Principles and

Techniques of
Biopsy
 Principles and Techniques of
Biopsy

 It is important to develop a systematic approach in

evaluating a patient with a lesion in the Oral and
Maxillofacial region.
These steps include :

 A detailed health history

 A history of the specific lesion
 A clinical examination
 A radiographic examination
 Laboratory investigations
 Surgical specimens for histopathologic evaluation
Health History

 An accurate health history may disclose

predisposing factors in the disease process
or factors that affect the patients
management.
 Up to 90% of systemic deseases can be
discovered through history taking.
 The same can be true of oral lesions when
one is familiar with the natural progression
of the more common disease processes.
Medical conditions that
warrant special care include:

 Congenital heart defects

 Coagulopathies
 Hypertension
 Poorly controlled diabetics
 Immunocompromised patients
History of the
Lesion
Questions to Ask

 Duration of the lesion

 Changes in size and rate of change
 Changes in the character of the lesion.
 Lump to ulcer, etc
 Associated systemic symptoms:
 fever
 nausea
 anorexia
More Questions to Ask

 Pain
 Abnormal sensations
 Anesthesia
 A feeling of swelling
 Bad taste or smell
 Dysphagia

 Swelling or tenderness of adjacent lymph nodes

 Character of the pain if present
Historical Reasons for the
Lesions:

 Trauma to the area

 Recent toothache
 Habits
Clinical Examination

 The clinical examination should always include

when possible:
 Inspection
 Palpation
 Percussion
 Auscultation
Clinical Evaluation

 The anatomic location of the lesion/mass

 The physical character of the lesion/mass
 The size and shape of the lesion/mass
 Single vs. multiple lesions
 The surface of the lesion
 The color of the lesion
 The sharpness of the boundaries of the lesion
 The consistency of the lesion to palpation
 Presence of pulsation
 Lymph node examination
Radiographic Examination

 The radiographic appearance may

provide clues that will help determine
the nature of the lesion.
 A radiolucency with sharp borders will
often be a cyst
 A ragged radiolucency will often be a
more aggressive lesion
 Radiopaque dyes and instruments can
help differentiate normal anatomy
Laboratory Investigation

 Oral lesions may be manifestations of systemic

disease.
 If a systemic disease is suspected it should be
pursued.
 These include:

 Tumor of hyperparathyroidism
 Padgets disease
 Multiple myeloma
 Determination of serum calcium, phosphorus, and alkaline
phosphatase and protein can be very useful in excluding certain
pathological processes.
 Indications for Biopsy

 Any lesion that persists for more than 2

weeks with no apparent etiologic basis
 Any inflammatory lesion that does not
respond to local treatment after 10 to 14
days.
 Persistent hyperkeratotic changes in
surface tissues.
 Any persistent tumescence, either visible
or palpable beneath relatively normal
tissue.
Indications for Biopsy

 Inflammatory changes of unknown

cause that persist for long periods
 Lesion that interfere with local
function
 Bone lesions not specifically
identified by clinical and
radiographic findings
 Any lesion that has the
characteristics of malignancy
Characteristics of lesions that
raise the suspicion of
malignancy.
 Erythroplasia- lesion is totally red or has a speckled red
appearance.
 Ulceration- lesion is ulcerated or presents as an ulcer.
 Duration- lesion has persisted for more than two weeks.
 Growth rate- lesion exhibits rapid growth
 Bleeding- lesion bleeds on gentle manipulation
 Induration- lesion and surrounding tissue is firm to the
touch
 Fixation- lesion feels attached to adjacent structures
What is a Biopsy?

 Biopsy is the removal of tissue for the purpose of

diagnostic examination.
Types of Biopsy

 Oral cytology
 Aspiration biopsy
 Incisional biopsy
 Excisional biopsy
 Needle biopsy (Fine Needle Aspiration Biopsy/Cytology)
Oral Cytology

 Developed as a diagnostic screening procedure to

monitor large tissue areas for dysplastic changes.
 May be helpful with monitoring postradiation
changes, herpes, pemphigus.
The Disadvantage of oral
cytological procedures
include:
 Not very reliable with many false
positives.
 Expertise in oral cytology is not
widely available
 The lesion is repeatedly scraped
with a moistened tongue depressor
or spatula type instrument. The cells
obtained are smeared on a glass
slide and immediately fixed with a
fixative spray or solution.
Aspiration Biopsy

 Aspiration biopsy is the use of a needle and

syringe to penetrate a lesion for aspiration if
its contents.
 Indications:
 To determine the presents of fluid within a lesion
 To a certain the type of fluid within a lesion
 When exploration of an intraosseous lesion is
indicated
Aspiration

 An 18/23 gauge needle on a 5 or 10 ml syringe is

inserted into the area under investigation after
anesthesia is obtained.
 The syringe is aspirated and the needle redirected if
necessary to find the fluid cavity.
Incisional Biopsy

 An incisional biopsy is a biopsy that samples only a

particular portion or representative part of a lesion.
 If a lesion is large or has different characteristics in
various locations more than one area may need to
be sampled
 Incisional Biopsy

 Indications:
 Size limitations
 Hazardous location of the lesion
 Great suspicion of malignancy
 Technique:
 Representative areas are biopsied in a wedge fashion.
 Margins normal tissue on the deep surface.
 Necrotic tissue should be avoided.
A narrow deep specimen is better than a broad shallow
one.
 Excisional Biopsy

An excisional biposy implies the complete

removal of the lesion.
 Indications:
 Should be employed with small lesions. Less than
1cm
 The lesion on clinical exam appears benign.
 When complete excision with a margin of normal
tissue is possible without mutilation.
 Excisional Biopsy

 Technique:
 The entire lesion with 2 to 3mm of normal appearing tissue surrounding the
lesion is excised if benign.
 Fine Needle Aspiration
Biopsy/Cytology
The purpose of FNA to obtain diagnostic material for
cytological study from organs that do not shed cells
spontaneously.

Sophisticated radiological imaging, computed tomography(CT),

ultrasonography(USG),and image intensified fluoroscopy have been
added to this method to perform FNA more accurately and precisely.
 MATERIALSREQUIRED

1. Needle 21 G /27 G
2. Disposable syringe 10 – 20 ml New glass slides
3. Syringe handle Toluidine blue Coplin jar Spirit swab
4. Cotton gauge / dry swab Adhesive tap
5. Pencil Tooth picks
6. Waste disposable containers (blood stained products , non stained
7. products)
FNAC reporting form Bed
8.
Table
9.
Tray for carrying the slides
10.
11.
12.
13.
14.
15.
16.
 PROCEDURE

Principle
The negative pressure created within the syringe by
aspiration holds the tissue against the sharp cutting
edge of the needle. So that the tissue will be cut by
the cutting end of the needle and accumulates with
in the lumen of the needle / syringe tip
 Procedure cont…

1. Put the clean glass slides on the table

2.Fill the coplin jars with ethanol
3.Explain the procedure to the patient and get the
written consent
4.Place the patient on the aspiration table in supine
position or any position which will expose the desired
aspiration site
5.Expose the aspiration site
6.Clean the site with spirit swab from center outwards in
concentric fashion
7.Leave the area to dry
Procedure con……

8. Open the syringe from the plastic wrapper and the

needle to the syringe tip
9.Check the syringe by aspirating , air in and out of the
syringe , put the needle in the syringe holder
10.Prick the lump by vertical technique, in which the
needle is perpendicular to the skin
11.Aspirate the lump by pulling the piston, Rotate the
needle and continue to aspirate. Move the back and
forth and aspirate
Procedure con…….

12. If the lump is big change the direction of the needle and
again aspirate
13.if the lesion is huge, multiple sites aspiration may be
needed
14.Stop the aspiration, Let the piston go to its resting
position, withdraw the needle
15.Put a dry swab/cotton gauze over the aspiration site and
put an adhesive tap. Ask the patient to press the site for 5-
10 min.
16.Put a drop of aspirate on the surface of a clean glass
slide 2cm away from the end of the slide
 Procedure con….

17. Immediately, spread the material on the slide by holding the slide
with one hand and putting the flat surface of an another glass slide over
the material and move it smoothly, gently and swiftly to the other end of
the slide by applying gentle pressure
18.Slides planned for papanicolaou stain are subjected into ethanol
so that the aspirated material is totally submerged in the alcohol
solution
19.Slides planned to giemsa stain are left to dry in open air
20.Slides planned for immunocyto or histo should be prepare in
pretreated(albumenized) slides or pre-coated adhesive slides
prepared for the designated techniques.
DOCUMENTATION
1. Date on which the tests done
2. Fixative used for wet smear
3. Name of the pathologist/physician/radiologist
performing the test.
4. Name of the laboratory personnel assisting
5. Clinical diagnosis
6. Transfer the slide to the staining table in
cytopathology
laboratory
7. Date of preparation of fixative
 1. Grease free and clean slides should be used

2.A good quality 10ml or 20ml syringe should be

used to create sufficient negative pressure to aspirate
tissue

3.An experienced technologist or laboratory personnel

should perform the staining procedure
Principles of
Surgery
Anesthesia

 Block anesthesia is preferred to infiltration

 When blocks are not possible distant infiltration may
be used
 Never inject directly into the lesion
Tissue Stabilization

 Digital stabilization
 Specialized retractors/forceps
 Retraction sutures
 Towel Clips
Hemostasis

 Suction devices should be avoided

 Gauze compresses are usually adequate
 Gauze wrapped low volume suction may be used if
needed
 Incisions

 Incisions should be made with a scalpel.

 They should be converging
 Should extend beyond the suspected depth of the
lesion
 They should parallel important structures
 Margins should include 2 to 3mm of normal appearing
tissue if the lesion is thought to be benign.
 5mm or more may be necessary with lesions that
appear malignant, vascular, pigmented, or have
diffuse borders.
Handling of the Tissue
Specimen

 Direct handling of the lesion will expose it to crush

injury resulting in alteration the cellular architecture.
Specimen Care

 The specimen should be immediately placed in 10%

formalin solution, and be completely immersed.
Margins of the Biopsy

 Margins of the tissue should be identified to orient

the pathologist. A silk suture is often adequate.
Illustrations are also very helpful and should be
included.
Surgical Closure

 Primary closure of the wound is usually possible

 Mucosal undermining may be necessary
 Elliptical incision on the hard palate or attached
gingiva may be left to heal by secondary intention.
Biopsy Data Sheet

 A biopsy data sheet should be completed and the

specimen immediately labeled. All pertinent history
and descriptions of the lesion must be conveyed.
Intraosseous and Hard
Tissue Biopsy
 Intraosseous lesions are most often the result of
problems associated with the dentition.
Indications for
Intraosseous Biopsy
 Any intraosseous lesion that fails to respond to
routine treatment of the dentition.
 Any intraosseous lesion that appears unrelated to
the dentition.
 Clinical Exam

 Palpation of the area of the lesion with

comparison to the opposite side.
 Any radiolucent lesion should have an aspiration
biopsy performed prior to surgical exploration.
 Information from the aspiration will provide valuable
information about the lesion.
 Solid

 Fluid Filled
 Vascular

 Without Contents
 Principles of Surgery

 Mucperiosteal flaps should be designed to

allow adequate access for incisional/excisional
biopsy.
 Incisions should be over sound bone
 Cortical perforation must be considered when
designing flaps
 Flaps should be full thickness
 Major neurovascular structures should be
avoided
 Principles of Surgery

 Osseous windows should be submitted with the

specimen
 Osseous preformations can be enlarged to gain
access
 Avoid roots and neurovascular structures
 The tissue consistency and nature of the lesion
will determine the ease of removal
Principles of Surgery

 Incisional biopsies only require

removal of a section of tissue
 Soft tissue overlying the lesion
should be reapproximated
following thorough irrigation of
the operative site.
 The specimen should be handled
as previously described
Biopsy Results: What If ?

 They don’t corroborate your clinical

impression
 Repeat the biopsy!!!
 Determine if the tissue was looked at by an Oral
Pathologist
 The results show malignancy
When To Refer For Biopsy

 When the health of the patient requires special

management that the dentist feel unprepared to
handle
 The size and surgical difficulty is beyond the level of
skill that the dentist feels he/she possesses
 If the dentist is concerned about the possibility of
malignancy
Utk melakukan biosi perlu:utk jaringan lunak
-Alat suntik
-Skalpel
-Gunting dgn ujung yg tajam
-Penjepit jar. Lunak
-Hemostat kecil
-Suction
-Jarum,benang jahit dan pemegang jarum
-Botol tempat jaringan yg di biopsi
-Lembaran data biopsi
Alat utk jaringan yg bertulang:
-Elevator periosteal
-Bor dan hand piece
-Larutan saline utk irigasi
-Kuret

-Alat utk biopsi aspirasi:

-Syringe 5 – 10 cc
-Dgn jarum ukuran 18 gauge
 HARUS HATI HATI AGAR:
Kedalaman biopsi cukup supaya gambaran sel
pada dasar lesi bisa diperiksa/tampak nyata

UMUMNYA YANG BAIK ADALAH;

Potongan sempit tapi dalam
Bukan yg dangkal dan lebar

SELAIN ITU JUGA PERLU HATI HATI:

Bagian anatomi yg sudah kompromi dgn lesi
spt syaraf dan pembuluh darah
Perlu juga diperkirakan kemungkinan syaraf
atau pembuluh darah merupakan asal dari
lesi
 BIOPSI EKSISI:
ARTI:pengeluaran lesi seluruhnya
disertai jar. lunak sekitarnya 2-3mm
Lebarnya jaringan sehat yg diambil tergan
tung kesimpulan diagnosis kita

PENAMBAHAN 2-3MM INI DIPERLUKAN JIKA;

Diperkirakan ada keganasan
Termasuk sejumlah lesi yang alami pigmentasi
Lesi lain yg diperkirakan alami displasia atau
adanya sel maligna

Biopsi eksisi ini sering:

Sdh merupakan terapi definitif lesi
BIOPSI EKSISI BIASANYA DIGUNAKAN UTK:
Lesi yg kecil (kurang dari 1 cm)
atau lesi yg bisa dikeluarkan utuh seluruhnya
Biopsi ini tidak mempengaruhi penampilan
pasien atau fungsi oral lainnya
Atau lesi perlu dikeluarkan seluruhnya utk
keselamatan pasien
Asisten membantu menstabilkan jaringan
Insisi elips dibuat sekitar lesi
Eksisi submukosa terkait dgn
glandula kel.ludah minor
Jahitan dpt diresorpsi
Utk rapatkan otot
Mukosa sdh di undermind dan ditutup
Alat tipe chalazion utk fiksasi jaringan
Stabilisasi jaringan menggunakan
jahitan yg dpt menarik
 Lesi sdh dikeluarkan
sesdh insisi bentuk elips
Benang jahit yg bisa diserap
utk merapatkan otot
Mukosa ditutup
Jahitan yg ditempatkan pada
spesimen utk bisa ditarik