Tumors of Jaw

Volume VII Thursday, May 7, 1936 Number 27 r I' UNIVERSITY OF MIIDIESOTA HOSPITALS Volume VII Thursday, May 7, 1936 Number 27

r

I. ABSTRACT. •••••••••..••• 315 - 329

I I. LAST WEEK •••••• • •.•••••••..• 329

I II. MOVIE ...... 329

C 0 U R T E S Y 0 F CIT I ZEN S A IDS 0 C lET Y r 315

I. ABSTRACT 2. Malignant: - Osteogenic Sarcoma a. Osteolytic osteogenic TUMORS OF JAW (myxochondral) b. Osteoblastic osteogenic E. J. Semansky (sclerosing) c. Telangiectatic osteogenic

Classification D. Central Tumors in the Bone of Non­ osteogenic and Non-odontogenic Origin: The classification of the neoplasms 1. Central fibroblastoma of the jaw is extremely difficult. The a. Central fibroma Registry of Bone Sarcoma has adopted for b. Central fibrosarcoma all bone lesions a simplified classifica­ 2. Central angioma tion which has been used as a basis in 3. Ewing's tumor the treatment of jaw neoplasms: 4. Multiple myelooa 5. Intra-osseous mixed tumors Oral Neoplasms E. Tumors Derived from Epithelium: A. Peripheral Tumors of the Oral Tissues 1. Adenoma 1. HYPertrop~- or tumor-like 2. Precancerous overgrowths 3. Carcinoma t 2. Fibroblastoma: a. Epidermoid carcinoma a. Benign: - Peripheral Fibroma b. Basal-cell carcinoma Keloid c. Cylindrical-cell carcinoma Xanthoma d. Adeno-carcinoma b. Malignant: - Peripheral Fibrosarcoma F. Metastatic Tumors to Jaws: 3. Myxoblastoma - Myxoma 1. Carcinoma metaltatic to jaw 4. Lipoblastoma - Lipoma a. From lip 5. Neuroma - Amputation Neuroma b. from breast 6. Endothelioma c. from the prostate gland 7. AngiobIastoma d. from the stomach Vascular Nevus e. from the thyroid gland Haeluangioma f. from hypernephroma Lymphangioma 2. Sarcoma metastatic to jaw 8. Lymphoblastoma a. Melanosarcoma Lymphoma b. Lymphosarcoma Lym-.)ho sarcoma c. From various soft-tissue 9. Melanoblastoma sarcomata 10. Rhabdomyoma. 11. TeratoIJ.a Dental and benign osseous tumors B. Odontogenic Tumors: Radicular cysts 1. Adamantinoblastoma Follicular or dentigerous AdaIJJantinoma Adamantino-sarcoma Radicular or dentigerous cysts 2. Odontoma Giant cell epulis Central giant cell tumors C. Osteogenic Twnors 1. Benign: Hyperostosis Exostoses (Torus palatinus, The teeth are ectodermal and imbedded torus mandibulare) in the osseous substance of the upper and Osteoma lower jaws. The body of the tooth is Chondroma composed of dentine and the crown of 316

enamel. The enamel is a secretion of 4. Adamantinoma epithelial cells derived from the ecto­ True neoplasm arising from cells of derm and corresponds to elements of the one toot~germ layer (ameloblasts exoSkeleton found in other vertebrates. or dental debris). Solid, cystic, In both the dental lamina and itsderi­ differentiated or immature. vatives, the enamel organ may give rise to persistent strands of undiffer~ntiated 5. Odontomas basal-cells which may take part in tumor Malformations (or neoplasms?) in­ formation. From these cells, de~tal volving all the tooth elements root.cysts, follicular or dentige~bus producing nests of mature or cysts, adamantinomas may arise. The immature teeth. Mq be malignant. down-growing basal· cells nearest the primitive mucous membrane (known as' the 6. :Bone and soft tissue tumors epithelial debris of Malassez) may ,4if­ Variety and characteristics ferentiate to form a lining membrane. of generally as in other areas. squamous cells forming dental root Cysts. The cell le~ers of the enamel organs may expand about the non-erupted tooth Dental ~ Cysts to form a follicular or dentigerous Cyst. More primitive elements of the enamel Radicular cysts generally fonn at bUds may proliferate and differentiate the apex of the tooth but in rare in­ 1 in several directlons producing islands stances they may form at t he lateral of enameloblasts, squamous cells, basal surfaces of the root (paradental cysts). cells and epithelial elements character­ They derive their origin from chronic istic of adamantinomas. The enamel buds inflammatory changes of the paradental overly the dental papillae. From the membrane such as hemorrhage, infection, mesodermal papillae, the dentine is instrumentation or chemical. Radicular formed. The unossified portion of the cysts develop at any age. They occur dentine forms the tooth pulp. Prolifer­ on deciduous teeth, and must be carefully ation of these mesodermal elements occurs distinguished from extensive bone infec­ in odontomas. Eefore eruption of the tion. On permanent teeth, they are of permanent teeth, giant-cell odontoclasts frequent occurrence in the maxilla, as normally appear in the pericementum to well as in the mandible. If th~ are of loosen the temporary structures. These small size, they give no subjective or cells may give rise to giant-cell tumors objective symptoms. If'they assume larger of the alveolar ridge, known as giant­ proportions, they will at first expand cell epulides. between the cortical walls of the bone, but later resorption occurs on the inner side of the cortex and the thin wall ex­ Simplified Classification pands with a change in the outline of (Pathological Types) the jaw. In the mandible the expansion generally involves the external surface 1. Radicular cyst of the bones; while in the maxilla, these Simple cyst arising from paradental cysts expand both the outer surface and membrane. invade the maxillary sinu~palate or nasal fossa. The cys ts ma¥ ba found in 2. Dentigerous cyst edentulous parts of the jaws. Symptoms Simple cyst about crown of an of large cysts occur rather gradually. unerupted "normal" tooth. This is especially true of the change in contour of the oral surfaces. If the 3. Paradental cyst bony wall has become thin, palpation may Identical with either of apove two give a crepitating sensation. Occasion­ types but occurring around ally, paresthesia of the terminal supernumary teeth and fourth branches at the fifth nerve is produced. molars. In many old cases, the bone finally is 317

penetrated and an opening is formed into the mouth or Dose. The patient then complains of bad taste, sometimes salty Treatment of radicular cysts con­ in character, discharge or odor produced sists of extraction of the tooth, open­ by it. Maligna.."1t tumors and adamantinomas ing of the cavity and evacuation of its may arise from radicular cysts. contents, including removal of the epithelial lining and the cyst wall. The material removed should always be Pathology subjected to pathological examination. With such treatment, occurrences are In most radicular cysts, the sac can practically unknown. be removed in toto. The fluid, if aspirated, may be thick, mucous-like, watery, or thin. Generally, it has a Dentigerous Cysts yellowish and more often a brownish color• .Microscopic examination shows a fibrous Dentigerous cysts arise from the connective tissue wall of varying thick­ epithelium of the enamel orgarJ. during ness, covered by an epithelial lining, the development of the teeth. They are usually of the squamous type but rarely characterized by the presence of a non­ columnar. Inflammatory cells and choles­ erupted tooth, the ~st expanding about terin is present. the crown of the tooth rather than the root. Because of their relationship to Radicular cysts are generally single developing teeth the,y are usually found but may be multiple. They are falsely in young individuals. These lesions called multilocular cysts. They expand are frequently found in the regior. of the intervening bones but become con­ the third molar. There are no striking densed into a thin subste~ce. Cholesterin physical signs ex~ept failure of the crystals may become a very prominent fea­ tooth to erupt and expansion of the jaw .. ture and give the appearance of a choles­ at the tumor site. As the cyst expands, teatoma. the pressure exerted by the increasing contents of the cyst acts on the occlusal surface of the tooth, causing Diagnosis it to move apically, resulting in the extreme malpositions which are so fre­ Most radicular cysts are diagnosed quently observed. They show in the by routine roentgen examinations. The roentgenogram a non-erupted tooth cyst gives a shadow which has a char­ within a monolocular cyst. The tooth acteristic outline caused by the cortical is pushed ~- from the gum by the layer of bone lining the cavity. A cen­ growth of the cyst from the gum by the tral area of rarefaction with well-defined growth of the cyst which expands about outlines extends in semi-circular fashion the crown. Any of the various stages about the root of the devitalized tooth. of development, from a poorly This outline distinguishes the cyst from formed dense area of enamel to a co~ the ordi~ary root granuloma with hazy plete tooth may be found. Exploration margins. Expansion of the cyst about reveals a fibrous cyst wall lined by the apex rather than the crown of the stratified epithelium, containinG a tooth in the absence of a non-erupted serous or amber colored fluid. tooth distinguished these growths from dentigerous or follicular cysts. The cavity in the roentgenogram is usually Treatment monolocular but rarely multiple cysts

/ forming around several neighboring teeth Complete evacuation of the contents may give the impression of multilocularity. of the cyst, including the lining mem­ The involvement of neighboring structures, brane, and the non-erupted tooth. as well as the relation of the adjoining Recurrence is rare except in these cases teeth, must be studied if the cyst is which may be classified as cystic adaman­ large. tinomas with non-erupted teeth. 318

Simple Follicular Cysts of compact bone with evidence of osteoclastic resorption and new forma­ Follicular cysts are derived from tion in the peripheral marrow spaces. the epithelium of the enamel organ of the On the inner surface of the cyst sac, developing tooth. there is a lining of several rows o~ flattened squamous epithelium which in some cases becomes stratified. The Etiology of Follicular Cyst pressure of the cyst. besides causing bone resorption. may also cause the Bock and Jorgenson believe that resorption of the roots of the teeth. follicular cysts are of an inflammatory genesis caused by chronic peri-odontitis cf deciduous teeth. The reaction in the Paradental C~sts t00th germ causes an exudation and the ~~cumulation of exudate in the enamel Are identical with the preceding organ of the forming tooth produces a follicular or radicular simple cysts cyst. The tooth is not included in the except that they occur on supernumerary cyst. The fluid increases through teeth (4th molars or others). They transudation from the peri-follicular occur most frequently in the r~,ms of tissue. The bone cavity is enlarged to the mandible. correspond with the expansion of the cyst. This is accomplished by pressure resorption at the inner side of the bone cyst. The expansion of the cyst depends Adaman tinoma on the obstructions encountered. It grows in the direction of least resist­ Historical (Simmons) ance nnd hence destroys the spongiosa easier than the cortex of the bone. Synonyms: Adamantine epithelioma, Obviously. it has a tendency to expand cryPto sarcoma. adeno carcinoma, more along the long axis of the jaws and epithelial odontoma. Often confused even if it is not circular. it always with bone cysts. benign giant-cell shows a rounded circumference. They are tumors and carcinoma. The term, ada­ most common in the third molar region. mantinoma. is derived from the Greek invading the ramus. attaining very large word II adamas. II meaning hardness of dimensions before being discovered. stone. and the enamel forming cell is Paresthesia of the lip due to pressure on called "adamantoblast." Malassez the mandibular nerve :i,s often found. (1885) suggested the term lI adamantine while in other cases perforation and epitheliomall for tumors derived from for.mation of the fistula discharging into the enamel forming tissue. Borst (1902) the mouth is the primar,y and most promi­ instituted a now generally accepted nent symptom. Multiple cysts ~ be term "adamantinoma." The first descrip­ formed through malformation of two or tion of true adamantinoma seems to have more adjoining tooth germs, been made by Falkson in 1879.

Pathology pathology The contents of follicular cysts They vary in size from small insig-­ vary a great deal. Generally, there is nificant cellular overgrowths to enor­ a thin. clear amber colored fluid con­ mous cystic enlargements extending from taining cholesterin crystals which give the jaw to the surrounding :parts. (One it a dark metallic sheen; at other times. tumor weighed 1.5 kilograms). Ewing the contents may be thick and of a mucoid states that an adamantinoma as large as character. This may contain products of a child's head was once observed. They decomposition and of infection. The cyst may be cystic or solid. The surrounding sac in most instances is substantial and bone becomes thin and as it enlarges may be peeled out, The base shows a wall the eye tic areas may rupture ~..nd their 319 cavities become secondarily infected. good mentions that the differential The cysts are invariably multilocular. diagnosis between dentigerous cysts and The cavities may be smooth walled or adamantinoma ce.rmot be made until lined with epithelial projections. The exploratory operation is done. solid tu.'!lors and the walls of the cystic ones are composed of fibrous tissue with occasional calcareous areas and masses X-RaY Findings in Adamantinoma of bone and cementum and epithelium. In rare instances, bits of well-formed enamel Adamantinoma is a monocystic or poly­ are present lying on shallow beds of cystic central tumor of sharp outline dentine. Masses of epithelium in broad without an overlying periosteal reac­ anastomosing strands are a prominent char­ tion as is seen in sarcoma and without acteristic of the tumor. These epithel­ the worn edge of cancer or the associa­ ial masses undergo central degeneration tion of bone production as seen in forming cysts. There may be present osteomyelitis. The polycystic tj~e a distinct layer of tall columnar cells with a honeycomb appearance is to be resembling ameloblasts. The cysts m~ differentiated from the trabeculated be microscopic and mayan section resemble giant-cell tumor or the monocystic glandular structures that have been mis­ radicular or follicular cysts. Differ­ named Iladenoma adamantinum. 1t Degeneration entiation in the roentgenogram is by of septa may lead to breaking down of no means absolute as occasionally many walls, and larger and larger cysts may of the central tumors of the jaw may develop. produce the same picture. .

Origin Reported Cases

One may find many theories of genesis. MCFarlane and Patterson, in a Of these two are most accepted: (1) origin review of reported cases of adamantinoma., from the inner l~er of the enamel organ found 166 cases. (ameloblasts); and (2) origin from the dental debris layer of Malassez. It is Sex: (18 cases) interesting that the tumor is common in 73 females and 45 males. negroes (due to rickets'. with secondary irregular malformed enamel organ?). Age: (114 cases) Youngest 6 months; oldest 73 years; average slightly Metastasis less than 40 years.

Adamantinoma of the jaw is locally The average length of time between malignant but systemically benign. In the onset of symptoms and examination the literature, a few cases of adamanti­ of a physician (14 cases): 9 years. noma with metastasis have been reported. Site of tumor: (114 cases) 96 were in lower jaw, Clinical 17 upper jaw. (In one, tumors in upper and Facial deformity is quite a common lower jaws.) feature. Loose teeth are also a striking symptom. The tumors are dow, symptom­ In the lower jaw, the side less growths. There ~ be a loss of was not given in 5, in 12 the tumor teeth in the area involved with no in­ was in midline and extended to both flammatory infiltration. Voeller states sides; in 27, the tumor was on the right that adamantinoma should be suspected and in 52 on the left. In 16 upper jaw, when an area of bone destruction is the right was infected in 18, and left larger than a five-cent piece but never in 8, and both in one. In 74 cases, the to make a dia~10sis until biopsy. Blood- character of the tumor was described: 320

49 cystic, 8 solid, and 12 both solid McFarland and Pattersou were able and cystic areas. to draw the followi~ conclusions from their review of'the cases reported in the literature: Treatment 1. Adamantinomas arise in the jaws The consensus of opinion is that from paradental epithelial debris and radical resection should be done at the in the hypop~sis from squamous first operation if this is not too epithelial debris of the hypop~-seal mutilating a procedure. Incision, drain­ duct. ·age, curettage, excision of the tumor with part of the jaw. excision of the 2. Irritation may be a cause of the tumor along with x-ray and coagulation, tumor of jaw, probably not in the cautery and total or partial resection pituitary. were all attempted in the report of 166 cases. 3. Adamantinoma in whatever location has approximately the histological Simmons, Zoeller and Bloodgood structure. report a series of cases in which no previous operations had been done. In 4. ' The tumor is locall~' malignant. all the bone involved was completely but generally benign and does not r resected and there was a permanent cure. metastasize. Two cases have been re­ ported, however, which seemed to be the Conservative operations are insuffi­ exception to the rule. cient. Some permanent cures have been reported after such treatment, but rarely 5. Cases have been reported elsewhere are incision, curettage, or partial ex­ 2 in the tibia, 1 in the upper lip, cision followed by anything except re­ and a doubtful 1 in the nasal region. currence of the tumor. Adamantinomas are radio-resistant and radiation osteitis 6 •. Adamantinomas of the jaw are more of the jaw is prone to complicate an common than in the pituitary. adequate dosage of x-ray. permanent cures were obtained in about 80% in the Johns 7. They are more frequent in women Hopkins series reported by GesChlckter than in men in a proportion of 3 to 2. and Copeland. 'B. The average age is 40 years at the time the patient entered the hospi­ Adamantinoma of the HYpophysis tal. '

Of 166 cases, 26 were adamantinoma 9., The average duration of symptoms of the hypophysis. The location (in 22 is 7 years•. cases) was: 17 supersellar, 1 in front of the sella, and 4 in the sellar sub- 10. They occur in the upper and lower stance itself. Fourteen of these were jaws in the proportions of 5 to 1; females and 12 were males. ' Age ranged twice as often in the left lower than from 16 to 60 years,with an average in the right•. slightly less than 24. Removal is recom­ mended. The mortality is very high 11. In the upper jaw, the two sides without operation. A few successful were evenly affected.· operations are reported. 12. There were about 6 cystic to 1 solid tumor.. Other Locations 13. Complete radical eXC1Slon seems A few cases of adamantinoma have to be the only method to obtain a cure.. been observed elsewhere than in the jaws or pituitary: tibia, lip,. eyelids. 14.. Twenty-six cases of adamantinoma 321

of the pituitary have been reported, Classification of odontomas: 90% of which were supersellar in position. 1. Mature benign hard odontomata. 15. The average age is 24. The average a. Geminated composite odontoma. duration of symptoms is 3 years. b. Compound-composite odontoma. c. Complex-composite odontoma. 16. The two sexes are about equally affected. 2. Mature benign soft odontomata. a. Fibrous odontoma. 17. About 9~ of these tumors are cystic. 3. Immature odontomata. a. Hard odonto-adamantinoma. 18. Operation is indicated for this b. Soft adamantino-sarcoma. type of lesion.

Mature Benign Hard Odontomata Odontomas Benign odontomata consist Odontomas are mixed tumors closely generally of various mature parts of related to adamantinomas containing tooth substances. There may not only derivatives of the enamel epithelium be the 3 types of calcified tooth r and of the connective tissue of the den­ structure - enamel, dentin and cementum, tal papilla. Epi thelium strands like but also the soft tissue. pulp and those in adamantinomas occur also in peridental connective tissue. In ~~ odontomas but are over-shadowed in quan­ cases, they contain true bone and often tity by mesenchymal elements. In so­ en~e1 organ epithelium. called immature or soft odontomas, large amounts of undifferentiated connective A. Geminated Composite Odontoma tissue with varying amounts of ~xomatous change are combined with epithelium of Gemination implies the union the adamantinoma type. Clinically, these of two or more teeth. This union gener­ tumors behave like adamantinomas and ally prevents eruption of the teeth and represent a transitional group which they are found unerupted and retained merges with the more frequent and benign in the bone of the jaws. In very rare hard odontom[·.s. The hard or differen­ cases, however, the teeth will erupt tiated odontomas are about twice as partially or even completely. Fusion frequent in occurrence as adamantinomas may occur in either the crovms or the of all types. They are usually found roots. The disturbance ~ involve in the lOlWer jaw of young individuals at teeth in the deciduous and pern~nent the site of an unerupted tooth. They set,. The tumor may involve super­ may arise from the imperfectly differ­ numerary teeth in various states of entiated elements replacing the unerupted perfection. Sometimes geminated compo­ tooth or from accessory tooth germs ad­ site odontomata are caused by faulty joining the unerupted tooth (composite development. One enamel organ may odontoma). WIlen two or more tissues give rise to dentin papilla so that one of the germ are involved, t:nese tumors crown develops with several roots have the pot8ntial ability to form all fused or separate. At other times. the types of tissue found in the tooth, enamel organ divides and forms several namely enamel, dentin" cementum, pulp crowns while the dentin organs fuse and and peridentRl tissue. They are c8used connect their root~. Geminated compo­ by faulty tooth formation. They are more site odontomata occur in any part of common in the mandible than the maxilla. the jaws. The only clinical indication, They may be solid or cystic. as a rule, is the absence of one or more • 322

teeth. Their tooth germs have given with fibrous tissue, the,y may be re­ rise to the tuu10r and it m~ have been moved singly without the main part of prevented from erupting by the tumor mass. the odontoma being discovered. If th~ They are benign in character and seldom are united by calcified tissue, attempted cause disturbances which is the reason why tooth extraction will produce difficulty. they remain undiscovered, often for many As odontoma are often formed from years. At times, however, they produce deciduous tooth germs, th~ should be enlarged spaces in the dental arch and discovered and removed promptly to prevent prevent normal eruption or position of malocclusion of the permanent set. If neighboring teoth. When partly erupted, a tooth is absent, the x-ra¥ examination r they are likely to cause infection of will disclose whether an odontoma is the peridental tissue. If dental caries present. Permanent teeth are prevented set in and progress, the pulp becomes from eruption by an odontoma. At opera­ infected, in such cases, dental neuralgia tion in large composite odontoma, some results. These tumors ~ readily be of the particles may be overlooked and enucleated but sometimes on account of the results should be checked with imme­ projection and curvature of the roots diate postoperative x~r~s. coming from the tmaor mass the mecha-~ical interference requires a considerable amount of bone resection. C. Complex Composite Odontomata

x-~ Exronination In this tumor, the arrangement of the tissue is not regular. and tooth-like, Careful studies by x-r~ are impor­ and contains tissue in various stages of tant, especially if the tumor is deep in development. It is not as highly the bone as it sives information about developed a tumor as the previous form the shape of the tooth and its relation of odontomata a.nd m~ be8.r no resemblance to neighboring teeth. to a tooth or compound dental structure. The tumor is contained in the jaw and generally presents a rounded, hard, B~ Compound Composite Odontoma calcified mass which may vary in size from a small pea to one of 5 to 6 em. This type of odontoma contains a in diameter. These tumors though large number of teeth, sometimes as many frequently found in childhood may often as several hundred. The mass is incor­ remain undiscovered for a long time. porated within either a cyst or a The growth may not become active until fibrous membrane. They are produced by the neighboring teeth which sometimes the dental epithelium which instead of hold it in place have been extracted. forming the normal organ produces many The mechanical preB~re exerted by a small enamel organs which all develop plate in turn may become a stimulus. into teeth gorms and give rise to all These tumors consist of a hard, solid kinds and shapes of small teeth. They mass of rounded or oval shape surrounded may be united by fibrous connective tis­ by a fibrous capsule from which they sue, cementum or bone. usually may readily be shelled out at the time of operation. The tumor may be Clinical Features geminated, fairly smooth, lobulated, or the surface ~ be covered with c~nontum This type of odontoma m~ be or have nodules of enamel distributed of considerable size and may cause over it. Microscopically, great variation swelling of the jaw visible on examina­ of the structure and proportion of the tion. Often the neighboring teeth erupt tooth elements are found. In so;ne cases,. in irregular position with abnormallY the tumors contain an arrange'.1ont of tis­ large spaces where the teeth which form sue along the lines of normal tootll forma­ the tumor are missing. A crown of a tion interrupted by a regularly formed tooth, part of the tumor m~ erupt and tissue. In other tumors. abnor;:1D.1 a.rrange­ caURe irritation and inflammation of the ment of tooth substances is the fea.ture. gingiva. If tl~ parts are connected Enamel, dentin or cementum ~ be pre- 323

domin~t and those tissues IDa1 be ar­ which are preceded by a deciduous ranged in lamellar or radial fashion. aentition. The new growths arise from. Soft tissue, such as enamel ~ithelium the alveolar dental periosteum (cementum) and dental pulp, may be seen between and form a mass beneath the mucous mem­ the calcified l~ers. brane of the gum, immediately surround­ ing a tooth, or rarely protrudes from the interior of the root socket of an ~ Diagnosis extracted tooth. Symptoms other than a localized swelling are rare. A history , X~r~ SilOWS a uniform striation of trauma or local irritation ~ be f or radial arrangement of calcified struc­ elicited. The tumor expands outwardly ture. X-ray examination is useful in and anteriorly or between the crevices. determination of location of the tumor of the teeth and ~ be distinguished and its relation to normal structures from a malignant growth by the restric­ for necessary surgical procedures. tion of the point of attachment to one side of the alveolar margin. These are usually firm and somewhat redder than D. Soft Benign Fibrous Odontoma the surrounding mucous membrane. Tumors of more than 1 or 2 c~ in circumference The soft or fibrous odontoma. are rare although in one case reported is very rare clinically~ Grossly, it the masses were of sufficient size to is not possible to distinguish it from include the entire oral cavity. a true central fibroma. Microscopic Microscopically, the mucous membrane is examination, however, shows that though hypertrophied and beneath this are seen consisting of connective tissue it con­ many multinucleated giant-cells and a tains scarce amounts of dental epithelium. fibrous stroma containing small spindle It resembles adamantinoma except for the and round-cells. The growths when not fact that the tumor is primarily a too large ~ be treated by simple e~ fibroma and the epithelium pl~s an un­ cision with cauterization of the box important role. wi thout extraction of the neighboring teeth., Recurrences are rare wi th such treatment. External irradiation with E. Immature Odontoma x-ra:y or radium is also successful in some instances but care must be exorcised These are infiltrating tumors to avoid irradiation osteitis. which have a tendency to recur and some m~ be malignant. The odonto-adamantino­ The giant-cell epulis is related to ma has the general characteristics of a normal proliferation of odontoclasts adamantinoma but contain teeth or tooth occurring in the cementum about the root particles. The adamantino-sarcoma is a of the deciduous teeth. The function of soft odontoma in wInch both the epithelial these is to absorb the cementum and pro­ as well as the mesodermal part of the vide for the shedding of these structures. tooth forming tissue has become neoplas­ Since these deciduous teeth are loosened tic, the latter having malignant proper­ during the first decade, the majority ties. They show a marked tendency to of these giant-cell tumors occur in the recur after operation. second' decade. Subsequent development of the tumors is accounted for by the slow growth of these benign tumors and by Giant-Cell Epulis the occasional activation of the odonto­ clasts in pregnancy. The occurrence of These tumors occur most frequently giant cell epulis as an initial manifesta­ in children and young adults, the major­ tion in multiple giant-cell tun10rs and ity between 10 and 20 years of age during bone cysts, associated with adenoma of the period of eruption of the permanent the parathyroid gland, relates these teeth. The most common site is near the growths to disturbances of the para­ canine, bicuspid or incisor teeth and thyroid hormone. The increase in par~ about the roots of those permanent teeth tho:rmone in the blood in early pregnancy 324 probably bears some relation to these the sphenoid process. The maxillary Cases of alveolar giant-cell tumor which sinus in the upper jaw is frequently have their onset or increase in size invaded. The tumor involves the mucous· during gestation. The tumors are fre­ membrane of the antrum and fills the quently referred to as pregnancy tumors sinus like a carcinoma. Generally, how­ of the alveolar margin. ever, the tumor expands the bone both in the maxilla and maudible. The wall of the antrum and the palate ma.Y show dis­ Giant-Cell Tumors (Central) tinct bulging and in the mandible the bone is often greatly enlarged with The lower jaw is most frequently normal appearance of the mucous membrane involved in the ratio of 2 to 1. Like and a hard, cystic feeling on palpation. giant-cell ~pulis these lesions occur Destruction of the spongiosa takes place in young adults between the ages of 10 and later even the cortex mB¥ be involved. .and 25 years. This is in contrast with The periosteum, however, is not broken giant-cell tumors of long bones which through. Instead new periosteal cortex are rare under 20 years of age. In the is often formed. The teeth become dis­ lower jaw, these tumors affect the region placed, later they become loose and ma1 of the symphysi s or the angle in the even drop out. upper jaw. In the upper jaw, they show a tendency to invade the antrum and orbit. Central giant-cell tumors grow and de- . X-R~ Examination stroy bone rapidly. The average duration at the time of operation was about 7 The x-r~ study of giant-cell months in the series reported by tumors must be carefully made. In some Geschickter and Copeland~ In the roent­ cases, there may be only a defect in the genogram. a central trabeculated area of bone of irregular and often lobulated reabso:rption expands a thin shell of outline with sharp demarcation. In cases bone. In younger patients, unerupted of long standing, bulging of the .. thin, teeth mB¥ be found in the vicinity of unbroken cortex ~ be observed. The the lesion leading to the erroneous shadow is one of an asymetrical globular diagnosis of dentigerous cysts. nature. There is almost always coarse trabeculation present which, however, . may not be distinctly visible, if the Clinical Findings tumor area is over-exposed. The trabe­ culae are not constant and vary consider-­ Giant-cell tumors lD8tY be peripheral ably in size and clearness in the pic­ (periosteal) and endosteal (central). ture. The tumors may be distinguished The peripheral types are generally on from adamantinoma because the areas of the ex\ernal surface of the bone and pro­ the tumor subdivisions made by the septae duce a painless swelling in the mouth. are not circular in giant-cell tumors. The swelling JIl8\V be pedunculated but The antrum II1l\V be filled by tumor tissue generally it is attached to the bone and and appears radio-opaque. on a wide base. It is usually well­ circumscribed, of firm consistency and early shows a characteristic bluish, Treatment livid color. The teeth are frequently pushed apart from the tumor. The central Treatment should alw~s be conserva­ form of giant-cell tumors occurs both in tive. In the lower jaw curettage follow­ t' the maxilla and mandible. It chooses ed by chanical cauterization is preferable I the part of the bbne of cartilaginous In large tumors of the upper jaws, par­ origin, the so-called "chondro-cranium or ticularly those extending into the its remnantsll : the condylar process of antrum and temporal fossa, irradiation the mandible where Meckel's cartilage and should be combined with surgery. ~noma its accessory cartilages have been built recommends the use of a sclerosing solu­ into the bone, the maxilla, the region tion following operation. It causes less of the canine fossa, ethmoid region and local reaction than phenol or Zenker's 325 . solution. It consists of absolute round, nodular or tuberous or globular. alcohol (6 cc.), chloroform (3 cc.), Cases of multiple exostosis may occur. glacial acetic acid (1 cc.) and ferric Most frequently, this condition occurs chloride (1 gram). on the internal surface of the mandi ble~ Round protuberances, generally multiple, The question of recurrence is of symmetrical and bilateral, are found utmost importance. Any tumor tissue on the lingual aspect of the mandible in after operation will continue to grow. the premolar region. Thi s is spoken of Recurrence therefore is no doubt fre­ as torus mandibulare. A favorite loca­ quently due to incomplete removal of the tion is the vault of the hard palate. tumor. Very little has been written Here we find an oblong bony elevation, concerning the possibility that some of a ridge, and in more extreme cases an the recurrent cases might have a systemic overhanging lobulated, bony mass which. factor exciting its recurrence, i. e., often has the appearance of being con­ hyperparat~oidism. It should prove nected with the palate by a pedicle ex- interesting to study the calcium and t ending along the median line. This is phosphorus metabolism in such cases. known as torus palatinus. Both the aandibular and palatine tori are found in older individuals. According to Tumors with Skeletal and Jaw Involvement Crane, 12% of adults have torus palatinus in some form. Patients are rarely con­ Paget's osteitis deformans, von scious of its existence until they have Recklinghausen's fibrocystic disease and artificial teeth made. At this time, multiple myeloma may show lesions in the the overgrowth may interfere with proper jaws. Enlargement of the jaw produced fitting of the denture. Torus pale-tims by large deposits of porous bone and arises as two distinct masses from the characterized roentgenologically by median line but is covered by a mucous widening and increase in the size of the membrane and appears as a single growth. trabeculae may antidate by many years the 7% of these lesions undergo degenerative appearance of Paget's disease in the changes and become chondromyxo-sarcomas rest of the Skeleton. In some instances They are apt to become malignant after of multiple osteitis fibrosa cystica 30 years of age. If symptomless, they the onset of the condition may be a giant­ should nevertheless m observed with cell tumor of the alveolar margin. x"rays every 6 months. If changes are Thuma has described a case of multiple found or if the lesion is growing. myeloma, with initial involvement of the excision should be carried out. lower jaw.

Osteogenic Sarcoma Tumors, Metastatic, to the Jaw In the Registry of :Bone Sarcoma, Neoplasms metastatic to the jaw are there are among 44 tumors of the jaws. comparatively rare. Thoma reports 12 osteogenic sarcomas, 8 in the maxilla, metaatasis to the jaw from carcinoma of 4 in the mandible. The giant-cell the lip, breast, pr.ostate, thyroid, tumors are more common: 17 in both bones. hypernephroma and from sarcoma. Erhardt Osteogenic sarcoma, therefore, occurs reported 30 cases of metastasis to the more frequently in the maxilla than in jaw from primary malignancy of the the mandible. thyroid.

SYEptoms Exostoses The symptoms are pain in the teeth, Exostosis is not a true neoplasm paresthesia of the face and changeable although it is sometimes difficult to draw symptoms of pressure in the jaw. At a line between self-limited hyperplastic other times, the tumor spreads rapidly, growths and true osteoma. They may be especially in the mandibular canal of the r- 326 A !~p' lower jaw. and gives pain of the most Ewing's Tumor severe nature, producing loosening of the teeth. Such symptoms unfortunately The jaw cases permitted to the are still often misunderstood and many Registry showed a solitary lesion. tumor patients are not treated as modern procedure would incidate. While hoping for relief by tooth extraction and medication, valuable time is often 10 st. Late symptoms are those of a spreading Incidence of tumor of the jaw (Surgical tumor mass. There ~ be fever, especial­ and Pathological Laboratories of Johns lyin the presence of pulmonary metastasis. Hopkins) is as follows:

1. Dental and benign osseous tumors ­ X-ray Examination .a6.5 cases.

The roentgenographic appearance of Osteomas and ossifying osteogenic twnors of the jaws presents fibromas 70 cases the characteristics of these tumors as Radicular cysts 57 found in other bones. Giant-cell epulis 51 Adamantinomas 45 Central giant cell-tumors 25 Chondroma, Myxochondroma and MYxoma Follicular or dentiger- ous cysts 12 Chondroma is a rare naoplasm of the Odontomas 5 jaw. Occasionally they reach enormous size. 2. Malignant osseous tumors composed of osteogenic sarcoma - * c~. Non-osteogenic and Non-odontogenic Bone Tumors Ewing's sarcoma 19 cases Sclerosing type 10 These neoplasms arrive from the Tumors with skeletal fibrous tissue, from the marrow cells or and jaw involvement 8 from the blood vessel walls and peri­ Chondral type 7 neurial sheaths contained in bone and have no osteogenic or odontogenic tissue. Without considoration for the length of time. they may grow, the tumor cells Incidence of ,jaw neoplasms (University never produce bone though they induce of Minnesota Dental School) during the formation of normal bone about or even last 10 ;years: in a tumor owing to stimulation of nor­ mal osteoblasts not related to the neo­ Epulis - 1Q.1. ~ plasm. Likewise, osteolytic action on 1. Chronic inflammatory 39 cases the bone is affected not generally through 2. Giant-cell 29 their own activity but presumably through 3. Pyogenic granuloma 17 pressure effect and circulatory dis­ 4. Hard fibroma 16 turbances. 5. Fibroma 14 6. Soft fibroma 10 7. Papilloma 4 Classific2,tion 8. Angioma 3 9. Xanthoma 1 1. Central fibroblastoma. 10. Neurofibroma 1 a. Central fibroma 11. Keloid 1 b. Central fibrosarcoma 12. Miscellaneous 16 2. Central angioma 3. Ewing1 s tumor 4. Multiple myeloma 5. Intra-osseous mixed tumors 'I' I 327 J i i Cysts and Tumors - 162 cases ~ Incidence of Bone Tumors of Jaw 1. Dental root 96 cases (UniversitY-of Minnesota Hospital) .. 2. Dentigerous 18 (Incomplete index) I 3. Exostosis 15 j; 4. Undetermined 14 Those involving maxilla - §. cases. 5. Adamantinoma 13 1. Osteogenic sarcoma 4 cases ~ 6. Osteitis fibrosa 2. Osteoma 1 cystica 12 3. Fibrosarcoma 1 •i 7• Giant-cell tumors 10 8. Mixed tumors ( salivary) 8 " Those involving mandible - 16 cases 9. Submucous cysts 8 1. Central gi8nt-cell r 10. Osteogenic sarcoma 7 tumors 6 cases 11. Compound composite 2. Adamantinoma 4 r odontoma 6 3. Osteogenic sarcoma 3 ~ 12. Compound odontoma l 5 Osteochondrosarcoma 1 j 4. 13. ;, Naso-palatine 4 5. Osteoma 1 14. Cementoma 4 6. Myxosarcoma 1 I 15. Sarcoma 3 ,. 16. Osteoma 3 17• Complex composite .. odontoma 3 18. ,Adenoma 2 19. Chondro-sarcoma 1 20. Fibro-sarcoma 1 ~ 21. Os teo-fibroma 1 ~ 22. Hyperostosis 2 23. M! scellaneous 26

~"

•

1

(, j ) "'"',.•."., ....."-'.-""t --.-""',",,¥ ....,,""-~._", .. ,"'~" ...... "~~ .". ~"~,"O_"...... "'.,.. ... ~~1it .. -""'"-_.... <.<~ "~<'_""cr ~» ."."'~, «« co....,.,. .. ., II _ "" __ cc.. ,,_. '_ .."". """'"I ...... • 11 ."" •. "' .... - ."--~ 1-. '~-II ":'.-"'--"<40"'''~'

DIFFEREl~IAL DIAGNOSIS

Characteristics Ewi~t s Tumor Osteogenic Sarcoma Chronic Osteomyelitis

1• .Age Children and young adults. Young adults and middle age. More common in youth. Lesion usually single in Lesion single. Single or multiple. early stage. 2. Antecedent In 50% In 50% In 33% local trauma 3. Duration Short Short Apt to be longest 4. Pain Usually first sJ'ID.ptom. First symptom. First symptom. 5. Local swelling Few weeks or months Few weeks or months after More slo\'Tly developing following pain pain 6. Local swelling Bare in early stages. Few weeks or months a.fter Rare in early stages. Common in later. pain CODmon in Inter. 7. Temperature Usually elevated Rare Rare or low g.- BloDd pi~ture If leqcocytosis differen­ Leucocytosis i'7i. th Change in tial is normal differential

9~ Location ~or No difference (jnw) No difference (jaw) No difference (jaw) 10. Multiple in bone Usually Barely IW.rely 11. Pathological re­ Osteolytic. Widens bon€. Osteoblastic. Does not Osteolytic and osteoblastic. actions Destroys cortex evenly widen bone. Ms¥ narrow it. Destroys bone irregularly. and vertically.. Only Does not destroy cortex. Marked prolifera.tive reaction. slight proliferative New bone if a~. Does not New bone irregular or perpendi­ reaction excited. New Change periosteum much. cU.lax ~ eburnation. bone if any parallel to shaft. Osteophytes may occu.r. Destroys perios­ teum and elevates it. 12. Metastasis to glands. Not infrequent. Very rare Rarely 13. Radium effect Badio-sensitive Radio-resistant 1""0 response 14. Toxin (Coley's effect) Very sensitive Resistant in most cases 1;"0 response

15. Spontaneous fractures Often present Often present Rarely ~ co t 329 ~ 1. Bloodgood, J. C. 17, Lewis, D•• r Lewis t Practice of Surgery, IV, Geschickter and Cope1and. i Coopt. IV. Tumors of Bone~ Am.J. Caneer. 1931, 2. Scudder,C. L. r Tumors of Jaw. ,. w. B. Saunders, 1912. ..I I 3. Thoma•. K. H• Clinical Pathology of Jaws, April 30, 1936 Chas. C. Thomas, Springfield, Ill., 1934. f Place: Recrea.tion Room, Nurses 1 Hall r 4. Ziskiny D. E., B1ackberg, S. N., • Stout, A. D. 12:15 to 1:15 Gingivae during pregnancy. Surg., G~l. and Obst. 57: 719, 1933. Program: Movie: Timber Giants r Biophysics, • 5. Geschickter, C. F. Physical Therapj'-, f Tumors of Jaw. Radiation T}~rapy r Am. J. of Cancer, 24~ 90 (May) 1935., t Present: 100 j; 6. Kolodny, A. Bone Sarcoma. Discussion: Stenstrom Surg. Pub. Ca. of Chicago, 1927•. K. W. r A. L. Abraham ~ C. N. Borman J 7. Gatewood L. G. Jacobs Surge Clin. North Am., 7: 547, 1927. f I. C. Vigness J. C. Litzenberg t 8. Codman, E. A. Surg., Gyn. & Obst., 42: 381, 1926. 1 r 9. Bunting, R. W. Oral Pathology, Lea and Febiger. •I i t III. MOVIE I 10. Conner, C. L. t Calif. & West. Med. J., 34: 325, 1931. Title: Attention - Suckers ~ I 11. Ivy, R. H. Released by: M-G-M r Ann. Surg., 85: 27, 192~. ~ 12. Ewing, J. 1 Neoplastic diseases. • Phi1a. W. B. Saunders Co• I 13. Figi, F. A. Surge .Clin•. North Amer.'t 10: 110-113, 1930. fIi 14. Godman, E. A. r Am. J. Roentgen., 13: 105-126, 1925. ~ r 15. Cutler, E. C. and Zollinger, R. i I Am. J• Surg. , 19: .411, 1933. I f 16. New. G. B. \ Surg., C1in. of North Amer., 4: 524, ( 1924.