30. Connective Tissue Oral Lesions (1).pptx

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1. Connective Tissue Oral Lesions (1) Assoc. Professor Dr. Naveed Khawaja HOD/Oral Pathology

2. Contents (CH 9; p 287) 1. Fibrous tissue Hyperplasia Focal fibrous hyperplasia Peripheral ossifying fibroma Peripheral giant cell granuloma Inflammatory fibrous hyperplasia Inflammatory papillary hyperplasia Hyperplastic gingivitis Hereditary gingival fibromatosis Drug induced gingival hyperplasia Benign fibrous neoplasms Fibromatosis, myofibromatosis Nodular fasciitis Benign fibrous histocytoma Benign solitary fibrous tumor Malignant fibrous neoplasms Fibrosarcoma Malignant fibrous histocytosis Malignant solitary fibrous tumor

3. Fibrous Tissue Hyperplasias

4. Learning outcomes Definition Basic understanding and concept Clinical features Histopathology correlation Differential diagnosis

5. Contents (CH 9; P 287) 3. Muscle tissue Neoplasms Leiomyoma Rhabdomyosarcoma 4. Adipose tissue Neoplasms Lipoma Liposarcoma 5. Vascular tissue Hyperplasia Pyogenic granuloma Hamartomas and Neoplasms Hemangioma Lymphangioma Angiosarcoma Kaposi sarcoma

6. introduction Tumor? Benign Malignant Hamartoma? Hyperplasia? Hypertrophy? Connective tissues Fibroblasts Endothelial Skeletal muscle Smooth muscle Lipocytes Nerve sheaths Osteoprogenitor cell Collagens

7. Fibroblast cells Dispersed in CT throughout the body, contributed to formation of CT. These cells produce a diverse group pf products including collagen type I, III, and IV, proteoglycans, fibronectin, laminins, glycosaminoglycans, metalloproteinases, and even prostaglandins. The fibroblasts are predominant stromal cell type seen in soft CT. the appear as plump spindle shaped or stellate shaped cells (active fibroblast) with centrally placed oval or round nucleus.

8. 1-Fibrous tissue Fibrous proliferation occur as a result of reaction to injury, spontaneous benign neoplastic transformation, and malignant transformation of fibroblastic cells. True benign fibroblastic neoplasms fibromas probably do not occur within oral submucosa. In oral cavity, as a result of reactive hyperplasia and are composed primarily of one or more of the following CT components; mature collagen, focal bone formation, endothelial cells and multinucleated giant cells. Confined to gingiva called Epulis Most common lesions referred as Epulides are Peripheral fibroma. Reactive hyperplasia gingiva (Epulis) Peripheral fibroma Peripheral ossifying fibroma Pyogenic granuloma (pregnancy tumor) Peripheral giant cell granuloma

9. Fibrous tissue (hyperplasia)

10. a. Focal fibrous hyperplasia (Irritation Fibroma) Hyperplasia of fibrous CT that evolves in response to chronic irritation in which extensive elaboration of collagen resembling scar tissue exists. Reaction to chronic injury (cheek and lip biting, denture irritation) in which production of mature bundles of collagens predominant. Irritation fibroma represents a pathologic overgrowth of both fibroblasts and their collagenous products. Most common nodular swelling within oral cavity.

11. Clinical features Common in adults Primarily on gingiva, lips and buccal mucosa, even on borders of tongue. Clinically, nodular or domelike growth with a smooth mucosal surface of normal coloration. Ulceration rare Surface keratinization sometimes depends upon low-grade intensity of irritation. When irritation removed, lesions often become slightly smaller or completely regress with resolve of inflammatory process. When it is on the attached gingiva in the area of gingival sulcus or interdental papilla, termed as peripheral fibroma Causes Toothpick fragments Food debris Calculus Mainly irritation factors include bite, denture, overhanged restoration, or any other like.

12. histopathology Consisting of dense bundles of collagen. Lesion is usually chronically irritated, so hyperkeratosis is common on surface epithelium. Sustained fibroma can be giant cell fibroma. Rx- Local excision with removal of all sources of irritation

13. Peripheral ossifying fibroma A gingival nodular consisting of a reactive hyperplasia of CT containing focal areas of bone. Also a reactive fibrous proliferation (cells with osteogenic potential), probably of periosteal or periodontal ligament origin that synthesize both bone and cementum. More common in women and tends to occur during reproductive years (3-4 decades of life). Not in children and elderly. An epulis that originate from interdental papillae, occasionally seen to arise from facial or lingual attached gingiva.

14. Thought to be responsible for stimulating periodontal ligament fibroblasts that also possess osteogenic and cementogenic potential. The overlying mucosa may be smooth and of normal coloration or foci of surface ulceration. Hard to palpate and are fixed to underlying tissue. Radiographically, radiopacities within the soft tissue swelling. Lesions frequently become large and interfere with mastication.

15. histopathology Low-power - A round mass with zone of cellular CT. High power – cellular zone of cellular and accompanied tracing demonstrates the islands of calcified bone trabeculae, osteoid deposits, osteoblasts and osteocytes that distinguish the lesion from a peripheral fibroma. Diffuse sheets of fibroblasts with plump monomorphic nuclei within CT. Overall hypercellularity with collagenous component somewhat hyalinized. Rx – excision to include periodontal ligament

16. Peripheral giant cell granuloma An extraosseous nodule composed of a proliferation of mononuclear and multinuclear giant cells with an associated prominent vascularity found on the gingiva or alveolar ridge. Hyperplastic reaction of gingival connective tissue in which histocytes and endothelial cellular components predominate. All age group (peak 30 years of age), in children during mixed dentition. More common in females, anterior and posterior region. Occasionally in edentulous patients, more domed, purple red and ulcerative on mastication. May loose and movement of teeth. Reddish or purplish dome-shaped swelling of interdental papillae or alveolar ridge. Large lesions usually encirule one or more teeth. On PA radiograph, a superficial saucer-shaped loss of cortical bone (crestal erosion), and more central area of bone remain uninvolved.

17. histopathology Giant cell tissue within periodontal membrane and surrounding the tooth. Giant cells consists of mononuclear and multinucleated giant cells against a background of extravasated red blood cells Some capillary vessels and irregularly shaped sinusoidal spaces are usually present. Fibrous stroma may be loose or dense and contains large, thin-walled vascular structures. Heavy deposits of hemosiderin are common. Rx: Surgical excision and control of bleeding due to vascularity.

18. Inflammatory fibrous hyperplasia (epulis fissuratum ) A proliferation of fibrous CT with an associated chronic inflammation in response to chronic injury. Ill-fitting denture with overextended flanges or older dentures that irritate vestibular tissue after alveolar ridge resorption may stimulate fibroblastic proliferation and collagen synthesis. Usually, multilobulated and diffuse. Lesions usually contain an elongated trough with a linear ulcer (fissure) at its base, commonly referred as to epulis fissuratum .

19. Clinical features Denture-induced fibrous hyperplasia. Lobulated or in folds and may fissured where denture flanges impinges on the tissue at a base of the linear trough. Most are erythematous due to ulceration, occasional in normal coloration. Consistently flabby, soft, and moveable. Anterior locations are more common.

20. histopathology Exhibit an abundance of dense fibrous CT interspersed with focal accumulations of inflammatory cells and an increase in vascularity, all which contribute to excessive tissue. Hyperplastic stratified squamous epithelium with acanthosis with elongated rete pegs. Ulcerated area care occupied by fibrin with entrapped leukocytes. Spindle-shaped fibroblasts are interspersed between dense collagen fibers in scar-like pattern. Not resolve completely on its own even removed the irritation. Must be excised in their entirely before fabrication of new dental prosthesis.

21. Inflammatory papillary hyperplasia Multiple small nodules that consist of a predilection of fibrous CT with an associated chronic inflammation found under ill-fitting dentures. Some loose and ill-fitting maxillary dentures will initiate a hyperplastic response on the tissue of palatal vault. The palatal tissue responds by producing numerous small areas of erythematous focal fibrous hyperplasia that resemble the surface of a papilloma. Sometimes this response is even more intense.

22. Clinical features Confined to palatal vault, seldom progressing onto alveolar ridge. Usually encountered under full dentures, may be in partial denture. Hyperplastic nodules are characteristically 3-4 mm in diameter, with a generalized erythematous “ cobblestone ” pattern resembling a field of confluent reddish-pink mushrooms. When probed, it can be seen that each polyp is independently attached.

23. histopathology An obvious polypoid appearance with smooth, round nodules covered with stratified squamous epithelium. Where two papillary projections meet at their base, the epithelium is usually quite hyperplastic and displays acanthosis with elongated, anastomosis rete pegs ( pseudoepitheliomatous hyperplasia). The individual hyperplastic cells fail to show any atypia cytologic features. Supporting each polypoid projection is a dense core of fibrous CT that is traversed by capillaries (invasion of mononuclear inflammatory cells). Rx : should be removed before fabrication of new maxillary partial or complete denture, that is achieved with scalpel, burr, electocautery , or laser surgery.

24. Hyperplastic gingivitis Focal or generalized fibrous hyperplasia of marginal gingiva with an associated inflammatory response. Edematous and somewhat enlarged in chronic gingivitis and periodontal disease. Represents as exuberant inflammatory fibrous hyperplastic response (calculus or plaque) that is often intensified by the patient’s hormonal status. Puberty gingivitis Pregnancy gingivitis

25. Clinical features Represents an excessive fibrous hyperplasia with an associated inflammatory cell infiltration that occurs in the response to elevated estrogen and other hormone metabolites. The enlargements are centered in interdental papillae where the tissue may be spongy and erythematous with a tendency to bleed with minimal provocation. Generalized gingival hyperplastic could be due to antiepileptic drugs.

26. histopathology Exhibits parakeratosis with marked acanthosis and epithelial hyperplasia characterized by elongated and anastomosing rete ridges. Transmigration of neutrophils into epithelium. Prominent vascularity. Mononuclear inflammatory cells – mainly plasma cells and lymphocytes. Rx: Dental prophylaxis – scaling and polishing (usually not resolve completely, reduce in size) Surgical removal of enlarged tissue, usually after delivery.

27. Hereditary gingival fibromatosis A hereditary form of generalized gingival hyperplasia in which the autosomal dominant form may be associated with hypertrichosis (excessive hair growth), craniofacial deformities, epilepsy, and mental retardation. Diffuse gingival hyperplasia may occur as a hereditary disorder. Appears to be restricted to the fibroblasts that populate the gingiva. Does not involve the periodontal ligament and occurs peripheral to alveolar bone within the attached gingiva. Autosomal dominant and autosomal recessive.

28. Clinical features Gingiva becomes markedly enlarged and may cover the crowns of teeth. Autosomal dominant- hypertrichosis, corneal dystrophy, craniofacial deformities, nail defects and deafness. Autosomal recessive- facial anomalies with hypertrichosis. In most patients, begins at puberty and shows progressive proliferation that involves both interdental papilla and attached gingiva. Lingual and labial gingiva tissues may be involved. Clinically the gingiva is bulbous, firm, and hard. No sex predilection exists.

29. histopathology Surface epithelium exhibits elongated, thin rete ridges. Fibrous CT is densely collagenous, with scattered mature spindle-shaped fibroblasts. Significant numbers of mast cells exist that are associated with fibroelastic proliferation. No inflammatory condition May take many months or even years to reach massive size. Rx: Gingivectomy is only choice, tissue may recur. Better oral hygiene practices do not appear to influence the degree of hyperplasia.

30. Drug-induced gingival hyperplasia A generalized increase in fibrous proliferation of the gingiva in patients who have been taking long-term doses of phenytoin (Dilantin), cyclosporin, and nifedipine, a calcium channel blocker. Persistent dental plaque and gingival irritation appear to increase the severity of hyperplasia. Clinically enlargement is diffuse and firm. Inflammatory changes are variable, more in poor oral hygiene. Less severe in patients using cyclosporin (immunosuppressive) than Dilantin and nifedipine.

31. histopathology Reveal elongated sulcular epithelium and hyperplasia as the result of excessive production of dense bundles of collagen in a scar-like pattern. Thin epithelium and markedly elongated and delicate rete ridges, showing anastomosis. CT is composed of dense mature collagenous fibers with widely dispersed spindle-shaped fibroblasts. Inflammatory infiltration is variable, usually depending on the extent of patient’s oral hygiene. Advise good oral hygiene in case avoidance of drugs. Most patient cannot withdraw their medication, then symptomatic treatment Gingivectomy and gingivoplasty ofter required for functional and cosmetic reasons