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TITLE: Odontogenic Cysts and Tumors

There are a variety of cysts and tumors that affect the osseous marrow and cortex of the jaw bones, which may be uniquely derived from the tissues of developing teeth. It is important as an otolaryngologist to be aware of the variety of tumors and the presenting symptoms in these patients. A review of dental embryology is essential for further discussion of this topic.

In the earliest stage of tooth development, projections of dental lamina form invaginations into underlying ectomesenchyme. These cells differentiate into a layered cap with an inner and outer enamel epithelium, which contain inner stratum intermedium and stellate reticulum layers. Changes also occur in the underlying ectomesenchyme forming the dental follicle and dental papilla. esenchymally derived odontoblasts form along the dental papilla and secrete dentin, which induces the inner enamel epithelium to become ameloblasts. Ameloblasts are responsible for enamel production and eventual crown formation. Cementoblasts and fibroblasts from the dental follicle mesenchyme deposit cementum on the root surface and form the periodontal membrane, respectively. The penetration of these cells through !erwig"s sheath at the edge of the enamel organ give rise to epithelial rests of alasse# within the periodontal ligament. The enamel organ then involutes to a monolayer, which becomes squamoid and ultimately fuses with the gingiva during eruption.

Diagnosis of Odontogenic Cysts and Tumors

The most important concept in the management of odontogenic pathology is obtaining a complete history and thorough physical examination. $uestions about pain, loose teeth, recent occlusal problems, delayed tooth eruption, swellings, dysthesias or intraoral bleeding may be associated with odontogenic tumors and%or cysts. In addition, parasthesias, trismus, and significant malocclusion may indicate a malignant process. The onset and course of the growth rate of a mass should be elicited. The general head and nec& examination should include careful inspection, palpation, percussion and auscultation of the affected part of the jaw and overlying dentition. Auscultation of the affected part of the jaw, as well as the common carotid and bifurcation may identify the bruit of a vascular malformation or tumor. 'adiologic examination is usually the first procedure of choice in the evaluation of jaw related cyst and tumors. A panorex radiograph will often confirm clinical suspicions and have implications as to differential diagnoses. There are a variety of dental radiographic views that are routinely obtained during a dentist office visit that may incidentally discover occult cysts or tumors. In general, well(demarcated lesions outlined by sclerotic borders suggest benign growth, while aggressive lesions tend to be ill(defined lytic lesions with possible root resorption. )ith larger more aggressive lesions, computeri#ed tomography may more clearly identify bony erosion and%or invasion into adjacent soft tissues.

A differential diagnosis is developed and tissue is then obtained for histologic identification of the lesion. *ine needle aspiration is excellent for ruling out vascular lesions prior to open biopsy and may be helpful to diagnose inflammatory or secondarily infected lesions. +pen biopsy may be incisional ,preferred especially for larger lesions prior to definitive therapy- or excisional ,for smaller cysts and unilocular tumors-.

Odontogenic Cysts
All true odontogenic cysts are characteri#ed by epithelium lining a collagenous cyst wall. They are believed to arise from proliferation of normally quiescent epithelium in the jaw , i.e., gingival rests of .erres, rests of alasse#- Cysts can be divided into inflammatory and developmental categories. Inflammatory Cysts Radicular (periapical) Cyst This is the most common odontogenic cyst ,/01- and is thought to arise from the epithelial cell rests of alasse# in response to inflammation. In fact, practically all radicular cysts originate in preexisting periapical granulomas. 'adiographic findings consist of a pulpless, nonvital tooth that has a small well(defined periapical radiolucency at its apex are diagnostic. 2arge cysts may involve a complete quadrant with some of the teeth occasionally mobile and some of the pulps nonvital. 'oot resorption may be seen. The cyst is painless when sterile and painful when infected. icroscopically, the cyst is described with a connective tissue wall that may vary in thic&ness, a stratified squamous epithelium lining, and foci of chronic inflammatory cells within the lumen. Treatment is extraction of the affected tooth and its periapical soft tissue or root canal if the tooth can be preserved. Paradental Cyst An inflammatory cyst forming most often along the distal or buccal root surface of partially impacted mandibular third molars, this cyst is thought to be the result of inflammation of the gingiva overlying a partly erupted third molar. 'adiographically, it presents as a radiolucency in the apical portion of the root and represents from 3.01 to 41 of all odontogenic cysts. Treatment is by enucleation. De elopmental Cysts Dentigerous (follicular) Cyst This is the most common developmental cyst ,541and is thought to originate via the accumulation of fluid between reduced enamel epithelium and a completed tooth crown. It is usually found in the mandibular third molars, maxillary canines, and maxillary third molars. These cysts are most prevalent in the second to fourth decades. 'adiographically, a unilocular radiolucency with well defined sclerotic margins encircling the crown of an unerrupted tooth is seen. ost cysts are asymptomatic, but large lesions can cause displacement or resorption of adjacent teeth and pain. !istologically, a cyst composed of thin connective tissue walls lined by stratified non(&eratini#ing squamous epithelium over a fibrocollagenous cyst wall. Treatment is with enucleation or decompression followed by enucleation if large.

De elopmental Lateral Periodontal Cyst ! This cyst may arise from epithelial rests in the periodontal ligament or may represent a primordial cyst originating from a supernumerary tooth bud. It is most frequently encountered in the mandibular premolar region in adult men over 43 years. +n radiographs, this cyst is an interradicular radiolucency with well(defined or corticated margins The adjacent teeth usually show some degree of root divergence and are vital. icroscopically, the cyst lining is either non&eratini#ing stratified squamous or stratified cuboidal epithelium with a minimally inflamed fibrous wall. The treatment is surgical enucleation or curettage with preservation of adjoining teeth. Odontogenic "eratocyst (O"C) This is a specific and microscopically distinct form of odontogenic cyst that may assume the character of any of the odontogenic cysts. +6C comprises approximately 771 of all cysts of the jaws and are most often seen in the mandibular ramus and angle. It may be associated with the crown of a tooth appearing as a dentigerous cyst or may represent a &eratini#ing variant of the lateral periodontal cyst. 'adiographically, it can mimic any of the jaw cysts and may appear as a well(marginated inter(radicular radiolucency, a pericoronal radiolucency or a multilocular radiolucency. )hen multiple &eratocysts of the jaws are observed, the nevoid basal cell carcinoma syndrome should be investigated. The histologic features of +6Cs include a thin epithelial lining with underlying connective tissue composed of a thin collagen layer with islands of epithelium that may represent other early cysts. .econdary inflammation may mas& these characteristic features of +6C, resulting in misdiagnosis of a dentigerous, lateral periodontal, paradental or other more benignly behaving cyst. The most problematic clinical aspect of the +6C is the high frequency of recurrence, up to /51 in some studies, most recurring within the first 0 years of treatment. The thin and friable lining of the cyst wall often ma&es complete removal with enucleation difficult. Also, satellite cysts within the fibrous cyst wall may lead to recurrence if incompletely removed. Treatment often depends on the extent of the initial lesion. .mall +6Cs may be treated with simple enucleation if the entire cyst lining can be removed. Association with an impacted tooth requires removal of the cyst and tooth. A number of authors advocate removal of overlying soft tissues, which may contain remnant epithelial elements, in an attempt to decrease recurrences. The most common current method is total enucleation with or without a 8peripheral ostectomy9 to carefully excise the entire specimen. A recent study by :ataineh, et al., promotes complete resection without continuity defects through an intraoral approach. They advocate resection of cortex bone approximately 7 cm around the lesion with sacrifice of any teeth incontinuity with the lesion. )hen perforation of the cortex occurred, the overlying mucosa%soft tissues were also excised. The osseous walls of the defect were abraded with course surgical burs and the defect was pac&ed with )hitehead"s varnish on Iodoform gau#e for 0 to ; days. The inferior alveolar nerve was free of pathologic tissue and spared in all cases. <o reported recurrences with a follow up from 5 to ; years were found with this method. 2ong term follow(up with periodic x(ray is recommended, as +6Cs have been &nown to recur 53 to 43 years after initial treatment. #landular Odontogenic Cyst (#OC) This is one of the more recently described odontogenic cysts. It is uncommon, originally described in 7=;; by >ardner, et al.. ost have been reported to occur in the mandible ,;?1-, particularly the anterior region ,=31-. The age range is from 74 to =3 years, with a mean of 4=.0 years. .welling is the most common complaint with pain about 431 of the time. These cysts tend to have a very slow progressive growth. 'adiographically, they can present as either unilocular or multilocular radiolucencies. Its histology shows a stratified epithelium with cuboidal, sometimes ciliated, surface lining cells.

There is a polycystic nature to the lesion with both secretory elements and stratified squamous epithelium, often with epithelial spheres, plaques, or plaque(li&e thic&enings. There is considerable overlap between the histologic features of the >+C and central low(grade mucoepidermoid carcinoma. This cyst has a considerable recurrence potential, about 501 after either enucleation or curettage, so some have suggested marginal resection. Curettage or enucleation can still be effective, provided the clinician follows the patient closely for several years, and the lesion does not involve the posterior maxilla. $onodontogenic cysts Incisi e Canal Cyst This is a developmental nonodontogenic cyst derived from embryonic epithelial remnants of the nasopalatine duct or incisive canal. It typically occurs in adults ,4th to /th decades- with no sex predilection. It is a well(delineated oval or heart(shaped radiolucency located between and apical to the two maxillary central incisors in the midline. @alatal swelling is common, and occasionally, the incisors will show evidence of root resorption. The cyst is asymptomatic and is usually an incidental finding on routine dental radiographs. !istologically, the cyst may be lined by stratified squamous epithelium, respiratory epithelium, or both. Treatment may consist of surgical enucleation or periodic radiographic follow(up. @rogressive enlargement warrants surgical intervention. %tafne &one Cyst The .tafne ,static- bone cyst or submandibular salivary gland depression is usually discovered incidentally on dental radiographs, It is asymptomatic and is not a true cyst, rather an anatomic depression in the lingual aspect of the body of the mandible where normal salivary gland tissue rests. The radiographs show a small, circular, corticated radiolucency below the level of the mandibular canal. !istologically, normal salivary tissue is found and no treatment is required except routine radiographic follow(up. Traumatic &one Cyst The traumatic cyst is not a true epithelial cyst, but represents an empty or fluid(filled cavity of bone lined with a fibrous or granulation tissue membrane. The term traumatic was used to implicate trauma as the cause. !owever, less than half of the instances are associated with any significant trauma to the jaw with an un&nown etiology. The lesion is located most often in the body or anterior portion of the mandible, and radiographically it is radiolucent. A classic feature is its tendency to scallop between the tooth roots. The overlying teeth are vital. icroscopically, a thin membrane of fibrous granulation tissue may line the cavity. Treatment with exploratory surgery following aspiration causes hemorrhage which may expedite healing. %urgical Ciliated Cyst (of 'a(illa) *ollowing a Caldwell(2uc operation, fragments of sinus epithelial lining may become entrapped in the surgical site. If this epithelium undergoes benign cystic proliferation, a unilocular well(delineated radiolucency will become evident in the maxilla. The lesion lies within the alveolar bone subjacent to the antral floor and is generally confined to an edentulous or inter(radicular area in the posterior maxilla. @ain or discomfort may be present. !istologically, the cyst is lined by pseudostratified columnar ciliated epithelium with an inflammatory connective tissue wall. Treatment is with surgical enucleation.

Odontogenic Tumors

Epit)elial Odontogenic Tumors *melo+lastoma The ameloblastoma is the most common odontogenic tumor. It is a benign but locally invasive neoplasm derived from odontogenic epithelium. It has three different clinicopathologic subtypesA multicystic ,;/1-, unicystic ,7B1- and peripheral ,extraosseus C 71-. It usually occurs in the 4th and 0th decades without a gender predilection. In the clinical sense, the ameloblastoma can be considered a basal(cell carcinoma, to which it may be related histologically. Classically, it presents as a multilocular radiolucency with a predilection for the posterior mandible. It may arise from the lining of a dentigerous cyst but more often arises independently of impacted teeth. It is characteri#ed by a progressive growth rate and , when untreated, may reach enormous proportions. Darly symptoms are often absent, but late symptoms may include a painless swelling, loose teeth, malocclusion, or nasal obstruction. axillary tumors frequently perforate into the antrum and may grow freely, with extension into the nasal cavity, ethmoid sinuses, and s&ull base. A small number of microscopically benign ameloblastomas have been reported to undergo distant metastases. 'adiographs classically show a well(circumscribed, expansile soap(bubble radiolucency with clearly demarcated borders. !owever, the unilocular lesion is indistinguishable from an odontogenic cyst. The extent of root resorption may indicate a neoplastic process. icroscopic features shows two patterns of arrangement, plexiform and follicular, with no bearing on growth potential, metastatic potential or prognosis. Classic features are sheets and islands of tumor cells showing an outer rim of columnar ameloblasts with nuclei polari#ed away from the basement membrane. The center of these nests is composed of stellate(shaped epithelial cells that mimic the stellate reticulum 'arely, they can exhibit cytologic features of malignancy with squamous differentiation ,less then 71-. These tumors are diagnosed as ameloblastic carcinoma and carry a poor prognosis. Treatment varies according to type and the growth characteristics of each neoplastic entity. The peripheral subtype occurs as a soft(tissue mass, which can be treated successfully with complete excision, including a small rim of clinically uninvolved tissue. The unicystic subtype may be treated with complete removal provided that no satellite lesions at the periphery or extension of tumor cells through the fibrous cyst wall is seen on histopathologic examination. If this occurs after initial enucleation, peripheral ostectomy or marginal resection should be performed. The treatment of the classic infiltrative, more aggressive ameloblastoma should not be ta&en lightly. andibular resection must include an adequate #one of normal(appearing bone around the main tumor mass. Dxtension of tumor into surrounding soft tissues is an ominous sign and demands surgery in these areas as vigorous as within the confines of the bone. axillary ameloblastomas require more aggressive initial management with at least a 7.0 cm margin of radiographically normal bone. @ostoperative follow(up is critical for a minimum of 0, and preferably 73, years. Ameloblastic carcinoma should be treated with radical surgical resection as for squamous cell carcinoma, with nec& dissection reserved for apparent lymphadenopathy. Calcifying Epit)elial Odontogenic Tumor C Also &nown as the @indorg tumor, this is an aggressive odontogenic neoplasm of epithelial derivation. ost cases are associated with an impacted tooth, and the mandibular body or ramus is by far the most common site. The chief sign is cortical expansion. @ain is usually not a complaint. +n x(ray, expanded cortices can be visuali#ed in buccal, lingual, and vertical dimensions. It is usually radiolucent with poorly defined, noncorticated borders. It may be unilocular, multilocular or moth(eaten. ultiple

radiopaque foci within the radiolucent #one may give it a 8driven(snow9 appearance. 'oot divergence and resorption are common findings and the impacted tooth is often significantly displaced with arrested root development. !istologically, sheets, nests and cords of eosinophilic epithelial cells prevail, which do no resemble tooth germ primordia. These islands of cells infiltrate bony trabeculae and often show degenerative nuclear hyperchromatism and pleomorphism, which may be misdiagnosed as squamous cell carcinoma. .mall psammoma(li&e concentric calcifications called 2iesegang rings are seen within the epithelial islands and aid the diagnosis. Their behavior is not unli&e that of ameloblastoma, although recurrence rates are less. Dn bloc resection, hemimandibulectomy, or partial maxillectomy, are the treatment methods required to eradicate the disease. *denomatoid Odontogenic Tumor )hile usually associated with the crown of an impacted anterior tooth, this tumor may arise between tooth roots as well. @ainless expansion is often the chief complaint. The maxillary incisor(cuspids are common sites. 'adiographically, the tumor is well defined, expansile with root divergence, and radiolucent with calcified flec&s ,target appearance-. icroscopic features include a thic& fibrous capsule with an inner epithelial neoplastic component composed of organoid clusters of spindle cells. Columnar cells are arranged in rosettes or ductal patterns dispersed throughout the organoid clusters. Treatment is with simple surgical enucleation and recurrence is extremely rare. %,uamous Odontogenic Tumor This is a hamartomatous proliferation of odontogenic epithelium, probably arising from the rests of alasse#. The maxillary incisor(canine area and mandibular molar area are most commonly involved. ost cases are unifocal and tooth mobility is the usual chief complaint. +n x(ray, a locali#ed radiolucent area between contiguous teeth is well(circumscribed. ost cases are either triangular or semicircular in configuration. !istologic features includes oval, round and curvilinear nests of squamous epithelium throughout a mature collagenous stroma. Cystic degeneration is commonly seen, and some of the nests exhibit ovoid crystalloid structures. Treatment is with extraction of the involved tooth and thorough curettage of the lesional tissue. axillary lesions may warrant resection to prevent recurrence if more extensive. 'ecurrences require more aggressive surgical treatment. Calcifying Odontogenic Cyst (#orlin cyst) This is a tumor(li&e cyst found predominantly in the mandibular premolar region. <early one quarter of such cysts are peripheral, producing radiographically evident calcification above the underlying cortex and manifesting a gingival swelling. Intrabony lesions may cause expansion, and teeth remain vital. 'adiographically, the lesion starts as a radiolucency and progressively calcifies, yielding a target lesion ,opaque, with a circumferential lucent halo-. 'oot divergence is common. !istologically, the cyst lining is composed of stratified squamous epithelium with a polari#ed basal layer. The lumen contains eosinophilic &eratini#ed cells devoid of nuclei ,ghost cells-. Dnucleation with curettage is the treatment of choice with rare recurrences. 'esenc)ymal Odontogenic Tumors Odontogenic 'y(oma This tumor is believed to originate from the dental papilla or follicular mesenchyme. It is usually multilocular and expansile, sometimes associated with impacted teeth. +n x(ray, the radiolucency has coursing septae which loo& li&e a finely reticulated spider web. These are slow growing tumors but are aggressively invasive and may

become quite large. The body of the mandible is the favored site. icroscopically, spindle and stellate fibroblasts are associated with basophilic ground substance and myxomatous tissue. Treatment should be with en bloc resection to prevent recurrence, although curettage may be attempted for more fibrotic lesions. Central Odontogenic -i+roma ! This tumor shows more collagen and less ground substance than the myxoma. Clinical findings, when present, include swelling or depression of the palate mucosa with tooth mobility. E(ray shows a uni( or multilocular radiolucency involving periodontal and crestal bone adjacent to dental roots. 'ecurrence is unli&ely following complete removal. Cemento+lastoma This is a true neoplasm of cementoblasts, which arises most often on the first mandibular molars. The cortex is slightly expanded both buccally and lingually without pain. The involved tooth is an&ylosed to the tumor mass and vital. @ercussion reveals an audible difference between affected and unaffected teeth. +n x(ray, the apical mass may be lucent with either central opacities or a solid opacity. A thin radiolucent halo can be seen around densely calcified lesions. icroscopic appearance of radially oriented trabeculae from the attached root cementum with a rim of osteoblasts and fibrous marrow is apparent. Treatment is with complete excision with sacrifice of the involved tooth. 'i(ed Odontogenic Tumors The mixed odontogenic tumors include ameloblastic fibroma, ameloblastic fibrodentinoma, ameloblastic fibro(odontoma, and odontoma. +nly ameloblastic fibroma is entirely radiolucent. )hile all of the mixed odontogenic tumors may begin as radiolucent lesions, the remainder will eventually develop radiopaque foci. The mixed odontogenic tumors possess both epithelial and mesenchymal tumor elements, and mimic the differentiation of the developing tooth germ. The least differentiated is the ameloblastic fibroma, which is composed of a diffuse mass of embryonic mesenchyme traversed by columnar or cuboidal odontogenic epithelium resembling the dental lamina. Ameloblastic fibrodentinomas are similar, yet a dense eosinophilic dentinoid material lies next to the epithelial element. Ameloblastic fibro(odontomas are further differentiated in that both dentin and enamel matrix are formed and mixed with ameloblastic fibroma #ones. The odontoma contains all elements of the mature tooth germ yet does not have a significant soft tissue cellular overgrowth. Dnucleation or thorough curettage with extraction of the impacted tooth is recommended for these tumors. The ameloblastic fibroma has a limited tendency to recur. There has been a microscopically malignant and aggressive mixed odontogenic tumor described as ameloblastic fibrosarcoma. The ameloblastic fibrosarcomas are aggressive and commonly recur after curettage, therefore en bloc resection is recommended for these tumors.

Related Jaw Lesions

#iant Cell Lesions Central #iant Cell #ranuloma (C#C#) This is a neoplastic(li&e reactive proliferation of the jaws that accounts for less than ?1 of all benign lesions of the jaws in tooth( bearing areas. It commonly occurs in children and young adults with a slight female

predilection. The lesion is more common in the mandible than maxilla underlying anterior or premolar teeth. Dxpansile lesions can cause root divergence or resorption. The clinical features vary according to the type of development the lesion assumes. 2esions may be slow(growing and asymptomatic or rapidly expanding with pain, facial swelling and root resorption. The fast growing variants have a high rate of recurrence. :ecause of the higher incidence of these lesions among girls and women of child(bearing years, hormonal influences have been suggested as influential in their development. The radiographic appearance ranges from unilocular to multilocular radiolucencies with either well(defined or irregular borders. ultinucleated giant cells, dispersed throughout a hypercellular fibrovascular stroma often with bony trabeculae are present on histology. Treatment regimens for C>C> have historically included curettage, segmental resection, and radiation therapy. 'adiation therapy has been discouraged recently, due to the small ris& of malignant transformation to osteogenic sarcoma. Intralesional steroids have also been advocated for managing C>C> in younger patients as a nonsurgical alternative. Individuali#ed treatment depending on the aggressiveness of the lesion is the rule. .mall, nonaggressive lesions will usually respond to through excision with careful curettage with a recurrence rate of less than 701. 2arger, more aggressive lesions, which have higher recurrence rates, require more extensive surgery, which may include en bloc resection. &ro.n Tumor of /yperparat)yroidism This represents a local manifestation of a systemic metabolic disease that is histologically identical to central giant cell granuloma. )hen this histology is present, serum calcium and phosphorus should be obtained, especially in older patients ,unli&ely to have central giant cell granulomas-, to rule out :rown tumor. *neurysmal &one Cyst This is not a true cyst, and is closely related to the giant cell granuloma with its aggressive reactive process. The lesion is composed of large vascular sinusoids, and blood can be aspirated with a syringe. A bruit, however, cannot be auscultated due to the low pressures. It has a great potential for growth and can result in mar&ed expansion and deformity. A multilocular radiolucency traversed by thin septae with cortical expansion is present on x(ray. The mandible body is the most frequent site. !istologically, large blood(filled sinusoids lined by an endothelial layer with surrounding fibroblastic, hypercellular tissue is present. .imple enucleation is the preferred treatment. 'ecurrence is rare. -i+roosseous Lesions -i+rous Dysplasia *ibrous dysplasia is the most common disease of the jaws to manifest a ground(glass radiographic pattern. There are two forms, monostotic form, which is more common in the jaws and cranium, and poyostotic, with is often associated with cCune( Albright"s syndrome ,cutaneous pigmentation, autonomic hyper(functioning endocrine glands, and precocious puberty-. The monostotic variant is by far the most common type seen when the jaw is involved and presents as a painless expansile dysplastic process of osteoprogenitor connective tissue. The maxilla is the most common site of involvement. The lesion does not cross the midline and tends to be limited to one bone. The antrum is often obliterated, and the orbital floor ,with globe displacement- may be involved. The histology is characteri#ed by irregular osseous trabeculae in a hypercellular fibrous stroma. Treatment should be deferred, if possible until s&eletal maturity. Children with fibrous dysplasia should be followed quarterly with clinical and radiographic evaluation. $uiescent and non(aggressive lesions that have been observed to exhibit no growth are treated by contour excision for esthetic and%or functional

reasons. )hen disabling functional impairment or paresthesia occurs, contour or en bloc excision may be performed. Accelerated growth or aggressive lesions require early surgical intervention with en bloc resection and bone graft reconstruction. alignant transformation has been reported after radiation therapy, which is contraindicated. Ossifying -i+roma .imilar to fibrous dysplasia histologically, this is a true neoplasm of the medullary portion of the jaws. These lesions arise from elements of the periodontal ligament, and tend to occur in younger patients, most often in the premolar(molar region of the mandible. These tumors when small are asymptomatic but frequently grow to expand the jaw bone. +n x(ray, a well(demarcated radiolucent lesion is seen in the early stages which becomes increasingly calcified with maturation. The progression from the radiolucent to the radiopaque stage ta&es at least / years. After surgical excision of the lesion which tends to shell out, recurrence is uncommon. Condensing Osteitis *ocal areas of radiodense sclerotic bone are found in about 41 to ;1 of the population. These are usually in the mandible around the apices of the first molar and are thought to be reactive bony sclerosis to low(grade pulpal inflammation. They are irregular in shape, radiopaque with superimposed periapical inflammation. +nce formed, these lesions are stable. <o treatment is necessary.

In summary, there are a multitude of odontogenic cysts and tumors that may present in head and nec& patients. The &ey to diagnosis is a careful history and physical examination accompanied by radiographic evidence and pathologic confirmation. any of these entities represent benign cysts and tumors, however significant pathologic disease may be lur&ing which necessitates prompt treatment and immediate consultation as necessary.

6umamoto, !, et al. Clear cell odontogenic tumor in the mandibleA report of a case with duct( li&e appearances and dentinoid induction. Fournal of +ral @athology G edicine. 5=,7-A 4B(4?. 5333 Hamamoto, !, et al. Clear cell odontogenic carcinomaA A case report and literature review of odontogenic tumors with clear cells. +ral .urg, +ral ed, +ral @ath, +ral 'adiol Dndod. ;/,7-A ;/(;=. 7==;. anor, H, erdinger, +, 6at#, F, Taicher, .. Inusual peripheral odontogenic tumors in the differential diagnosis of gingival swellings. Fournal of Clin @eriodon. 5/,75-A ;3/(;3=. 7===. 'oberson, F, Croc&er, J, .chiller, T. The diagnosis and treatment of central giant cell granuloma. FAJA. 75;A ;7(;4. 7==?.

Tallan D, et al. Advanced giant cell granulomaA A twenty(year study. +tolaryngol C !<.773,4-A 47B(47;. 7==4. 6oppang, !, et al. >landular odontogenic cystA report of two cases and literature review of 40 previously reported cases. F +ral @athol ed. 5?,=-A 400(4/5. 7==;. 'amer, , anta#em, A, 2ane, ., 2umerman, !. >landular odontogenic cystA 'eport of a case and review of the literature. +ral .urg +ral ed +ral @athol +ral 'adiol Dndod. ;4,7-A 04(0?. 7==?. :ataineh, A, Al $udah, . Treatment of mandibular odontogenic &eratocysts. +ral .urg +ral ed +ral @athol +ral 'adiol Dndod. ;/,7-A 45(4?. 7==;. Toida, . .o(called calcifying odontogenic cystA review and discussion on the terminology and classification. F +ral @athol ed. 5?,5-A 4=(05. 7==;. @hilipsen, !, 'eichart, @. .quamous odontogenic tumorA a benign neoplasm of the periodontiumA a review of B/ reported cases. F Clin @eriodontol. 5B,73-A =55(=5/. 7==/. acIntosh, '. Aggressive surgical management of ameloblastoma. + *. Clin of < Amer. B,7-A ?B(=?. 7==7. 6aban, 2. Aggressive jaw tumors in children. + *. Clin of < Amer. 0,5-A 54=(5/0. 7==B. :ailey, et al. !ead G <ec& .urgery C +tolaryngology. 5nd edition. Kolume 5,73;-A 7047(70/5. Jier&s, D and :ernstein, . +dontogenic cysts, tumors, and related jaw lesions. LLLLLLL @osted 5%74%5335

NTRODUCTION : INTRODUCTION A case history is defined as a planned professional conversation that enables the patient to communicate his/her symptoms, feelin s, and fears to the clinician so as to obtain an insi ht into the nature of the patient!s illness and his/her attitude to them" In eneral, a case history is nothin but an evaluation of the patient prior to the dental treatment" ###"r$dentistry"net Slide 3: A case history is of immense value in the follo#in #ays% &" to establish the dia nosis" '" to detect any medical problem (" evaluation of other systemic problems )" discovery of communicable diseases" *" mana ement of emer encies" +" for effective treatment plannin " ###"r$dentistry"net STEPS IN THE DIAGNOSTIC PROCEDURE : ,T-., IN T/- DIA0NO,TIC .ROC-DUR- Ta1in and recordin of the case history" .hysical e$amination" Relevant investi ation to aid in the dia nosis" -stablishin a dia nosis after assessin the case history, physical e$amination and investi ative procedures" Outlinin the treatment plan of the dental patient" 2edical ris1 assessment of the patient" .ro nosis or a clinical evaluation of the most probable outcome of therapy" ###"r$dentistry"net METHODS OF RECORDING A CASE HISTORY : 2-T/OD, O3 R-CORDIN0 A CA,- /I,TOR4 There is usually a traditional approach in the desi n of a case history" The preliminary part of the case history is usually based on 5uestionnaires" Ne#er techni5ues of recordin a case history are% &" Computer aided data atherin " '" Open ended intervie#in #hich includes the #eed!s problem oriented record 6.OR7" (" Russel!s 8condition dia ram9" )" CD method" ###"r$dentistry"net SEQUENCE OF CASE RECORDING AND EVALUATION : ,-:U-NC- O3 CA,- R-CORDIN0 AND -;A<UATION ,TATI,TIC, C/I-3 CO2.<AINT /I,TOR4 O3 .R-,-NT I<<N-,, 2-DICA< /I,TOR4 .A,T D-NTA< /I,TOR4 3A2I<4 /I,TOR4 0-N-RA< -=A2INATION -=TRA ORA< -=A2INATION INTRA ORA< -=A2INATION .RO;I,IONA< DIA0NO,I, IN;-,TI0ATION, 3INA< DIA0NO,I, TR-AT2-NT .<AN ###"r$dentistry"net STATISTICS : ,TATI,TIC, It is defined as a systemic approach to collect and compile in numerical form the information related to vital events, live births, deaths, reco nition, social structure and le islation .atient re istration number useful for% >record maintainence >billin purposes >medicole al aspects" Date% useful for% >for reference >for record maintainence ###"r$dentistry"net Slide 8: Name% useful for% >for identification >for communication >formin a rapport #ith patient >record maintainence >psycholo ical benefit >information of patient such as reli ion A e% useful for% >dia nosis >treatment plannin >behaviour mana ement techni5ues ###"r$dentistry"net AGE : A0- &" Dia nosis% there is a predilection of certain diseases at different a e levels% e " Diseases commonly present at birth% >cleft lip and palate >an1ylo lossia >teratoma >haemophilia etc" Diseases commonly present in children and youn adults >papilloma >?uvenile periodontits >scarlet fever etc" Diseases commonly occurin in adults% >attrition/abrasion >periodontitis >pulp stones >root resorption etc" ###"r$dentistry"net Slide 10: '" Treatment plannin % > Comparison of chronolo ical a e #ith dental a e Chronolo ic a e @ a e accordin to date of birth Dental a e @ a e accordin to last erupted tooth in oral cavity in order of se5uence > 0ro#th spurts% &" Infantile / childhood ro#th spurt '" 2i$ed dentition / ?uvenile ro#th spurt (" .repubertal / adolescent ro#th spurt >Calculation of child!s dosa e (" Aehavoiur mana ement techni5ues% >2ana ement of patients of different a e roups re5uire different behaviuor modification methods" ###"r$dentistry"net SEX : ,-= Bno#in the se$ of patient is important for% &" Dia nosis% there is a predilection of different diseases in both se$es" e " Diseases more common in females% >iron deficiency anaemia >s?o ren!s syndrome >myasthenia ravis >?uvenile periodontitis Diseases more common in males% >attrition >oral carcinoma >hod 1in!s disease >pernicious anaemia '" -sthetic% irls are much concious about their esthetics" (" Child abuse% e$ploitation is more common in males and se$ual abuse in females" ###"r$dentistry"net

Slide 1 : -ducation% it determines &" ,ocio>economic status '" I":" for effective communication (" Attitude to#ards eneral and oral health" Address% it is important for &" for future correspondence '" ives a vie# of the socio>economic status (" prevalence of diseases% for e " a7 fluorosis as a result of increased level of fluorides in #ater are spread differently in va ue parts of country" b7 caries are more common in modern industrialiCed areas, #hereas periodontal diseases are more common in rural areas" ###"r$dentistry"net Slide 13: Occupation% it is important for &" Assessin the socioeconomic status '" .redilection of diseases in different occupations e " &7 Attrition and abrasion are found in industrial #or1ers havin an atmosphere of abrasive dust" '7 /epatitis>A is more common in dentists and sur eons " Reli ion% it is important for% &7 Identifyin the festive periods #hen reli ious people are reluctant to under o treatment procedures" '7 .redliction of diseases in specific reli ions ###"r$dentistry"net CHIEF COMPLAINT : C/I-3 CO2.<AINT The chief complaint is established by as1in the patient to describe the problem for #hich he or she is see1in help or treatment" It is recorded in patient!s o#n #ords as much as possible, and no documentary or technical lan ua e should be used" It is recorded in chronolo ical order of their appearance, and in the order of their severity" The chief complaint aids in the dia nosis and treatment plannin and should be iven the first priority" ###"r$dentistry"net COMMON CHIEF COMPLAINTS : CO22ON C/I-3 CO2.<AINT, &" .ain '" Aurnin sensation (" Aleedin )" <oose teeth *" Recent occlusal problems +" Delayed tooth eruptions D" =erostomia E" ,#ellin s F" Aad taste &G" .aresthesia and anaesthesia &&" /alitosis ###"r$dentistry"net HISTORY OF PRESENT ILLNESS : /I,TOR4 O3 .R-,-NT I<<N-,, Initially, the patient may not volunteer the detailed history of the problem, so the e$aminer has to elicit out the additional information by the possible 5uestionnaire about the symptoms" The patient!s response to these 5uestions is termed history of present illness" The 5uestions can be as1ed in the manner% &" #hen did the problem startH '" #hat did you noticed firstH (" did you have any problems or symptoms related to thisH )" #hat ma1es the problem #orse or betterH *" have any tests been performed before to dia nose this complaintH +" have you consulted any other e$aminer for this problemH D" #hat have you done to treat this problemH -tc" ###"r$dentistry"net Slide 1!: In eneral, the symptoms can be elaborated under% &" mode of onset" '" cause of onset" (" duration )" pro ress and referred pain *" relapse and remission +" treatment D" ne ative history ###"r$dentistry"net DETAIL HISTORY OF PARTICULAR SYMPTOM : D-TAI< /I,TOR4 O3 .ARTICU<AR ,42.TO2 .AIN% &" anatomical location 6site7 '" ori in and mode of onset (" intensity of pain )" nature of pain *" pro ression of pain +" duration of pain D" movement of pain E" localiCation behavior F" effect of functional activity &G" neurolo ical si ns &&" temporal behavior ,I-<<IN0% &" anatomical location 6site7 '" duration (" mode of onset )" symptoms *" pro ress of s#ellin +" associated features D" secondary chan es E" impairment of function F" recurrence of s#ellin U<C-R &" mode of onset '" duration (" associated pain )" dischar e *" associated diseases ###"r$dentistry"net PAST DENTAL HISTORY : .A,T D-NTA< /I,TOR4 0ives attitude of the patient to#ards dentistry" 0ives a eneral vie# about ho# the patient is a#are about pursuin oral health" If history of previous bad e$perience is present then mouldin of behavior is done usin behavior mana ement techni5ue" ,i nificant 1no#led e can be dra#n about the patient!s previous treatment procedures and can be helpful to#ards the present situation" ###"r$dentistry"net PAST MEDICAL HISTORY : .A,T 2-DICA< /I,TOR4 Recordin of past medical history includes history of past illnesses, hospitaliCations and evaluation of the patient!s health based on the history provided by the patient" All diseases suffered by the patient should be recorded in chronolo ical order" .atient should be evaluated for% >cardiovascular diseases >respiratory

diseases > astrointestinal > enitourinary >endocrine >neurolo ical >haematolo ical >psychiatric >aller ic reactions >e$tremities and ?oints ###"r$dentistry"net Slide 1: .atient should be assessed by the 5uestionnaire% > #hether he is sufferin or has suffered before from any ma?or systemic diseaseH > Ihat is the duration and treatment of the diseaseH > Is he on any medicationH > /istory of all the hospitaliCations and their purpose should be assessed" etc ,ome important e$amples include% >.ostpone treatment if sufferin from acute illness li1e mumps or chic1enpo$ >.atient #ith cardiac defects need to et a physician!s report >.atient on anticoa ulant therapy >Asthma @ N,AID are contraindicated >Juvenile diabetes mellitus ###"r$dentistry"net PERSONAL HISTORY : .-R,ONA< /I,TOR4 It includes% &7 Oral habits '7 Oral hy iene practices (7 Adverse habits )7 3amily history ###"r$dentistry"net ORAL HA"ITS : ORA< /AAIT, &7 2outh breathin % it is the adverse oral habit characteriCed by habitual respiration of the patient occurrin predominantly throu h the mouth" >It is characteriCed by presence of narro# arch of ma$illa, deep over?et and overbite, potentially competent or incompetent lips and a tendency to develop a posterior crossbite" ###"r$dentistry"net Slide #: '7 3in er and thumb suc1in % it is the habitual prolon ed suc1in of the thumb or the fin er by the child patient" It may lead to many dental problems such as hyperactive mentalis activity, proclination of upper incisors, tendency to posterior crossbite etc" > it can be dia nosed by assessin the thumb of the child #hich presents a shiny, clean area #ith calculus present at the base of the nail" ###"r$dentistry"net Slide $: (7 Nail bitin % it is the constant trimmin of the nail parts by the patient at the subconscious level" >it presents #ith the features as retroclination of the upper incisors, irre ular nail mar ins, abrasion of lo#er incisor mar ins etc" )7 Ton ue thrustin % it is the habitual abnormal function of the ton ue #hich protrudes durin the s#allo#in pattern to touch the lin ual surface of the lo#er incisors" >It is basically the persistence of infantile s#allo#in " ###"r$dentistry"net Slide %: It presents #ith the features% >open bite >mar inal in ivitis >potentially competent/ incompetent lips etc" ###"r$dentistry"net ORAL HYGIENE PRACTICES : ORA< /40I-N- .RACTIC-, It is important so as to% >assess the 1no#led e of dental care the patient possesses" >to determine the level of hy iene maintained by the patient" It includes% >Re ularity of brushin >3re5uency and method of brushin >Use of fluoridated and non fluoridated tooth pastes >Type of brush and ho# often it is chan ed ###"r$dentistry"net ADVERSE HA"ITS : AD;-R,- /AAIT, It includes% >smo1in % record the type, fre5uency and duration >alcohol consumption% record the amount, fre5uency and duration >tobacco che#in % record the type, amount, fre5uency and duration ###"r$dentistry"net FAMILY HISTORY : 3A2I<4 /I,TOR4 3amily history is as1ed to assess the presence of any inherited disease pattern or trait" It includes% >No" of siblin s and their a e >Is there a history of this disease in your familyH 3or e " Diseases li1e haemophilia, diabetes, hypertension recur in families eneration after eneration" ###"r$dentistry"net GENERAL EXAMINATION : 0-N-RA< -=A2INATION .U<,-% it is an important inde$ of severity of the vascular system and heart abnormalities" It is useful to record% >rate% fast or slo# 6normal rate is +G>&GG/min7 >rhythm% re ular or irre ular >volume% hi h, normal or lo# pulse pressure 6normal pulse pressure is )G>+G mm h 7 >tension and force >character>

some vascular diseases may sho# different pulse character such as K#ater hammer! pulse in aortic re ur itation, Kpulsus parado$icus! in pericardial effusion etc" ###"r$dentistry"net Slide 31: Alood pressure% it is useful to determine% >the stro1e volume of the heart and stiffness of the arterial vessels" >to assess severity of hyper and hypotension and aortic incompetence" 6normal level of blood pressure is &'G/EGbmm of h 7 Aody temperature Respiration Cyanosis ###"r$dentistry"net EXTRA ORAL EXAMINATION : -=TRA ORA< -=A2INATION ,BIN% s1in is loo1ed for% >appearance> any rashes, sores or itchin may reveal a positive history >color> anaemia patients have a pale s1in colour, yello# tint is seen in ?aundice patients etc" >te$ture >si ns >pi mentation >edema ###"r$dentistry"net Slide 33: 3acial symmetry% facial symmetry is important to note so as to assess the fullness on both the halves of the face and to loo1 for any ross disorder that may reveal a si nificant history" It is noted as symmetrical or asymmetrical" T2J6temporomandibular ?oint7% observed for% >symmetry% ross deran ement in symmetry may reflect ro#th disturbances" >ma$imum interincisal openin 6normal value> (*>*G mm7 >any deviation in openin >ran e of vertical movement >ran e of lateral movement ><isten for clic1in and crepitus sounds >Note for tenderness over ?oint or masticatory muscles ###"r$dentistry"net Slide 3#: .alpation of the ?oint area% > palpation of the pretra us area% the patient should be re5uested to slo#ly open and close the mouth #hile the doctor bilaterally palpates the pretra us depression #ith his/her inde$ fin ers" >intra>auricular depression% it is also performed by insertin a small fin er into the ear canal pressin anteriorly" >palpation is also used to detect the tenderness, clic1in and crepitus" >the masseter muscle is e$amined by simultaneously pressin it both from inside and outside, termed as bimanual palpation" >the lateral ptery oid muscle is e$amined by insertin a fin er each behind the ma$illary tuberosities, and the medial ptery oid by runnin a fin er in anteroposterior direction alon the medial aspect of mandible in the floor of the mouth" ###"r$dentistry"net Slide 3$: <42./ NOD-,% palpation of lymph node is done to% >1no# the position >number of nodes >tenderness >fi$ity to underlyin tissues .alpation of the lymph nodes of the nec1 commonly be ins the most superior nodes and is #or1ed do#n to the clavicle to the supraclavicular nodes" ###"r$dentistry"net Slide 3%: The superficial and the deep lymph nodes of the nec1 are best e$amined from behind the patient, #ith the patient!s head inclined for#ard and side#ays sufficiently to rela$ the muscles near the lymph nodes, and then palpated" Also loo1 for any distension present in the superficial veins or any thyroid enlar ement ###"r$dentistry"net Slide 3!: -4- >Indicator of the anaemia and ?aundice >Infection of the ma$illary teeth may e$tend to orbital re ion @ causin s#ellin of the eyelid and con?uctivitis" NO,- >,iCe @ should be &/(rd of total facial hei ht >Deviated nasal septum in mouth breathers >,addle nose in con enital syphilis ###"r$dentistry"net INTRA ORAL EXAMINATION : INTRA ORA< -=A2INATION ,O3T TI,,U-, &" TON0U-% e$amination should be done to chec1% >volume of the ton ue% enlar ed ton ue may be due to lymphan ioma, heman ioma and neurofibroma" >inte rity of the papillae% note the distribution and 1eratosis of the papillae >any crac1s or fissures% con enital fissures are mainly transverse but syphilitic fissures are usually lon itudinal" >any s#ellin s or ulcers% >mobility of the ton ue% chec1 for the impairment of nerve supply and an1ylo lossia" > note for presence of cyanosis" ###"r$dentistry"net Slide 3&: .alpation of the ton ue% the ton ue should be rela$ed and at rest #ithin the mouth" A protruded ton ue may ive a false impression because of tensed muscles" .A<AT-% chec1 for% >clefts, perforations, ulcerations or any s#ellin >recent burns or hyper1eratiniCation >fistulae, tori, papillary hyperplasia etc" <I.% inspection of lip constitutes% > lip color, te$ture and chec1in of surface abnormalities > cleft lip > pi mentation" - " .i mentation of lips occurs in adison!s disease and peutC ?e herts syndrome" > any presence of neoplasm or chancre or diffuse enlar ement of lip" ###"r$dentistry"net

Slide #0: 3<OOR O3 2OUT/% patient is as1ed toopen his mouth and to 1eep the tip of the ton ue up#ard to touch the palate" This #ill e$pose the floor of the mouth" Chec1 for% >color >s#ellin , if any > any presence of patches" >an1ylo lossia AUCCA< 2UCO,A% the chee1 is retracted usin a mouth mirror and chec1ed for% >any ulcer, #hite patch or neoplasia" >pi mentation >observe the openin of stenson!s duct and establish their patency" ###"r$dentistry"net Slide #1: ,A<I;AR4 0<AND,% .AROTID 0<AND >chec1 for any s#ellin over the re ion" >in case of parotid abscess, the s1in over the area becomes edematous #ith pittin on pressure" >-$amine the area for presence of any fistula, and enlar ement of lymph nodes or involvement of facial nerves" ,UA2ANDIAU<AR 0<AND >history of the patient is to be noted% e s#ellin #ith pain at the time of meals su ests obstruction in submandibular duct" >chec1 for any nodal s#ellin , it may su est of lumph node enlar ement" >bimanual palpation> in the open mouth, the physician!s fin er of one hand is placed on the floor of the mouth and pressed as far as possible" The fin er of the other hand is placed on the e$terior at the inferior mar in of the mandible" These fin ers are pushed up#ards and palpation is achieved" ###"r$dentistry"net GINGIVA : 0IN0I;A Color% the color of attached and mar inal in iva is normally described as coral pin1" In in ivitis, the color chan es to reddish blue" .i mentation% present in all normal individuals" ,iCe% it is the sum total of cellular and intercllular elements" Contour% the contour of in iva varies differently accordin to shape of teeth and ali nment in arch" Normal contour is termed as scalloped" ,hape% it is overned by contour of pro$imal surface and location and shape of in ival embrasures" Consistency% the normal in iva is firm and resilient, e$cept at the free in ival mar in" In inflammation, it becomed soft and edematous" ###"r$dentistry"net Slide #3: ,urface te$ture% the normal in iva ives an oran e peel appearance and is called as stippled" It occurs in attached in iva" ,tipplin is a form of adaptive specialiCation or reinforcement for function" .osition% it refers to the level at #hich the in ival mar in is attached to the tooth" Aleedin on probin % it is a method to chec1 in ival inflammation" The insertion of a probe to the bottom of the poc1et elicits bleedin if the in iva is inflamed and the poc1et epithelium is atrophic or ulcerated" The probe is carefully introduced into the bottom of the poc1et and ently moved laterally alon the poc1et #all" After insertin the e$aminer should #ait for (G>+G seconds" ###"r$dentistry"net PERIODONTIUM : .-RIODONTIU2 .<A:U- AND CA<CU<U,% the dental tissues are carefully inspected for the presence of pla5ue and calculus" .-RIODONTA< .OCB-T,% a poc1et is defined as a patholo ical deepenin of in ival sulcus" The e$amination includes assessin the surface of the tooth, the poc1et depth and the type of the poc1et" A periodontal probe is used for the assessment in a K#al1in ! fashion" TOOT/ 2OAI<IT4% all teeth have a sli ht amount of physiolo ic mobility" The destruction of periodontium ma1es the tooth loose in the soc1et" Tooth mobility is raded as% rade I> sli ht mobility, upto G"* mm" rade II> moderate mobility, more than G"* mm but less than & mm" rade III> severe mobility, tooth is movable both mesiodistally and labiolin ually and may be depressible in the soc1et" ###"r$dentistry"net Slide #$: 3URCATION IN;O<;-2-NT% the pro ress of inflammatory periodontal disease to the bifurcation or trifurcation of multirooted teeth is called as furcation involvement" It is raded as% rade I @ incipient sta e, the poc1et is suprabony and primarily affects the soft tissues" rade II @ lesion is called Kcul>de>sac!, havin a definite horiContal component" rade III @ the destruction has pro ressed and the bone is not attached to the dome of the furcation, the probe can be passed completely throu h the furcation" rade I; @ interdental bone is completely destroyed, and the soft tissues have receded completely" ###"r$dentistry"net HARD TISSUE EXAMINATION : /ARD TI,,U- -=A2INATION T--T/ > a7NU2A-R b7NOTATION% by any of the three methods of notation% &7 3DI .rimary/Deciduous teeth Ri ht <eft ** *) *( *' *& +& +' +( +) +* E* E) E( E' E& D& D' D( D) D* .ermanent teeth Ri ht <eft &E &D &+ &* &) &( &' && '& '' '( ') '* '+ 'D 'E )E )D )+ )* )) )( )' )& (& (' (( () (* (+ (D (E ###"r$dentistry"net

Slide #!: '7 Lsin mondy/palmer method deciduous teeth -DCAA AACD- -DCAA AACD- permanent teeth ED+*)('& &'()*+DE ED+*)('& &'()*+DE ###"r$dentistry"net Slide #8: (7 UNI;-R,A< ,4,T-2 deciduous teeth AACD- 30/IJ T,R:. ON2<B permanent teeth & ' ( ) * + D E F &G && &' &( &) &* &+ (' (& (G 'F 'E 'D '+ '* ') '( '' '& 'G &F &E &D ###"r$dentistry"net Slide #&: C7 Caries assessment% count the total number of caries and the tooth number is to be noted" D7 3illed teeth -7 Any defected/fractured restoration 37 Attrition, erosion and abrasion% Attrition is defined as the #ear caused by tooth to tooth contact" A certain amount of attrition is normal called as physiolo ic attrition" -rosion% Tooth surface loss caused by chemical or electrochemical action is termed 8corrosion"9 Abrasion% 3riction bet#een a tooth and an e$o enous a ent causes #ear called 8abrasion9" 07 Root stumps" /7 3luorosis% it is an endemic disease in eo raphic areas #here the content of fluoride ion in the drinin #ater e$ceeds ' ppm" 3luorosis is estimated by the dean!s fluorosis method" i7 Any con enital deformity ###"r$dentistry"net Slide $0: J7 Trauma to teeth% tooth trauma is cate oriCed under -llis classification% C<A,, & % simple fracture of cro#n involvin little or no dentine C<A,, ' % e$tensive fracture of cro#n involvin considerable dentine but not the dental pulp C<A,, ( % e$tensive fracture of the cro#n involvin considerable dentine and e$posin dental pulp C<A,, )% traumatiCed tooth become non vital #ith or #ithout loss of cro#n structure ###"r$dentistry"net Slide $1: C<A,, *% tooth lost as a result of trauma C<A,, +%fracture of root #ith or #ithout loss of cro#n" C<A,, D%displacement of a tooth #ithout fracture of cro#n or root C<A,, E% fracture of cro#n en masse and its replacement C<A,, F% traumatic in?uries to deciduous teeth ###"r$dentistry"net Slide $ : &7D23T/dmft R-CORDIN0 3OR CARIOU, T--T/ CARIOU, ,TATU, ,COR- DM dM 2M mM 3M fM D23TM dmftM ###"r$dentistry"net OCCLUSAL REVIE' : OCC<U,A< R-;I-I 2O<AR R-<ATION,/I. .RI2AR4 B-4 TOOT/ is deciduous 'nd molar R-3-R-NC.<AN- is line passin throu h distal surface of ma$illary and mandibular deciduous molars 3<U,/ T-R2INA< 2-,IA< ,T-. DI,TA< ,T-. ###"r$dentistry"net Slide $#: OCC<U,A< R-;I-I 2O<AR R-<ATION,/I. .-R2AN-NT B-4 TO OCC<U,ION I, .-R2AN-NT 2A=I<<AR4 Ist 2O<AR AN0<-!, C<A,, I AN0<-!, C<A,, II DI; I DI; II AN0<-!, C<A,, III -ND ON R-<ATION @ CU,. TO CU,. TOUC/IN0 IN ,A2- <IN- ###"r$dentistry"net Slide $$: OCC<U,A< R-;I-I O;-RJ-T %>horiContal distance bet#een lin ual aspect of ma$illary incisors and labial aspect of mandibular incisors Normal value & to 'mm O;-RAIT-%>vertical overlap of ma$illary incisors over mandibular incisors Normal value & to 'mm ###"r$dentistry"net CRO'DING : CRO,, AIT- -RU.TION ,-:U-NC- AND TI2IN0 To compare chronolo ical a e #ith dental a e CROIDIN0 AANOR2A< ,.AC-, 6 2ID<IN- DIA,T-2A 7 OCC<U,A< R-;I-I CROIDIN0 ###"r$dentistry"net Slide $!: .rovisional Dia nosis .rovisional dia nosis is also called as tentative dia nosis or #or1in dia nosis and is arriver at after evaluatin the case history and performin the physical e$amination" .rovisional dia nosis is ?ust a temporary The dentist shoulde 1eep in mind the differential dia nosis" The postive findin s are listed do#n and the possibility of a specific dia nosis is evaluated" ###"r$dentistry"net

DIFFERENTIAL DIAGNOSIS : DI33-R-NTIA< DIA0NO,I, If the dia nosis is not conclusive for a definite disease process, a list of probable dia noses is recorded in the patient!s case history" These diseases may have a similar course, pro ress, or si ns and symptoms" A final dia nosis may be possible only after carryin out furthur investi ations" ###"r$dentistry"net RADIOGRAPHIC INVESTIGATIONS : RADIO0RA./, A7 OCC<U,A< A7 IO.A C7 AIT-IIN0 D7 O.0 6ORT/O2O.-NTO0RA27 RADIO0RA./IC IN;-,TI0ATION, ###"r$dentistry"net LA"ORATORY INVESTIGATIONS : <AAORATOR4 IN;-,TI0ATION, It helps to come to the final dia nosis" a7 .U<. T-,TIN0 b7 AIOC/-2ICA< IN;-,TI0ATION, c7 A<OOD -=A2INATION d7 URIN- -=A2INATION -7 ,.-CIA< IN;-,TI0ATION, <IB,IA<O0RA./4, 2RI etc ###"r$dentistry"net Slide %1: 3INA< DIA0NO,I, % Usually reached by chronolo ic or aniCation and critical evaluation of the information obtained from patients case history, physical e$amination and the result of radiolo ical and laboratory e$aminations" it usually identifies the chief complaint first and then the subsidiary dia nosis of other problems" ###"r$dentistry"net Slide % : TR-AT2-NT .<AN &" -2-R0-NC4 ./A,- this is the first and the preliminary phase of treatment plannin " The emer ency complication is the first thin to be treated and mana ed" 3or e " <ud#i s an ina involves hi h morbidty due to air#ay obstruction, thus trecheostomy is the first procedure to be performed" Also, in cases of acute pulpal abcess, access openin is done so as to immediately relieve the pressure #ithin the root canal" ###"r$dentistry"net Slide %3: '" .R-;-NTI;- ./A,- this is the second line of treatment" The preventive phase involves protection and prevention of the hi h ris1 factors such as stic1y, su ary diet, calculus retentive factors, deep pits and fissures etc" for e " In cases of caries ris1 assessment i"e" hi h caries ris1/lo# caries ris1, preventive phase is achieved by% Dietary Counselin % Add more cereals ,pulses ,mil1 N dairy product and poultry .it and fissure ,ealant Application % Indication A e more than + year 3luoride Treatment % A e less than + year @;arnish application A e more than + year @ A.3 el ###"r$dentistry"net Slide %#: (" .R-.RATOR4 ./A,-% Oral prophyla$is Caries control -ndodontic Treatment -$traction Orthodontic consultation )" CORR-CTI;- ./A,- % .ermanent Restoration and other prosthetic replacement ,tainless steel cro#n ,pace maintainer *" 2AINTAINANC- ./A,- % a follo# up is essential ###"r$dentistry"net PROGNOSIS : .RO0NO,I, The pro nosis is the prediction of the probable course, duration, and outcome of a disease based on a eneral 1no#led e of the patho enesis of the disease and the presence of ris1 factors for the disease" The pro nosis is evaluated and informed to the patient" The final treatment protocol is then determined" ###"r$dentistry"net