CONNECTIVE TISSUE LESIONS

CONNECTIVE TISSUE LESIONS

FIBROUS
TISSUE

NEURAL TISSUE

MUSCLE TISSUE

ADIPOSE
TISSUE

VASCULAR
TISSUE

OSSEOUS &
CARTILAGINOUS
TISSUES

FIBROUS TISSUE
FIBROMA
:Also known as
Irritation fibroma
Focal fibrous hyperplasia
Fibrous nodule
Traumatic fibroma

FIBROMA
Hyperplasia of fibrous connective tissue
that evolves in response to chronic
irritation in which there is extensive
elaboration of collagen resembling scar
.tissue

FIBROMA
Most common tumor of the oral cavity

Not a true neoplasm of fibroblasts

Represents hyperplasia of fibrous tissue in

response to trauma or irritation
Production of mature collagen bundles is
increased

FIBROMA
cheek biting
Lip biting
Denture irritation

Most common
contributing factors

FIBROMA
Most common site: buccal mucosa along
.the bite line

FIBROMA
:Other common sites
Labial mucosa
Tongue
gingiva

FIBROMA
:Appearance
Smooth surfaced
Pink dome shaped nodule resembling the
.surrounding mucosa
.Can be white due to hyperkeratosis

FIBROMA
.Sessile or pedunculated
.Mostly sessile
.Size: 1.5cm or less in diameter
Age: 4-6th decade
Sex: more in Females

FIBROMA
Can represent fibrous maturation of a pre.existing Pyogenic granuloma

FIBROMA
:Frenal Tag
Type of fibroma that is found on the
.maxillary labial frenum
Small in size
Asymptomatic
Exophytic growth

HISTOPATHOLOGY OF FIBROMA

TREATMENT
Surgical excision
.Recurrence is rare
.Important to send for biopsy
No treatment required for Frenal tag

GIANT CELL FIBROMA

A fibrous tumor which does not appear to
.be associated with chronic irritation

GIANT CELL FIBROMA

GIANT CELL FIBROMA

HISTOPATHOLOGICAL
FEATURES
Epithelium is thin & atrophic with narrow &
.elongated rete ridges
Mass of loosely arranged vascular
.fibrous connective tissue
Presence of large,stellate multinucleated
fibroblasts within superficial connective
tissue

TREATMENT
.Surgical excision

INFLAMMATORY FIBROUS
HYPERPLASIA
:Also known as
Epulis Fissuratum
Denture Epulis
Denture injury tumor

INFLAMMATORY FIBROUS
HYPERPLASIA
Tumor like hyperplasia of fibrous
connective tissue that develops in
association with the flange of an ill-fitting
.complete or partial denture

CLINICAL FEATURES

CLINICAL FEATURES

CLINICAL FEATURES

CLINICAL FEATURES

HISTOPATHOLOGICAL
FEATURES

HISTOPATHOLOGICAL
FEATURES

INFLAMMATORY PAPILLARY
HYPERPLASIA
Multiple small nodules that consist of a
proliferation of fibrous connective tissue
with an associated chronic inflammation
.found under ill-fitting dentures

INFLAMMATORY PAPILLARY
HYPERPLASIA

INFLAMMATORY PAPILLARY
HYPERPLASIA

HISTOPATHOLOGY
Gross specimen has a polypoidal
.appearnace
Multiple small round nodules are seen
covered with stratified squamous
.epithelium
Epithelium shows pseudoepitheliomatous
.hyperplasia
.Dense connective tissue
.Scattered inflammatory cells

TREATMENT
HYPERPLASTIC TISSUE SHOULD BE
REMOVED BEFORE FABRICATION OF
.A NEW DENTURE

HEREDITARY GINGIVAL
FIBROMATOSIS
Hereditary form of generalized gingival
hyperplasia in which the autosomal
dominant form maybe associated with
hypertrichosis, craniofacial
deformities,epilepsy and mental
.retardation

HEREDITARY GINGIVAL
FIBROMATOSIS

CLINICAL FEATURES

AUTOSOMAL
DOMINANT TYPE

RECESSIVE FORM

HISTOPATHOLOGY

PERIPHERAL OSSIFYING
FIBROMA
Gingival nodule consisting of a reactive
hyperplasia of connective tissue
.containing focal areas of bone
:Also known as
Ossifying Fibroid Epulis
Peripheral Fibroma with Calcification
Calcifying Fibroblastic Granuloma

PERIPHERAL OSSIFYING
FIBROMA

PERIPHERAL OSSIFYING
FIBROMA

PERIPHERAL OSSIFYING
FIBROMA
Site: Occurs exclusively on the gingiva

PERIPHERAL OSSIFYING
FIBROMA
Appearance: nodular mass
Pedunculated/sessile

PERIPHERAL OSSIFYING
FIBROMA
Appearance: color ranges from pink to
.red
Mostly ulcerated
Initially ulcerated, older lesions
demonstrate healing of ulcer & an intact
.surface

PERIPHERAL OSSIFYING
FIBROMA

PERIPHERAL OSSIFYING
FIBROMA

HISTOPATHOLOGY

HISTOPATHOLOGY

PYOGENIC
GRANULOMA
Common tumor like growth of the oral
.cavity
.Non-neoplastic
Also known as Lobullar Capillary
Hemangioma

PYOGENIC
GRANULOMA
Currently categorized as a vascular tumor
under the classification scheme of the
International society for the study of
Vascular Anomalies

PYOGENIC
GRANULOMA
Fast growing reactive proliferation of
endothelial cells commonly on the
gingiva & usually in response to chronic
. irritation
A focal reactive growth of fibrovascular or
granulation tissue with extensive
. endothelial proliferation

PYOGENIC
GRANULOMA

PRECIPITATING
FACTORS

PYOGENIC
GRANULOMA

PYOGENIC
GRANULOMA

PYOGENIC
GRANULOMA

PYOGENIC
GRANULOMA

PREGNANCY TUMOR

PREGNANCY TUMOR

DIFFERENTIAL
DIAGNOSIS

HISTOPATHOLOGY
A highly vascular proliferation resembling
.granulation tissue
Numerous small & large endothelial lined
.channels engorged with RBCs
Vessels are arranged in lobular pattern
thats why given the name lobular
.capillary hemangioma
Surface is ulcerated, covered by
.fibrinopurulent membrane

HISTOPATHOLOGY
A mixed inflammtory infiltrate is seen
comprising of neutrophils,plasma cells &
.lymphocytes
Neutrophils are more towards the
.ulcerated surface
.Chronic inflammatory cells are deeper
Older lesions have more fibrous
.component

TREATMENT

BENIGN FIBROUS
HISTIOCYTOMA
A true neoplasm having fibroblastic &
.histiocytic differentiation
:Also known as
Dermatofibroma
Sclerosing hemangioma
Fibroxanthoma
.Nodular subepidermal fibrosis

BENIGN FIBROUS
HISTIOCYTOMA

CUTANEOUS LESIONS

ORAL LESIONS

HISTOPATHOLOGY

HISTOPATHOLOGY
Proliferation of spindle shaped fibroblasts with
.vesicular nuclei
Arranged in short intersecting fascicles storiform
.pattern because it resembles straw mat
Rounded histiocytes
Lipid containing xanthoma cells
Mutlinucleated giant cells
Lymphocytes
Myxoid change or hyalinization can be seen
.focally

TREATMENT
Surgical excision

MALIGNANT FIBROUS
HISTIOCYTOMA
Malignant neoplasm of fibroblasts with a
propensity to differentiate into histiocytic
.& fibrohistocytic cells

MALIGNANT FIBROUS
HISTIOCYTOMA

MALIGNANT FIBROUS
HISTIOCYTOMA

MALIGNANT FIBROUS
HISTIOCYTOMA

HISTOLOGICAL
SUBTYPES

STORIFORM-PLEOMORPHIC
TYPE
Short fascicles of plump spindle shaped
.cells arranged in storiform patten
pleomorphic & giant cells are seen with
abundant cytoplasm
Foamy cells are also seen
Nuclei show marked pleomorphism, high
.mitotic activity & atypical mitotic figures
.Invasion into adjacent structures seen

STORIFORM

GIANT CELL

PLEOMORPHIC

TREATMENT
Aggressive tumor
Radical surgical excision
recurrence rate 40%
metastasis seen 40%
.Oral tumors have worst prognosis

FIBROSARCOMA
.Malignant neoplasm of fibroblastic cells

FIBROSARCOMA
Most common
in extremeties.
Only 10% in
head & neck

Oral
cavity

Gingiva

Floor of
the mouth

Buccal
mucosa

Tongue

Mandible

FIBROSARCOMA

Age

Children &
young adults

Gender

No gender
predilection

FIBROSARCOMA

Clinical Features
Rapidly
proliferating
tumor

Firm &
indurated
on
palpation

Ulceration
No capsule
Fixation to
adjacent
structures

FIBROSARCOMA

Radiographic Features
Sharply
defined
radiolucencie
s

Root
resorption
Tooth
displacement

Cortical
expansion

HISTOPATHOLOGY
Highly cellular tumor
Composed of cells having anaplastic
.spindle shaped nuclei
Atypical mitotic figures are numerous
Cells are arranged in fascicles know as
herringbone pattern

TREATMENT
Aggressive tumor
Wide surgical excision
recurrence rate 50%
.Prognosis is not good

FIBROMATOSIS
Benign diffuse infiltrative proliferation of
fibroblasts & mature collagen occurring
within the soft tissues of head & neck in
.young patients

FIBROMATOSIS

FIBROMATOSIS

Gender

No
predilection

FIBROMATOSIS OF
NECK

ORAL FIBROMATOSIS

FIBROMATOSIS

DESMOPLASTIC FIBROMA
Benign diffuse infiltrative proliferation of
fibroblasts & mature collagen occurring
primarily within the mandible in young
.patients

DESMOPLASTIC FIBROMA
Site: Distinct aggressive tumor occurring
.within the mandible

DESMOPLASTIC FIBROMA
Young patients

Bony expansion

Displacement of teeth

Resorption of roots

Unilocular/multilocular
radiolucency

Well defined margins

at the radiograph

DESMOPLASTIC FIBROMA

NEURAL TISSUE
Neurofibroma

Traumatic Neuroma
Neural
tissue
Neruilemoma

Neurofibromatosis

TRAUMATIC NEUROMA
Painful nodular proliferation of nerve &
fibrous tissue of the nerve sheath
resulting from the futile attempt of nerve
fibers to reunite with their severed distal
.portion

TRAUMATIC NEUROMA OF
ORAL MUCOSA

HISTOPATHOLOGY
Haphazard proliferation of mature myelinated
.& unmyelinated nerve bundles
Fibrous connective tissue stroma ranges
from densely collagenized to myxomatous
.in nature
.Mild chronic inflammatory infiltrate

TREATMENT
Surgical excision including a small portion
.of involved nerve bundle
Do no recur but pain persists or return
.later

NEURILEMOMA(SCHWANNOM
A)
Well demarcated benign lesion consisting
of a fibroblastic proliferation of the nerve
sheath cell (schwann cell) producing
distinctive patterns reffered to as Antoni
.A and Antoni B tissue

NEURILEMOMA(SCHWANNOM
A)
Benign neural neoplasm of schwann cell
.origin
.Uncommon tumor
.occur in head & neck 25-48%

NEURILEMOMA(SCHWANNOM
A)

NEURILEMOMA(SCHWANNOM
A)

HISTOPATHOLOGY
.An encapsulated tumor
:Shows two microscopic patterns

ANTONI A
Streaming fascicles of spindle shaped
.schwann cells
These cells form a palisaded arrangement
around central eosinophilic acellular
zone known as verocay bodies
Verocay bodies are reduplicated basement
membrane & cytoplasmic processes

ANTONI B
Less cellular
Less organized
Spindle cells are randomly arranged
within loose myxomatous stroma

DEGENERATIVE
CHANGES
Hemorrhage
Hemosiderin deposits
Inflammation
Fibrosis
Nuclear atypia

GRANULAR CELL
TUMOR
Submucosal mass consisting of diffuse
sheets of large cells of either nerve or
muscle origin with a cytoplasm of
densely packed eosinophilic granules
(lysosomal bodies) and commonly found
.on the dorsal surface of tongue

GRANULAR CELL
TUMOR

GRANULAR CELL
TUMOR

APPEARANCE

GRANULAR CELL
TUMOR
Composed of large polygonal cells
Having abundant pale eosinophilic
cytoplasm & vesicular nuclei

GRANULAR CELL
TUMOR
Cells are arranged in sheets, cords or
.nests
.Cell borders are indistinct

GRANULAR CELL
TUMOR

GRANULAR CELL
TUMOR
Significant microscopic finding is
pseudoepitheliomatous hyperplasia of
.overlying epithelium
Can be mistaken for SCC

IMMUNOMARKERS
S-100
NSE (neuron specific enolase)
Laminin

TREATMENT
.Conservative local excision

CONEGNITAL EPULIS
Pedunculated growth on the anterior
maxilla or mandible of newborns that is
.composed of granular cells
:Also known as
Congenital gingival granular cell tumor
Congenital granular cell epulis
Congenital epulis of the newborn

CONEGNITAL EPULIS
Uncommon soft tissue tumor that occurs
almost exclusively on the alveolar ridges
.of newborn
.Also seen on the tongue

CLINICAL FEATURES

HISTOPATHOLOGY
Large rounded cells with abundant
granular eosinophilic cytoplasm
.Round to oval basophilic nuclei
Atrophy of rete ridges seen in overlying
.epithelium
Tumor cells are negative for S-100

TREATMENT
.Surgical excision
After birth tumor stops growing & decrease
.in size

LIPOMA

ORAL LIPOMA

ORAL LIPOMA

HISTOPATHOLOGY
Well circumscribed tumor with a thin
.fibrous capsule
Composed of mature fat cells which
.closely resemble normal fat cells
.Lobular arrangement of cells is seen

VARIANTS

TREATMENT
.Conservative local excision
.Variants do not affect the prognosis
Infiltrative lipomas have high recurrence
.rate

LIPOSARCOMA

LIPOSARCOMA

LIPOSARCOMA

LIPOSARCOMA

WELL-DIFFERENTIATED
LIPOSARCOMA
.Most common in the oral cavity
.of all cases 55-90%
Resemble benign lipomas
Show scattered lipoblasts & atypical
.hyperchromatic stromal cells

MYXOID
LIPOSARCOMA
Lipoblasts within myxoid stroma
.Stroma has a rich capillary network

ROUND CELL
LIPOSARCOMA
More aggressive form of myxoid
liposarcoma having less differentiated
.round cells

PLEOMORPHIC LIPOSARCOMA
Extreme cellular pleomorphism
.Giant cells

TREATMENT
.Radical excision
.recurrence rate 50%
Prognosis of pleomorphic liposarcoma is
much worse as compared to myxoid &
.well differentiated
Prognosis of oral liposarcoma is good

Leiomyoma

Muscle
tissue
Rhabdomyoma

LEIOMYOMA
Benign tumor of smooth muscle within the
oral cavity, usually of the blood vessels,
that appear as firm,movable,submucosal
.nodule
Most common sites are: uterus, GIT &
.skin
.Oral leiomyoma are rare

ORAL LEIOMYOMA
Slow growing
Firm mucosal nodule
Can occur at any age
Asymptomatic mostly
Lips, tongue, palate & cheeks

HISTOPATHOLOGY
SOLID

VASCULAR

EPITHELIOD

Well circumscribed Well circumscribed

Interlacing bundles
Multiple tortuous
of spindle shape
blood vessels with
smooth muscle
thickened walls
cells
with intertwining
Mitotic figures not bundles of smooth
muscle
common

Composed
primarily of
epitheloid cells

HISTOPATHOLOGY
Smooth muscle cells are spindle shaped
with elongated nuclei and blunt ends
cigar-shaped appearance

TREATMENT
.Local surgical excision

LEIOMYOSARCOMA
Malignant neoplasm of smooth muscle
.differentiation
.Most common sites: uterine wall & GIT
Oral leiomyosarcoma are rare

ORAL
LEIOMYOSARCOMA
Middle age & older adults
occur in jaw bones 50%
Enlarging mass ay or may snot be painful

HISTOPATHOLOGY
.Fascicles of spindle shaped cells
Pleomorphism & atypical mitotic figures
.seen
.Epitheloid cells also present

LEIOMYOSARCOMA

LEIOMYOSARCOMA

IMMUNOMARKERS
Desmin
Smooth muscle actin
Smooth muscle myosin
Muscle specific actin

TREATMENT&
PROGNOSIS
.Radical surgical excision
Prognosis for oral tumor is not good with
the potential for local recurrence &
.distant metastasis

RHABDOMYOMA
Benign neoplasm of skeletal muscle
.Extremely rare
Rhabdomyomas of head & neck are
classified into

Adult

Fetal

ADULT
RHABDOMYOMA

CLINICAL FEATURES
Middle age & older
adults
Can be
multinodular
& multicentric

Nodule or
mass, rapid
growth

found 70%
in men

ADULT
RHABDOMYOMA
Floor of
the mouth
Oral
cavity

Soft
palate
Base of
tongue

Site
Pharynx

Larynx

ADULT
RHABDOMYOMA
:HISTOPATHOLOGY
.Well circumscribed tumor
Composed of large polygonal cells having
abundant granular eosinophilic
.cytoplasm
Cells show peripheral vacuolization which
.gives a spider web appearance
.Focal cells with cross striations are seen

ADULT
RHABDOMYOMA
:IMMUNOHISTOCHEMICAL STUDIES
Desmin
Myoglobin
.Muscle-specific actin

FETAL
RHABDOMYOMA

CLINICAL FEATURES
Young children
Face

Periauricular
region

Males

FETAL
RHABDOMYOMA
:HISTOPATHOLOGY
Haphazard arrangement of spindle shaped
.muscle cells within a myxoid stroma
Some tumors are mistaken for
rhabdomyosarcoma for high cellularity &
.Pleomorphism

TREATMENT
.Local surgical excision

RHABDOMYOSARCOM
A
Malignant neoplasm characterized by
.skeletal muscle differentiation

RHABDOMYOSARCOM
A

RHABDOMYOSARCOM
A

RHABDOMYOSARCOM
A

RHABDOMYOSARCOM
A

RHABDOMYOSARCOM
A

HISTOPATHOLOGY
EMBRYONAL RHABDOMYOSARCOMA
Small round or oval cells with hyperchromatic
.nuclei & indistinct cytoplasm
.Strap shaped rhabdomyoblasts are seen
:Markers
Desmin
Myogenin
Muscle specific-actin

HISTOPATHOLOGY
ALVEOLAR RHABDOMYOSARCOMA

Aggregates of poorly differentiated round to oval cells separated

.by fibrous septa
Cells demonstrate central loss of cohesiveness which results in
.alveolar pattern
Peripheral cells adhere to septal walls in a single layer and
.central cells appear to float freely within the alveolar space
Mitosis
.Multinucleated giant cells

PLEOMORPHIC
RHABDOMYOSARCOMA

TREATMENT
.Local surgical excision
.Chemotherapy

ANGIOSARCOMA
Rare malignancy of vascular endothelium
which can arise from either blood or
.lymphatic channels
More than 50% cases occur in head &
.neck region
Scalp & forehead are the most common
.sites
.Oral lesions are rare

APPEARANCE

ORAL
ANGIOSARCOMA

HISTOPATHOLOGY
Infiltrative proliferation of endothelium lined
.blood vessels
Vessels form an anastomosing network
Endothelial cells are hyperchromatic &
atypical and tend to pile within the
.vascular Lumina
.Increase mitotic activity seen

IMMUNOHISTOCHEMICAL
STUDIES
CD31
Factor VIII-related antigen

TREATMENT&PROGNO
SIS
Radical surgical excision
Radiotherapy
.Prognosis for face & scalp is poor
Oral outcome is better

NASOPHARYNGEAL
ANGIOFIBROMA
Rare vascular & fibrous tumor like lesion
.that occurs only in nasopharynx
Benign lesion but locally aggressive &
.destructive behaviour
May represent a vascular malformation
.then a true neoplasm

NASOPHARYNGEAL
ANGIOFIBROMA

NASOPHARYNGEAL
ANGIOFIBROMA

NASOPHARYNGEAL
ANGIOFIBROMA
CT
scan
MRI

NASOPHARYNGEAL
ANGIOFIBROMA

NASOPHARYNGEAL
ANGIOFIBROMA
TREATMENT
Surgical excision
Radiation therapy in case of recurrence
Recurrence is 20-40%
Malignant transformation into
.Fibrosarcoma

LYMPHANGIOMA
Benign proliferation of lymphatic vessels
that occur as focal,superficial lesion
within the oral cavity and as a massive
.diffuse lesion of neck (cystic hygroma)

LYMPHANGIOMA
These are developmental malformations of
lymphatic tissue which do not
communicate with rest of the lymphatic
.system

LYMPHANGIOMA

LYMPHANGIOMA

CERVICAL
LYMPHANGIOMA

CERVICAL
LYMPHANGIOMA

ORAL LYMPHANGIOMA

HISTOPATHOLOGY
Composed of lymphatic vessels showing
.marked dilatation or cyst like spaces

HISTOPATHOLOGY
Vessels infiltrate the soft tissues & may
demonstrate lymphoid aggregates in
their walls

HISTOPATHOLOGY
Lining is thin & space contains
proteinaceous fluid & some
.lymphocytes
.

HISTOPATHOLOGY
Intra oral tumors are located just beneath
the epithelial surface & often replace
. connective tissue

TREATMENT
.Local surgical excision
High recurrence rate in case of oral
.lymphangiomas
Low recurrence rate in case of cervical
.lymphangioma
.Prognosis is good
Respiratory complications & death can
.occur

HEMANGIOMA & VASCULAR

MALFORMATIONS
HEMANGIOMA
Benign tumors of infancy that show a rapid
growth phase with endothelial cell
.proliferation followed by gradual involution
VASCULAR MALFORMATIONS
Structural anomalies of blood vessels without
endothelial proliferation. They are present
.at birth & persist throughout life

HEMANGIOMA OF
INFANCY

HEMANGIOMA OF
INFANCY

HISTOPATHOLOGY
Numerous plump endothelial cells &
indistinct vascular lumina known as
.juvenile or cellular hemangioma
As the lesion matures endothelial cells
flatten and vascular spaces become
.more evident
Involution: vascular spaces less prominent
and replaced by fibrous connective
.tissue

VASCULAR
MALFORMATIONS
:PORT WINE STAIN
A vascular anomaly of superficial & deep
dilated capillaries in the skin producing
.reddish to purplish discoloration of skin
Most common on the face along the
.distribution of trigeminal nerve
.in newborns 0.3-1%
.Persist through out life

VASCULAR
MALFORMATIONS

INTRABONY VASCULAR
MALFORMATIONS

INTRABONY VASCULAR
MALFORMATIONS

HISTOPATHOLOGY
Do not show active endothelial
.proliferation
Capillary malformations: capillary sized
vessels
Venous malformations: more dilated
vessels
Arterio-venous malformations: mixture of
thick walled arteries, veins and
.capillaries

NEUROFIBROMA
It arises from schwann cells and perineural
.fibroblasts
Site: most common site is skin. In oral
.cavity, tongue & buccal mucosa

NEUROFIBROMATOSIS

NEUROFIBROMATOSIS
TYPE I

DIAGNOSTIC CRITERIA FOR

NEUROFIBROMATOSIS TYPE I

DIAGNOSTIC CRITERIA FOR

NEUROFIBROMATOSIS TYPE I

ORAL
MANIFESTATIONS

ORAL
MANIFESTATIONS

TREATMENT
No specific therapy and treatment is just
done to prevent and manage
.complications

COMPLICATIONS

PROGNOSIS
Prognosis in case of Malignant Peripheral
nerve sheath tumor is poor with 5 year
.survival rate in only 15 cases
Average lifespan of NF1 patient is reduced
by 15 years