BENIGN

ODONTOGENIC & NON

ODONTOGENIC
TUMORS OF THE JAW
ANGKATAN 18
Pembimbing : drg. Djodi Asmoro, SU.,
Sp.BM(K)

Pengertian
TUMOR / NEOPLASIA : proliferasi yang
berlebihan dari jaringan yang tidak
terkontrol dan tidak terkoordinasi.
Pertumbuhannya menetap meskipun
stimulus sudah hilang.
Merupakan semua jenis

TUMOR JINAK ATAU GANAS ?

jinak berkapsul, ekspansif, hiperkeratosis,
hiperplasi, dan sel radang akut serta kronis.
Ganas infiltratif, metastasis, cenderung
mudah berdarah, gambaran sel epitel yang
abnormal, mengalami perubahan ukuran,
morfologi, orientasi dan kematangan.

Pemeriksaan Tumor
LESI :
- Durasi
- Onset dan progres
- Lokasi dan bentuk
- Perubahan karakter lesi tumor
- Gejala
- penurunan bera badan
- tingkat kekambuhan
- Kebiasaan/ habit

Inspeksi

jumlah
Ukuran
Lokasi anatomis
warna
permukaan
bentuk pedunculated/ sessile
kulit sekitar

Palpasi

Konsistensi lesi : padat lunak, keras

Ada tidaknya pulsasi
fixed
pemeriksaan limfonodi

Klasifikasi
WHO
BENIGN
TUMOR

Odontogenic epithelium with mature,

fibrous stroma without odontogenic
ectomesenchyme
1.
2.

3.
4.
5.
6.
7.
8.

Ameloblastoma, solid/multicystic type

Ameloblastoma, extraosseous/peripheral
type
Ameloblastoma, desmoplastic type
Ameloblastoma, unicystic type
Squamous odontogenic tumor
Calcifying epithelial odontogenic tumors
Adenomatoid odontogenic tumor
Keratocystic odontogenic tumor

Odontogenic epithelium with odontogenic ectomesenchyme, with or

without hard tissue formation

1.
2.
3.
4.
5.
6.
7.
8.

Ameloblastic fibroma
Ameloblastic fibrodentinoma
Ameloblastic fibro-odontoma
Odontoma, complex type
Odontoma, compound type
Odontoameloblastoma
Calcifying cystic odontogenic tumor
Dentinogenic ghost cell tumor

Mesenchyme and/or odontogenic ectomesenchyme

with or without odontogenic epithelium

1.
2.
3.

Odontogenic fibroma
Odontogenic myxoma/myxofibroma
Cementoblastoma

Bone-Related lesions
Ossifying fibroma
Fibrous dysplasia
Osseous dysplasias
Central giant cell lesion (granuloma)

NON ODONTOGENIC BENIGN

TUMOR

AMELOBLASTOMA

Ameloblastoma

This a true neoplasm

of odontogenic
epithelium

It is an aggressive
neoplasm the arises
from the remnants of
the dental lamina and
dental
organ( odontogenic
epithelium)

Ameloblastoma

Benign, locally aggressive

odontogenic tumor. Usually it
slowly grows as painless
swelling of the affected site.

It can occur at any age.

Localized invasion into the

surrounding bone.

80-95% in the mandible

(posterior body, ramus
region). In the maxilla mostly
in the premolar-molar region.

Ameloblastoma

Unilocular (small lesions).

Multilocular (large discrete
areas or honeycomb
appearance)

Smooth, well-defined, wellcorticated margins

Adjacent teeth are often

displaced and resorbed.

It causes extensive bone

expansion.

Incomplete removal can result

in recurrence.

Ameloblastoma

Ameloblastoma

PRINCIPLES OF DIAGNOSIS
&MANAGEMENT
HISTORY :
Duration: long /short/prolonged with(out) pain?.
Mode of onset: spontaneous/ following trauma
or infection?
Progress of tumour: slow/stationary or rapid/fast?
Site, Shape of swelling?
Surface characteristics smooth, normal
overlying skin/mucosa, engorged, ulcerated ?
etc.
Consistency: hard, firm, soft fluctuant.

Associated symptoms: pain, abnormal

sensations, anaesthesia/parasthesia,
discharge, tenderness, lymphadenopathy,
trismus, nasal obstruction etc.
Any similar swelling somewhere else?
Associated loss of weight, recurrence,
Drug history
Family history: hereditary?
Social History: Habit

PRINCIPLES OF DIAGNOSIS
&MANAGEMENT
Inspection
No, Size, Shape, Colour, Site(anatomical
location).
Surface: smooth, lobulated , irregular,
ulcerated, fungating growth.
Attachments: Pedunculated /sessile
Integrity of overlying skin or mucosa.
Temperature of overlying skin

Palpation for:
Consistency- soft , firm, hard/ indurated,
bony hard, cystic/fluctuant
Relationship with overlying & underlying
structures.
Lymph nodes
Bimanual palpation for large lesions to
determine extent of tumour

Percussion: related teeth.

Auscultation: if suspecting vascular lesion.
Aspiration: if cystic or contains fluid.

INVESTIGATIONS: IMAGING
Plain: LO, PA, OMV, OPG
Advanced imaging tech:
Computerized tomographic Scans -CT Scans
Three dimensional reconstruction CT
Complete bone scan / Scintigraphy to detect
distant metastasis if malignancy is suspected
Magnetic resonance imaging (MRI) soft
tissue & nodal involvements.
Angiographic studies(CT angiogram)

Fine Needle Aspiration Cytology (FNAC)

Tissue Biopsy for histological diagnosis is
confirmatory.
Techniques Exfoliative , Aspiration, FNAC,
Excisional, Incisional

Terapi tumor di rongga mulut

biopsi

Pengambilan sejumlah kecil jaringan

dari tubuh manusia
untukpemeriksaan patologis
mikroskopik.
Dari bahasa latin
bios:hidup dan
opsi: tampilan.

Manfaat biopsi
1)Diagnosis lesi neoplasma,
2)Memeriksa lesi spesifik, proses
granulomatosa, penyakit metabolik
tertentu, dan kelainan darah,
3)Mengetahui adanya gangguan
pertumbuhan,
4)Menentukan tindakan yang akan dilakukan
pada penyakit tertentu, dan
5)Evaluasi kemajuan hasil pengobatan

Indikasi biopsi
1.
2.
3.

4.
5.

6.
7.

8.

Lesi merah & lesi putih

Lesi yang mengandung pigment
Massa jaringan lunak superficial, distorsi
permukaan, misalnya mucocele
Lesi pada tulang
Ulserasi yang persistensi selama 3 minggu yg tidak
menunjukkan perubahan
Kecurigaan suatu keganasan
Pembengkakan yang persistensi tanpa ada
diagnosa yg jelas
Lesi oral yg tdk menunjukkan respon adekuat thd
terapi

Kontraindikasi biopsi
Variasi anatomi yang normal (misalnya
linea alba dan pigmentasi rasial fisiologis),
2. Lesi yang disebabkan trauma yang belum
lama terjadi,
3. Lesi inflamatorik akut ataupun subakut,
4. Lesi radiolusen tanpa aspirasi inisial
1.

Tipe-tipe biopsi
Eksisional
insisional,
Needle Aspirasi Biopsy
Punch Biopsy
Oral sitologi

Excisional Biopsy = Fractional Currettage

=Surgical Biopsy
Biopsy yang dilakukan dengan mengambil satu area atau bagian
(seluruh massa) yang dicurigai bersifat patologis.meliputi
pengeluaran secara bedah dari seluruh massa tumor dan teknik
diagnosa yang secara simultan sebagai perawatan.
Biasanya dilakukan bila massa tumor kecil dan belum ada metstase
tumor. Pengambilan jaringan dilakukan tanpa menyentuh tumor atau
keseluruhan tumor dengan batas bebas tumor. Biopsi ini bersifat
diagnosis bagi tumor ganas dan penyembuhan bagi tumor
jinak

Incisional Biopsy = Core Biopsy =

Microcurrettage

Yaitu biopsy yang dilakukan dengan hanya mengambil

contoh jaringan dari lesi (jaringan patologis).
Biopsi ini melakukan pengeluaran bagian tumor dari tumor
yang besar. Pengambilan jaringan dilakukan dengan
menembus tumor dan diambil sedikit untuk diperiksa.
Biopsi incisional dilakukan pada tumor yang terletak
didalam tubuh dan setelah biopsi needle awal gagal untuk
menyediakan jaringan yang cukup untuk diagnosa.Biopsi ini
murni untuk menentukan diagnosis hingga harus diikuti
dengan tindakan lanjutan apakah operasi dan atau radiasi
serta kemoterapi
Biopsi tipe ini adalah teknik yang dianjurkan untuk
mendiagnosa kanker jaringan lunak dan osteosarcoma

Incisional biopsy

Incisional biopsy

Needle aspiration biopsy= biopsi

jarum
Biopsy yang pengambilan sampel jaringan atau cairan dengan
aspirasi jarum. Cara ini bisa dilakukan langsung atau dibantu
dengan radiologi seperti CT scan atau USG sebagai panduan bagi
dokter untuk membuat jarum mencapai massa atau lokasi yang
diinginkan.
Bila biopsi jarum menggunakan jarum berukuran besar maka
disebut Core Biopsy/ wide core needle biopsy/cutting core biopsy,
meliputi penggunaan jarum bor yang besar dan metode yang paling
sederhana pada diagnosa patologi kanker . Hasilnya adalah
kerusakan minimal dari jaringan sekitar dan sampel yang solid
masih menempel. Tumor yang terletak di liver dan payudara sering
menggunakan biopsi jenis ini
Menggunakan jarum kecil atau halus maka disebut Fine-Needle
Aspiration (FNA) Biopsy. dikenal juga sebagai biopsy suction
meliputi aplikasi tekanan negatif dengan menggunakan suntikan
dan jarum hypodermic berlubang. Tipe biopsy ini sering digunakan
sebagai prosedur diagnosa pada leher dan jaringan thyroid

Fine needle aspiration

Biopsi ini menghasilkan pengambilan jaringan yang

dibagi lagi menjadi sel dan satu sampel dari jaringan
yang tidak rusak. Biopsi fine needle aspiration adalah
prosedur yang sering dilakukan karena mempunyai
ketidaknyamanan yang minimal dan dengan harga
yang lebih murah daripada tipe biopsi yang lainnya.
Teknik FNA yaitu biopsy yang menggunakan 20-22 buah
jarum. FNA sitologi biasa digunakan untuk menentukan
alternatif pengobatan apa saja yang sesuai untuk
pasien. Negative FNA tidk menjamin pasien tidak
menderita keganasan dan bisanya dilakukan open
biopsy / excisional biopsy untuk koreksi.

Fine needle biopsy

Punch biopsy
Biopsi ini biasa dilakukan pada kelainan di
kulit.
Metode ini dilakukan dengan alat yang
ukurannya seperti pensil yang kemudian
ditekankan pada kelainan di kulit, lalu
instrument tajam didalamnya akan
mengambil jaringan kulit yang ditekan. Bila
pengambilan kulit tidak besar maka tidak
perlu dijahit

Intraosseous biopsy

Untuk lesi intraosseous, jika telah terjadi

ekspansi dan penipisan tulang kortikal,
jarum harus diaplikasikan melewati
mucoperiosteum tulang lalu dibelokkan
(twisted) ketika telah menembus tulang
kortikal. Jika hal tersebut gagal, maka
sebuah flap mucoperiosteal kecil dielevasi
dan bur digunakan untukmempenetrasi
tulang kortikal. Jarum lalu dimasukkan
melalui lubang-lubang kortikal.

Armamentarium biopsi:

prosedur biopsi :

Prosedur biopsi:

Prosedur biopsi:

Teknik stabilisasi jaringan dengan bantuan asisten

Stabilisasi menggunakan alat

Principles of Treatment
Goals.
1. Complete eradication of tumour.
2. Preservation of normal tissue.
3. Removal with least morbidity.
4. Reconstruction to replace tissue loss and
form.
5. Rehabilitation and Restoration of
function.
6. Long term follow up to detect recurrence
early.

Principles of Treatment

The treatment of odontogenic tumours requires

correct histological diagnosis.
The appropriate choice of surgical treatment
method is after proper and adequate
evaluation before surgery and depends on:
(1) Histological type
benign Vs Malignant
- encapsulated/ non-infiltrative
- non-encapsulated/infiltrative
(2)
Anatomical location/ Site of tumour Oral Cavity -- -- Anterior Vs Posterior
-- Maxilla Vs Mandible

Principles of Treatment
(3) Size of Tumour/ confinement to bone- small
lesionLocal excision.
- large or malignant lesion- Radical/Extensive
excision.
(4)
Age of Pt
- ability to withstand stress of
radical surgery
(5) If malignant--Presence/ absence of distant
metastasis.
(6) Proximity to adjacent vital structures.
(7) Rehabilitation or reconstruction methods.


Odontogenic
Tumors

Epithelial

Mixed

Mesodermal

Epithelial
Odontogenic
Tumors

Ameloblastoma

Adenomatoid
odontogenic
tumor

Calcifying
epithelial
odontogenic
tumor

Adenomatoid Odontogenic
Tumor ("Adenoameloblastoma")

These are
uncommon ,
nonaggressive tumors
of odontoginc
epthilum.

Adenomatoid odontogenic
tumor
Features

Benign. Relatively rare.

It occurs in young patients (70% of

cases in patients younger than 20
years).

Most common site: anterior maxilla.

Often surrounds an entire unerupted

tooth (most commonly the canine).

Usually well defined, well corticated.

Some tumors are totally radiolucent;
others show evidence of internal
classification.

Calcifying epithelial odontogenic

tumor (Pindborg tumor

These are rare

neoplasms of the
tooth producing
apparuts.

Calcifying epithelial odontogenic

tumor (Pindborg tumor)

Rare benign neoplasm.

It occurs more often in middleaged patients.

Usually in mandible.

Small lesions may be

radiolucent. In advanced
stages irregularly sized
calcifications may be scattered
in the radiolucency.

It can cause displacement and

impaction of teeth.

Mixed
Odontogenic
Tumors

Odontomas

Ameloblastic
fibro-odontoma

Ameloblastic
fibroma

Ameloblastic
odontoma

Odontoma
It is a tumor that is
radiogrphically and
histologically
characterized by
the production of
mature enamel ,
dentin , cementum
and pulp tissue .
Compound #
complex

Odontoma

Features

Relatively common lesion.

It usually occurs in young patients.

Usually asymptomatic.

Failure of eruption of a permanent

tooth may be the first presenting
symptom.It is commonly found
occlusal to the involved tooth.

Odontoma

Features

Two types: complex and compound

odontoma.

Complex odontoma is composed of

haphazardly arranged dental hard
and soft tissues.

Compound odontoma is composed

of many small "denticles" .

Well defined. The internal aspect is

very radiopaque in comparison to
bone.

Odontoma

Ameloblastic fibroma

These are benign mixed

odontogenic tumors .

They are characterized

by neoplastic
proliferation of
maturing and early
functional ameloblasts
as well as the primitive
mesnchymel
components of the
dental papilla

Ameloblastic fibroma

Benign Rare. Occurs in children and

adolescents.

Most common site: mandible

posterior region.

Often associated with an unerupted

tooth.

Well defined, well corticated. Small

lesions are monolocular. Large lesions
are multilocular.

It may cause displacement of

adjacent teeth. Large lesions cause
buccal/lingual expansion.

Ameloblastic fibroma

Ameloblastic
fibro-odontoma

This is an extremely rare lesion. It consists

of elements of ameloblastic fibroma with
small segments of enamel and dentin.

Mesodermal
Odontogenic
Tumors

Odontogenic
myxoma
(myxofibroma)

Cementoblastoma

Odontogenic
fibroma

Odontogenic myxoma

They are benign,

intraosseous
neoplasms that
arise from the
mesenchymal
portion of the
dental papilla.

(myxofibroma)

Odontogenic myxoma

Features

It represents approximately 3
- 6% of all odontogenic
tumors. It is painless and
grows slowly.

It can occur at any age but

most commonly in the second
and third decades of life.

More often affect the

mandible (molar/premolar
region).

(myxofibroma)

Odontogenic myxoma

Features

Typically multilocular (internal

septa- strings of a tennis
racket or honeycomb
appearance). Large lesions
can have the sun ray
appearance of an
osteosarcoma.

Often well-defined.

Adjacent teeth can be

displaced but rarely resorbed.
It causes less bone expansion
than in other benign tumors.

(myxofibroma)

Odontogenic myxoma

(myxofibroma)

Cementoblastoma

This is a slow
growing
mesenchymal
neoplasms
composed
principally of
cementum.

Cementoblastoma

Features

Benign neoplasm. Most commonly

in the second and third decade.

Site: usually mandibular premolar

and molar regions.

Attached to the root of the

affected tooth. Tooth
displacement, resorption are
common.

Pain in 50% of the cases, swelling.

When radiopaque is usually

surrounded by a thin radiolucent
halo.

Radiographic Features

Location:

Periphery: well defined RO

with RL hallo surrounding
the calcified mass.

Internal structure: mixed RLRO leseions may be

amorphous

Effect on surrounding
tissues:
expansion, external root
resorption

Cementoblastoma

Odontogenic fibroma

Features

Rare neoplasm. More often between

the ages 10 and 40 years.

Asymptomatic or swelling and tooth

mobility

More common sites: mandible

(premolar-molar region), maxilla
(anterior region)

Small lesions are usually unilocular,

and larger lesions multilocular.

Well-defined margins.

Adjacent teeth: often displaced,

impaction, root resorption.

Surgical Treatment

Most odontogenic tumours are benign and

surgery is the first choice.
Adequate resection with margin of normal tissue
is the recommended surgical treatment.
Well-circumscribed (encapsulated) noninfiltrative lesions (A.O.T, Ameloblastic Fibroma,
Fibro-odontomas , odontomas, cementoblastoma)
may however be treated by Conservative
surgery .
- - Enucleation or Local Excision (Curettage)
with or without saucerization or treatment of
adjacent bone will suffice

.Chemical Cautery
--- Thermal
* Locally invasive (infiltrative) Lesions
(Ameloblastoma , ameloblastic odontoma,
fibromyxoma, CEOT, KCOT, SOT) a slightly
more aggressive approach is needed
Resection with margin of normal bone.

Resection
Removal of tumour by cutting through uninvolved
tissue around the tumour and delivering the
tumour without direct contact with the tumour
en bloc resection.
Marginal Resection (Resection with
preservation of lower cortical plates if still intact
and uninvolved). Also called \Resection without
continuity defect (Peripheral Ostectomy or En
bloc resection)
Partial Resection. (Removing a complete
segment of the jaw) Resection with continuity
defect).
It can vary from a small portion to

Resection

Total Resection: Removal of the whole involved

bone Maxillectomy or Mandibulectomy

Resections can be
-- Marginal, partial, total,
-- with or without disarticulation.
-- Composite resection for malignant tumours

Reconstruction
Surgical resection leads to disfigurement, deviation
of jaw during movement, disturbance of function.
Therefore, the need for reconstruction to:
Restore movement and equilibrium of mandible
To maintain normal occlusal plane , floor of
mouth and tongues anatomical position.
To restore functioneg feeding.
To restore aesthetics appearance and a more
favourable social acceptance

Reconstruction

+ Reconstruction * Primary (Immediate) or

Secondary (delayed)
IMMEDIATE :
Advantages: Single stage surgery, Early return
to function, Minimal compromise of aesthetics,
No muscular deformation or scar/ fibrosis
limitations.
Disadvantages: Recurrence may occur in graft
and risk of infection leading to loss of graft.
- Intraoral approach
.- both intraoral (excision) and Extraoral
(grafting) approach.
- extra oral approach only

Secondary / delay

-- Steinnmans Pin
-- Kirschners wires
-- Acrylic implants
-- Metallic implant Reconstruction Plates.
--Bowerman-Conroys mandibular implant.
(All these are temporary materials to
maintain tissue space and /or bone continuity
if you are planning secondary reconstruction

Bone grafts - autogenic (iliac/ribs)

alloplastic bone grafts or synthetic materials
Microvascular Flap Reconstruction

Rehabilitations
Acrylic dentures
Obturators with teeth(Maxilla).
Dental Implants following bone
(Microvascular) grafts.
May need RCT for related adjacent teeth if the
apices are at risk.

Follow up. For many years

Factors for Consideration

before surgery

Anatomical location of tumour

Aggressiveness of Tumour
Size of tumour
Location of tumour(Confinement to bone).
Proximity to adjacent vital structures.
Involvement of mandible/maxilla.
Rehabilitation or reconstruction methods
Age of patient

Thank you