BushraAyaz1, Nadia Zaib2, Sajid Mushtaq3, Nadira Mamoon4, Noreen Akhter5, Sabben Abbas6, M. Tahir Khadim7
How to CITE:
Ayaz B, Zaib N, Mushtaq S, Mamoon N,Akhter N,Abbas S, KhadimM. T. Pathological spectrum of jaw lesions: analysis of 178 cases. J PakDentAssoc. 2012: 21 (02) : 78 – 84
To analyze the pathological spectrum of jaw lesions at Armed Forces Institute of Pathology, Rawalpindi.
A retrospective observational study was conducted of 178 jaw lesions diagnosed at Armed Forces Institute of Pathology (AFIP), Rawalpindi All cases diagnosed during the period jan 2003 to dec 2006were included in the study through non-purposive convenience sampling.The datawas analyzed by SPSS version 10.
The commonest lesion were odontogenic cysts making upto 73 cases, followed by 29 cases of odontogenic tumors, 29 cases of non-odontogenic tumors, 23 fibro-osseous lesions, 13 giant cell lesions, 8 infectious lesions and 3 non-odontogenic cysts.The overall peak age of incidencewas the second decade of life and male to female ratio was 1.5:1. The mandible was involved in 83 cases and the maxilla in 70 cases, while no information regarding sitewas provided in 25 cases.
Odontogenic cysts were found to be the commonest among the jaw lesions. The mandible was more commonly involved than themaxilla
Odontogenic tumors, radicular cyst, ameloblastoma.
Jaw bones are the most common sites for epithelial cysts and tumors in the human skeleton due to the close relationship with teeth and odontogenesis. Most of these cysts and tumors have in common an origin fromthe tissues involved in tooth formation and constitute an important aspect of oral and maxillofacial pathology . Cysts are pathologic cavities with liquid, semi liquid or gaseous contents, partially or totally covered by epithelial tissue . Most jaw cysts are lined by epithelium that is derived from odontogenic (tooth forming) epithelium and are sub classified as inflammatory and developmental in origin depending upon the origin from tooth-forming epithelium or inflammatory process respectively. Odontogenic tumors comprise a complex group of lesions of diverse histopathologic subtypes and clinical behavior. There are tumours composed only of odontogenic epithelium, mixed odontogenic tumors comprising both odontogenic epithelium and ectomesenchyme and a third group comprising those arising purely from ectomesenchymal element. Non-odontogenic cysts are epithelial lined pathological cavities in which the source of epithelium is other than that of the tooth forming organ and usually derived from the remnants of tissues involved in face development.
In addition to cysts, fibro-osseous lesions also comprise a good number of lesions affecting the oral cavity. Fibro-osseous lesions are those in which normal bone architecture is replaced by fibrous tissue with some mineral content in it. Maxillofacial fibro-osseous lesions consist of lesions that differ, with the exception of fibrous dysplasia, from those found in the rest of the skeleton. Fibro-osseous lesions of the face and jaws are cementoosseous dysplasia, fibrous dysplasia, cemento-ossifying fibroma
Another categorywhich involve the oral cavity are the giant cell lesions, which are non-neoplastic, painless swellings containing fibrous, vascular and other connective tissue stroma dispersed with multinucleated giant cells. They are of the aggressive and non-aggressive types; with the later being more common, showing few symptoms There is another large group of lesions. The nonodontogenic tumors which comprise up of tumors originating from within jaw bones and arise from tissue other than the tooth-forming organ. This includes long list of both benign and malignant neoplasms of epithelial, mesenchymal, salivary gland, lymphoid origin and so on.
Last but not the least, there are certain cases of inflammatory lesions (infections) reported as well. The common inflammatory lesions of the oral mucosa are caused by viruses, bacteria and fungi. This study discusses the spectrum of lesions affecting the jaw bones which are host to bacterial infections more than viral and fungal.
This studywas undertaken to evaluate the spectrumof jaw lesions encountered in our patients and to document any differences with local or international literature. However, this should be notified that this study has analyzed the lesions that primarily arise within jawbones, thus all other lesions that affect oral mucosa (e.g. the commonest squamous cell carcinoma) and primary salivary gland lesions are excluded fromthe study.
In the present study 178 jaw lesions diagnosed between Jan 2003- Dec 2006 at Histopathology department of Armed Forces Institute of Pathology (AFIP), Rawalpindi, were reviewed after having written consent from the patients and furthermore the patients record and consent form were reviewed and approved by institutional review board (IRB). The study design was retrospective observational. The cases were selected by non-purposive convenience sampling. The Lesions of the jawbonewere includedwhile lesions ofmucusmembrane or salivary glands were excluded. The institute is a referral laboratory which receives samples from military aswell as government and private hospitals in the northern Pakistan. The cases were retrieved from record files, studied and analyzed as to their histological type, anatomical site, age and sex of the patient. and analyzed by using SPSS version 10.
A total of 178 jaw lesions were analyzed forhistological type. Odontogenic cysts were found to be most common followed by odontogenic tumours, nonodontogenic tumors, fibro-osseous lesions, giant cell lesions, inflammatory lesions and non-odontogenic cysts. Distribution of histological types of jawlesions according to their relative number is presented inTable 1.
Of the entire lesions 108 (60.7%) occurred in males and 70 (39.3%) in females (Table 2).
The peak age of incidence was the second decade followed by the third decade of life.The age of the patients ranged from 5 months to 80 years (Fig.1). The mandible (n=83) was themost frequently affected jaw, as compared to maxilla (n=70). No information regarding site was provided in 25 cases. The anatomical sites of all cases are presented inTable 3.
In most respects, the microscopic features of the mandible and maxilla differ in no significant way from those of any other bones. Their peculiarity is derived from their close proximity to the mucosal surface of the oral cavity and the fact that they enclose the odontogenic apparatus, a highly specialized structure that gives rise to a large variety of malformative, inflammatory and neoplastic conditions . The jaws are host to a wide variety of cysts and neoplasms, due in large part to the tissues involved in tooth formation.Many benign jawtumors and several cysts (some recently described), of both Odontogenic and non-odontogenic origin can exhibit a biologically aggressive course and can be diagnostically difficult.
Although, these lesions are quite common in clinical practice, but as in the past, oral pathology was not recognised as a speciality in Pakistan, hence there is not much local literature available on this subject. However, recently a very comprehensive study was carried out at Mayo Hospital Lahore on tumors and tumor like lesions, which includes both the mucosal as well as the bony lesions of the oro-facial region, retrospect over a 5 year period. In the above mentioned study total of 189 cases were studied, of which only 99 originated from the jaw bones. Thus the results of our study and mayo hospitalstudy vary significantly. Since Mayo hospital study analysed only tumour and tumour like lesions, so theyprobably excluded all jaw cysts, which on the other hand are the commonest lesion of our study. As far as odontogenic tumours are concerned, ameloblastoma was commonest in both the studies but there was a huge difference in the number of the lesions and this turns out to statistically very significant. In our study there were 17 cases of ameloblastoma out of 178 cases and 61 out of 99 cases in mayo hospital study significant number of squamous cell carcinoma and salivary gland neoplasms were analysed inmayo hospital study, however thesewere excluded fromour study.
Most of the studies that have been carried out worldwide did not include all of the jaw lesions instead focused on either one or two entities. Thus our study was one of the fewones that includedmost of the jawlesions.
The presentation of jaw lesions in our study was entirely different from a study carried out in Nigeria in which odontogenic tumors were the commonest lesions while cystic lesions were the 3rd commonest lesions , which was in contrast to our study in which odontogenic cysts were the commonest jaw lesion followed by odontogenic tumors.
Odontogenic cysts can be problematic because of recurrence and / or aggressive growth. 41% of our cases comprised of odontogenic cysts, among them the most common were radicular cysts followed by dentigerous cyst and keratocyst. These findings are similar to other French , Jordanian , Turkish and Chilean studies. Our finding is also similar to the 15year Brazilian study at the Pernambuco school of Dentistry. It reported 507 cases of odontogenic cysts out of 5100 medical reports ofwhich 265 were Radicular and 156 were dentigerous cysts. In contrast to the above studies results of a Nigerian study zshowed that developmental odontogenic cysts were more common than inflammatory, dentigerous cysts being the most common followed by radicular cysts A very detailed study was carried out in Istanbul University which studied the prevalence of odontogenic and non odontogenic cysts over the period of 40 years. Their results also showed radicular cysts to be commonest i.e. 3284 out of 5088 cysts. In case of developmental cysts some difference is seen as in our study dentigerous cysts weremore common than theOKC, however 1048 and 529 cases of odontogenic keratocyst and dentigerous cysts were diagnosed at Istanbul, respectively. This finding is also reported in a Japanese study in which keratocyst was found to be the second most common cyst rather than dentigerous cyst.
Out of seventy-three cases of odontogenic cysts in our study 53 were males and 20 were females, having ratio of 2.6:1. This data showsmore of amale preponderance than females. Similar results are seen in French and Jordanian studies with male to female ratio of 1.86:1 and 1.7:1 respectively. Comparable results are shown in Turkish ndBrazilian studywithmale to female ratio of 1.77:1 and 1.36:1, respectively.
In our study radicular cysts and periodontal cysts occurred most frequently in the maxilla while odontogenic keratocysts and dentigerous cysts in the mandible, which is similar to a Turkish study. Corresponding results are documented in the Turkish study which also showed radicular cysts to be common in maxilla as 1978 out of 3284 were involving maxilla. In case of Odontogenic keratocyst 652 out of 1048 were affecting the mandible and 345 out of 529 cases of dentigerous cyst were also present in the mandibular region.
In our study over all occurrence of the cysts predominates in the mandible (62.5%), in contrast to studies from Jordan and Lithuania which states maxilla to be themost common anatomic site. TheBrazilian study reported increased predominance of Radicular, Dentigerous and periodontal cysts in the mandible.
Present study reported 3 cases of Non-odontogenic cysts, one case each of Nasolabial cyst,Aneurysmal bone cyst and Nasopalatine cyst. Making a conclusion of relative predominance is not possiblewith such less data. Present study reported 3 cases of Non-odontogenic cysts, one case each of Nasolabial cyst,Aneurysmal bone cyst and Nasopalatine cyst. Making a conclusion of relative predominance is not possiblewith such less data. An 8 year long study carried out in Turkey reported 459 cases of cysts out of 12,350 patient’s record. Out of these only 7 (%=1.5) were Non-odontogenic cysts and all of themwereNasopalatine duct cysts. Our study concluded cystic lesions as the most common jaw bone lesions comprising of 76 cases out of 178. Of these 73 lesions were odontogenic(%=41) and 3 were Non-odontogenic(%=1.7).Radicular cysts were the most commonOdontogenic cysts(n=36,%=49).
Our study includes twenty-nine cases of odontogenictumors, having ameloblastoma as the commonest tumor, followed by adenomatoid odontogenic tumors which is similar to two of Nigerian studies. Contrasting results were noted in studies conducted in Brazil, Turkey, Argentina and California in which odontomas were the commonest tumors, . Not a single case of odontoma was reported in our study. This may represent a low incidence of odontomas in our population. Alternatively, based on clinical and radiological findings the clinicians are so definite in their diagnosis that they do not send the sample for histopathology, though this seems less likely.
Fibro-osseous lesions of the jaws show considerable microscopic overlap and include fibrous dysplasia,ossifying fibroma, Periapical cement-osseous dysplasia. Twenty-three cases of fibro-osseous lesion were diagnosed in the present study; (table no.1). Five cases were not sub typed due to lack of clinical and radiological data.
Present study reported no significant difference between the male (n=12, %=52) and female (n=11, %=47.8) predominance.
Though the results of this study are based on a small number of lesions reported, the results are coherent with the study carried out inThailand for 34 years from 1973 to 2006, in retrospect. That study reported ossifying fibroma (50.8%) as the commonest FOL, followed by Fibrous dysplasia (42.6%).The Thailand study also reported more females affected by these lesions thanmales In contrast, a Jamaican study reported Fibrous dysplasia (51.7%) as the most common followed by Ossifying Fibroma (34.5%) A review article on benign fibro-osseous lesions in maxillofacial region by Faizan Alawi stated Ossifying Fibroma affecting females more. He also illustrated an increased occurrence of this lesion in theMolar-Premolar region of themandible than themaxilla. While our study reported no difference between the maxilla (n=11, %=47.8) and themandible (n=10,%=43.4).
The predominant giant cell lesions of the oral cavity include peripheral and central giant cell granuloma, Cherubism,Aneurysmal Bone cyst. Present study focused on jaw bone lesions only, hence excluding PGCG and cases of ABC are included in Non-odontogenic cysts. Central giant cell granuloma is a relatively common jaw lesion of young adults that has an unpredictable behavior. Thirteen cases of central giant cell lesions were reported of which 8 cases were reported in females and 5 in males. Our results regarding the gender and age of the patients are similar to the results of studies from Turkey and China including a recent study carried out in Iranwhich reported female predominance with 66.1% cases affecting females except that, in these studies more cases were seen in the mandible, especially anterior region, as compared to the maxilla, in contrast to our study in which therewas nearly samenumber of cases in both the jaws.
Another category of lesions studied were non- Odontogenic tumors ofwhich non-Hodgkin’s lymphomas were themost commonly reported type, the other types are mentioned inTable 1. Lymphomas a re mal ignant neopl asm of lymphoreticular cells. They fall into two main categories Hodgkin’s (B cell type) and Non-Hodgkin’s (B and T cell types) lymphomas. Primary extra nodal lymphomas arising in the jawsare very rare. Our study revealed fifteen cases of Non- Hodgkin’s lymphomas affecting the jawbones,making up for 8.42% of all jaw lesions.All of these cases were of Bcell origin with 8 being Diffuse Large B Cell Lymphoma (DLBCL), 3 Burkitt’s lymphoma and 1 Lymphopblastic Lymphoma. Slight male predominance is seen with 1.5:1 male to female ratio.9 out of 15 cases were reported in the maxilla. While comparing the frequency of lymphomas affecting the jaws with worldwide studies, very limited data is available.
However, a very comprehensive study regarding oral nonHodgkin lymphomaswas carried out in Boston evaluating 40 cases. Results of the histological subtypes of the lymphomas was nearly analogous to our study as 39/40 cases were B cell lymphomas. Out of 39 cases 23 were DLBCL which again is comparable to our study in which 8 out 15 cases were of DLBCL. Conversely, 3 cases of burkitt lymphoma were diagnosed in our setup but none was reported in the study discussed above. In a Ghanaian study regarding the frequency of tumors affecting the lower face, fifteen cases of lymphomas (8.77%) were diagnosed. But the comparison between the two studies is not significant becausewe have eleven cases of lymphomas affecting the maxilla while only four were reported in the mandible. A Nigerian study regarding the incidence of orofacial tumors in patients less than 19 years of age reported a high percentage of lymphomas in the oral and maxillofacial region, comprising 67 cases out of 146 (45.89 %). This is most likely because of the high incidence of Burkitt’s lymphoma in the African pediatric population. Our study included only 3 cases of Burkitt’s lymphoma which is relatively raremalignancy in our population.
Last but not the least group to be included in the study are the inflammatory conditions.The presence of diseased teeth may represent a pathway for micro-organisms causing infection of jaw bone. Both pyogenic and anaerobic bacteria are usually responsible for acute or chronic in fection of the jaw bones, common being the osteomyelitis and actinomycosis. Present study reported 8 cases of infectious lesions affecting the jaw bones. Out of these 7were cases of chronic osteomyelitis and 1was of Actinomycosis. All the cases were affecting males and 5 out of 8 cases were involving mandible as compare to maxilla. The cases of osteomyelitis were not sub divided into various classes because of lack of complete clinical and radiological data and therefore comparisonwith other studies cannot bemade.
Odontogenic cysts were found to be the commonest among the jaw lesions. Mandible was more commonly involved than maxilla. Jaw lesions were more common amongmale patients andmainly occurred in young adults.
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