Clinic of benign tumors and deaf-like formations of the jaws. Surgical treatment: removal of an impacted tooth, cystectomy

RCHD (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Archive - Clinical protocols Ministry of Health of the Republic of Kazakhstan - 2010 (Order No. 239)

Bones of the skull and face (D16.4)

general information

Short description

Tumor- pathological processes that arise as a result of the proliferation of the body's own cells differ in their biological entity and are the body's response to various damaging factors of external and internal character. (I.T. Shevchenko)

Protocol"Benign tumors and tumor-like formations of the bones of the face. Other diseases of the jaws"

ICD-10 code:

D 16.4 Benign facial bone formation

D 16.5 - Benign formation of the lower jaw

K 10.1 - Giant cell granuloma (osteoclastoma), central

K 10.8 - Other specified diseases of jaws (fibrous dysplasia)

K 01.0 - Impacted teeth

K 07.3 - Anomalies in the position of the teeth

K 09.- - Cysts of the oral cavity and jaws (nonodontogenic, follicular)

Classification

Classification of primary benign tumors and tumor-like formations of facial bones (Yu.I. Bernadsky, 1983)

Group of tumors and tumor-like formations	Tumors	Tumor-like formations
osteogenic	Osteoma Osteoid osteoma Osteoclastoma (giant cell tumor) central and peripheral	fibrous dysplasia Cherubism Deforming ostosis Hyperparathyroid fibrous osteodystrophy Hyperostosis Exostosis Eosinophilic granuloma
Non-osteogenic and non-odontogenic	Hemangioma Hemangioendothelioma Fibroma neurofibroma Myxoma Chondroma	cholesteatoma
Odontogenic	Adamantinoma Odontoma soft Odontoma hard Odontogenic fibroma	Odontogenic cysts of the jaws: radicular Follicular cyst Retromalar cyst Primary odontogenic cyst Cementoma "Banal" (non-giant cell) epulid

Diagnostics

Diagnostic criteria

Complaints and anamnesis
Complaints of patients are rather monotonous - for the presence of facial deformity due to the tumor, tumor growth, violation of chewing, food intake, restriction of mouth opening, tooth mobility, cosmetic defect.
From the anamnesis: there may be chronic inflammatory processes, different kind trauma, which could be the cause of the development of the tumor. The duration of the process, from several months to several years. Some tumors develop transiently, others slowly, over the years, increase in size, which plays an important role in the diagnosis of benign tumors.

Physical examination: benign tumors develop, as a rule, painlessly, and attract attention when there is already a more or less pronounced deformation of the jaw and a change in the position of the teeth or a violation of nasal breathing with damage to the anterior section upper jaw.

Swelling due to local increase in bone volume is another important clinical sign. When a tumor affects the periosteum or the cortical layer of the bone, swelling is detected relatively early. Much later, swelling is detected when the neoplasm is localized in the thickness of the bone, especially in the upper jaw. Skin and mucous membrane alveolar process and the body of the jaw, located above the tumor, usually has a normal color.

Palpation examination of the lesion should clarify the consistency, surface, boundaries of the tumor and its relationship to the surrounding tissues, the zone and depth of infiltration, displacement, as well as pain and local boost temperature. The bumpy surface is usually with fibrous dysplasia, chondroma, osteoblastoclastoma. The soft doughy consistency of the tumor as well as its swaying speaks of the non-osseous origin of the tumor. Pulsation in tumors of the jaw bone is rarely detected, but its presence indicates a vascular origin. A symptom of parchment crunch, with a thinned cortical plate, occurs in the cystic form of osteoblastoclastoma.

We pay special attention to the condition of the teeth: their position, mobility, reaction to percussion, sensitivity. Violation right position more often with osteoblastoclastoma, chondroma, fibrous dysplasia, eosinophilic granuloma.

Restriction of the movement of the lower jaw, occurs with a tumor lesion of the branch and articular process of the lower jaw.

Indicators laboratory research do not change.

X-ray picture tumor lesions jaw bones not numerous, it is destruction, bone deformity and periosteal reaction. Destruction is observed in the form of a single (fibroma, myxoma, enchondroma, osteoblastoclastoma, osteosarcoma etc.) and multiple foci (eosinophilic granuloma, polyosseous fibrous dysplasia). The shape of the destruction foci can be round, oblong, irregular; the foci of destruction can be localized in any part of the jaw bone, located centrally or peripherally.
The nature of the boundaries is quite typical: for example, the osteoma is a direct continuation of the cortical layer and, merging with it, is located on the surface of the bone. The focus of fibrous dysplasia, located intraosseously, usually has a clear border in the form of a sclerotic border.
Eosinophilic granulomas are characterized by multiscalloped "stamped" borders.
Osteoblastoclastoma in the case of a cystic form is surrounded on all sides by a zone of sclerotic tissue, and in the lytic form, in the direction of continuing growth, the boundaries lose their clarity.

Bone deformity is manifested by swelling if the neoplasm is inside the bone, thickening due to periosteal layers or in the form of additional formations emanating from the bone (osteoma, echondroma). However, pathognomonic for benign primary bone tumor jaws do not exist.

Histological diagnosis of tumors of the bones of the jaws and face is mandatory.

Indication for specialist advice: oncologist - in case of suspicion of malignancy of the tumor or the malignant nature of the tumor; in the presence of comorbidities. Consultation of a dentist, ENT doctor, gynecologist - for the rehabilitation of infections of the nasopharynx, oral cavity and external genital organs; allergist - with manifestations of allergies; violations of the ECG, etc. are an indication for consultation with a cardiologist; in the presence of viral hepatitis, zoonotic and intrauterine and other infections - infectious disease specialist.

List of main diagnostic measures:

1. General analysis blood (6 parameters).

2. General analysis of urine.

3. Biochemical analysis blood.

4. Examination of feces for worm eggs.

5. Determination of the clotting time of capillary blood.

6. Determination of blood group and Rh factor.

7. Histological examination of the surgical material.

8. Consultation of an anesthesiologist.

10. Radiography of the jaw bones in two projections.

List of additional diagnostic measures:

1. CT scan temporomandibular joint.

2. Panoramic radiography jaws.

3. Coagulogram.

4. Ultrasound of the abdominal organs.

The list of minimum examinations before hospitalization:

1. ALT, AST.

3. Buck. stool culture for children under 2 years of age.

4. Radiography of organs chest(in children under 3 years of age).

Differential Diagnosis

	Benign tumors of the bones of the face	Malignant tumors of the bones of the face	Inflammatory diseases jaw bones
Complaints	For swelling, slow growth, facial deformity	Painful swelling, enlargement, deformity of the face	Painful swelling, edema, deformity of the face
Anamnesis	Often slowly increasing swelling, sometimes for years. As a rule, at the beginning of the disease they did not bother, they turn to when a pronounced deformity of the face appears.	The onset of the disease is more often within 2-6 months. Which did not bother, after pain, mobility of the teeth, ulceration of the mucosa over the lesion may be noted. Possible previous surgeries for this disease	A history of a previously treated or disturbed tooth that was undertreated or the patient did not go to a specialist. Previously transferred periostitis of the jaw
Objective Status	Painless swelling of the bone or formation with clear boundaries, the mucosa is not changed	Swelling of the bone, painful on palpation, ulceration of the mucosa over the tumor is possible. The boundaries are not clear. Movable teeth	Muff-like infiltrate, painful on palpation, the surrounding mucosa is hyperemic, palpation is sharply painful. Mobile teeth, painful percussion, purulent discharge, fistula
X-ray picture	Destruction bone tissue with clear, even edges	The boundaries of the tumor are indistinct, scalloped. periosteal reaction	At acute form osteomyelitis may not be chronic forms bone destruction with smooth edges, there is always a causative tooth

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Treatment

Treatment tactics

Purpose of treatment: surgical removal of pathologically altered bone tissue within healthy tissues.

Excochleation(scraping). The indication for this operation is clearly limited benign neoplasms: eosinophilic granuloma, focal form fibrous dysplasia, fibroma, osteoblastoclastoma (cystic, cellular and peripheral).

Resection of the jaw. Indications are tumors prone to recurrence (chondroma, myxoma, lytic form of osteoblastoclastoma, etc.). Need jaw resection also occurs with an extensive lesion of the jaw by a benign tumor. In such cases, simultaneous bone grafting is possible.

At vascular tumors bones of the face and oral cavity before the main operation, ligation of the external carotid artery is necessary.

Non-drug treatment: protective mode, semi-bed. Diet table 1a, 1b.

Medical treatment: antibiotic therapy in order to prevent purulent-inflammatory complications (lincomycin, cephalosporins, macrolides, aminoglycosides). Infusion, symptomatic, vitamin-, hyposensitizing therapy. According to the indications, transfusion of FFP or erythrocyte mass.

Preventive actions:

1. Compliance with the regime and diet.

2. With extensive lesions of the lower jaw, in order to prevent a pathological fracture, splinting is necessary.

3. Orthodontic and orthopedic treatment according to the place of residence.

Further management: rehabilitation under conditions dental clinic at the place of residence. Observation and treatment at the orthodontist at the place of residence. Dispensary observation at maxillofacial surgeon at the place of residence. Therapeutic gymnastics. Sanitation of the oral cavity. Control radiography of the jaws.

List of essential medicines:

generic name	Quantity
Promedol 2% - amp.
Tramadol amp.
Diphenhydramine 1% - amp.
Lincomycin 30% amp.
Medocef 1 gr fl.
Furacillin 1:5000 l
Alcohol 96% gr	0.05
Syringes 2.0
Gauze, m
Povidone iodine, ml	200
Solution of potassium permanganate 3% ml	100
Atropine 0.1% amp.
Relanium, amp.
Droperidol, fl.
Alcohol 70% gr
Aevit, fl.
Cotton wool, g	100
Gloves, pair
Heparin ointment, tube.	1/2

Additional medicines in the department:

Anesthesia medications and in the department. AIT:

generic name	Quantity
Calypsol, ml
Dormicum, amp.
Fentanyl, amp.
Droperidol, ml
Fluorotan, fl.
Ditilin 100 mg, amp.
Arduan 4 mg, amp.
Physical solution 0.9% vial.
Glucose 5% 200 ml, vial
Insulin, units
Calcium chloride, 10% ml
Dicynon, amp.
Ascorbic acid, mg
Cordiamin, ml
Prednisolone 30 mg, amp.
Prozerin 0.06% amp.
Oxygen
soda lime
Glucose 10% 200 ml, vial
Insulin, Unit
Novacaine 0.25%, ml
Promedol 2% amp.
Relanium, 10 mg
Syringes, 5 ml
Systems, pack.
Angiocatheters, pcs.
Cocorboxylase, mg
Riboxin, ml
Cerucal, amp.
FFP, ml
Erythra. weight

Treatment indicators:

1. Wound healing by primary intention.

2. Absence clinical signs tumors or their reduction in partial removal tumors.

3. Absence radiological signs tumors.

Hospitalization

Indications for hospitalization: planned. The presence of a growing tumor leading to facial deformity. Destruction of bone tissue by a tumor, violation of chewing and eating.

Information

Sources and literature

Protocols for the diagnosis and treatment of diseases of the Ministry of Health of the Republic of Kazakhstan (Order No. 239 of 04/07/2010)
1. 1. V.S. Dmitrieva, V.S. Pogosov, V.A. Savitsky "Benign tumors of the face, mouth and neck" Moscow, 1968. 2. A.A. Kolesov "Neoplasms facial skeleton» Medicine, 1969 3. Yu.I. Bernadsky "Fundamentals maxillofacial surgery and surgical dentistry» Moscow, 2000
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28.1. ODONTOGENIC BENIGN TUMORS OF THE JAWS

♦ Ameloblastoma (adamantinoma)

Under ameloblastoma unite a group of odontogenic tumors of epithelial origin, which are located in the thickness of the jaw. This group of tumors includes true ameloblastoma(synonyms: adamantinoma, adamantine epithelioma, adamantine blastoma etc.), and ameloblastic fibroma(synonym: soft odontoma)adenoameloblastoma(synonym: adenomatoid odontogenic tumor)ameloblastic fibroodontoma, odontoameloblastoma. These tumors are characterized by the ability to zivny (destructive, infiltrative) growth. Sprouting the jawbone, the tumor grows in soft tissues, and on the upper jaw - in the maxillary sinus.

Rice. 28.1.1. Macroscopic view of the ameloblastoma of the mandible. The latter is cut along.

Ameloblastomas are more common in patients aged 17-45 years, although they can be detected at other ages. Found in both women and men. They are localized more often on the lower jaw in the area of its angle and branch, but can occur in the area of the body of the lower jaw, as well as on the upper jaw. According to our data, ameloblastomas are found in 18% of all benign tumors and tumor-like formations of the jaws. In about 94% of cases, the tumor is localized in the lower jaw.

Rice. 28.1.2. Appearance patient (a - full face, b - side) with ameloblastoma of the lower jaw

Pathomorphology tumor depends on the variant of the identified form of ameloblastoma.

R
is. 28.1.3. Appearance of a patient with ameloblastoma of the upper jaw. Histopathological diagnosis - odontoameloblastoma

Rice. 28.1.4. X-ray picture of true ameloblastomas of the lower jaw, localized in the region of the branch (a, b), body (c), and also involving all these departments (d, e, f). Radiographs of the lower jaw of a patient with soft odontoma - ameloblastic fibroma (w - overview, h - lateral).

Rice. 28.1.4. (continuation).

R
is. 28.1.5. X-ray picture of ameloblastomas of the lower jaw with teeth in the tumor zone: a, b, c - true ameloblastomas; d – odontoameloblastoma; e - adenoameloblastomas; f - electroroentgenogram of a patient with ameloblastic fibroodontoma of the lower jaw.

Macroscopically the neoplasm is represented by a grayish-pink fine-grained tissue with multiple cysts, does not contain foci of calcification (Fig. 28.1.1). Histologically distinguish follicular, plexiform, acanthomatous, basal cell, granular cellth variants of the structure of true ameloblastoma (N.A. Kraevsky et al., 1993).

Most typical follicular a type of structure represented by epithelial complexes of various sizes, which resemble the developing enamel organ of the tooth germ. Epithelial complexes are surrounded by high cylindrical cells, in the center - the epithelium with the phenomena of reticulation.

Plexiform variant is characterized by epithelial strands of irregular shape, intertwined in the form of a network with frequent reticulation in central departments.

Acanthomatous the type of structure in the central sections is represented by polygonal cells that resemble cells of the prickly layer of squamous epithelium. There is a tendency to form "horn pearls".

Basal cell variant resembles elements of skin basalioma, and when granular-cellular type of structure in the central sections there are large cells with a granular (oxyphilic) cytoplasm (the grains shift the nucleus to the periphery of the cells).

Ameloblastic fibroma (soft odontoma)microscopically It is represented by islets and strands of odontogenic epithelium, located in a cellular fibrous tissue resembling the tissue of the dental papilla in the rudiment. Cylindrical or cubic cells are located along the periphery of the complexes.

Adenoameloblastoma (adenomatoid odontogenic tumor)microscopically built of glandular-like structures formed by cuboidal epithelium. The epithelium forms strands of an annular structure or lies in solid islands. In the lumen of these glandular structures, a homogeneous oxyphilic substance is found.

At ameloblastic fibroodontoma the tumor consists of areas having the structure of an ameloblastic fibroma, as well as deposits of dentin and enamel. The epithelium does not form typical ameloblastoma complexes.

Odontoameloblastoma represented by ameloblastoma structures, combined with the deposition of dentin and enamel, which resemble a tooth germ.

All variants (types) of ameloblastomas have locally destructive growth.

Clinic . Ameloblastomas grow slowly and painlessly. Therefore, patients go to the doctor only after a long time after the onset of the tumor. (Fig. 28.1.2 - 28.1.3).

Complaints of patients are reduced to the presence of asymmetry of the face, aching pain in the jaw and teeth. Patients are asked to remove intact teeth where pain is located. Wells after tooth extraction do not heal for a long time. In the anamnesis there are indications of periodic swelling of the affected area of the jaw, i.e. tumor growth was accompanied by inflammatory phenomena (periostitis, abscesses, phlegmon), and fistulas were periodically opened on the oral mucosa with purulent or bloody discharge. If the tumor reaches a large size, then the act of chewing and speech may be disturbed.

During external examination, patients have asymmetry of the face due to the spindle-shaped thickening of the jaw. The skin over the tumor is usually not changed in color and is folded. Regional lymph nodes may be enlarged. On palpation, the tumor is painless, dense, and may be bumpy. Opening the mouth is usually not difficult. From the side of the vestibule of the oral cavity, the smoothness or bulging of the jaw along the transitional fold is determined, and in some cases, the thickening of the anterior edge of the lower jaw branch. There may be swelling of the body of the jaw from the lingual (palatal) side. The mucous membrane in the area of the pathological focus was not changed in color. In some areas, the tumor can grow into the cortical plate of the jaw and spread to soft tissues. Palpation of the tumor is painless, dense. With a bone defect, a symptom of a parchment crunch is possible or a fluctuation appears. The teeth that are in the zone of the pathological focus can be both fixed and mobile.

Ameloblastomas sometimes suppurate as a result of injury to the tumor by antagonist teeth. Festering ameloblastomas clinically manifest themselves as a common odontogenic inflammatory process.

There is no uniformity in the clinical picture of ameloblastomas, therefore, in establishing a diagnosis great importance has an X-ray method for examining the jaws. Typical for the radiographic picture of most ameloblastomas is a series of rounded cavities of various sizes, which are separated from each other by bony septa. (Fig. 28.1.4). The latter can become thinner as the tumor grows and completely disappear. The cavities touch, overlap, and even merge with each other. Cysts may have a rounded shape, clear, but uneven edges. Ameloblastoma can also be represented by a single cystic cavity. Around it, in some cases, there are a number of small cavities. The cystic cavity may contain an impacted or dystopic tooth. (Fig. 28.1.5). It is possible that the roots of the teeth turn out to be turned into the cavity of the cyst. (Fig. 28.1.6 - 28.1.7). A. L. Kozyreva (1959) offers the following options for the x-ray picture of ameloblastoma (Fig. 28.1.8). By comparing layer-by-layer radiographs and pathomorphological studies, Yu. A. Zorin (1965) and N. N. Mazalova (1974) proved the presence of tumor spurs in the bone in the form of strands that penetrate to a depth of 0.7 cm into a healthy bone, which in most cases invisible on plain radiographs. This fact must be taken into account when performing surgical treatment for radical removal of the tumor. Computed tomography clarifies the localization of the tumor (Fig. 28.1.9).

Diagnostics primarily performed with jaw cysts, osteoblastoma, fibrous osteodysplasia, malignant tumors jaw bones as well as with chronic osteomyelitis.

For osteoblastoma, Unlike ameloblastoma, more characteristically: the tumor is not accompanied by pain; extremely rarely suppuration is observed; regional lymph nodes are not enlarged; the punctate contains hemolyzed blood, not a clear liquid; resorption of the roots of the teeth facing the tumor is more often noted; on the radiograph there is an alternation of areas of compaction and rarefaction of bone tissue. However, all distinguishing features are relative and the final diagnosis is established after pathohistological examination.

Jaw cysts characterized by: the presence of a carious (radicular cysts) or non-erupted (follicular cysts) tooth; at a puncture it is possible to receive transparent yellowish liquid with crystals of cholesterol; on the x-ray there is a clear connection between the cystic cavity and the apex of the causative tooth (radicular cysts) or the coronal part of the unerupted tooth is located in the cyst cavity strictly along its anatomical neck. The final diagnosis is specified after the pathohistological examination.

Malignant tumors are characterized by: jaw sarcoma is more common in the young, and cancer in the elderly; violated general state the patient's body; rapid growth; pronounced pain in the jaw; regional lymph nodes are early involved in the process; on the radiograph there is a bone defect with corroded edges, blurring and indistinctness of the boundaries of the bone defect.

Chronic osteomyelitis in history it is characterized by an acute stage of the disease, a change in the general condition of the body and laboratory blood tests, enlarged and painful regional lymph nodes, the presence of fistulas with purulent discharge on the mucous membrane or skin, inflammatory changes in the soft tissues around the pathological focus, areas of destruction and ossification are combined on the x-ray (the presence of sequesters), there is a periosteal reaction along the periphery of the bone lesion.

Rice. 28.1.6. Radiographs of the upper jaw of patients with ameloblastomas (a, b).

Rice. 28.1.7. X-ray of the upper jaw of a patient with soft odontoma (ameloblastic fibroma).

Rice. 28.1.8. Variants of X-ray pictures of ameloblastoma (according to A.L. Kozyreva, 1959)

1 - a number of rounded cavities;

2 - one cavity, surrounded by smaller cavities;

3 - rounded cavities containing a tooth;

4 - polygonal cavities;

5 - small cysts forming the looping of the bone;

6 - single large cystic cavities;

7 - one cystic cavity with jagged edges;

8 - the roots of the teeth are turned into the cystic cavity;

9 - the crown of the tooth is turned into the cystic cavity.

Rice. 28.1.9. Computed tomograms of patients with odontoameloblastoma of the upper jaw (a) and soft odontoma of the lower jaw (b - the cut was made at the level of the "wisdom" tooth, c - at the level of the angle).

R
is. 28.1.10. X-ray of a patient with ameloblastoma of the lower jaw (a), who, after resection of half of the lower jaw, underwent autoplasty of the resulting defect with a rib (overview - b and lateral - c radiographs).

R
is. 28.1.11. X-ray of the lower jaw Rice. 28.1.12. Invasion of ameloblastoma

with a complication of ameloblastoma pathological allograft. X-ray taken

fracture. one year after bone grafting

Treatment ameloblastoma is the radical removal of the tumor within healthy tissues. Curettage of the tumor necessarily leads to a recurrence, tk. ameloblastomas have locally destructive (infiltrative) growth. In patients with ameloblastoma that is located within the alveolar process or the inner edge of the mandibular branch, sparing resection of the jaw is acceptable while maintaining bone continuity. When performing a resection of the lower jaw, it is necessary to retreat 2 cm towards the healthy bone from the radiologically visible borders of the tumor. If the ameloblastoma is located on the upper jaw, then it is removed by partial or complete resection of the jaw, leaving, if possible, the infraorbital margin (to maintain support eyeball). Resection of the jaw is performed subperiosteally if the tumor does not grow into the bone tissue. When ameloblastoma spreads into soft tissues, resection of surrounding tissues is performed. After surgery on the lower jaw, it is necessary to simultaneously carry out bone grafting. Auto- or allo-bone is used as a graft (Fig. 28.1.10). If untimely removal of ameloblastoma is possible about
complication - pathological fracture of the lower jaw (Fig. 28.1.11).

Rice. 28.1.13. Appearance titanium prosthesis, developed in the clinic of maxillofacial surgery KMAPE named after. P.L. Shupik and used to replace a partial or half defect of the lower jaw (issued by the Institute of Materials Science Problems of the Academy of Sciences of Ukraine).

Analysis of the nearest and long-term results of osteoplastic operations with an allograft allows us to identify the following possible complications:

Suppuration of the surgical wound with subsequent transplant rejection;

The formation of fistulas on the skin in the area of \u200b\u200bthe bone suture (metal or other) a few months after the operation;

Partial resorption of the graft;

Tumor recurrence - germination of ameloblastoma into the allograft with non-radical removal of the tumor (Fig. 28.1.12).

Thus, complications after bone alloplasty of the lower jaw are diverse. Some of them lead to rejection of the graft, others lengthen the treatment time for the patient, but allow the graft to be saved.

In recent years, the use of titanium mandibular prostheses as a transplant has been increasingly used in maxillofacial surgery. (Fig. 28.1.13-28.1.14). Our clinic has developed titanium lower jaw prostheses with prefabricated sections in it, which are used to fix dental implants, and dentures are strengthened on the latter (A. A. Timofeev, A. N. Likhota, E. V. Gorobets, 1998). With non-radical removal of ameloblastoma and its recurrence, malignancy of the tumor is possible. (Fig. 28.1.15) with the development of malignant ameloblastoma (formed from the epithelial component of the tumor) or ameloblastic fibrosarcoma (the mesodermal component of the tumor is malignant). The prognosis is favorable if the tumor is removed radically.

Odontoma is a tumor-like formation, consisting of epithelial and mesenchymal components of tooth-forming tissues. Odontomas are a malformation of dental tissues.

Odontoma (synonym: hard odontoma) develops from one or more tooth buds. This formation cannot be attributed to true tumors.

A. I. Evdokimov (1959) divides odontomas into simple(represented by the tissues of one tooth, mixed in various combinations) and complex(constructed from several rudiments of teeth or many rudimentary teeth). Simple odontomas are in turn divided into full(have a tooth-like or rounded shape) and incomplete(depending on localization called crown, root or periodontoma- "pendants" to the roots of the teeth). Complex odontomas can be mixed(consists of randomly mixed dental tissues of several teeth) and constituent(consists of many correctly formed and deformed teeth soldered together). The division of complex odontomas into mixed and compound purely conditional because there are no reliable criteria for differentiating two types of complex odontomas. Odontomas are surrounded by a connective tissue capsule.

Rice. 28.1.14. Radiographs of patients who used titanium prostheses to replace a postoperative mandibular defect (a, b, c). Radiographs were taken six months after plastic surgery.

Rice. 28.1.15. Appearance of a patient with malignant ameloblastoma. Recurrence and malignancy of the tumor occurred during its non-radical removal (a - full face, b - side, c -

According to our data, odontomas occur in 7% of cases among all benign tumors and tumor-like formations of the jaws. More common in young people. Predominantly occurs on the lower jaw in the region of the molars. It is found more often in women.

Rice. 28.1.16. Radiographs of the lower jaw of patients with simple complete odontomas: round (a) and tooth-like (b) shape.

Rice. 28.1.17. Radiographs of the lower jaw of patients with simple incomplete

odontomas (a, b).

Rice. 28.1.18. Radiographs of the lower jaw of patients with complex odontomas (a, b, c).

Photograph from a radiograph (c).

Rice. 28.1.19. Radiographs of the upper jaw of patients with simple complete

odontomas (a, b).

Rice. 28.1.20. X-ray of a patient with a simple incomplete odontoma localized in the anterior-internal section of the right maxillary bone (a - overview, b - lateral radiographs).

Rice. 28.1.21. Radiographs of the upper jaw of patients with complex odontomas (a, b, c).

Fig 28.1.22. Appearance of complex odontomas.

Rice. 28.1.23. Radiographs of the lower jaw of patients with calculous submaxillitis. Shadow salivary stone resembles an odontoma or an impacted tooth (a, b).

Clinic . Odontomas grow very slowly, painlessly. Having formed at a certain age, their growth most often stops and they do not increase in size. In the place where this tumor is located, a permanent tooth may be absent. If the odontoma is located at the site of the passage of the nerve, then its growth is accompanied by pain, which sometimes simulates neurological symptoms. Increasing in size, the tumor can grow into the bone. When the odontoma is injured by antagonist teeth, it becomes infected and suppurated with the appearance of corresponding clinical symptoms.

The main method in diagnostics odontoma is radiography. The radiograph is characteristic (Fig. 28.1.16. - 28.1.21). A homogeneous tissue of a certain shape is revealed (in density it corresponds to a tooth) with clear and uneven edges (Fig. 28.1.22). Along the border of the tumor, a narrow strip of enlightenment about 1 mm wide is determined, which corresponds to the capsule of the odontoma. The bone at the border with the tumor may be sclerosed. Radiographically, salivary stones in the submandibular gland may mimic a mandibular odontoma. (Fig. 28.1.23). To clarify the diagnosis, it is necessary to conduct an x-ray of the soft tissues of the floor of the mouth and, with calculous submaxillitis, we determine a more accurate localization of the salivary stone. Osteoma in terms of radiographic density can approach odontoma, but unlike the latter, osteoma is less dense, more homogeneous, and it always lacks a strip of enlightenment along the periphery of the tumor (no capsule).

Treatment is to remove the odontoma together with the capsule. The remaining capsule can serve as a source for further tumor growth. During the removal of large odontomas, a mandibular fracture may occur. To fill an extensive postoperative jaw defect, bioinert or bioactive ceramics can be used, which significantly stimulates regenerative processes in bone tissue.

Forecast favorable.

The non-osteogenic group of jaw tumors includes: hemangiomas, hemangioendotheliomas, fibromas, neurofibromas, nervolemmomas, myxomas, chondromas. Cholesteatoma can be attributed to the category of non-osteogenic tumor-like formations.

HEMANGIOMA

Isolated hemangiomas of the jaws are relatively rare. More often there is a combination of hemangioma of the soft tissues of the face or oral cavity with hemangioma of the jaw. In such cases, the mucous membrane of the gums and palate is bright red or blue-purple, which facilitates the diagnosis.

It is much more difficult to establish the diagnosis of jaw hemangioma in cases where the surrounding soft tissues are not involved in the lesion. Such isolated hemangiomas of the jaws can be manifested by increased "unreasonable" bleeding of the gums; in the treatment of pulpitis and periodontitis, persistent bleeding from the root canals occurs.

A serious complication is the powerful arterial bleeding from a hemangioma of the jaw that case when delivered misdiagnosis(osteoclastoma, osteodysplasia, osteofibroma, etc.) and a biopsy or removal of a sharply loosened tooth located in the hemangioma zone is performed. Such a sudden onset of bleeding can be fatal, especially if it occurs in a clinic, at an appointment with an inexperienced doctor.

The clinic depends on the location, degree of spread of the tumor and its histological structure. Jaw hemangioma can be limited and widespread, capillary and cavernous. Spreading the cortical part of the jaw, it can cause a symptom of a celluloid toy or a symptom of fluctuation, destruction of the alveolar process and the associated progressive increase in the symptom of loose teeth, swelling of the bone. Growing from the periosteum into the mucous membrane of the gums, the hemangioma of the jaw becomes noticeable in its bluish color; the teeth are barely held in the soft tissues.

On the radiograph, the hemangioma of the jaw is manifested by a swelling of the bone, a small or medium mesh pattern, sometimes there are periosteal layers.

Diagnosis of hemangiomas of the jaws presents significant difficulties when there are no complaints about bleeding gums and the tumor has not come close to the mucous membrane of the gums.

It is necessary to differentiate hemangioma from osteoblastoclastoma, adamantinoma, myxoma.

Puncture of a hemangioma is almost always a sufficient guideline. However, the absence of blood in the syringe does not give full reason to reject the diagnosis of hemangioma.

Having decided to take a piece of a suspected hemangioma, the surgeon must be prepared for the fact that during the biopsy there will be heavy bleeding, which will need to be urgently stopped and replenish the blood loss.

Angiography allows you to establish the source of the hemangioma, as well as the vastness of its spread to the base of the skull when localized in the upper jaw.

Treatment. Small bony hemangiomas can be cured with repeated injections into the tumor 1-2 ml 95% ethyl alcohol or 2% solution salicylic acid on 80% alcohol, a solution of quinine hydrochloride with urethane, etc.

Extensive hemangiomas of the jaw are usually exposed surgical treatment. If the hemangioma is localized in the upper jaw, it is resected. If the hemangioma is localized in the thickness of the body of the lower jaw, it is possible to perform (through extraoral access) resection of the outer cortical plate of the jaw, plug the bottom of the bone wound with a flap masseter muscle.

Even before the start of the operation, it is necessary for hemostatic purposes to make a bilateral ligation of the external carotid arteries, and during the operation to monitor adequate replenishment of blood loss.

HEMANGIOENDOTHELIOMA

The tumor originates from the endothelium blood vessels jaws. In terms of maturity intermediate position between hemangioma and hemangioscarcoma.

Clinic. It is observed mainly in children. More different from angiomas rapid growth with infiltration and germination into surrounding tissues; more often causes bleeding and ulceration of the mucous membrane of the gums. Regional lymph nodes are not enlarged.

Treatment.Deep X-ray therapy with subsequent radical removal of the tumor within healthy tissues.

FIBROMA

Fibromasjaws occur in 2% of patients hospitalized in the maxillofacial clinic for primary tumors and tumor-like formations of the jaw.

More often (3 times) they occur in women aged 10-60 years, localized mainly on the lower jaw and hard palate.

Clinic. Developing slowly and painlessly at first, the tumor can be detected by chance, after the appearance of paresthesia of the lip or minor pain in the jaw (the result of compression of the mandibular nerve in the jaw canal).

There are three options clinical course fibromas of the mandible:

1. the tumor is localized in the thickness of the bone, due to which the bone thickens like a spindle; at the same time, the tumor does not grow into the surrounding tissues;

2. the body of the jaw is destroyed by a tumor localized on inner surface it and in the thickness of the soft tissues of the bottom of the mouth;

3. The tumor originates from the palatine processes of the upper jaw and protrudes above the surface of the hard palate.

Radiologically, in the presence of intramaxillary fibroma, a clearly defined, rounded or oval focus of destruction is determined. If there is a petrifying fibroma, dense areas are determined on the radiograph, and in the presence of myxomatous inclusions, foci of rarefaction are visible.

Treatment: surgical removal.

NEUROFIBROMA (NEVRILEMMOMA)

neurofibromadevelops in the lower jaw from the lower alveolar nerve laid down here, and in the upper jaw - from the branches of the upper alveolar nerve. The tumor can reach the size of a plum; gradually increasing pains are replaced by paresthesia or anesthesia of half lower lip or corresponding maxillary teeth.

The clinical picture does not have specific symptoms, so the diagnosis is established only after surgery with a histological examination.

Treatment: surgical.

MIXOMA

Myxoma occupies an intermediate position between neoplasms of fibrous connective tissue and tumors of cartilage, bone, and fat.

It is rare in the jawbones between the ages of 14 and 30 years. It is localized mainly in the anterolateral part of the lower jaw and the lateral part of the upper jaw. Often combined with other tumors, therefore it acquires a double name - myxochondroma, fibromyxoma, microlipoma, microsarcoma, etc.

Myxoma grows from under the periosteum, from the mucous bags near the joint, the mucous membrane of the maxillary sinus.

It grows slowly, painlessly, growing into the surrounding bone in the form of bay-like depressions. Having reached a significant size, it leads to deformation of the jaw in the form of a dense, painless, smooth protrusion. Growing into the alveolar process, causes displacement of the teeth into the deformation of the dentition; localized in the region of the jaw branch, it can simulate a disease of the parotid salivary gland or masticatory muscle (cyst, fibroids).

The radiographic picture is quite typical against the background of rarefaction of the bone tissue, clearly defined cells are visible; the tumor does not have clear boundaries and borderline bone sclerosis; there is a tendency to cause resorption of the roots of the teeth.

The final diagnosis is usually established on the basis of a puncture or histological examination.

Treatmentsurgical. Surgery is to remove the tumor within a known healthy bone.

CHONDROMA

Chondromas of the jaws are rare, more common in women.

Chondroma is usually localized in the anterior part of the upper jaw along the median suture, less common in the area of the articular and alveolar processes of the lower jaw.

Echondromamanifests itself in the form of a round or oval dense, and sometimes densely elastic tumor. Its surface can be smooth or lobed and bumpy.

The tumor has a wide base, is located on the vestibular surface of the upper jaw or covers its alveolar process in the form of a saddle on both sides. Upper lip at the same time it is raised and pushed forward; the oral fissure with a large ecchondroma may not close. The mucous membrane covering the tumor is anemic. The tumor is painless, soldered to the bone, it may grow into nasal cavity, maxillary sinus and orbit, in connection with which neuralgic pain and paresthesia are sometimes noted.

Radiographic picture: on the anterior wall of the upper jaw, a formation is determined, inside of which there are areas of calcification.

Echondromas, especially those calcified in many places, are very prone to recurrence after operations.

Enchondromaslocalized both in the upper and lower jaws. The tumor usually grows slowly (up to 20-40 years), without showing itself. The first signs are: pain, mobility and displacement of the teeth in the tumor area. Then a protrusion appears - dense, motionless, soldered to the bone, often painful on palpation, sometimes with a symptom of a parchment crunch.

Radiographically, it looks like a cyst, into which the resorbable roots of the teeth are turned. In other cases, the loss of bone substance is almost not captured, since the tumor is calcified or ossified.

The final diagnosis is established on the basis of histopathological examination.

Treatment- radical removal by economical (possibly partial) resection of the jaw, but within apparently healthy tissues. After non-radical removal, relapses are possible with the degeneration of the tumor into chondrosarcoma.

Cholesteatoma

Cholesteatoma of the jaw is a tumor-like formation containing horny masses and cholesterol crystals. Cholesteatomas develop as a result of dysontogenesis (true, or congenital, cholesteatoma) or as a result of a traumatic or other chronic inflammatory process (false cholesteatoma).

The tumor is usually localized in the zone of formation of the middle ear and maxillary sinuses.

Types of cholesteatoma of the jaws:

1. An epidermoid that does not contain a tooth.

2. Periodental (follicular cyst), surrounding the crown of an unerupted tooth, but containing cholesteatoma masses. Inside the cholesteatoma cavity there is always a mass that has a mother-of-pearl, pearl-like luster (this luster quickly disappears under the influence of its contact with external environment). The pearly sheen of cholesteatoma is due to the presence in it of concentrically layered cell aggregates from keratinized epithelium.

Clinic. Cholesteatoma of the jaws is almost no different from odontogenic cysts, and sometimes it can resemble a 2-3-chamber cystic adamantine. That's why accurate diagnosis cholesteatoma is usually established only on the basis of a combination of radiographic and histological studies.

In punctate, in particular, up to 160-180 mg% of cholesterol can be found.

Treatmentconsists in the complete extirpation of the cholesteatoma cyst or cystomy. It is preferable to perform extirpation and fill the bone cavity with an allo- or xenograft from the spongy part of the bone tissue.

Benign tumors of the jaws, developing for a long time, do not have a significant impact on the general condition of the body. Local changes depend on the location of the tumor. Diagnosis of benign formations in some cases presents certain difficulties associated with the anatomical and topographic features of the maxillofacial region, similarity clinical symptoms with a number of dental diseases, nerve damage, inflammatory processes. Therefore, when examining such patients, it is necessary to carefully collect an anamnesis, use functional, radiological and morphological methods.

True odontogenic tumors of a benign nature include adamantine, soft odontoma and odontogenic fibroma. Tumor-like formations, in addition to jaw cysts, include hard odontoma, cemeitis, as well as fibrous and angiomatous epulis.

Adamantinoma (ameloblastoma) is a benign epithelial tumor, the structure of which is similar to the structure of the tissue of the enamel organ of the tooth germ. Distinguish dense and cystic form of the tumor. The microscopic picture of adamantinoma is varied. The variant of the structure is most often described, in which structures that reflect the early stages of development of the enamel organ predominate. Characteristic is the presence among the stroma of epithelial growths of cylindrical, polygonal and stellate cells. The tumor has infiltrative growth.

Clinical manifestations at the beginning of the disease are uncommon. Subsequently, there is a deformation of the jaws (often the lower one), a symptom of a "parchment" crunch, displacement and mobility of the teeth, with suppuration - a change in the color of the skin over the tumor, an increase in lymph nodes, increased body temperature.

Soft odontoma

X-ray reveals one or more cystic cavities, more often there is a cellular or looped pattern. On the border with unchanged bone, a narrow zone of sclerosis is noted. Clinical and radiological data make it possible to establish a preliminary diagnosis, which is specified during cytological and pathohistological studies.

Soft odontoma is characterized by epithelial growths (as in adamantinoma) and the presence of loose, soft fibrous connective tissue, which together seem to reflect early stage development of the tooth germ. Clinical and radiological manifestations resemble adamantinoma. Verification requires a morphological study of the tumor.

Treatment of these tumors is surgical - resection of the jaw is performed, according to indications - primary bone grafting.

Odontogenic fibroma is a type of intraosseous fibroma of the jaw bones. It is separated from the surrounding bone tissue by a thin membrane. In the process of tumor growth, resorption of bone tissue is noted according to the type of smooth resorption. Clinical and radiological manifestations of odontogenic fibromas are oligosymptomatic. The diagnosis is confirmed histological examination: among the connective tissue structures of the tumor, remnants of the dentition epithelium are found. Treatment - surgical (the tumor is carefully exfoliated).

Solid odontoma

Solid odontoma is a tumor that is a conglomeration of tooth and periodontal tissues. The main tissue of which the tumor is composed is a dentine-like substance. Distinguish between simple, complex and cystic form solid odontomes. A simple odontoma arises from the tissues of one tooth germ and differs from the tooth by a violation of the ratio of hard tissues. This tumor can be complete, consisting of all the tissues of the tooth, and incomplete, containing some tissues. A complex odontoma consists of a conglomerate of teeth and tooth-like tissues. Cystic odontoma resembles a cyst lined with multilayer squamous epithelium. Surgical treatment of solid odontomas.

Cementoma - a tumor built from a tissue similar to the cement of a tooth. Many authors consider cementoma as a kind of solid odontoma, in the structure of which cement-like tissue predominates. There are two varieties: one is characterized by the growth of cement-like tissue, resembling the structure of osteomas, and the other is the growth of cellular fibrous tissue, in which dense calcified formations such as denticles are located. Cementoma is rare. Radiologically determined round shape almost homogeneous dense tissue located around the root of one or more teeth. Surgical treatment.

Tumor-like formation

Epulis is a tumor-like formation located on the alveolar process of the jaws. There are fibrous, angiomatous and giant cell epulis. The diagnosis is established on the basis of clinical and radiological examination data. On the radiograph, foci of bone tissue destruction in the area of the alveolar process are possible. Treatment of epulis is surgical. The tumor is excised within the limits of healthy tissue, according to indications, teeth are removed and the alveolar process is resected.

Benign nonodontogenic tumors

In the dental hospital there is a patient with a diagnosis of solid odontoma of the lower jaw on the left. On the X-ray of the jaw, the boundaries of the tumor are determined from 6 to 8 teeth. The lower edge of the jaw is preserved. Make a plan for surgical treatment.

Benign tumors include neoplasms morphologically, as a rule, not much different from the original tissue, with expansive growth, not giving metastases. Benign tumors of the jaws develop from the tissues involved in bone formation, which is reflected in their name. This principle is often taken as a basis in the construction of a classification of tumors.

Among benign tumors of the jaws, osteoblast to the lasts is most common, and according to localization, central (in the thickness of the bone) and peripheral (on the alveolar process) osteoblastoclastoma are distinguished. The name of the tumor reflects its histological structure. Based on clinical and radiological data, three forms of central osteoblastoclastoma are distinguished: cellular, cystic and lytic. The tumor usually develops slowly. The first clinical signs may be jaw deformity, pain in the teeth in the area of the neoplasm, tooth mobility. On the x-ray of the jaw is determined by the destruction of bone tissue. Peripheral osteoblastoclastoma (giant cell epulis) is located on the alveolar process of the jaw. Unlike fibrous and angiomatous epulis, foci of destruction appear in the adjacent bone tissue.

Other benign tumors of the jaws (osteoma, osteoid osteoma, chondroma, myxoma, intraosseous fibroma, hemangioma, neurinoma, and neurilemmoma) are rare. These tumors are characterized by slow growth and the absence of characteristic clinical signs. In diagnosing them important role belongs to radiography and morphological methods.

Surgical treatment of benign tumors of the jaws - removal of formations.

Tumor-like formations of the jaws include fibrous dysplasia, hyperparathyroid osteodystrophy (Recklinghausen's disease), deforming osteodystrophy (Paget's disease), eosipophilic granuloma (Taratynov's disease), and gingival fibromatosis.

In the practical work of a dentist, these formations are relatively rare. Their origin is often not clear. Many researchers point to the genetic nature of the occurrence of tumor-like formations. Clinical manifestations of tumor-like formations of the jaws are uncharacteristic (except for gingival fibromatosis). They are differentiated from benign and malignant tumors of the jaws. The diagnosis is specified by pathohistological examination of the surgical material. In unclear cases, a study of biopsy material is used.

Benign neoplasms

Distinguish between benign neoplasms of the maxillofacial region, emanating from the integumentary epithelium (papilloma), glandular epithelium(adenomas), connective tissue (fibromas), adipose tissue (lipomas), blood vessels (hemangiomas, lymphangiomas), muscles (myomas), nerves (neurofibromas). This group includes conditionally cystic formations salivary glands (retention cysts), sebaceous glands (atheromas), cysts and fistulas from embryonic remains (lateral and median cysts and fistulas of the neck). In some cases, neoplasms originate from various tissues (“mixed” tumors of the salivary glands, dermoid cysts).

Benign tumors and cystic formations of the maxillofacial region are characterized by slow growth. Patients turn to medical institutions at a relatively late date, when pain or significant deformation. Diagnosis of these neoplasms usually does not present great difficulties. The diagnosis is specified with the help of pathohistological and cytological methods, angiography, radioisotope research.

Treatment of tumors of this group, as a rule, is surgical. For small vascular tumors, sclerosing and cryotherapy are used. In the treatment of extensive cavernous, branched hemangiomas of the buccal, parotid-masticatory areas, sclerosing therapy and subsequent surgical excision are performed.

Being very diverse in tissue genesis and, accordingly, in histological structure, at the same time they are extremely non-specific in their symptoms and clinical manifestations.

These tumors and tumor-like formations, developing in the thickness of the jaw bones, long time do not manifest themselves in any way and are detected only when the shape of the jaws changes or pain appears.

In the clinical and morphological classification of tumors and tumor-like formations of the jaws, number 1 is ameloblastoma (adamantinoma).

Ameloblastoma (adamantinoma) is an odontogenic epithelial tumor similar to the tissue of the enamel organ of the tooth germ, so some authors believe that it occurs as a result of a developmental disorder of this germ. There are also opinions that ameloblastoma develops from the epithelium of the oral mucosa or from the remnants of the tooth-forming epithelium (Islets of Malasse) and even from the epithelium of the membrane follicular cysts. Ameloblastoma (adamantinoma) is more common in people aged 20-40 years. The lower jaw in the region of the body or branch is predominantly affected. Its two forms are noted: dense (solid) and cystic.

The development of ameloblastoma is asymptomatic at first, but then the jaw is gradually deformed, and asymmetry of the face occurs. Skin usually do not change in color. On palpation of the jaw, swelling of the bone with a smooth or slightly bumpy surface is noted. Opening of the mouth is usually not disturbed. In the oral cavity, according to the location of the tumor, swelling of the alveolar process of the upper jaw or the alveolar part of the lower jaw is determined, sometimes (with suppuration) - displacement and mobility of the teeth. Their percussion along the axis is painless, but there is a clear shortening of the percussion sound, indicating damage to the periapical tissues. Ameloblastomas can suppurate. Cases of malignancy of this tumor are described.

On x-ray examination, radiographs often show one or more cavities separated by thin septa, or multiple cysts are noted. Morphological structure ameloblastoma is extremely diverse. There are 9 histological variants of this tumor. AT classic version the tumor parenchyma is represented by epithelial growths in the form of strands or round-oval formations, consisting of cells of various shapes, arranged in a certain order: cylindrical along the periphery, polygonal in the middle part, and stellate in the central parts. The stroma in some cases is loose connective tissue, in others - cicatricial with a tendency to hyalinosis. In some cases, there are many vessels, cavities with blood elements.