Soft Tissue Lesions of the Oral and Maxillofacial Region

Soft Tissue Lesions of the Oral and Maxillofacial Region

1. Reactive Fibrous Hyperplasia (RFH)

• Other names:

• Traumatic fibroma

• Reactive fibrous hyperplasia

• Etiology:

• Trauma

• May develop from granulation tissue

• Microscopic features:

• Dense fibrous connective tissue

• No blood vessels

• No capsule

• Atrophic epithelium

• Clinical features:

• Nodular, non-pedunculated

• Painless, normal color, non-malignant

• Slow growth, < 3-4 cm

• Location:

• Cheek, lips, tongue, gingiva

• Fibroepithelial polyp:

• A type of RFH

• Caused by dentures, appearing under the base of the denture

• Etiology of Giant Cell Fibroma (GCF):

• Unknown

• Not related to trauma

• Etiology of Fissured Palatal Papilloma:

• Trauma caused by the BORDER of the denture

• Etiology of Papillary hyperplasia:

• Trauma caused by the BASE of the denture

• Etiology of Juvenile Aggressive Fibroma (JAF):

• Unknown

• Rare in the mouth

2. Other Lesions:

• Fibrosarcoma:

• Malignant neoplasm of fibroblasts

• Fibrohistiocytic tumor:

• Neoplasm of histiocytes

• Granulation tissue:

• Deficiency or reduced fibrous tissue formation during wound healing

• Not related to infection

• Peripheral Ossifying Fibroma:

• Fibrous tissue hyperplasia due to inflammation

• Has the potential to produce bone or cementum

• Peripheral Giant Cell Granuloma:

• Hyperplasia of phagocytic cells due to inflammation

3. Detailed Description of Each Lesion:

3.1. RFH

• Microscopic features:

• Similar to GCF, with the addition of fibroblasts beneath the epithelium that are very large, star-shaped, and sometimes multinucleated.

• Clinical features:

• Characteristically, a nodule behind the mandibular canine

• < 5 cm

3.2. Fissured Palatal Papilloma

• Location:

• Mandibular sulcus, anterior floor of mouth

• Microscopic features:

• Fibrous tissue folds

• Painless, often multilobular

• Papillary hyperplasia along the border of the lesion

• Differentiation from RFH:

• More chronic inflammatory cells in the connective tissue

3.3. Papillary Hyperplasia

• Other names:

• Papillary hyperplasia of the palate

• Denture hyperplasia

• Clinical features:

• Multiple papules spreading over the hard palate

• Painless, concentrated in the midline

• Treatment:

• Surgery or laser

3.4. JAF

• Clinical features:

• Firm, painless mass, often multilobular

• Destroys underlying bone LOCALLY, does not metastasize

• Treatment:

• Wide excision, including the affected bone

• Can result in jaw deformities

3.5. Fibrosarcoma

• Clinical features:

• Firm, painless mass

• Bone has a “sunburst” pattern

• Slow growth in the early stages, rapid growth later

• Destroys underlying bone

• Microscopic features:

• Spindle cell proliferation

• No capsule

• Numerous mitotic figures

3.6. Fibrohistiocytic Tumor

• Clinical features:

• Cheek, buccal sulcus

• Nodular, firm, painless, no capsule

• R42 (reddish-brown) color, growth can be significant

• Microscopic features:

• Malignant type: Malignant fibrous histiocytoma

• Spindle cells, open nuclei

• Malignant type can be very benign histologically

• Most common soft tissue cancer in adults:

• Fibrohistiocytic tumor

3.7. Granulation tissue

• Clinical features:

• Primarily gingiva

• Pregnancy tumor: On the gingival papillae of pregnant women

• Epulis: Poor wound healing after tooth extraction

• Red, painless mass, often ulcerated

3.8. Peripheral Ossifying Fibroma

• Clinical features:

• Gingival papilla, radiopaque

• Firm, painless

• Microscopic features:

• Formation of immature bone

• < 2 cm, treated with curettage

3.9. Peripheral Giant Cell Granuloma

• Clinical features:

• Gingiva

• Red/blue nodule, prone to bleeding

• Soft on palpation

• Differentiation from:

• Brown tumor in hyperparathyroidism

3.10. Lipoma

• Etiology:

• Benign neoplasm of fat cells

• Most common soft tissue tumor in the body but not common in the mouth:

• Lipoma

• Clinical features:

• Middle age

• Cheek, buccal sulcus

• Soft, yellow mass, non-pedunculated, painless

4. Gross and Microscopic Features of Benign and Malignant Tumors:

4.1. Gross:

• Benign tumors:

• Encapsulated, easily dissected, well-defined margins, not invasive, mobile on palpation

• Malignant tumors:

• Not encapsulated, poorly defined margins, invade deeply into surrounding tissues, immobile, form a firm mass

4.2. Microscopic:

• Benign tumors:

• Similar in structure to normal tissues, few or no mitotic figures, no bizarre nuclei, nuclear atypia

• Malignant tumors:

• Structure unlike normal tissues, disorganized structure, many mitotic figures, irregular nuclei, nuclear atypia

4.3. Progression:

• Benign:

• Slow progression, local, not fatal, except in special cases in dangerous locations, no metastasis

• Malignant:

• Rapid progression, fatal due to bleeding, necrosis, vascular occlusion, cachexia, metastasis

4.4. Treatment:

• Benign:

• Complete cure with excision

• Malignant:

• Easy to recur, difficult to treat

5. Multiple-choice questions:

• Which of the following are characteristics of malignant tumors (select multiple):

• A. No contact inhibition

• B. No anchorage dependence

• C. No requirement for collagen scaffolding

• D. Rapid swelling within 24 hours

• Answer: a, b, c

• The definition of a tumor is due to an increase in:

• A. Number

• B. Composition

• C. Size

• Answer: a

• What is the diagnosis when the lesion is nodular, reactive, and characterized by dense fibrous connective tissue:

• Answer: RFH

• Which lesion is similar to RFH but has an unknown etiology:

• A. Fissured Palatal Papilloma

• B. GCF

• C. Fibroepithelial polyp

• D. JAF

• E. Papillary hyperplasia

• Answer: b. GCF

• The lesion caused by repeated denture trauma, which may have fibrous tissue folds:

• A. Fissured Palatal Papilloma

• B. GCF

• C. Fibroepithelial polyp

• D. JAF

• E. Papillary hyperplasia

• Answer: a

• The lesion caused by wearing dentures for a long time without removing them for hygiene:

• A. Fissured Palatal Papilloma

• B. GCF

• C. Fibroepithelial polyp

• D. JAF

• E. Papillary hyperplasia

• Answer: e

• It is a type of borderline tumor, invasive (locally), destroys underlying bone (often with swelling in the gingiva underneath):

• A. Fissured Palatal Papilloma

• B. GCF

• C. Fibroepithelial polyp

• D. JAF

• E. Papillary hyperplasia

• F. Papilloma

• Answer: d

• Is JAF considered a benign or malignant tumor:

• Answer: Benign

• Why does JAF have an invasive nature:

• Answer: Because it has no capsule and requires wide surgical excision.

• Cauliflower-like, soft, not infiltrative, associated with HPV:

• A. Fissured Palatal Papilloma

• B. GCF

• C. Fibroepithelial polyp

• D. JAF

• E. Papillary hyperplasia

• F. Papilloma

• Answer: f

• Microscopic finger-like projections with a core of connective tissue and a thick layer of keratin on the outside:

• A. Fissured Palatal Papilloma

• B. GCF

• C. Fibroepithelial polyp

• D. JAF

• E. Papillary hyperplasia

• F. Papilloma

• Answer: f

• Malignant neoplasm of fibroblasts:

• A. Fissured Palatal Papilloma

• B. GCF

• C. Fibroepithelial polyp

• D. JAF

• E. Papillary hyperplasia

• F. Papilloma

• G. Fibrosarcoma

• Answer: g

• Slow growth in the early stages, very rapid growth later, strong bone destruction:

• A. Fissured Palatal Papilloma

• B. GCF

• C. Fibroepithelial polyp

• D. JAF

• E. Papillary hyperplasia

• F. Papilloma

• G. Fibrosarcoma

• I. Fibrohistiocytic tumor

• Answer: g

• Microscopic spindle cell proliferation, no capsule, numerous mitotic figures:

• A. Fissured Palatal Papilloma

• B. GCF

• C. Fibroepithelial polyp

• D. JAF

• E. Papillary hyperplasia

• F. Papilloma

• G. Fibrosarcoma

• I. Fibrohistiocytic tumor

• Answer: g

• Benign neoplasm of fibroblasts, may have malignant forms:

• A. JAF

• B. Papillary hyperplasia

• C. Papilloma

• D. Fibrosarcoma

• E. Fibrohistiocytic tumor

• F. Granulation tissue

• Answer: e

• If there is a discrepancy between the clinical and microscopic features of a fibrohistiocytic tumor, which should be prioritized?

• Answer: Microscopic features

• Deficiency in fibrous tissue formation during normal wound healing:

• A. JAF

• B. Papillary hyperplasia

• C. Papilloma

• D. Fibrosarcoma

• E. Fibrohistiocytic tumor

• F. Granulation tissue

• Answer: f

• Pregnancy tumor is a type of:

• A. JAF

• B. Papillary hyperplasia

• C. Papilloma

• D. Fibrosarcoma

• E. Fibrohistiocytic tumor

• F. Granulation tissue

• Answer: f

• Epulis is a type of:

• A. JAF

• B. Papillary hyperplasia

• C. Papilloma

• D. Fibrosarcoma

• E. Fibrohistiocytic tumor

• F. Granulation tissue

• Answer: f

• Poor wound healing after tooth extraction, treatment is local anesthesia and curettage of the extraction site:

• A. JAF

• B. Papillary hyperplasia

• C. Papilloma

• D. Fibrosarcoma

• E. Fibrohistiocytic tumor

• F. Epulis

• Answer: f

• Gingival papilla, firm, radiopaque, usually less than 2 cm, has the potential to produce bone or cementum:

• A. JAF

• B. Papillary hyperplasia

• C. Papilloma

• D. Fibrosarcoma

• E. Fibrohistiocytic tumor

• F. Epulis

• G. Peripheral Ossifying Fibroma

• Answer: g

• Formation of immature bone:

• A. JAF

• B. Papillary hyperplasia

• C. Papilloma

• D. Fibrosarcoma

• E. Fibrohistiocytic tumor

• F. Epulis

• G. Peripheral Ossifying Fibroma

• Answer: g

• Microscopic features: immature fibrous connective tissue with multinucleated giant cells:

• A. JAF

• B. Papillary hyperplasia

• C. Papilloma

• D. Fibrosarcoma

• E. Fibrohistiocytic tumor

• F. Epulis

• G. Peripheral Ossifying Fibroma

• J. Peripheral Giant Cell Granuloma

• K. Lipoma

• Answer: j

• If a Peripheral Giant Cell Granuloma is large in size and numerous, it may be a brown tumor. True or False?

• Answer: True

• The most common soft tissue tumor in the body but not common in the mouth:

• A. JAF

• B. Papillary hyperplasia

• C. Papilloma

• D. Fibrosarcoma

• E. Fibrohistiocytic tumor

• F. Epulis

• G. Peripheral Ossifying Fibroma

• J. Peripheral Giant Cell Granuloma

• K. Lipoma

• M. Liposarcoma

• Answer: k

• Soft, slow-growing, yellow mass:

• A. JAF

• B. Papillary hyperplasia

• C. Papilloma

• D. Fibrosarcoma

• E. Fibrohistiocytic tumor

• F. Epulis

• G. Peripheral Ossifying Fibroma

• J. Peripheral Giant Cell Granuloma

• K. Lipoma

• M. Liposarcoma

• Answer: m

• Hyperplasia of nerve cells due to a reactive response after nerve injury:

• G. Peripheral Ossifying Fibroma

• J. Peripheral Giant Cell Granuloma

• K. Lipoma

• M. Liposarcoma

• L. Traumatic neuroma

• Answer: l

• Autosomal dominant inheritance, von Recklinghausen:

• Multiple cutaneous neurofibromas, café-au-lait spots, Lisch nodules

• A. Traumatic neuroma

• B. Neurofibroma

• C. Schwannoma

• D. Melanocytic neuroectodermal tumor of infancy

• E. Malignant peripheral nerve sheath tumor (fibrosarcoma, malignant schwannoma)

• Answer: b

• Benign schwannoma, rarely becomes malignant, treated with surgery, soft nodule:

• A. Traumatic neuroma

• B. Neurofibroma

• C. Schwannoma

• D. Melanocytic neuroectodermal tumor of infancy

• E. Malignant peripheral nerve sheath tumor (fibrosarcoma, malignant schwannoma)

• F. Multiple mucosal neuroma syndrome

• Answer: c

• Rapid growth, metastasis:

• Answer: e

• Mutation in the NF1 gene, with signs of Abraham Lincoln:

• Multiple neurofibromas in a rope-like appearance, mainly cosmetic

• A. Traumatic neuroma

• B. Neurofibroma

• C. Schwannoma

• D. Melanocytic neuroectodermal tumor of infancy

• E. Malignant peripheral nerve sheath tumor (fibrosarcoma, malignant schwannoma)

• F. Multiple mucosal neuroma syndrome

• Answer: f

• Often located in the anterior maxilla, large swelling, bone destruction, bluish-purple color:

• A. Traumatic neuroma

• B. Neurofibroma

• C. Schwannoma

• D. Melanocytic neuroectodermal tumor of infancy

• E. Malignant peripheral nerve sheath tumor (fibrosarcoma, malignant schwannoma)

• F. Multiple mucosal neuroma syndrome

• Answer: d

• Common in newborn baby girls (90%):

• A. Congenital epulis

• B. Hemangioma

• C. Melanocytic neuroectodermal tumor of infancy

• Answer: a

• Pseudotumor, dilatation and cavernous transformation of capillaries, with signs of vessel collapse:

• A. Congenital epulis

• B. Hemangioma

• C. Melanocytic neuroectodermal tumor of infancy

• Answer: b

• Rapid growth, firm, no signs of vessel collapse:

• A. Hemangiosarcoma

• B. Sturge-Weber hemangioma

• Answer: a

• Port-wine stain on one side of the face, patient often has seizures, mental retardation, calcification of the skull:

• Red-purple discoloration distributed along the trigeminal nerve

• A. Hemangiosarcoma

• B. Sturge-Weber hemangioma

• C. Kaposi’s sarcoma

• D. Lymphangioma

• Answer: b

• Not a true neoplasm but caused by stimulated vascular proliferation due to HIV:

• Slightly firm, extravasated red blood cells

• A. Hemangiosarcoma

• B. Sturge-Weber hemangioma

• C. Kaposi’s sarcoma

• D. Lymphangioma

• E. Leiomyoma

• Answer: c, in the late stages of HIV, feels like a vascular tumor, firm, does not collapse on pressure, has extravasated red blood cells

• Treatment with vinblastine, a cytotoxic drug

• No vessel collapse, surface swelling and edema due to frequent infections:

• A. Hemangiosarcoma

• B. Sturge-Weber hemangioma

• C. Kaposi’s sarcoma

• D. Lymphangioma

• E. Leiomyoma

• F. Chondroma of soft tissues

• Answer: d

• Lymphangioma is a dilatation and cavernous transformation of lymphatic vessels

• Often ulcerated, causing keratinization

• Small lesions are completely excised, larger lesions are excised piecemeal

• Pseudotumor that feels as hard as bone, due to hyperplasia:

• A. Hemangiosarcoma

• B. Sturge-Weber hemangioma

• C. Kaposi’s sarcoma

• D. Lymphangioma

• E. Leiomyoma

• F. Chondroma of soft tissues

• G. Metastatic cancer in the oral cavity

• Answer: f, Chondroma of soft tissues is a pseudotumor due to hyperplasia

• Sturge-Weber syndrome / Encephalotrigeminal angiomatosis:

• Answer: Red-purple discoloration distributed along the trigeminal nerve

• Sturge-Weber hemangioma:

• Answer: Port-wine stain around the eye, treated with lasers

• Leiomyoma:

• …

Notes:

This article is a compilation of information about soft tissue lesions of the oral and maxillofacial region. It may not be exhaustive and requires further research to add to it. You should consult other professional materials for accurate and complete information.

Furthermore, diagnosis and treatment of these lesions should be performed by specialized physicians.