Ministry of health Ukraine

Higher state educational establishment of Ukraine

«Ukrainian medical stomatological academy»

It is ratified

on meeting of chair

surgical stomatology

and maxillofacial surgery

with plastic and reconstructive

surgery of head and neck

The head of chair, prof. ______________ Avetikov D.S.

METHODICAL DEVELOPMENT OF LECTURE

Educational discipline	Surgical stomatology
Module №	3
Rich in content module №	3
Theme of lecture	Odontogenic cysts of jaws that arise up as a result of teratosis and inflammatory nature. Odontogenic tumours of jaws are an ameloblastoma, odontomas, cementoma, odontogenic fibroma, epulids. Classification, morphological picture, clinic, diagnostics, treatment.
Course	ІV
Faculty	Stomatological

Poltava – 2012

Amount of hours - 2.

1. Scientifically-methodical ground of theme :

Odontogenic tumours and tumor-like formations of jaws belong to organospecific and can be only in jaw bones. The histogenesis of such new formations is related to the tissues from that a tooth is formed. It is necessary to confess that it is a widespread enough group of diseases, that meets in practice of stomatology and especially surgeon-stomatology. In order that right to diagnose, simultaneously to conduct curative measures, it is necessary except the clinical inspection of patient, to appoint and conduct a number of additional methods of inspection.

Good knowledge of clinical displays of every disease from this group of methods of inspection of such patients allows to the future specialist in good time to find out such patients, conduct correct medical tactics in relation to them.

2. Educational aims of lecture :

Students must know:

а) frequency, etiology, pathogeny, clinical displays of odontogenic tumours and cysts of jaws, methods of surgical treatment of this group of patients;

б) able correctly to appoint the inspection of patients with this pathology on results the conducted treatment, to diagnose, conduct differential diagnostics with alike diseases.

3. Aims of development of personality of future specialist (educator aims) :

– education for the students of the modern clinical thinking;

– education of careful and responsible attitude toward the tissues of cavity of mouth of patients,

• to fasten the concept of medical deontology and medical etiquette.

4. Interdisciplinary integration:

Disciplines	skills	able
1	2	3
Previous (providing) disciplines 1. Normal anatomy	normal anatomy of bones of facial skeleton
2.Topographical anatomy and operative surgery	topography of bones of facial skeleton, methods of operative interventions on bones and adherent soft tissues, surgical tool	to carry out the technique of operative interventions on the bones of facial skeleton
3. Normal physiology	cicatrization of wounds of mucous membrane, regeneration of bones of person and cavity of mouth
4. Preopedeutic of surgical stomatology	surgical stomatological tool, common and local anaesthetizing of maxillufacial area, asepsis and antisepsis.	to own the methods of treatment of hands of surgeon, surgical tool, methods of the general and local anaesthetizing, exodontia
5. General surgery	asepsis and antisepsis, types of debriding of wounds, types of guy-sutures, materials of guy-sutures	to own the methods of treatment of hands of surgeon, surgical tool, debriding of wounds, imposition of guy-sutures
Interdisciplinary integration (between the themes of surgical stomatology) 1. Inflammatory diseases of maxillofacial area	Inflammatory complications	treatments of inflammatory complications and their prophylaxis
2. Anaesthetizing is in stomatology	Anaesthetizing of operative interventions	Methods of the local and general anaesthetizing

5. Plan and organizational structure of lecture :

№	Basic stages of lecture but their maintenance	Aims in the levels of abstraction	Type of lecture. Facilities of activation of students. Materials of the methodical providing	Distribution of time
1.	Preparatory stage Determination of actuality of theme, educational aims and motivation		Introductory lecture: actuality of theme is conditioned by the features of clinic, diagnostics and treatment of одонтогенных tumours and tumular new formations	3 min
2.	Basic stage Exposition of lecture material according to plan: Anatomy and topography of bones of facial to the skeleton. Clinic, diagnostics and treatment of odontogenic tumours and cysts of jaws.		Clinical interdisciplinary lecture. Question to the students. Problem situations. Facilities of evidentness : multimedia presentation, charts of the stages of operative interventions, image of tool and remedies, coloured photos of patients	80 min
3	Final stage 1. resume of lecture and general conclusions		Prognosis and end of disease	2 min
	2. answers for the possible questions of students			2 min
	3. task for self-training of students		Educational basic and auxiliary literature	1 min

6. Table of contents of lecture material: а) the unfolded compendium of maintenance of theme

Inobediencetoclassificationby Ermolaev(1964)ephithelialcystsare:inflammatoryorigin(radicular,paradentar,dent completecyst)andbytheteratosisofdental formingepithelium(primary,follicle,gingival).

ROOT CYST.

94-96% of all cases of cyst formation makes in jaws (Bernadsky, 1983). Pathogeny up-to-date binds the mechanism of formation of РК to the ephithelial elements in apical cells, their origin is interpreted differently.

N.A.Astahov (1907) and other sure that brushes appear from bits and pieces of embryonic epithelium of mews of Malliase-Astahov.

A.L.Kosyreva (1954) thinks that mews of Malliase-Astahov nothing other, as endothelial mews of vascular tissue, that by chance got in histological preparation.

I.G.Lukomsky (1927) considers that ephithelial mews is the result of vegetation of them in a bone from the most deep layers of epithelium ash.

Not having a single point of view on the mechanism of origin of epithelium in a cyst, the greater amount of researchers considers that cyst formation passes under influence of irritating action of inflammation in a periodont.

Clinic and diagnostics.

Cyst on the initial stages of flow of disease in any way itself does not find out. On a sciagram the area of the destroyed bone takes place with clear borders.

In the clinical stage patients grumble about deformation of person. At objective examination there is a person asymmetric, displaced configuration of alveolar sprout. Sizes of the slight swelling from a pea to the egg of hen. A mucous membrane in the area of cyst is not changed. There is a positive symptom of Runge-Dupuitren at palpation - «parchment crunch».

In course of time a cyst increases in sizes, «windows» appear in a bone tissue, that results in appearance of new symptom of «fluctuation» (vacillations). On a sciagram takes place brightening of bone tissue of jaw with clear borders, a tooth looks a root in the area of cavity. The roots of nearby points are moved apart.

In punctuate the liquid of light-succinic color is revealed with cholesterol grains.

Differential diagnostics is conducted with the cystophorous form of adamantinoma, follicle cyst, odontogenic fibroma, soft odontoma, sharp and chronic antritis, abscess and phlegmon, cancer and sarcoma.

Treatment surgical.

In 1892 and 1910 of Партч offered two methods - cystotomy (Partch - І) and cystectomy (Partch - ІІ).

Cystotomy is used very rarely, essence of her in that from the cavity of cyst the additional bay of cavity of mouth is created.

This operation is shown at presence of cyst of largenesses, the removal of that threatens to the wounds of vessels or nerves, or by the break of bottom jaw. In addition she is used for patients declining years, weak patients, for children with a

suckling bite. Its advantages is simplicity, insignificant traumatization, exception of possibility of relapse. The lack of cystotomy is a long term of presence of cavity.

A cystectomy is a complete removal of shell of cyst with the further sewing up of wound tight. Advantages of operation are in that at her absent necessity of long postoperative care of wound. In possibility of acceleration of reparative processes.

By the lacks of operation I am casual traumatization vessels and nerves, penetration in a maxillary sinus, possibility of relapse of process, damage of nearby points.

toothcontain CYST, as a rule, arises out of enamel organ. As a rule, revealed, by chance, or when deformation of bone appears. Homogeneous rarefaction of area of bone of the rounded form takes place a not sciagram with clear borders. There is a tooth in a cavity. Treatment surgical is cystectomy or cystectomy.

paradentar CYST - meets early in life after 38 and by 48 teeth. In connection with laboured eraption of these teeth. By nothing proves, while deformation of bone fails to appear. Treatment surgical

• cystectomy or cystectomy.

PRIMARY CYST- more often early in life. Arises up from an odontogenic epithelium and is not investigation of inflammation. Clinically shows up deformation of bone, symptom of parchment crunch. Sciagraphy shows up as a large cavity with the rudiment of the second teeth. Treatment surgical is cystectomy or cystectomy.

FOLLICLE CYST- does not especially differ from a radicular cyst. Long time does not prove in any way. In the clinical stage asymmetry of person, absence of causal tooth, takes place in a dental arc. The rounded defect is sciagraphy revealed with clear borders. A tooth looks coroner part in this defect. At punction a liquid of light-succinic color is with grains of cholesterol. Treatment surgical. Plastic cystectomy for children, cystectomy for adults.

CYST of eraption - is situated above a tooth that will cut through. Clinical displays as an edema of mucous membrane of pinky or blue color in a place, where it is possible to expect appearance of the second teeth. Treatment surgical, artificial прорезывание to the tooth by means of removal of part of soft tissues ash above the crown of the tooth.

gingival CYST is other name "Gland of Serre", "pearl of Epstein". More often appears for children and in declining years. Flow without symptoms. The parents of children take her for the prematurely cut through tooth. Objectively as whitish, rounded, dense, with the mother-of-pearl tint of education. Does not need the special treatment.

According to MHCT (series № 5), odontogenic tumours are divided by next groups and separate types of new formations.

1. New formation arises out of structures of odontogenic vehicle.

А). of high quality: ameloblastoma, ephithelial odontogenic tumour, odontogenic fibroma, adentoenameloblastoma, dentinoma, odontogenic fibroodontoma, odontoameloblastoma, difficult odontoma, component odontoma, fibroma (odontogenic fibroma), myxoma (myxofibroma), cementoma, melanotic neuroectodermal tumour of pectoral children (melanoameloblastoma).

B). Malignant: 1) odontogenic cancer:

a) malignant ameloblastoma;

b) primary intraossal cancer;

c) other types of cancer, that arose up from a odontogenic epithelium and cysts

2. Odontogenic sarcoma:

а) ameloblastic fibrosarcoma;

b) ameloblastic odontosarcoma.

ІІ. New formations and tumor-like formations that arose out of bone.

A) Osteogenic tumours: ossifacal fibroma (fibroosteoma).

B) Untumour defeat: fibrotic dysplasia, cherubism, hygant-cell granulosum, cysts.

From the brought classification over we will consider of high quality new formations that arise out of structures of odontogenic vehicle.

Odontogenic tumours develop slowly and painlessly. The initial displays of tumour often pass unnoticed and can be educed by chance at X-ray research. Duration of asymptomatic period depends on localization of tumour, corresponding complications and character of tumour process.

AMELOBLASTOMA (adamantinoma) is a odontogenic ephithelial tumour structure of that, as many researchers consider, alike with the structure of enamel organ of dental to the rudiment. Determine two forms of adamantinomas - dense and cystophorous. However some authors object against such distribution, because consider that dense areas almost always alternate with cystophorous in every tumour.

Clinical presentation. Displays are ameloblastomas littlecharacteristic. Patients see a doctor with the same complaints that take place at odontogenic cysts, however deformation of jaw is more often marked. Sometimes there is an inflammatory process in the area of ameloblastoma. Duration of disease from the moment of appearance of the first clinical symptoms to establishment of diagnosis quite often makes a few years.

Much from clinical signs at an ameloblastoma meet at different tumours and tumor-like formations of bones. At first an ameloblastoma develops asymptomatic, then area of jaw thickened. A change of skin is only in the cases of inflammatory processes or at the tumours of largenesses. At palpation more often the fusiform explosing of bone develops with an obese or uneven surface. This clinical sign is often observed and at the cell-type forms of hygant-cell tumour of bottom jaw. Later because of sharp refinement of bone there can be a parchment crunch or fluctuation.

Regional submandibular lymphatic nodules at an ameloblastoma can be megascopic only in case of suppuration of cystophorous emptinesses of tumour. In patients with small tumours at the inspection of emptiness a company is determined smoothed out of transitional fold to the vault of threshold to the mouth. Alveolar part of body of bottom jaw according to the location of tumour is megascopic, teeth in the zone of defeat were displaced, a bit movable. Percussion of points is painless, but clear reduction of percussion sound that testifies to the defeat of tissues round an apex is marked.

At the defeat of supramaxilla an ameloblastoma germinates in a genyantrum, emptiness of nose, eye socket, an eyeball was displaced, that caused deformation alveolar to the sprout and hard palate. There are complaints about a labouring nasal breath, expiration of tears, diplopia at the compression of nervous completions paresthesias, decline of sensitiveness, are marked in the zone of throwing cold water on of nerves. At violation of cork I, soft consistency of tumour is determined at palpation.

In other cases an ameloblastoma can be a come-by-chance at roentgenologic research on other occasion. There are cases of germination of tumour from a bottom jaw in overhead and even in basis to the skull.

An origin of ameloblastoma while is obscure. Some authors consider that in most cases a tumour arises up at violation of development of dental to the rudiment. Many authors pull out a hypothesis about the origin of ameloblastomas from the ephithelial elements of mucous membrane of emptiness of mouth (integumentary epithelium, epithelium of glands). The row of researchers considers that ameloblastomas arise up with odontogenic of ephithelial bits (small islands of Maliase) and pieces. Other authors make possibility of origin of them from the ephithelial covering of follicle cysts.

Motion of ameloblastomas is considered of high quality, however there are many works in literature, where reported at ameloblastomas that have sign, inherent to the malignant tumours: by a germination in surrounding tissues and organs, metastases in lymphatic and easy. The cases of veritable malignant transformation of ameloblastoma do not exaggerate 4%.

A roentgenologic picture of ameloblastomas can be different. Most typical polycystouse (multicamerate) variant, rarer there is a single cystophorous form. A polycystouse variant has the appearance of numerous oval and round cells of rarefaction of bone tissue, reminding picture of bubbles of soap-suds. Contours of cells are destructions clear. At a comatose form the cell of destruction of bone tissues appears with incorrect polycyclic contours.

Both forms due to swelling cause deformation of jaw with displacement, refinement and breaking of cork layer in separate places. Teeth, that are in a zone the tumours displaced, root of them resorbt. The reaction of periosteum is absent. In the cell of defeat it is possible to show one or a few points that was not cut (for children) through.

Macroscopically: in the different places of tumour connection of solid areas is determined with cystophorous, filled by a rather yellow or brownish liquid. Depending on predominance of those or other areas it is possible conditionally to distinguish solid or polycystouse forms.

The microscopic picture of structure of ameloblastomas is various enough not only in different tumours but also in the different areas of one tumour that hampers their study.

After data WOH distinguish the next variants of histological structure :

а) a follicle variant is presented as the small islands that consist of centrally located many-sided mews or star-shaped reticular mews divided more or less, surrounded remind a dental epithelium. In small islands are cystophorous rarefaction;

b) plexyform variant of structure is the separate ephithelial small islands surrounded on periphery of separate star-shaped mews. Forming of cysts conditioned by degenerative changes in строме, but not in an epithelium.

c) acantomatouse variant is characterized by expressed metaplasia epithelium, sometimes with education keratins in the small islands of mews of tumour. The general picture of preparation is alike with the same at a follicle variant.

d) at the basale-checked variant of structure of mew remind the basale-checked cancer of skin. In these cases there are complications of differentiation from adenocystouse carcinoma.

e) a grainy-cellular variant is presented as dome-shaped or the rounded form of mews with oxphylic cytoplasm.

A connecting tissue on a border with an epithelium can be subject hyalinization an especially follicle. Appearance of the spaces filled by blood conditioned to expansions of blood vessels, that arises up because of degeneration of stroma of tumour.

Diagnostics of ameloblastoma is some difficulties. Clinic and X-ray research, cytological research it is helped to define only previous diagnosis. Basic are data of histological research.

Treatment.

Surgical oncotomy within the limits of healthy tissue. The volume of operation is conditioned to distributions of process and hesitates from the resection of area to the exarticulation with a primary bone by the plastic arts. P.V.Naumov (1981) offered an operation with abandonment of cork I; continuity of mundible is thus saved.

ODONTOMAS

An odontoma is a teratosis of points; marked the large variety of structure. A tumour arises up in the period of forming of permanent points. In adults more often appears near molars and points of wisdom, and also in the area of corner and branch of bottom jaw. Overhead and lower to the jaw is identically.

Clinical presentation of odontomas is marked a few of symptoms, here a large particle from them has secondary character. An odontoma is characterized by the slow rate of height. These that she meets in more mature age is explained to.

The macroscopic picture of odontomas is various: from educations that remind the underdeveloped tooth, to the massive complexes that consist of some or many зубоподобных educations. These educations can be easily divided or be densely united inter se. A tumour is surrounded by a capsule from an elastic tissue. At a tumour the soft tissues emptinesses appear sometimes, filled by a light liquid.

Microscopic picture. Different topographical correlations of dental tissues that have a different degree of painting, and sometimes and different degree of maturity, form a whimsical histological structure. On the decalcified cuts it is possible to distinguish points or tooth-like educations with the normal topographical location of enamel, dentine, cement and simultaneously with it conglomerates of dental tissues that have the disfigured correlation of dental structures. Round a tumour ordinary is capsule that consists of layer of fibrotic tissue, sometimes with dental tissues.

Distinguish two basic forms of odontomas: difficult and component.

A difficult odontoma has the appearance of education in that all dental tissues are presented separately. These tissues can be well-developed, but located in disorder. More often meet in the front departments of supramaxilla.

A component odontoma is tumor-like formation, that consists of conglomerate of shallow rudimentary points or tooth-like educations.

The difference of component odontoma from difficult is insignificant and is based on the degrees of disorganization of these tissues.

Homogeneous or inhomogenous to high intensity shade is X-ray determined with clear uneven contours. On periphery tumour stripe rarefaction of bone tissue, that is the reflection of connecting tissue capsule. An odontoma causes displacement near the located rudiments of points. In the process of height a tumour can break cork layer of jaw and to result in her refinement.

Diagnostics. To differentiate the odontoma of треба from остеомы. Shade last on a sciagram unlike an odontoma always homogeneous and to the less closeness, than tissue of tooth. On occasion distinguish an odontoma from ретинированных and дистопированных teeth.

Treatment of odontoma is a surgical curettement or resection of pathological cell. Curettements are conducted together with a capsule. Near-by to the tumour of area of bone separate a milling cutter. Tooth and the rudiments of teeth, displaced by a tumour, at possibility abandon.

CEMENTOMA

The characteristic structural element of цементомы is a грубоволокнистая dense tissue alike with cement of tooth. Accordingly IHCT (series № 5) distinguish 4 varieties of cementoma: of high quality cementoblastome (veritable cementoma), cementforming fibroma, periapical cementoma dysplasia (periapical fibrotic dysplasia), hygant cementoma (inherited plural cementoma).

In explanations it is marked to IHCT, that for all group by cement almost obligatory connection with teeth. Even temper of height and clear limitation from surrounding tissues.

Clinical presentation. Displays by cement littlecharacteristic. Usually they grow slowly, cause deformation of jaw. In a number of cases patients mark a sickliness at palpation of tumor. Sometimes in the area of цементомы an inflammatory process develops because of hit of infection through the root-canals of points or germination of tumor in soft tissues with further violation of mucous membrane of emptiness of mouth. Motion by cement conditionally of high quality, because, developing in a supramaxilla, she strikes vitally important areas.

Differential diagnostic the value of sciagraphy at cementoma is large, however, not such, as at odontomas.

A X-ray picture does not have pathognomonic signs. In one cases on a sciagram can be determined round, oval or incorrect form homogeneous dense shade, that located near the root of tooth and forms one unit with him. Contours of such education usually equal, rarer wavy, borders clear.

In other cases on a background ossifluence cells, without a bone to the picture, the generous amount of dense grains that answer the particles of cementoma tissue usually can be determined. More often on sciagrams on an anhistous background next to shallow and dense grains there are dense areas of largenesses.

Histological research. Cementoma more often has a structure of the second variety are cementforming fibromata, where the fields of cellular-fibred tissue with plenty of the extracted mews and oval kernel form group in short bunches and concentric figures, in the center of that the located laying of cement-like substance. Sometimes these laying remind bone beams that interlace inter se and form the looped net.

Treatment. cementomas have many checked elements for warning of relapse it is necessary excise together with the near-by areas of bone of jaw, i.e. necessary partial or complete resection of the staggered area.

odontogenic fibroma

Odontogenic fibromata behave to internal new formations of bones of jaws.

A main distinctive sign of this variety of fibromata is a presence of bits and pieces of зубообразующего epithelium between connecting tissues mass of tumour. An ephithelial component is presented by rare shallow small islands, and also separate tissues from homogeneous round mews or small single complexes, there are some rarefied checked elements in the central departments of that. These characteristic ephithelial bits and pieces give a certificate at odontogenic nature one the varieties of fibroma. Sometimes there can other indirect proof of it be some alikeness of their structure with the tissue of endodontium. This variety of fibroma of треба to distinguish from an ameloblastic fibroma at that both components of tumour, ephithelial and unephithelial, developing in a complex, are one unit, and represent the early stage of development of dental to the rudiment.

Clinical presentation of odontogenic fibromata of jaws is unspecific. A tumour usually develops slowly, painlessly deforming a jaw. On occasion the height of tumour can be accompanied to the bill, terms from appearance of the first symptoms to the address to the doctor different - from a few months to a few years. Eruption of points rises in the process of height of tumour, more often on a bottom jaw.

Centrally located поликистозные educations are X-ray determined with involvement of large departments of jaw. Meet including of dense shadows of tooth-like conglomerates. Borders are tumours clear, marked retention points.

An odontogenic fibroma must be distinguished from an ameloblastoma, myxoma, keratocyst and ameloblastic fibromata. A final diagnosis can be set only on the basis of clinicoradiological and microscopic comparison.

Treatment. Oncotomy. Many authors recommend is limited to the curettement of formation.

Peripheral hygant-cell granulosum - (hygant-cell epulid) is new formation rounded, rarer than ovoid form with an uneven surface, soft or elastic consistency, crimson color, more often with the expressed brown tint. Possessing a progressive height a peripheral hygant-cell granulosum can arrive at largenesses. These educations painless, slightly bleeding at a trauma, as a rule, covered by an epithelium. Sometimes on the surface of epulid it is possible to see the imprints of teeth-antagonists, surface of areas of tumour, participating in mastication, eroded.

With a height epulid teeth can be displaced. Epulid increases usually slowly: the changes of his sizes are determined on completion a few weeks, months and even years. At an incomplete removal epulid can arise up relapses.

X-ray at hygant-cell epulid the bones of alveolar sprout, that spread from a surface deep into and on the form remind the wrong triangle turned by a top to the alveolar sprout of jaw, find out the areas of destruction, to his basis. The contours of area of destructions are unclear, spread, a periosteal reaction is absent.

Basic treatment - surgical, excision of epulid within the limits of healthy tissues. The basic zone of height of epulid are tissues of periodont, therefore the tooth located in the zone of defeat of bone subject to the removal.