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tissue from a living organism for its microscopical examination, usually to perform a diagnosis.
persist for long periods y Lesion that interfere with local function y Bone lesions not specifically identified by clinical and radiographic findings y Any lesion that has the characteristics of malignancy
Types of Biopsy
y The four major types of biopsy routinely used in and
around the oral cavity are : y cytology, y aspiration biopsy, y incisional biopsy, y and excisional biopsy.
Oral Cytology
y Oral cytology is typically used as an adjunct to, not a
substitute for, incisional or excisional biopsy procedures y Cytology allows examination of individual cells, but cannot provide the histologic features crucial for an accurate and definitive diagnosis y Developed as a diagnostic screening procedure to monitor large tissue areas for dysplastic changes. y Lesions that lend themselves to cytologic examination may include; post-radiation changes, herpes, fungal infections, and pemphigus.
repeatedly and firmly with a moistened tongue depressor or cytology brush. y The cells are then transferred to and smeared evenly on a glass slide. y The slide is immediately immersed in a fixing solution or sprayed with a fixative, such as hairspray. y The cells can be stained with any of a myriad of laboratory preparations and examined under the microscope.
Aspiration Biopsy
y Aspiration biopsy is the use of a needle and syringe to
remove a sample of cells or contents of a lesion. y The inability to withdraw fluid or air indicates that the lesion is probably solid
Aspiration Biopsy
Indications:
y To determine the presents of fluid within a lesion y To a certain the type of fluid within a lesion y When exploration of an intraosseous lesion is indicated
Aspiration
Procedures:
y An 18-gauge needle is connected to a 5 or 10 ml syringe and is inserted into the center of the mass via a small hole in the lesion. y The tip of the needle may need to be positioned in multiple directions to locate a potential fluid center. y The material withdrawn during aspiration biopsy can be submitted for pathologic examination and/or culturing.
lesion is probably solid. y A radiolucent lesion in the jaw that yields strawcolored fluid on aspiration is most likely a cystic lesion. y If purulent exudate (pus) is withdrawn, then an inflammatory or infectious process should be considered..
malformation within the bone. y Any intrabony radiolucent lesion should be aspirated before surgical intervention to rule out a vascular lesion. y If the lesion is determined to be vascular in nature, the flow rate (high versus low) should be determined because uncontrollable hemorrhage can occur if incised
Incisional Biopsy
y The intent of an incisional biopsy is to sample only a
representative portion of the lesion. y If the lesion is large or has many differing characteristics, more than one area may require sampling.
Incisional Biopsy
extensive size y in cases where appropriate excisional surgical management requires hospitalization or complicated wound management.
Incisional biopsy
Punch biopsy
Punch biopsy
y . Another tool that can be used for incisional or
excisional purposes. y biopsy is especially well suited for diagnosis of oral manifestations of mucocutaneous and vesiculoulcerative diseases, such as lichen planus, pemphigus, etc
Punch biopsy
Brush biopsy
y Firm pressure with a circular
diameter y the smaller diameters should be avoided due to the risk of over-manipulating and crushing the tissue . y The technique is easily performed with a low incidence of postsurgical morbidity. y Suturing in regards to a punch biopsy procedure is usually not required as the surgical wounds heal by secondary intention.
Disadvantages
y One disadvantage of using the biopsy punch is that it
is difficult to obtain adequate, representative tissue deeper than the superficial lamina propria (1).
Excisional Biopsy
Indications:
y Should be employed with small lesions. Less than 1cm y The lesion on clinical exam appears benign. y When complete excision with a margin of normal tissue is
Technique
y An excisional biposy implies the complete removal of the lesion.
y A perimeter of normal tissue (2-3 mm) surrounding the lesion is included with the specimen. y Excisional biopsy should be performed on smaller lesions (less than 1 cm in diameter) that appear clinically benign. y Pigmented and vascular lesions should be removed, if possible, in their entirety. This avoids seeding of the melanin producing tumor cells into the wound site or in the case of a hemangioma, allows the clinician to address the feeder vessels.
Exisional biopsy
Anesthesia
y Block anesthesia is preferred to infiltration y When blocks are not possible distant infiltration may
Tissue Stabilization
y Digital stabilization y Specialized retractors/forceps y Retraction sutures y Towel Clips
Hemostasis
y Suction devices should be avoided y Gauze compresses are usually adequate y Gauze wrapped low volume suction may be used if
needed
Incisions
y Incisions should be made with a scalpel. y They should be converging y Should extend beyond the suspected depth of the lesion y They should parallel important structures y Margins should include 2 to 3mm of normal appearing
tissue if the lesion is thought to be benign. y 5mm or more may be necessary with lesions that appear malignant, vascular, pigmented, or have diffuse borders.
specimen gently at the periphery of the sample. y Injection of large amounts of anesthetic solution in the biopsy area, while providing hemostasis, can produce hemorrhage, which masks the normal cellular architecture. y Infiltration of local anesthetic around the lesion is acceptable if the field is wide enough in relation to the lesion;
Specimen Care
y The specimen should be immediately placed in 10%
pathologist. A silk suture is often adequate. Illustrations are also very helpful and should be included.
Surgical Closure
y Primary closure of the wound is usually possible y Mucosal undermining may be necessary y Elliptical incision on the hard palate or attached
specimen immediately labeled. All pertinent history and descriptions of the lesion must be conveyed.
margins, consistency, and relative radiodensity of the lesion are all important findings that should be included in the description of the specimen. y If the lesion is evident on radiographs, it is very important to submit good quality radiographs with the specimen to aid in pathologic correlation and diagnosis.
treatment of the dentition. y Any intraosseous lesion that appears unrelated to the dentition.
Principles of Surgery
y Mucperiosteal flaps should be designed to allow
adequate access for incisional/excisional biopsy. y Incisions should be over sound bone y Cortical perforation must be considered when designing flaps y Flaps should be full thickness y Major neurovascular structures should be avoided
Principles of Surgery
y Osseous windows should be submitted with the
specimen y Osseous preformations can be enlarged to gain access y Avoid roots and neurovascular structures y The tissue consistency and nature of the lesion will determine the ease of removal
Principles of Surgery
y Incisional biopsies only require removal of a
section of tissue y Soft tissue overlying the lesion should be reapproximated following thorough irrigation of the operative site. y The specimen should be handled as previously described
References
y 1. Lynch DP, Morris LF. The oral mucosal punch
biopsy: indica-tions and technique. J Am Dent Assoc 1990 Jul;121(1):145-9. y 2. Margarone JE, Natiella JR, Vaughan CD. Artifacts in oral biopsy specimens. J Oral Maxillofac Surg 1985 Mar;43(3):163-72. y 3. Sheehan DC, Hrapchak BB. Theory and practice of histo-technology. Saint Louis: C. V. Mosby Co.; 1973. y Dent Assoc 1996 Mar;127(3):363-8.
biopsy specimens. Va Dent J 1972 Dec;49(6):31-4. y 5. Zegarelli DJ. Common problems in biopsy procedure. J Oral Surg 1978 Aug;36(8):644-7. y 6.Sol Silverman, L Roy Eversole , Edmond L. Truelove, Essentials of Oral Medicine .Hamilton, Ontario 2002 BC Decker Inc