Surgery OF THE
D.D.S., F.A.C.D., AND IRWIN LANGEL,** D.D.S., NEW YORK, N. Y.
HE benign soft tissue tumors of the oral cavity are of either connective or epithelial tissue in origin. It is fortunate that the majority of these tumors are of connective tissue. We know that well over 90 per cent of t,he malignant tumors found in the oral cavity are epithelial in nature. Therrfore, the probability of a soft tissue fibrous neoplasm, as compared with a benign epithelial neoplasm, in the oral cavity, becoming malignant is practically nil and certainly would be worthy of a case report. In discussing soft tissue tumors of the mouth we first must describe some inflammatory conditions, which, by their appearance and location, clinically resemble some of the benign tumors. Hypertrophied
This is not a neoplasm, but an inflamnmtory process, and often resembles some of the benign tumors. It is the most prevalent type of tissue growth seen in the mouth and forms at the site of chronic irritation. Hypertrophied tissue may be seen in various parts of the mouth. However, extensive overgrowth of tissue is seen most frequently in the upper anterior region. ‘This is due to poor occlusion and excessive anterior stress often observed in mouths in which a full upper denture functions against the six lower anterior teeth without any posterior replacements in the lower arch. It also is observed in mouths in which an absorption of alveolar bone has taken place anteriorly due to the patient’s failure to return periodically to his dentist, for checking and correction of any changes that might have occurred. Absorption of the alveolar bone causes a constant riding of the flanges of t’he denture into the mucobuccal fold, resulting in the formation of this overgrowth of tissue. These lesions are painless and seldom ulcerate. They may be singIe or they may occur in multiple folds. They have a sessile base. The overlying College of Dentistry, New *Assistant professor of oral surgery, New York Knixrsity York, N. Y.: director and attending oral surgeon, Feth Israel Hospital, New York, N. Y.; Oral Surgeon, Monteflore Hospital, New York, N. Y. **Assistant clinical professor of oral surgery, New York Tniversity, College of Dentistry. New York, N. Y. ; oral surgeon, Rockaway Beach Hospital, New York, N. Y.
mucous membrane is normal in color. They are rather firm and do not bleed easily. It is surprising to see to what extent the lesions will grow and over how long a period the dentures are tolerated over them before patients will Present themselves for diagnosis and treatment. In spite of their long duration and the constant irritation these lesions receive, we have never seen a case of hypertrophied tissue become malignant. %?erplasia occasionally is seen on the palate due to poor relief of hard areas or where vacuum chambers are used. Papillary hyperplasia of the entire palate is seen occasionally where, due to absorption of the underlying bone of the ridges, there is marked ,mobility and a movement of the denture laterally. Individual papillae between teeth may become hypertrophic due to irritation from malocclusion, presence of caries, calcareous deposits under the of the gingival margins, ill-fitting restorations, etc. Generalized hypertrophy papillae, upper and lower jaws, can be seen in vitamin deficiencies such as scurvy ; in blood dyscrasies (for example, lymphatic and myelogenous leuIn the use of Dilantin Sodium for kemias), and in endocrine disturbances. central nervous system diseases such as epilepsy, some patients will show a reaction to the drug, manifested by gingival hyperplasia consisting of overgrowth of submucosal fibrous tissue covered by normal or thickened mucosa. Differential diagnosis is made by a careful history and clinical and laboratory examinations. Treatment.-The operative procedure involves the removal of this redundant tissue at its base, with either scalpel or high-frequency current. The height of the buccal sulcus can be maintained by proper suturing of the lips of the wound to the underlying periosteum or by the use of a modeling compound stent or gauze dressings, with or without the denture in position, until epithelization takes place (Fig. 1). Fibrous This fibroma fingerlike which is a sessile lip (Fig.
so-called tumor is not a true neoplasm, but it does resemble the and papilloma except that it is softer in texture. It is a localized projection of fibrous tissue and has an overlying mucous membrane, normal in color. It usually is pedunculated, but at times it may have base. It is most frequently located on the cheek, palate, tongue, and 2). It will not recur if removed thoroughly. Epulis
The term epulis, meaning “growth on the gums, ” is no longer of any value. Gingival tumors should be classified according to their clinical and If epulis is used, it should be qualified by the name histologic characteristics. denoting its pathogenic identification. Fibroma The fibroma is a common tumor in the mouth. It varies in size, grows slowly, and can be found throughout the oral cavity. Clinically, the fibroma
OF ORAT, CAVITY
Fig. 1.--A, Photograph showing ill-fltting denture : B, hyperplasia of mucous membrane with numerous folds due to invagination of denture; 0, photograph after removal of redundant photograph, twenty-four hours after removal of tissue. tissue: D, postoperative
polyps of the cheek.
is firm, covered by smooth mucous membrane, and normal ill color. It Inay be pedunculated or it may have a sessile base (Fig. 3). It is said t,hat it arises from the periosteum in edentulous areas or from the periodontal membrane or periosteum when teeth are present. A fibroma generally does not recur when removed thoroughly.
Angiofibroma This growth clinically lies between the fibroma and the peripheral giantcell tumor. It is more vascular in appearance than the fibroma and is covered by smooth epithelium. It is found chiefly on the gingiva, arising from the periosteum or periodontal membrane. It may have either a pedicle or a sessile base. Bleeding may occur when it is irritated. Its texture is not as firm as the fibroma (Fig. 4). The chief differential picture, histologically, from the peripheral giant-cell tumor is the absence of giant cells of foreign body type. The angiofibroma may cause spreading of teeth and destruction of underlying bone. It grows more rapidly than the fibroma and, when removed, may have a tendency to recur. Following its removal, it is best to cauterize its base with the high-frequency current to prevent recurrence.
Peripheral Giant-Cell Tumor Most men using the term epulis confine it to mean the peripheral giantcell tumor. Here, too, I believe it would be best to qualify it with its proper name of identification, such as peripheral giant-cell epulis. This tumor is more vascular than the fibroma and angiofibroma. It is bluish or purplish red in color. It is softer in texture and has a tendency to bleed readily when irritated. It may be lobulated in appearance, and it varies in size from that of a pea to larger than a plum (Fig. 5). It is the most frequent of these benign tumors and is predominately seen in women. It is seen in all perinds of life, but occurs, mostly in the fourth, fifth, and sixth decades. When found between the teeth, it will cause separation and often invade and destroy the underlying bone. This tumor grows more rapidly than either the fibroma or the angiofibroma and may recur even if removal is followed by cauterization of its base. Where an attempt at conservation has been made to retain the adjacent teeth and recurrence follows, these teeth should be removed, along with a block of underlying bone below the origin of the growth. This should be followed by cauterization of the new base. Histologically, the picture is decidedly vascular and giant cells, which seem to take their origin from the vessel spaces, are present.
Pregnancy Tumors The pregnancy tumor resembles the peripheral giant-cell tumor in color during pregnancy may cause and texture (Fig. 6). Hormonal stimulation hypertrophy of the gingival papillae, and at times this hypertrophy may deGenerally, after parturition, velop into one or more pedunculated tumors. the hypertrophy of the papillae will disappear. If the process has developed into pedunculated growbhs, they may recede and reduce in size, but they do not completely disappear.
of the pingiva
of th+% upper
of the upper year later.
If these tumors interfere with the eating of solid foods, or if they bleed easily when traumatized, they should be removed during the pregnancy. They are best removed by the use of the high-frequency current.
Myxofibroma Myxofibromas occasionally may be seen really they are central bone tumors. This type to recur than the fibroma, and it generally The operation for the removal of this type of in nature than for the removal of a fibroma.
as peripheral tumors, but genof tumor has a greater tendency destroys the underlying bone. growth should be more radical
Case Report A 27-year-old
Past History.--No history of childhood diseases was revealed. The patient had been married nine years and had three children, the youngest 3 years of age. There was no history of any miscarriages. Present History.-The patient was conscious of a bulging and growing mass in the upper left side of the mouth for about nine months. She did not seek any medical or dental services, for fear that this might prove to be a cancer. In the past month she noticed that an upper molar tooth was becoming loose and about Sept. 15, 1933, when she developed some discomfort in eating, she sought the services of her physician, who referred He thought her condition or infection, as he her to her dentist for removal of the tooth. Her dentist removed the upper first molar called it, was all due to the offending molar. and referred her for diagnosis and treatment. fifteen
The patient had suffered from severe pounds in weight in the past two
Clinical Examination.-A to the left third molar,
cauliflower with marked
headaches months. growth bulging
the past two years
and had lost
extended from the upper left first preon the palatal and buccal surfaces (Fig.
Rig. 7.- AC :auliflower molar.
TLl1\IORS OF ORhI, ChVITY
growth extending from the upper left first premolar to the with marked bulging on the pal&al and buccal surfaces.
Fig, R.--Intraoral fllm and occlusal view showing marked destruction of bone in premolar molar area with radiating spicules of bone within the soft tissue mass.
Fig. 9.- -1
into the left m axil
BEKIGN SOFT TISSUE TU~IORS OF 011.\1, C.\VITY i).
(the second molar w:ts removed by her dentist) Yho\ved X;o adenopathy was presrr~t. There was no pain or bleeding. marked mobility. Radiograpfic Examination.-Intraoral and occlusai films showed marked destructioli of bone in premolar and molar area with radiating spicules of bone within the soft tissue mass. There appeared to be an extension of the growth into the maxillary sinus (Fig. $1. The posteroanterior plate showed the growth extending into the left mnxillxry 3inus :I.7 if it, pushed t.he floor upward, filling one-half of the sinus (Fig. 9 1. Clinical Diagnosis.--Fibroma or osteofibroma. Biopsy Report.-Sept. 27, 1933. Myxofibroma. Operative Note.-Ott, 6, 1933. Under local anesthesia, complete removal of the gro0wl.h was accomplished. This was a thiek, fibrous mass extending into the antrum, the size being about that of a small apple (Fig. 10, A). There was very little bleeding. The growth was somewhat circumscribed. The upper left third molar was removed. A dressing was inscrtcd. Postoperative Note.-The dressing was changed daily for ten days, and on Nov. 6, 193::. the patient WRYdischarged, with orders to report in six weeks for further observation. On Jan. 8, 1934, the tissues appeared normal (Fig. IO, B) and the roentgenograms WY negative. tihc was eomplrtely relieved of headaches and had gained ten pounds in weight. upper
Lipoma This tumor is rather rare in the oral cavity. It can be found wherever, adipose tissue is present normally, as in the cheeks, in the region of the cu~pus adiposum buccal. IJypomas are generally movable ma.sse. They may be lobulated and, when not too deeply imbedded beneath the surface, will show through yellowish in color. The lipomas will not recur if completely removtrtl.
Mixed Tumor These tumors may be found in any of the salivary glands, but most fr-Vquently in the parotid gland. In the oral cavity they may OWUT where H~L~COUS gland Gssue is present. They are seen most frequently on the hard and so.ft. palates, occasionally in the cheek, ant1 more ra~,ely in the lips. They vary i!i size and grow slowly. On the palate they are located off the midline nntf allpear as a distinct nonfluctuant, noninfla.mmatory swelling. The overlying epithelium is normal in color and appearance. They may he encapsulattttl, but more often are not. If not, they spread, infiltrating the adjacent tissucx. These mixed:tumors in the mouth are usually benign in nature. Unless cottapletely removed, they will recur because of t.heir infiltrating charactcAGstic:s. Excision should be wide and thorough. Where t,hese growths are encapsulatrct the overlying mucous ,membrane e&n he split and preserved; otherwise wicie excision, including t,he overlying mucous membrane, should be made. with either the knife or high frequency current. The wound then can 1~ packe;l with Vaseline gauze and permitted to granulate in from its base. The difficulty in diagnosis of mixed tumors of t.he salivary tissue licls in the possibility that these tumors may be benign in one area and malignant in another area. Biopsies of these growths are not definitive, as the cells from the region from which the biopsy wns taken may not have the SRIIIV (ahilract&sties as cells found in another part, of the same growth.
Case Report a gr
Oil Malrch 29, 1946, a man, 45 years of age, was referred for diagnosis and t.rea.tment of on the palate. A.
Palate; B, photograph of growth after
Present History.-The growth extended from the upper right first premolar to the soft palate, from a few millimeters off the gingival margin to the midline. This growth had 21 sessile base and was rather firm to the touch. There was no pain. and duration, according to the patient, was about thirty years (Fig. 11, .i). Radiographic Clinical
films were negative.
April 12, 1946.-An encapsulated growth from right. hard palate vias removed uudel local anesthesia (Pig. 11, B). Bone was destroyed about 2 mm. by 2 mm. in the center of membrane could be seen, bol the right palate opposite the molar area. The schneiderian The edges of the lips of the thin mucous membrane were did not appear to be penetrated. approximated and sutured. It PIas questiouable whether this membrane would have enough blood supply to live. The specimen was sent. for microscopic examination. the patient felt very little pain; April 15, 1946.-The wound was healing nicelv; Penicillin tablets were in there was some sloughing at anterior margins of the wound. serted, and the opening was covered with gauze dressing. ning
April 17, 1946.-‘l’herc to set in. April
May 7, 1946.-The June 12, 1946.-The Microscopic
was no extension wound
Feb. 21, 1947.-The wound The patient was dismissed (Fig.
was granulating. was granulating. was completely tumor
was healed, 12).
and the patient
(C. 0. Darlington, was wearing
M.D.). a partial
Adenoma It is found on Adenoma resembles the mixed tumor of the salivary type. the hard and soft palates and off the midline. This tumor does not occur as bluer or purplish &Ie frequently as the mizred tumor. The color is OrdiIIarily to the small blue or purple basa,l type cells. It usually is well encapsuate(l and, therefore, comparatively easier to enucleate.
Case Report Present History.-On April University College of Dentistry, months.
8, 3937, a 31.year-old woman presented at the New York complaining of a swelling on the palate for the past fexv
Clinical Examination.-Examination revealed a painless, well-circumscribed growth about the size of a hazel nut, on the right hard palate, extending from the first premolar to the first molar region. The overlying mucous membrane was smooth. It was bluish reti in color and had a sessile base (Fig. 13). Clinical
Operative Note.-Under local anesthesia, an incision was made 0.25 cm. away, circumscribing the entire growth. This mass was removed en toto. The wound was packed to control bleeding. Ihe section studied showed a strip of epiderm and a Microscopic Examination.-’ nodule beneath it. A zone of aeellular collagen separated the two. The nodule wns well defined, separated from the surrounding tissue by a condensation of connective tissue. In this capsule there were remnants of an acinar duct system resembling salivary gland. The nodule itself, in several fields, was made up ,of acinar-like spaces. Even serving ducts eould
be made out. For the most part, its acinar structure had been distorted. elaborated secretions were spilling over into adjacent acini. The cells round regular nuclei. Diagnosis.-Adenoma
Lining cells and were pale, with
The dressing was changed several times within the next week, and the wound ulated in from the base and was completely epithelized within three weeks.
side of palate.
report : adenoma.
Hemangioma .These tumors of the oral cavity may be single or multiple. They are due to proliferation and dilation of capillaries and smaller veins, or they may consist of spaces filled with blood. They are generally congenital, but may arise from trauma. These vascular tumors may be found on the lip, cheeks, tongue, floor of the mouth, buccal mucosa, and practically any part of the oral cavity. They vary in size and are bluish red, soft, and painless. The cavernous type is usually uneven or nodular in nature and can be emptied or may flatten out on pressure, only to refill when pressure is released. The localized and smalLer vascular tumors of the oral cavity can be treated successfully by injecting the tumor with sclerosing solution, Sclerosing solution in hemangiomas destroys the epithelial lining of these spaces and so causes obliteration of the space by formation of fibrous tissue in the area. In a vessel, the solution causes thrombosis with secondary sclerosis, atrophy, and absorption of the vessel. To be effective, it does not have to come in contact with the vessel lining.
Case Report On Oct. 5, 1941, a man, aged 42, presented himself at the oral surgery clinic, New York University College of Dentistry, for removal of teeth. ‘Clinical Examination.-Examination revealed a bluish raised mass on the inner surface of the left cheek, about 1 cm. from the corner of the mouth. It measured about 1.5 The base was sessile (Fig. 14, a). The surface was rather lobulated. cm. in diameter.
Fig. 14.- A, [email protected]
of left cheek;
[:, yostopera tive
report : papilloma.
The Patient claimed this growth had been present as long as he could remember. It never bothered him. He was advised to have this treated, especially in view of the anticipated removal of teeth and replacement with artificial dentures. Oct. 5, 1941.-One-half cubic centimeter of sodium psylliate was injected into the mass after the growth had been penetrated with a needle attached to a syringe, and some blood aspirated. Oct. 12, 1941.-The color of the lesion changed to pale blue, and appeared to be reduced about one-half in size. The patient claimed he had no discomfort following the treatment. The same procedure was repeated, and again 0.5 CL. sodium psylliate was injected. Oct. ,19, 1941.-The color of the area was almost that of normal mucous membrane; the lesion had practically disappeared. There was a alight indurated feel to the tissue in this area. Nov. 2, 1941.-The lesion had completely disappeared. The mucous membrane was normal in color and character (Fig. 14, B).
Papilloma This is an epithelial outgrowth, benign in nature. It usually is seen on the cheeks, palate, and tongue. This tumor may be pedunculated or it may have a sessile base. It is covered by mucous membrane, papillary in nature and normal in color (Fig. 15). It is painless, does not bleed, and is firmer in character than the polyp. It is even more essential to avoid any irritation to this type of growth than to the fibrous type. Constant irritation to epithelial type tissues may change the character of the cells. Papillomas with hornified surfaces may have malignant changes. This tumor will not recur if thoroughly removed.
Summary Many of these soft tissue tumors do resemble each other. A clinical differential description for recognition has been presented. A true diagnosis can be made only from a microscopic examination of the tissue after removal. (This is the first of a series of six articles, which will be continued in forthReferences for the entire series will appear at the coming issues of the Journal. end of the sixth article.)