of underlying bone in
about 5% of cases and in cases of multiple myxomas
(Mazabraud Syndrome)
Myxoma

Oral Manifestations
 Intraoral soft-tissue myxoma is an extremely rare lesion.
 Cases occurring centrally within the bone of the jaws are called as
odontogenic myxomas.
 It appears to originate from the dental papilla, follicle, or periodontal
ligament.
 It occurs in the second and third decades.
 The mandible is involved more frequently than the maxilla, and most
reports show a slight predilection for females.
 It is usually painless and displacement of teeth and paresthesia are
uncommon clinical features.
 Therefore, it reaches considerable size before being detected, and
perforation of the cortices of the involved bone may be seen.
 It is occasionally association with missing or unerupted teeth, and the
presence of an odontogenic epithelium.
Myxoma

OM is locally aggressive and invasive with the potential for persistent
local growth and bone destruction.
Myxoma

The tumoral potential to destroy bone extensively also includes its ability
to invade the adjacent soft tissues.
Myxoma

 The tumor presents as a unilocular or
multilocular radiolucent lesion
 Well-defined borders and fine, bony
trabeculae within its interior structure
 A ‘honeycombed,’ ‘soap bubble,’ or
‘tennis racket’ appearance.
 Displacement of teeth is a relatively
common finding, root resorption is
uncommon.
 The tumor is often scalloped between
the roots.
Myxoma
Radiography

Histopathology
Merges with
surrounding
skeletal
muscle and
fascial tissue
Myxoma
Poorlycircumscribed,infiltrativelesion

Characteristically a loose-textured
tissue containing moderate number of
delicate reticulin fibers and mucoid
material.
Myxoma

Myxoma
the tumor consists of
rounded, spindled, and
stellate cells arranged
in loose, myxoid
stroma, with few
collagen fibrils.

Myxoma
Small islands of apparently
inactive epithelial
odontogenic rests may be
scattered through the
myxoid stroma.

Treatment & Prognosis
 Benign and do not metastasize
•Not treated with any forms of chemotherapy nor radiation.
 Recurrence is common.
 Surgery: the sacrifice of an appreciable amount of apparently
uninvolved surrounding tissue
Myxoma

Benign Tumors of Connective Tissue origin Chondroma
 It is a benign central tumor composed of mature cartilage and is not
very common in the maxilla or the mandible.
 It can undergo malignant transformation.
 It can develop at any age and has no sex predilection.

 It often appears as a painless, slowly
growing swelling of the jaw and may
cause loosening of teeth.
 The anterior portion of the maxilla is
commonly involved.
 In the mandible it involves the condyle or
the coronoid process and in some cases
the body.
 It is also documented in the nasal septum
and nasal spine.
 It is a destructive lesion.
Clinical Features

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Chondromas are circumscribed, expansile masses that consist of
relatively well-differentiated cartilage.

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Chondromas are composed of lobules or nodules of well-
differentiated hyaline cartilage.

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The tumour cells generally occur individually within lacunae, but lack
orderly arrangement.

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The cartilage cells appear small, contain only single nuclei and do not
exhibit great variation in size, shape or staining reaction.

Treatment of chondroma is surgical and the
tumor is resistant to radiation.
Treatment

Benign Tumors of Connective Tissue origin Osteoma
 It is a benign tumor characterized by
proliferation of either compact or
cancellous bone usually in an endosteal
or periosteal location.
 It is not a common oral lesion.
 It is common in young adult and is a
slow growing lesion.
 Considered developmental lesions.
Osteoma is a non
malignant mostly
asymptomatic
neoplasm,
comprising of well
differentiated
matured bone.

ClinicalFeatures
 The most frequent sites affected in
the mandible are the posterior body,
followed by the condyle, angle,
ascending ramus, coronoid process,
anterior body, and sigmoid notch.
 Peripheral osteomas are slow-
growing lesions and, clinically, they
usually remain asymptomatic.
 The lesion of periosteal origin
manifests itself as a circumscribed
swelling on the jaw producing
obvious asymmetry.
 Gardner’s syndrome

 The lingual surface posterior to the premolars and in the condylar region.
 Appears as an unilateral and well-circumscribed mass
 Lesions are usually asymptomatic and can be discovered in routine clinical and
radiographic examination.
 It may cause swelling, facial asymmetry, and functional impairment.
 The swelling is usuallypainless.

Radiology
 a well defined, round or oval, dense radiopaque mass with distinct borders with a
density indistinguishable to normal bone.
 The lesion may be sessile and attached to the cortical plates with a broad base.
 If pedinculated, a narrow contact area can be seen between the lesion and the
compact bone.

Histopathology
• often well circumscribed, but not encapsulated.
• consisting entirely of dense lameller compact bone

Treatment
 Removal of an asymptomatic
peripheral osteoma is not generally
necessary.
 Surgical intervention is indicated only
if it becomes large enough to cause
facial asymmetry and functional
impairment

Osteoid osteoma
 a benign tumor of bone
 occurs in young persons <30 years of age
 males predominate over females; 2:1
 frequently in the femur or in the tibia
 One of the chief symptoms of the
condition is severe pain out of all
proportion to the small size of the lesion.
 The pain of osteoid osteoma is described
as unrelenting and sharp, worse at night.
 Classically, the pain is relieved by aspirin.
 Localized swelling of the soft tissue over
the involved area of bone may occur and
may be tender.

 a well-circumscribed radiolucent defect, usually less than 1 cm in diameter, with a
surrounding zone of reactive sclerosis of varying thickness.
 The central radiolucency may exhibit some calcification- Nidus; target like appearance.
Radiological Features
Osteoid osteoma

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consists of a central nidus composed of compact osteoid tissue,
varying in degree of calcification, interspersed by a vascular
Osteoid osteoma

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Formation of definite trabeculae occurs, outlined by active
osteoblasts.
Osteoid osteoma

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the morphology of the osteoblasts is similar to that of normal
osteoblasts
Osteoid osteoma

Treatment of osteoid osteoma is surgical
excision and recurrence is uncommon.
Treatment
Osteoid osteoma

 It is a slow growing, flat-based
bony protuberance which occurs in
the midline of the hard palate.
 Women are more affected than
men.
 It’s peak incidence is shortly before
the age of 30 years.
Torus palatinus

 an outgrowth in the midline of the
palate and may assume a variety of
shapes.
 The mucosa overlying the torus is
intact, but occasionally appears
blanched.
 It may become ulcerated if
traumatized.
 The torus itself is composed of either
dense compact bone or a shell of
compact bone with a center of
cancellous bone.
Torus palatinus

The Torus palatinus does not require any treatment unless it produce any mucosal
surface ulceration due to trauma as in eating or for prosthodontic reasons.
Treatment
Torus palatinus

Torus Mandibularis

 It is an exostosis or outgrowth of
bone found on the lingual surface
of the mandible.
 It occurs above the mylohyoid line
in the mandible, usually opposite
the bicuspid teeth.
 It may vary in size and shape and
can be seen as unilateral or
bilateral.
Torus mandibularis

Surgical removal of the Torus-Mandibularis is carried
out for prosthodontic reasons.
Torus mandibularis
Treatment

Central Giant cell tumor of the bone.

Central Giant cell tumor of the bone
 Central giant cell granuloma (CGCG) is an uncommon, benign, and
proliferative lesion whose etiology is not defined.
 considered widely to be a nonneoplastic lesion.
 giant cell reparative granuloma- Jaffe
 since a reparative response was quite rare and most of these
lesions were found to be destructive rather than reparative, the
word ‘reparative’ was omitted from that term.

 Currently there are two schools of thought regarding the
existence of giant cell tumors in the facial skeleton.
 Some like Jaffe, firmly believe that true giant cell tumors either
do not exist or occur very rarely in the maxillofacial region.
 However other pathologists and clinicians remain convinced
that giant cell tumors do occur within the jaws.

 Abrams and shear in 1974, consolidated these
two positions, and suggested that certain jaw
lesions may be true giant cell tumors and
certain giant cell lesions outside the jaws maybe
giant cell granulomas.

 These lesions occurs between the age of 2 to
81 years, but the average age is within the
second decade of life.
 Sex: 2:1 female predilection.
 The mandible is clearly the preferred site.
Clinical features

 These lesions mainly occur in the anterior portion
of the maxilla and mandible.
 Posterior maxilla or mandible is rarely involved.
 A painless local swelling is the most commonest
presenting symptom although some patients
may have pain or anesthesia.

 Essentially a destructive lesion,
producing a radiolucent area with
either a relatively smooth or a
ragged border, and sometimes
showing faint trabeculae.
 The x-ray feature is a
radiolucency within bone and can
either have an multilocular or
unilocular configuration.
 Resorption of teeth very
common.
 V-shaped bony ridges separating
the locules.
Radiography

 a loose fibrillar connective tissue stroma with many interspersed
proliferating fibroblasts and small capillaries.
Histopathology Benign Tumors of Connective Tissue origin

groups of fibers will often
present a whorled
appearance
 Areas of erythrocyte
extravasation and
hemosiderin deposition
often are prominent.

 the presence of few to many multinucleatedgiant cells in a background of
ovoid to spindle-shaped mesenchymal cells and round monocyte-
macrophages

 Foci of osteoid and newly formed bone are occasionally present within
the lesion.

 Small, slow growing, asymptomatic
mass responds well to curettage.
 However, the large and aggressive
mass produces recurs frequently,
especially in younger patients.
 Surgical curettage is the most
commonest procedure.
 Large aggressive lesions of the maxilla
and mandible may require an en-bloc
resection.
Treatment

Peripheral Giant Cell Granuloma
(GIANT CELL EPULIS)

• This tumor is similar to the central giant cell
granuloma of bone, because of the presence
of multinucleated giant cells in the
lesion, however it occurs peripherally in
the oral cavity.
• The role of trauma as in tooth extraction,
calculus deposits, ill fitting dentures and poor
restorations may be a source of etiology of
this lesion.

Clinical Features
 It always occurs on the gingiva or
alveolar process, most frequently
anterior to the molars.
 Thus it seems to originate from either
the periodontal ligament or
mucoperiosteum.
 The lesion is usually between 0.5 to 1.5
cm in diameter.

 The lesions typically present with a bluish – purple color.
 Females are affected twice as much as males.
 It is more commonly seen between the age of 30 to 50
years.
 Treatment is surgical excision.

Radiographic Features
 “cupping” resorption of the underlying alveolar
bone sometimes is seen.

Histopathological Features
 a nonencapsulated mass of tissue composed of a delicate reticular
and fibrillar connective tissue stromaa proliferation of multinucleated
giant cells within a background of plump ovoid and spindle-shaped
mesenchymal cells.

 The giant cells in some instances resemble osteoclasts and in other cases are
considerably larger than the typical osteoclast.
 Capillaries are numerous, particularly around the periphery of the lesion, and
the giant

 The treatment of the peripheral giant cell granuloma consists
of local surgical excision down to the underlying bone.
 The adjacent teeth should be carefully scaled to remove any
source of irritation and to minimize the risk of recurrence.
 Approximately 10% of lesions are reported to recur, and
reexcision must be performed.
Peripheral Giant cell tumor of the bone
Treatment

Hemangioma
 Hemangiomas are lesions that are not present at birth.
 They manifest within the first month of life, exhibit a rapid proliferative phase,
and slowly involute to nonexistent.
 It is a common tumor characterized by the proliferation of blood vessels.
 It is often congenital in nature and is not a true neoplasm but a developmental
anomaly i.e an abnormal proliferation of tissues of structures native to the part.
 Hemangiomas are tumors identified by rapid endothelial cell proliferation in
early infancy, followed by involution over time

Capillary
Cavernous
Angioblastic
Racemose
Diffuse systemic
Port-wine stain
Hereditary hemorrhagic
telangiectasia
Hemangioma

Hemangioma

 Hemangiomas are about three times
more common in females than in males.
 The most commonly affected facial bones
are the mandible, the maxilla, and the
nasal bones. Intraosseous lesions affect
the mandible more often than the
maxilla, with a ratio of 2:1.
 Involvement of the zygoma is rare.
 Intramuscular hemangiomas in the oral
region are most commonly seen in the
masseter, comprising 5% of all
intramuscular hemangiomas.
Hemangioma
Clinical Features

 Hemangiomas of the oral cavity are not common pathologic entities, but the
head and neck are common sites.
 Most cases of hemangioma are present at birth or arise at an early age.
 Intraorally they appear as a flat or raised lesion of the mucosa, usually deep red
or bluish red and seldom well circumscribed.
 It commonly occurs in the tongue, lips, buccal mucosa and palate.
Hemangioma
Oral Manifestations

 Central hemangiomas of the maxilla and mandible occur and have to be carefully
diagnosed and managed.
 In the bone, the tumor is destructive lesion which may be of varying size and
appearance, but is often suggestive of a cyst.
 Root resorption of the teeth has been reported in 30% of cases, but the vitality of the
teeth is usually not affected.
 Some of them present a honeycombed appearance in the X-rays; sunburst pattern.
Hemangioma

 Composed of many small capillaries lined by a single layer of endothelial cells
supported by a connective tissue stroma of varying density.
Hemangioma
Histologic Features

 The cavernous form of hemangioma consists of large dilated blood sinuses with
thin walls, each showing an endothelial lining.
 The sinusoidal spaces usually are filled with blood,
Hemangioma

 􀁕 Endothelial cell hyperplasia forming syncytial masses.
 􀁕 Thickened (multilaminated) endothelial basement membrane.
Hemangiomaproliferative phase

 Many congenital hemangiomas have been found to undergo spontaneous
regression at a relatively early age.
 Have been treated in a variety of ways, including:
(1) surgery,
(2) radiation therapy(external radiation or radium),
(3) sclerosing agents, such as sodium morrhuate or psylliate, injected into the
lesion
(4) carbon dioxide snow,
(5) cryotherap and
(6) compression
Hemangioma
Treatment and
Prognosis

Benign Tumors of
Muscle Tissue
origin

Benign Tumors of Muscle Tissue origin
Leiomyoma
 Leiomyomas are benign tumors of smooth muscle that most commonly
occur in the uterus, gastrointestinal tract, and skin.
 Leiomyomas of the oral cavity are rare.
 Most of these probably have their origin from vascular smooth muscle.
 The three types are as follows:
1. Solid leiomyomas
2. Vascular leiomyomas (angiomyomas or angioleiomyomas)
3. Epithelioid leiomyomas (leiomyoblastomas)
 Almost all oral leiomyomas are either solid or vascular in type;
angiomyomas account for nearly 75% of all oral cases.

 The majority of oral leiomyomas occur in adults in the middle decades of life, over
65% being found in patients older than 30 years of age,
 Usually a slow-growing, firm, mucosal nodule.
 Most lesions are asymptomatic, although occasional tumors can be painful.
 The oral lesion is slow growing painles lesion which is superficial and often
pedunculated.
 The presenting symptoms are that of “sore throat” or “tumor in the throat”.
Leiomyoma
Clinical Features

 The majority of cases of leiomyoma have occurred on the posterior portion of the
tongue, although others have been found on the palate, cheeks, gingiva, lips and
salivary glands, which together account for 80% of cases.
 It resembles normal mucosa in color; although angiomyomas may exhibit a bluish
hue.
Leiomyoma

 composed of interlacing bundles of smooth muscle fibers interspersed by varying
amounts of fibrous connective tissue.
Leiomyoma
HISTOPATHOLOGIC
FEATURES

 The muscle nuclei are typically spindle-shaped with blunt ends and quite vesicular.
Leiomyoma

 The bundles of fibers appear to form whorls because of their fascicular arrangement
in varying planes.
Leiomyoma

 some lesions are quite vascular, being composed of large numbers of blood vessels of an
atypical nature with disoriented smooth muscle layers (the angiomyoma), while others are
relatively avascular.
LeiomyomaAngiomyoma

 This smooth muscle neoplasm is best treated by conservative surgical excision.
 it does not tend to recur or become malignant.
Leiomyoma

Rhabdomyoma
 It is a benign tumor of striated muscle origin.
 The most common locations are the tongue and
the floor of the mouth.
 It is a painless, well circumscribed tumor mass
that is slow growing.
 Treatment is surgical excision.

Rhabdomyoma
 The tumor is composed of large, round cells that have a granular, eosinophilic
vacuolated cytoplasm and show irregular cross-striations.
 A fibrous stroma is present and mitotic activity is extremely low.

Rhabdomyoma
 composed of well-circumscribed lobules of large, polygonal cells, which exhibit
abundant granular, eosinophilic cytoplasm

Rhabdomyoma
 These cells often demonstrate peripheral vacuolization that results in a “spider web”
appearance of the cytoplasm.

Rhabdomyoma
 Focal cells with cross striations can be identified in most cases

Benign Tumors of
Nerve Tissue origin

Benign Tumors of Nerve Tissue origin
Traumatic Neuroma
 It is not a true neoplasm; a reactive proliferation of neural tissue after transection or
other damage of a nerve bundle.
 a hyperplasia of nerve fibers and their supporting tissues.
 This constitutes a traumatic neuroma.
 In a severed or injured nerve, if the proximal and distal stumps are not approximated
(or if there is no distal stump), haphazard proliferation of Schwann cells at the
proximal stump gives rise to a traumatic neuroma.

 usually appears as a small nodule or
swelling of the mucosa, typically near
the mental foramen, on the alveolar
ridge in edentulous areas or on the
lips or tongue.
Clinical Features
Traumatic Neuroma
 A central lesion within the substance
of the bone associated with a nerve
trunk may also occur.

 Traumatic neuromas can occur at any age, but they are diagnosed most often in
middle-aged adults.
 They appear to be slightly more common in women.
 This is a slowly growing lesion and seldom reaches a size greater than a centimeter
in diameter.
 Digital pressure may cause considerable pain locally, and
 in some instances along the course of the nerve involved.
 Traumatic neuromas of the oral mucosa are typically smooth-surfaced,
nonulcerated nodules.
 A history of trauma often can be elicited.
 Palisaded Encapsulated Neuroma
Traumatic Neuroma

 Palisaded encapsulated neuroma (solitary
circumscribed neuroma) is a common
asymptomatic lesion that presents as a
solitary papule on the face (nose,
nasolabial folds, cheeks) and within oral
cavity of middle-aged and older adults.
 It may represent a primary hyperplasia of
nerve fibers, the axons and their sheath
cells.
 An alternative theory is that it represents
a benign neoplasm.
Traumatic Neuroma
Palisaded Encapsulated
Neuroma

 they consist of
unencapsulated,
small nerve bundles
haphazardly
arranged in a fibrous,
collagenous stroma
often seen in
continuation with
undamaged but
disorganized
segments of nerve
HISTOPATHOLOGIC
FEATURES
Traumatic Neuroma

 The proliferating nerve fibers themselves may occur either in small discrete bundles
or spread diffusely throughout the tissue
Traumatic Neuroma

Traumatic Neuroma
Palisaded Encapsulated Neuroma
it appears as a circumscribed dermal or subcutaneous nodule but it may
show multinodular or plexiform growth pattern.

 It is composed of Schwann cells with wavy hyperchromatic nuclei, arranged in
short intersecting fascicles. Nuclear palisading is uncommon.
Traumatic Neuroma

 This neoplasm is best treated by conservative surgical excision.
 it does not tend to recur or become malignant.
Traumatic Neuroma

 The neurofibroma is the most common type of peripheral nerve
neoplasm.
 It arises from a mixture of cell types, including Schwann cells and
perineural fibroblasts; specifically arising from cells of the sheath of
schawnn with intermingled neurites.
 It most frequently involves the skin and oral mucosa and does not
differ form the multiple form of the disease known as
neurofibromatosis or von recklinghausen’s disease.
Neurofibroma

Clinical Features
 It has a slight predilection in
men.
 Solitary tumors are most
common in young adults and
present as slow-growing, soft,
painless lesions that vary in size
from small nodules to larger
masses.
 The skin is the most frequent
location for neurofibromas, but
lesions of the oral cavity are not
uncommon.
Neurofibroma
 Based on the growth pattern, it is subdivided into
1.localized,
2.plexiform, and
3.diffuse types.

 The tongue and buccal mucosa are the most common intraoral sites.
 Discrete, nonulcerated nodules, which tend to be of the same color as the normal
mucosa.
 Macroglossia due to diffuse involvement of the tongue is well recognized.
Neurofibroma

 generally composed of a proliferation of delicate spindle cells with thin, wavy
nuclei intermingled with neurites in an irregular pattern as well as delicate,
intertwining connective tissue fibrils.
Neurofibroma
Localized Neurofibroma

Neurofibroma
 The Schwann cells appear as intersecting bundles of spindle cells with compact,
hyperchromatic wavy nuclei with pointed ends.

 increased cellularity, dense collagen bundles and little or no mucoid stroma (as
seen here), storiform pattern.
Neurofibroma

NeurofibromaMyxoid Neurofibroma
 This localized neurofibroma is composed of thick intersecting bundles of
Schwann cells separated by myxoid stroma.
 Scattered mast cells and lymphocytes are present in the stroma.

NeurofibromaMyxoid Neurofibroma
 hypocellular and contain sparse number of Schwann cells scattered in a highly
myxoid stroma

 Solitary oral neurofibromas are usually treated by surgical excision, depending on
the extent and the site.
 Surgical removal may result in recurrence, and multiple recurrences have been
associated with malignant transformation (5–15%).
Neurofibroma

(VON RECKLINGHAUSEN’S DISEASE OFTHE
SKIN)
NEUROFIBROMATOSIS

 Neurofibromatosis is a relatively common hereditary condition.
 At least eight forms of neurofibromatosis have been recognized, but
the most common form is neurofibromatosis type I (NF1).
 Von Recklinghausen’s disease of the skin, accounts for 85% to 97%
of cases and is inherited as an autosomal dominant trait.
 It is caused by a variety of mutations of the NF1 gene, which is
located on chromosome region 17q11.2 and is responsible for a
tumor suppressor protein product known as neurofi bromin.
Neurofibromatosis

Clinical Features
 The clinical appearance can vary from small papules to larger soft nodules to massive
baggy, pendulous masses (elephantiasis neuromatosa) on the skin.
 The plexiform variant of neurofi
 broma, which feels like a “bag of worms,” is considered pathognomonic for NF1.
Neurofibromatosis
 multiple neurofibromas that can occur anywhere in the body but are most
common on the skin.

 The tumors may be present at birth, but they
often begin to appear during puberty and may
continue to develop slowly throughout
adulthood.
 Accelerated growth may be seen during
pregnancy.
Neurofibromatosis
 Another highly characteristic feature is the presence of café au lait (coffee with milk)
pigmentation on the skin.
 These spots are smooth-edged, yellow tan to dark-brown macules that vary in diameter from
1 to 2 mm to several centimeters.
 They are usually present at birth or may develop during the fi rst year of life.

 Axillary freckling (Crowe’s sign) is also a highly suggestive sign.
Neurofibromatosis
 Lisch nodules, translucent brown-pigmented spots on the iris, are found in
nearly all affected individuals.
 The most common general medical problem is hypertension, which may
develop secondary to coarctation of the aorta, pheochromocytoma, or renal
artery stenosis.

 oral manifestations may occur in as many as 72% to 92% of cases, especially if a
detailed clinical and radiographic examination is performed.
Neurofibromatosis
 The most common reported finding is enlargement of the fungiform papillae
(in about 50% of all affected patients).
 Intraoral neurofibromas.

Radiography Benign Tumors of Nerve Tissue origin
Neurofibromatosis
 Radiographic findings may include enlargement of the mandibular foramen,
enlargement or branching of the mandibular canal, increased bone density,
concavity of the medial surface of the ramus, and increase in dimension of the
coronoid notch.

Diagnostic Criteria for
Neurofibromatosis Type I (NF1)
 The diagnostic criteria are met if a patient has two or more of the following
features:
1. Six or more café au lait macules more than 5 mm in greatest diameter in prepubertal
persons and more than 15 mm in greatest diameter in postpubertal persons
2. Two or more neurofi bromas of any type or one plexiform neurofi broma
3. Freckling in the axillary or inguinal regions
4. Optic glioma
5. Two or more Lisch nodules (iris hamartomas)
6. A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex
with or without pseudoarthrosis
7. A fi rst-degree relative (parent, sibling, or offspring) with NF1, based on the previously
mentioned criteria
Neurofibroma

 There is no specific therapy for NF1, and treatment often is directed toward
prevention or management of complications.
 Facial neurofi bromas can be removed.
 malignant peripheral nerve sheath tumor (neurofibrosarcoma; malignant
schwannoma), which has been reported to occur in about 5% of cases.
Neurofibroma

N
E
U
R
I
L
E
M
M
O
M
A
S
C
H
W
A
N
N
O
M
A
(Neurolemmoma, perineural fibroblastoma, neurinoma,

 The neurilemoma is a benign neural neoplasm of Schwann cell origin.
 It is relatively uncommon, although 25% to 48% of all cases occur in the head
and neck region.
 Bilateral neurilemomas of the auditoryvestibular nerve are a characteristic
feature of the hereditary condition, neurofibromatosis type II (NF2).
 Neurites are not a component of the tumor as in the neurofibroma but may be
found on the surface of the tumor.
Schwannoma

Clinical Features
 Usually, the mass is asymptomatic, although tenderness or pain may occur in some
instances.
 The lesion is most common in young and middle-aged adults and can range from a
few millimeters to several centimeters in size.
 The solitary neurilemoma is a slow-growing, encapsulated tumor that typically
arises in association with a nerve trunk.
 As it grows, it pushes the nerve aside.
Schwannoma

Oral Manifestations
 The soft-tissue lesion is usually a single, circumscribed nodule of varying size that
presents no pathognomonic features.
 Intraosseous examples are most common in the posterior mandible and usually
appear as either unilocular or multilocular radiolucencies on radiographs.
 The tongue is the most common location for oral neurilemomas, although the
tumor can occur almost anywhere in the mouth.
Schwannoma

 The neurilemoma is usually an encapsulated tumor that demonstrates two microscopic patterns in
varying amounts; Antoni A & Anoni B.
Neurofibroma

 the fibrous capsule underneath which is a proliferation of spindled Schwann cells
Neurofibroma

 Schwannomas are composed of cellular Antoni A areas alternating with hypocellular Antoni B
areas.
Neurofibroma

 Antoni A areas are composed of interlacing bundles of spindle cells (Schwann cells) (as
shown here) with wavy or oval nuclei, eosinophilic cytoplasm, and indistinct cytoplasmic
borders. Intranuclear vacuoles may be present.
Neurofibroma

 Frequently, the Schwann cells in Antoni A areas show nuclear palisading, whorling patterns,
and Verocay bodies that formed by a highly ordered arrangement of Schwann cell nuclei in
parallel rows separated by fibrillary processes.
Neurofibroma

Neurofibroma
 Varocay Bodies are formed by a highly ordered arrangement of Schwann cell nuclei in rows
separated by fibrillary processes.

Neurofibroma
 The Verocay bodies are interspersed with hypocellular Antoni B areas composed of
haphazardly arranged spindle cells in myxoid stroma.

Lymphangioma

Lymphangioma
 It is a benign tumor of the
lymphatic vessels.
 It is present at birth in most
of the cases.
 It most commonly occurs in
the tongue, but is also seen
in the palate, buccal
mucosa, gingiva and lips.

Lymphangioma
The superficial lesions are
papillary and slightly red in
color, but the deep lesions
appear as diffuse nodules or
masses without any change in
color.
Treatment is by surgical excision
for small lesions and large
deeper lesions are treated by
sclerosing agents.

Benign tumors of oral cavity sonal

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