07 soft tissue

8/3/2019 07 Soft Tissue

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Soft Tissue Swellings


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Pyogenic Granuloma

Pregnancy Tumor


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Pyogenic Granuloma

Pyogenic ???

Granuloma???

Pyogenic granulomas of the gingiva frequentlydevelop in pregnant women and therefore theterms pregnancy tumor or granulomagravidarium are often used.


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Pyogenic Granuloma: Clinical

Features This common oral tumor usually appears as an

asymptomatic, red tumescence, which may besecondarily ulcerated. As the lesion ages it becomesmore collagenized and less vascular and thus more pink

than red in color. It is composed of granulation tissue. The site predilection is the gingiva but may be seen

anywhere in the oral cavity and, in fact, anywhere in the

body. The pyogenic granuloma can exhibit rapid growth and

many early lesions bleed easily. These features oftencreate alarm in both the patient and dentist.


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Pyogenic Granuloma: Cause

The pyogenic granuloma is a reactive lesion totrauma or chronic irritation. It is neither agranuloma nor a neoplasm.

The size of a pyogenic granuloma may bemodified by hormonal changes.


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Pyogenic Granuloma: Treatment

Excision is the treatment of choice.


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Pyogenic Granuloma: Significance

If untreated a pyogenic granuloma will remainindefinitely although its appearance may change

as it ages.

Recurrence may occur if it is incompletelyexcised or if the cause is not removed.

A reduction in size may occur if the cause aloneis removed or after pregnancy.


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Traumatic (Irritation)

Fibroma


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Traumatic (Irritation) Fibroma:

Clinical Features

Traumatic fibromas appear as firm,asymptomatic nodules covered by epitheliumunless secondarily traumatized.

They usually occur along the line of occlusion inthe lower lip or buccal mucosa; they may,however, be found anywhere in the oral cavity.

These lesions, which are reactive hyperplasiasrather than true neoplasms as suggested by theterm fibroma, are very common oral lesions.


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Cause

It is a reactive lesion to trauma or chronicirritation.

Although rare according to research studies,clinically similar lesions may be true neoplasms(fibromas).


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Treatment

Surgical excision is the treatment of choice.


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Significance

This lesion is a reactive one which has limitedgrowth potential.

No malignant transformation has been reported.


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Epulis Fissuratum

Denture Injury Tumor

Inflammatory Fibrous HyperplasiaDenture Epulis


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Epulis Fissuratum: Clinical Features

Tumor-like hyperplasia of fibrous connective tissueassociated with denture flange.

Presents as fold (s), usually two, with flange fitting in

between. The lesion is usually firm and fibrous but may show

erythema and ulceration.

Most common on facial aspect in the anterior of either

jaw. It is more common in middle-aged and older females

(two-thirds to three-fourths of the cases are in females).


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Epulis Fissuratum: Cause

Chronic irritation or trauma from denture flangemaking the lesion a reactive hyperplasia.

The denture is typically ill-fitting.


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Epulis Fissuratum: Treatment

Treatment consists of surgical removal of excesstissue with microscopic examination and.

The poorly fitting denture should be remade orrelined.


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Epulis Fissuratum: Significance

Lesion will recur (or remain) if ill-fitting dentureis not remade or relined.


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Papillary Hyperplasia

Inflammatory Papillary Hyperplasia

Palatal PapillomatosisDenture Papillomatosis


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(Inflammatory) Papillary

Hyperplasia: Clinical Features

Papillary hyperplasia is a reactive tissue growth thatusually, but not always, develops beneath a denture.

It typically appears as a painless, papillomatous,

cobblestone lesion of hard palate althoughoccasionally it occurs on the edentulous mandibularridge or in association with epulis fissuratum.

The lesion is usually asymptomatic and red because ofinflammation.

It is a common lesion in denture wearers.


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Papillary Hyperplasia: Cause

Soft tissue reaction to ill-fitting denture andprobable fungal overgrowth.

Patients generally have poor oral/denturehygiene.

One study indicated approximately 20 % of thepatients wore their dentures 24 hours per day.


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Papillary Hyperplasia: Treatment

In cases of very early inflammatory papillaryhyperplasia, removal of the denture may allow theerythema and edema to subside and the tissues mayresume a more normal appearance.

Lesions may show some improvement after topical orsystemic antifungal therapy. For advanced cases, excision of the lesion is treatment

of choice prior to the fabrication of a new denture.

Partial and full-thickness surgical blade excision,curettage, electrosurgery and cryrosurgery have all beenused with success in particular cases.


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Papillary Hyperplasia: Significance

The lesion is not premalignant.

Following surgery the old denture can be linedwith a temporary tissue conditioner that acts as adressing and promotes healing.

After healing, the patient should be encouragedto leave the new denture out at night and to

practice good denture hygiene.


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Peripheral Giant Cell

GranulomaGiant Cell Epulis


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Peripheral Giant Cell Granuloma:

Clinical Features Appears as an asymptomatic red tumescence of the

gingiva composed of fibroblasts and multinucleatedgiant cells.

It is most commonly discovered in adult patients in the

former areas of the primary teeth. As the term peripheral indicates, it is a soft tissue lesion

overlying the bone; however PGCGs may produce acupping radiolucency of the bone superficiallyparticularly in edentulous areas of the jaw.

Unlike the pyogenic granuloma, which PGCGsresemble, this is an uncommon lesion.


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Cause

This is a reactive lesion associated with chronictrauma or irritation.


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Treatment

Excision is the treatment of choice down to theunderlying bone.

Adjacent teeth should be carefully scaled toremove any source of irritation thus minimizingthe risk of recurrence.

C


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Significance

These lesions will remain indefinitely if nottreated.

Remember, it is a reactive lesion similar in

clinical appearance to the pyogenic granuloma.


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Peripheral Ossifying

FibromaOssifying Fibroid Epulis

Peripheral Fibroma with CalcificationCalcifying Fibroblastic Granuloma


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Peripheral Ossifying Fibroma (POF)

The POF is a common reactive gingival growth.

Its pathogenesis is best describe as uncertain;some POFs have been suggested to develop

from pyogenic granulomas.

It should be noted that POFs are not the sameas peripheral odontogenic fibromas and they are

not the soft tissue counterpart of the centralossifying fibroma.

P i h l O if i Fib (POF)


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Peripheral Ossifying Fibroma (POF):

Clinical Features

This lesion occurs exclusively on the gingiva.

It appears as a nodular mass usually arising fromthe interdental papilla area.

It is red to pink in color and the surface is oftenulcerated.

POFs are more common in young adults and

females.There is a slight predilection for the maxilla and

the anterior region of the jaws.

P i h l O if i Fib


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Peripheral Ossifying Fibroma:

Treatment and Prognosis

The treatment of choice is local surgical excisiondown to the periosteum to prevent recurrence.

The adjacent teeth should be scaled to eliminate

irritants such as calculus.

A recurrence rate of 16 % has been reported inthe literature.


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Hemangioma and

Vascular Malformations

Hemangioma and Vasc lar


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Hemangioma and Vascular

Malformations

The term hemangioma has traditionally been used todescribe a variety of developmental vascular anomalies.

Currently, hemangiomas are considered to be benigntumors of infancy that are characterized by a rapidgrowth phase with endothelial cell proliferation,followed by a gradual involution. Most cannot berecognized at birth but make their appearance in mostinstances during the first 8 weeks of life.

Vascular malformations are structural anomalies ofblood vessels without endothelial proliferation and arepresent at birth and persist throughout life.


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Hemangioma

Hemangiomas are the most common tumors ofinfancy.

They have a female gender predilection (3:1) and are

most common in the White population. 60% of the hemangiomas occur in the head and neck

region with 80% of them occurring as single lesions.Multiple lesions may be part of a syndrome.

About 50 % of all hemangiomas will show completeresolution by 5 years of age.


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Vascular Malformations

These lesions are present from birth and persistthroughout life.

As with hemangiomas, these lesions tend to darkenwith age.

Low-flow venous malformations typically have a bluecolor and are easily compressible.

Arteriovenous malformations are high-flow lesions thatresult from persistent direct arterial and venous

communications. A palpable thrill or bruit is oftennoticeable and the overlying skin typically feels warmerto the touch.



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Malformations Because most hemangiomas undergo involution, management

often consists of watchful neglect. For problematichemangiomas, surgical resection or pharmacologic therapy maybe indicated (systemic steroids or interferon--2a). Flashlamp-pulsed dye lasers can be effective in treating port wine stains.

Management of vascular malformations depends on their size,location and associated complications. Sclerotherapy andsurgical excision are the mainstays.

Treatment of arteriovenous malformations is more challengingand may involve surgical resection or embolization.

Central vascular malformations of the jaws are potentiallydangerous lesions because of severe bleeding. Needle aspirationof any undiagnosed intrabony lesion before biopsy is a wiseprecaution to rule out these lesions.


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Lymphangioma


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Lymphangioma

Lymphangiomas are benign, hamartomatous tumors oflymphatic vessels.

There are three types of lymphangiomas:

1) lymphangioma simplex (capillary size vessels) 2) cavernous lymphangioma (larger vessels)

3) cystic lymphangioma (cystic hygroma) with large

macroscopic cystic spaces Lymphangiomas have a predilection for the head and

neck with about half of all lesions present at birth.


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Lymphangioma: Clinical Features

Oral lymphangiomas occur most frequent on theanterior 2/3 of the tongue where they may producemacroglossia.

They appear as a spongy, diffuse, painless mass whichusually has a pebbly surface. Their appearance is one ofa cluster of translucent vesicles having a red-blue hue.

Small lymphangiomas may appear on the alveolar ridgesof neonates and are more common in African-

Americans. These often occur bilaterally, have a malegender predilection and spontaneously resolve.

Lymphangioma: Treatment and


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Lymphangioma: Treatment and

Prognosis

Treatment usually consists of surgical excisionalthough total removal may not be possible in allcases.

Lymphangiomas generally do not respond tosclerosing agents although recent studiesindicate some success with OK-432.

The prognosis is good for most patientsalthough large tumors (cystic hygromas) maycause airway obstruction.


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Giant Cell Fibroma

Giant Cell Fibroma: Clinical


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Giant Cell Fibroma: Clinical

Features

Giant cell fibromas usually present as asymptomatic,sessile or pedunculated nodules less than onecentimeter in size.

While they may have a smooth surface, they often havea papillary surface.

Sixty percent are diagnosed during the first threedecades with a slight female gender predilection.

Fifty percent occur on the gingiva and the mandible ismore commonly site of this lesion (2:1).

Giant Cell Fibroma: Histological


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Giant Cell Fibroma: Histological

Features

The mass is composed of vascular, loosely arrangedfibrous connective tissue.

The hallmark of the lesion is the presence of large,stellate fibroblasts, which may contain several nuclei,

within the fibrous connective tissue. The covering epithelium is often thin and atropic and

the rete ridges may be elongated and narrow. Lesions with a similar histological appearance found on

the lingual mandibular gingiva in the region of themandibular canine, have been called retrocuspidpapillae.

Giant Cell Fibroma: Treatment and


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Giant Cell Fibroma: Treatment and

Prognosis

Treatment consists of conservative surgicalexcision.

If properly excised, the lesion rarely recurs.


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Lipoma


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Li T d P i


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Lipoma: Treatment and Prognosis

Excision is the treatment of choice for the orallipoma.

Oral lipomas seem to have a limited growth

potential and recurrence is not expected afterremoval.


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Traumatic Neuroma

Amputation Neuroma

Traumatic Neuroma


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(Amputation Neuroma)

This lesion is a reactive proliferation of neuraltissue following transection or damage to thenerve bundle.

Traumatic Neuroma: Clinical


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Features

These lesions generally present as smooth, non-ulcerated nodules.

Predilection sites include: mental foramen,

tongue and lip.

There is often a history of trauma.

They may produce a RL defect if bone is

involved.

Traumatic Neuroma: Clinical


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Features Continued

They may occur at any age but most cases occurin middle-aged adults and there is a slight femalegender predilection.

Only 25-33% are reported to be painful. Ifpainful, the pain can be constant or intermittentand mild to severe.

Lesions involving the mental foramen are mostoften painful especially if there is contact by adenture.

Traumatic Neuroma: Histological


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Features

Presents as a haphazard proliferation of mature,myelinated nerve bundles within a fibrousconnective tissue stoma.

The lesion may have an associated chronicinflammatory cell infiltrate.

Traumatic Neuroma: Treatment and


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Prognosis

Surgical excision is the treatment of choice withthe excision to include a small portion of theinvolved nerve bundle.

Most lesions do not recur.


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Traumatic Neuroma


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Traumatic Neuroma


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Palisaded Encapsulated

Neuroma

Palisaded Encapsulated Neuroma:


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Clinical Features

The etiology of this lesion is unknown buttrauma has been suggested as a cause.

The lesion usually appears as a solitary, smooth,

painless, dome-shaped papule or nodule. It occurs more commonly in adults and there is

no gender predilection.

Common sites include the face, palate and lip.



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Histological Features

As the name suggests the lesion is typically well-circumscribed and often encapsulated.

The tumor consists of interlacing fascicles of

spindle cells, which are probably Schwann cells.The nuclei are wavy and pointed.

While there is palisading there are no Verocay

bodies of Antoni A tissue.



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Treatment consists of conservative localexcision and recurrence is rare.

This lesions is not associated with

neurofibromatosis, multiple endocrine neoplasiasyndrome and it does not undergo malignantchange.


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Palisaded Encapsulated Neuroma


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Palisaded Encapsulated Neuroma

PEN VS Schwannoma


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PEN VS Schwannoma


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Neurilemoma

Schwannoma

Neurilemoma (Schwannoma)


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Neurilemoma (Schwannoma)

This lesion is a benign neural neoplasm ofSchwann cell origin.

It is a relatively uncommon lesion, although 25-

48 % of all cases occur in the head and neckregion.

Neurilemoma: Clinical Features


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Neurilemoma: Clinical Features

The neurilemoma is a slow-growing,encapsulated tumor associated with the nervetrunk.

It is usually asymptomatic but pain may occur. Most lesions occur in young to middle-aged

adults.

The tongue is the most common oral site. Thelesion may occur in bone where it may causeexpansion, radiolucency, pain or paresthesia.

Neurilemoma: Histological Features


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The neurilemoma is an encapsulated tumorcomposed of varying amounts of Antoni A andAntoni B tissue.

Antoni A tissue appears as streaming fascicles ofspindle-shaped Schwann cells. These cells oftenform a palisaded arrangement around an

acellular eosinophilic area known as a Verocaybody.



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Continued

Verocay bodies represent reduplicated basementmembrane and cytoplasmic processes.

Antoni B tissue is less cellular and less well

organized. Neurites can not be demonstrated within the

mass.

Ancient neurilemomas

Neurilemoma: Treatment and


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Prognosis

Surgical excision is the treatment of choice andthe lesion should not recur.

Extremely rare malignant transformation.


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Neurofibroma/Neuro-

fibromatosis

Neurofibroma/Neuro-

fib i Cli i l F


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fibromatosis: Clinical Features

These lesions are soft, single or multiple,asymptomatic nodules covered by epithelium.

Intraorally, they may appear as the same color as

or lighter in color than the surrounding mucosa. Most frequently they are found on the tongue,

buccal mucosa and vestibule but may occuranywhere.

They may occur at any age and there is nogender predilection.

Neurofibroma/Neurofibromatosis:

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Cause

Unknown for the solitary neurofibromas whileneurofibromatosis is an autosomal dominantdisease entity.

Approximately 50 % of cases ofneurofibromatosis present no family history andare considered the result of spontaneousmutation.

Neurofibromatosis is associated with NF1 andNF2 genes.

Neurofibroma/Neurofibromatosis:

T d P i


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The treatment of solitary neurofibromas isexcision and recurrence is not expected.

Multiple neurofibromas should suggest

neurofibromatosis (von Recklinghausen disease),which consists of multiple neurofibromas withmalignant potential, caf au lait spots, optic

gliomas, Lisch nodules (iris hamartomas) andbony lesions as outlined in the next slide.

Box 12-1 Diagnostic Criteria for Neurofibromatosis Type I


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The diagnostic criteria are met if a patient has two or more of thefollowing features:

1. Six or more caf au laitmacules over 5 mm in greatestdiameter in prepubertal persons and over 15 mm in greatestdiameter in postpubertal persons

2. Two or more neurofibromas of any type or one plexiform

neurofibroma 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 orthinning of long bone cortex with or without

pseudoarthrosis 7. A first-degree relative (parent, sibling, or offspring) with

neurofibromatosis type I, based on the above criteria


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Neural Tumors: Comparative

Features


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Features


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Granular Cell Tumor

Granular Cell Tumor: Clinical

Features


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Features

These lesion typically appear as painless,elevated tumescences covered by an intactepithelium.

Their color may be the same as or lighter thanthe surrounding tissue.

There is a strong predilection for the dorsum ofthe tongue but may be found anywhere.

Granular cell tumors are rare in children andthere is a 2:1 female gender predilection.

Granular Cell Tumor


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The cause of the granular cell tumor is unknown andthe cell of origin is undetermined. Originally, it was considered to be of skeletal muscle

origin but current research suggests origin fromSchwann cells or neuorendocrine cells.

Treatment consists of surgical excision and the lesiondoes not recur.

The lesion must be differentiated from other lesions ofthe tongue particularly squamous cell carcinoma as a

superficial biopsy of a granular cell tumor with PEHmay be confused with this cancer.


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Congenital Epulis

Congenital Epulis of the Newborn

Congenital Granular Cell Lesion


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Soft Tissue Sarcomas

Soft tissue sarcomas are rare malignanttumors of the oral and maxillofacial region

accounting for less than 1% of the cancers inthis area.

Fibrosarcoma


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Fibrosarcomas are malignant tumors offibroblasts.

They were once considered the most common

soft tissue sarcoma but are considereduncommon today (and only 10% of them occurin the head and neck region).

Fibrosarcoma: Clinical Features


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Fibrosarcomas most often present as slow-growing masses which may reach considerablesize before producing pain.

They can occur anywhere in the oral region. Anumber of cases have been reported in the noseand paranasal sinuses where obstructivesymptoms are the chief complaint.

They can occur at any age but are morecommon in children and young adults.

Fibrosarcoma: Treatment and

Prognosis


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Prognosis

Surgical excision with wide margins is thetreatment of choice.

The 5-year survival rates range from 40-70 %.


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Malignant Fibrous Histiocytoma


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This sarcoma, which has both fibroblastic andhistiocytic features, is now considered to be themost common soft tissue sarcoma in adults.

Malignant Fibrous Histiocytoma:

Clinical Features


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This is primarily a tumor of older age groups.The most common complaint is an expanding

mass that may or may not be ulcerated or

painful.Tumors of the nasal cavity or paranasal sinuses

usually produce obstructive symptoms.

Malignant Fibrous Histiocytoma:



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This is an aggressive tumor that typicallyrequires radical surgical resection.

Approximately 40 % of patients have local

recurrences with a similar number developingmetastases within 2 years of initial diagnosis.

The survival rate for patients with oral tumors

seems to be worse that for those with the tumorat other body sites.


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