Swellings of the Jaw

Classification of jaw swellings

A. Arising from the mucoperiosteum (Epulis)
i. Fibrous
ii. Granulomatous
iii. Myeloid
iv. Sarcomatous
v. Carcinomatous
B. Arising from tooth germ (Odontomes)
1. Epithelial odontomes ( arising from connective
tissue elements)
i. Dental cyst
ii. Dentigerous cyst
iii. Adamantinoma
Following varieties are rare varieties
2. Connective tissue odontomes ( arising from
connective tissue elements)
i. Fibrous odontome
ii. Cementomes
iii. Sarcomatous odontomes
3. Compoite odontomes ( arising from both
epithelial and connective tissue elements)
iv. Radicular odontome
v. Compound follicular odontome
vi. Complex composite odontome
C. Osseous tumours- bone tumours which occur
more often in the jaws
D. Inflammatory group
i. Alveolar abscess
ii. Osteomyelitis
iii. Actinomycosis
 Adamantinoma( ameloblastoma;
multilocular cystic disease; Eve’s disease
• Is a true neoplasm of the odontogenic epithelium
• An epithelial tumour arising from ameloblasts
(enamel- forming cells)
Pathology:
• Macroscopically: filled with transparent fluid/jelly
• Microscopically: varies in appearance
– Outer layer of columnar cells- the ameloblasts and a
core of ‘ star cells’ with large vacuoles in the cytoplasm
• Sometimes this tumour is composed of
epithelial strands or islands of varying sizes
• Central cells may degenerate leaving cystic
spaces
Adamantoma can occur elsewhere than the
Jaw
a) stalk of the pituitary- suprasellar tumour
(both the pituitary stalk and enamel, arise
from the oral epithelium)
b) may occur in the tibia.
 Extremely rare tumour, due to abnormal embryonic
epithelial invaginations
Spead: locally invasive tumour, not known for
distant spread even to lymph nodes
Clinical features:
 Rare tumour of jaw
 Commences usually in childhood or early adult life.
Majority of the patients were in 4th / 5th decades
 Shows slight predilection for males
 Usually found in the molar area of the mandible
 Slow growing tumour
 Painless tumour
 Expansion mostly of the outer table
 Swelling more visible from outside than inside of
the mouth
 Cystic degeneration leads to areas of softening and egg-shell
crackling on palpation
Like other odontomes, it is not associated with any carious
tooth or any missing tooth
Investigation: X-ray shows large loculi and a fine honey-
comb appearance

Treatment:
 resection of the tumour along with a margin of healthy bone
 If no recurrence takes place after several months, bone graft
should be used to make good the mandibular defect
 If tumour is very large, hemimandibulectomy
 Mandibular defect is substituted by a prosthesis/ salistic rod
carved to the design and moulded over a K-wire
 After a few months, prosthesis is replaced by a block bone graft
 Osseous tumours
1. Benign tumours:
i. Fibro-osseous group
ii. Paget’s disease
iii. Osteoclastoma
iv. Giant-cell reparative granuloma
2. Malignant tumours of the maxilla:
v. Osteosarcoma
vi. Columnar cell carcinoma of the maxillary antrum
vii. Squamous cell carcinoma derived from
epithelium overlying the hard palate, tooth
socket or the gum
 iv. Invasion of the maxilla by sarcoma of the
ethmoid
v. Burkitt’s tumour
3. Malignant tumours of the mandible:
i. Primary malignant neoplasm is extremely rare
ii. Secondary malignant tumour may occur from
a) Carcinoma of tongue
b) Floor of the mouth
c) Carcinoma of the lip
d) Metastatic involvement of the facial lymph nodes
which lie injuxtaposition of the mandible near the
groove for the facial artery
 Fibro-osseous group
 Jaws are mainly membrane bones. so fibro-osseous
dysplasia is often seen here
 Tumour has varying amount of fibrous tissue and bone
 If fibrous tissue element is more with myxomatous
degeneration, tumour will be soft in major parts
 If only one tumour is found- monostotic fibrous
dysplasia
 If the condition is diffuse, polyostotic fibrous dysplasia
 If the tumour composed of solely bone and localised-
ivory osteoma
 If this bony tumour is diffuse- leontiasis ossea
 X- ray appeance of fibrous dysplasia are strips and
bubbles within the jaw
 Ivory osteoma is a benign dense localised tumour
Clinical features:
 Fibrous dysplasia is more often seen in the 1st /2nd
decade
 Its growth stops when the individual is fully grown
 Such tumour has been associated with dental sepsis
or some sort of oral sepsis
Treatment:
 When individual is fully grown, excision of the
tumour is made under antibiotic cover
 Osteoclastoma
• Extremely rare tumour in the jaw
• More seen in the lower jaw
• Occur under the gum as myeloid epulis
• Osteoclastoma, gaint celled reparative
granuloma and adamantinoma mimic one
another
 Gaint celled reparative granuloma
• This lesion occurs due to haemorrhage within the
bone marrow
Pathology:
• Macroscopically: consists of opaque, semisolid, dark
red material
• Microcsopically: there are multinuclear gaint cells
which are few in number
Clinical features:
• More often between the ages of 10 and 25 years
• Females are more frequently involved
• Swelling is painless
• Often involves the mandible
• X-ray shows, round/oval area of radiotranslucency
• It expands and thins out the cortex , not perforate

Treatment:
• Thorough curettage through external incision is the
treatment of choice
• Bone cavity shouldn't be opened into the mouth
 Adamntinoma Osteoclastoma Gaint cell reparative granuloma

Age Child hood/elderly 25 to 40 years 10 to 25 years

adult

Sex Males Males Females

Rate of Slow growing Relatively rapid A slow growing lesion

growth tumour growing tumour

Jaw affected Mandible Mandible Mandible

Pain Rarely causes pain Painless painless

X-ray Fine honey- comb Soap bubble Rounded/ oval translucent area
appearance With small loculi appearance with whivh expands the cortex
larger cysts

Radio Not radiosensitive radiosensitive

sensitivity

Malignancy It is a locally May turn into Malignancy is never seen

malignant tumour malignancy
 Osteosarcoma
• Maxilla is often affected- maxillary antrum whose
prognosis is worst
• Best prognosis is seen in lesions of the mandibular
symphysis
• It affects mostly the anterior aspect of the jaw
Clinical features:
• Pain and swelling-main complaint
• Nasal obstruction and epiphora(abnormal outflow of
tears down the cheek due to obstruction of lacrimal
duct)- in late cases
Treatment: radiotherapy followed by surgery
 Carcinoma of the maxillary antrum
Pathology
Two varieties:
1. Columnar cell carcinoma of the maxillary antrum
2. Squamous cell carcinoma arising from the
epithelium overlying the hard palate/the gum
3. Lymph node metastasis occurs early-deep cervical
groups
Clinical features:
• Age: above 40 years
• Both sexes equally involved
• Foul, purulent blood-stained discharge from the
nose is the common symptom
• If the growth originates on the floor of the antrum,
toothache is the main complaint
• If floor of the antrum is involved, hard palate will
show bulging
• If the growth involves anterolateral wall of the
maxillary antrum, swelling will be seen on the face
• If the medial wall of the antrum is affected, nasal
obstruction and epiphora
• If roof of the antrum is invaded, proptosis and
diplopia
• Cervical lymph node metastasis is quite early
• Biopsy may require to confirm the diagnosis
Treatment:
• Radiotherapy – main mode of treatment
• Palatal Antrostomy
• Surgery: radiotherapy cannot control the disease,
excision of the maxilla
 Burkitt’s tumour
• Commonest neoplasm in children/first decade
• Involvement becomes progressively diminished as age
increases
• It is a type of multifocal lymphoma whose etiology is not
clear
• Viral origin has been strongly suggested
• Maxillary tumour: present in relation to the molar and
premolar teeth
• As tumour develops, the alveolus expands on both sides
and affected teeth loose their attachments to the bone
• Tumour develops around the teeth with external
swelling-appears under cheek
Mandibular tumour:
• Develop in the same way with marked distortion of
the face
• Multiple jaw lesions with involvement of several jaw
quadrants – characteristic features
• When two jaw quadrents are involved, it is nearly
always the maxilla and the mandible of the same side
• Radiological features: disappearance of lamina dura
round the affected teeth
• Multiple small areas of bone dissolution appear
• Coalesce forming larger areas of bone distruction
• Abdominal tumours-frequent mode of presentation
• Retroperitoneal mass, liver enlargement, ovarian
tumours
• Adrenal and pancreatic involvements-common
• Enlargement of mesenteric lymph nodes- epigastric
mass
• Paravertebral mass in the lower dorsal or upper
lumbar region
• Intracranial lesions in the form of cranial nerve
palsies
• tumour may affect the salivary gland, thyroid, the
breast, bones and lymph nodes
Treatment:
• Exceedingly sensitive to radiotherapy
• But this is multifocal tumour, so remissions from local
radiotherapy have been followed by development of
tumours in other sites
• Chemotheraphy: treatment of choice
• Orally/intravenously
• Treatment reaches all the tumours and shrinks in
demonstrable tumours
 Alveolar abscess
• Acute alveolar abscess can occur at any age
• Most often in children and early adult life
• Abscess connected with the first dentition are
distributed equally between two jaws
• Those connected with the second dentition concern
particularly the teeth of the lower jaw, especially a
molar tooth
Pathology:
• Result of acute pulpitis
• Putrifying pulp generates gases that exert pressure
through the root canal into the osseous tissue around
the apex of the tooth
• Localized osteitis and abscess formation
• Almost always abscess points on the labial aspect
• Only common abscess to point lingually is that in
relation to the upper lateral incisor, which gives rise
to swelling on the palate
• Abscess can point into the maxillary antrum in some
cases
• If early resolution is not brought by antibiotic or
drainage, osteomyelitis of the jaw results
Clinical feature:
• Dull and constant pain
• Relieving factor: application of cold / iced water /
decreasing the volume of gas in the pulp chamber
• Heat increases the pain- hot mouth wash
• Biting on the tooth, increases the pain
• Swelling on the cheek
• Signs:
• tapping on affected tooth-increases pain
• Redness and edema of the gum in the neighbourhood
of the culpable tooth are characteristic sign
• General reaction to the infective process
• Tender enlargement of the lymph nodes
Diagnosis and radiography:
• Careful dental examination is required
• Alveolar abscess, dental cause must be found-
carries, an impacted wisdom tooth, retained tooth,
dead tooth
• Only when sufficient time(ten/more days) has
elapsed for resorption of bone to occur will
rarefaction around the apex of the affected tooth-
become apparent on X-ray
Treatment: drainage and antiboitics
• Surgical principals must be followed
1. Drainage
2. Antiboitics- has value before pus has formed-stage
of cellulitis, used in the support of drainage
operation
3. Pencillin group drugs are drug of choice
4. Cold applications externally and hot intra oral
irrigations are useful adjuncts
Drainage of an alveolar abscess:
• Into the mouth:
• When cystic swelling in relation to the gum becomes
apparent, abscess should be drained into the mouth
by incising the periosteum
• Extra oral drainage:
• When abscess is pointed externally- external incision
must be made
• ½ inch below and parallel to the lower border of the
mandible
• Drainage by extraction of offending tooth:
• In case of primary dentition- accepted
 Osteomyelitis of the jaw
Pathology:
• Three varieties noted in the jaw
1. Acute osteomyelitis
2. Subacute osteomyelitis
3. Chronic osteomyelitis
Acute osteomyelitis:
• Often occurs in children as a complication of specific
fever ex: measles, scarlet fever
• It may also be caused by spread of infection from the
antrum or the dental sac of the first molar tooth
• Measles –either maxilla/mandible may be involved,
later cases maxilla is more often involved
Clinical features:
• Puffiness of the eye-lids and swelling of the maxilla
• Temperature
• Discharging sinus if the abscess has naturally drained
• Pressure on the maxilla will cause discharge of the
pus through the sinus
Treatment:
• Appropriate antibiotics
• Polythene catheter is introduced by trocar and
cannula via the nose and the cavity is irrigated with
normal saline twice daily
Subacute osteomyelitis:
• Commonest among the different varieties of osteomyelitis
affecting the jaw
• Pathogenesis:
– Spread of apical dental abscess
– Spread of alveolar abscess
– Fracture of the jaw
• Causative organism: staphylococcus aureus
• Mandible is mostly affected
• [reason- it possesses a single tenuous blood supply along its
long axis, which is easily obstructed by infection/trauma.
• Obstruction of blood supply leads to necrosis of bone,
subsequently osteomyelitis of the jaw
• Maxilla is protected by series of vertical arteries with
anastomosis, obstruction of a single artery cannot cause
necrosis of the bone]
Clinical features:
• Pain
• Swelling
• Tenderness- three main features of lower jaw
• Increased pressure in the dental canal compresses
the inferior dental nerve- causes numbness of the
chin in the distribution of mental nerve- diagnostic
• Gradually swelling points externally/internally
• If the swelling bursts, a sinus is formed
externally/internally
• This will relieve pain
• X- ray shows, bone necrosis in about 3 weeks time or
more
Treatment:
• Antibiotic started immediately
• Removal of sequestrum- relieve tension and to get
rid of disease and dead bone
Chronic osteomyelitis:
• Mandible is more often affected than maxilla
• Causes:
– Fracture of the mandible
– Alveolar abscess
– Radiation and chemical necrosis
– Phosphorus poisoning causes chronic osteomyelitis
 – X-ray, periosteal reaction/local osteitis
– Important finding: formation of cavity due to osteolytic
lesion with surrounding sclerosis
– Bone necrosis becomes evident in X-ray after 3 weeks
Treatment:
• Sequestrectomy is the treatment of choice
• Suitable incision is made at the dependent part of
the affected area of the mandible
• Involucrum is chiselled and the cavity is made open
• Sequestrum is removed if present
• Cavity is packed lightly with petroleum jelly gauze
• Appropriate antibiotics should be given