BENIGN TUMORS

OF
ORAL CAVITY

 Neoplasm (Willis 1952):

defined as an abnormal mass of tissue, the growth of which
exceeds and is uncoordinated with that of normal tissues and persists
in the same excessive manner after cessation of stimuli which
evoked the change
Hamartoma:
malformation that presents as mass of disorganized tissue
localized to particular site. Cells are mature
Choristoma:
heterotopic cell rests

BENIGN

MALIGNANT

CAPSULE

present

absent

INVASIVENESS

Non invasive

invasive

GROWTH RATE

slow

rapid

MITOTIC FIGURES

normal

Increased and abnormal

N:C RATIO

normal

increased

METASTASIS

absent

metastasize

RECURRENCE

rare

High tendency

INFLAMMATION

Absent normally

Frequently present

 Tumors of epithelial origin:

1.
2.
3.
4.

Squamous papilloma
Squamous acanthoma
Keratoacanthoma
Oral nevi

. Tumors of connective tissue origin:

A. Fibrous tissue:
1.
2.
3.
4.
5.

Fibroma
Fibromatoses
Giant cell fibroma
Myofibroma
Fibrous histiocytoma

B. Bone tissue:
1.
2.
3.
4.
5.
6.
7.

Ossifying fibroma
Giant cell granuloma
Giant cell tumor of bone
Osteoma
Osteoblastoma
Osteiod osteoma
ABC

C. Fat tissue:
1.
2.
3.

Lipoma
Lipoblastoma
Verruciform xanthoma

D. Vascular tissue:
1.
2.
3.
4.
5.

Hemangioma
Vascular malformations
HHT
Sturge Weber syndrome
Nasopharyngeal angiofibroma

E.

Lymphoid tissue:

1.

Lymphangioma

F. Cartilage tissue:
2.
3.
4.

Chondroma
Chondroblastoma
Chondromyxoid fibroma

G. Myxoid tissue:
1.

Myxoma

H. Muscle tissue:
1.
2.
3.
4.
5.

Rhabdomyoma
Leiomyoma
Angiomyoma
Granular cell myoblastoma
Congenital epulis of newborn

I.
1.
2.
3.
4.

Nerve tissue:
Traumatic neuroma
Neurofibroma
Neurilemmoma
MEN

BENIGN EPITHELIAL
TUMORS

SQUAMOUS PAPILLOMA

Low risk: 6, 11, 42, 43 and 44 - associated with benign lesions like squamous
papilloma, verruca vulgaris, condyloma accuminatum and focal epithelial hyperplasia
High risk: 16, 18, 31, 33, 35, 45, 51, 52, 56 and 58 associated with OPMDs and
OSCC

ETIOPATHOGENESIS

E6: prevents apoptosis which occurs

as normal response

E7: capacity to overcome blockade of DNA

synthesis at G1/S phase in post mitotic
cells
In turn activates mature cells to reenter S phase

Most common papillary lesion accounting for approx 2.5% of all oral lesions
Commonly associated with HPV 6&11, rarely with HPV 2 &57
Common on vermillion border of lips, hard and soft palate
Pink to white exophytic granular/cauliflower like surface alteration
Pedunculated or sessile
2 types:
1. Isolated solitary:
. Adults
. Exophytic, pedunculated (cauliflower)
. White in color
2. Multiple recurring:
. Childs laryngotracheobronchial complex
. High malignant transformation

Surface is parakeratinized
Spinous cells proliferate in papillary pattern.
Occasional basilar hyperplasia & mild mitotic
activity

Narrow stalk below a mass with numerous,

thin finger like projections
Finger like projection is lined by stratified
squamous epithelium, containing thin central
CT which is continuous with stroma of stalk and
body mass

Common in superficial and middle layers

Occasionally focal areas covered by
mixed bacterial colonies

Koilocytes: HPV altered cells. Upper epithelial

cells show pyknotic & crenated nuclei
surrounded by edematous clear zone

SQUAMOUS ACANTHOMA:
More of reactive lesion than neoplasm due to trauma
Older adults
Flat/elevated, white, sessile/pedunculated
H/F:
Well demarcated, umbilical appearance
Thick layer of orthokeratin
Acanthosis
Rare to recur

KERATOACANTHOMA:
Self healing Ca, verrucoma, molluscum pseudocacrinomatosum
Resemble clinically & histologically SCC considered as variant
Etiology:
1. Trauma
2. Chemical carcinogens
3. HPV
4. Genetic factors
5. Immunocompromised state
6. Genetic alterations
C/F:
. Whites & Men
. Sun exposed areas face, neck, dorsum of hands, vermilion borders

 Solitary, firm, round, reddish papules ---------- dome shaped nodules with smooth
surface and central crateriform ulceration project like horn
Painful with associated lymphadenopathy
H/F:
Hyperplastic squamous epithelium:
Thick keratin layer plugging
Occasional dysplastic features
Basal layer appear invading pseudo epithelial proliferation dont extend beyond
sweat glands
CT CIC infiltrate
Rx: excision
Rare to recur

ORAL NEVI: melanocytic nevus, mole, nevocellular nevus

Considered as hamartomas or developmental malformations
Benign proliferation of nevus cells in epithelium and CT
classified as:
1. congenital small and garment
2. Acquired
CONGENITAL:
Garment >10 cm
small >1 cm
Flat tan macules or elevated verrucous hairy
Rare intra orally

ACQUIRED:
More common. Increase with age
No. is genetically determined
1. intradermal: most common
Smooth or elevated
soles of feet & hands
2. Junctional: similar to intradermal
3. Compound: combination of junctional and intradermal
SPINDLE CELL / EPITHELOID/ SPITZ TYPE:
Common in children
Clinically benign and histologically malignant

BLUE NEVUS:
Common in childhood and birth
Composed of dermal melanocytes
Buttocks, dorsum of feet and hands, face
Smooth, blue black
O/M:
4th decade, whites, females
Hard palate, BM, vermilion border, labial mucosa
Asymptomatic
85% pigmented: brown blackish blue
Round/oval, well defined, raised
15% non pigmented: amelanotic
Sessile growth fibroma/papillomas
Blue nevus: palate
Intramucosal: palate & BM. Rare on labial mucosa and gingiva

NEVUS CELL:
Large, ovoid/round/spindle shape
Pale cytoplasm with granules of melanin (melanasomes)
Vesicular nucleus
No dendritic process
No contact inhibition arranged as sheets (nests / theques)
Multinucleated giant cell are present
JUNCTIONAL :
Nevus cells limited to basal layer
No demarcation zone
Epi grows down into CT dropping off effect / Abtrofung effect
Can transform into malignant melanoma
COMPOUND:
o Nevus cells in both epi and CT
o Dropping cells from Epi and large islands in CT

INTRAMUCOSAL:
Nevus cell rests are entirely in CT
Most common
Cells are separated from Epi by band of CT
SPINDLE TYPE:
3 types of cells:
1. Spindle
2. Oval/epitheloid
3. Mono / multinuclear giant cells
. Cells arranged as sheets
BLUE NEVUS:
. COMMON: elongated melanocytes with long branching dendrites
lie in bundles parallel to Epi
packed with melanin granules and extend in to dendrites
. CELLULAR: melanocytes along with large round/spindle cell with pale vacoulated
cytoplasm. Cells are arranged in alveolar pattern

BLUE NEVUS

SPINDLE NEVUS

 Associated with BK mole syndrome: large pigmented nevi with

malignant transformation
Rx: excision

BENIGN
FIBROUS
TISSUE
TUMORS

FIBROMA: focal fibrous hyperplasia / irritational fibroma

Most common benign neoplasm
Etiology: trauma, local irritation
C/F:
3rd 5th decade
Female predominance
BM > gingiva > tongue > lips
Elevated nodule of normal color
Well defined, sessile/pedunculated
H/F:
Bundles of interlacing collagen fibers
Varying no of fibroblasts/fibrocytes
Covered by stratified squamaous epithelium with flat rete pegs
If traumatized vasodilation, edema and infl cell infiltrate
Rx: excision

FIBROMATOSES: aggressive fibromatoses

Moderate aggressive neoplasm
C/F:
Rare intraorally
Common in submandibular area
Oral counterpart: desmoplastic fibroma
H/F:
Poor demarcation
Infiltrating fibrous proliferation at margins
Mature spindle cells
Prominent collagen
No atypia
Rx: excision

GIANT CELL FIBROMA:

C/F:
Asymptomatic
Nodular, Sessile/pedunculated
Bosselated surface
Gingiva, tongue & palate
H/F:
Loose fibrous CT
Fibroblasts 2 types:
a. Large plump spindle/stellate shape multinucleated mainly in periphery
b. Fusiform cells central portion
. Atrophic corrugated epi. With thin elongated rete pegs
Rx: excision

MYOFIBROMA:
Predominantly myofibroblasts (fibroblasts + smooth muscle cells)
Less aggressive
C/F:
Firm submucosal nodule / exophytic growth
Asymptomatic
Tongue, lips and BM
Mand unilocular, well defined
H/F:
Biphasic
Fascicles of spindle cells with abundant cytoplasm (muscle like) with fibroblasts
Primitive spindle cells with hemangiopericytoma like vascular pattern (stag horn)

Rx: excision

FIBROUS HISTIOCYTOMA:
both fibroblastic and histiocytic differentiation
Cell of origin histiocyte
Common: extremities as small firm nodule
Oral & perioral: BM & vestibule as painless submucosal nodule

H/F:
Aggregates of spindle fibroblasts with pale nuclei
Scattered round foamy histiocytes xanthomatous aggrergates
Touton giant cells peripheral nuclei with phagocytosed lipids
Stroma dense collagenous and vascular
Storiform / crisscross pattern: large areas of tumor cells as interlacing fascicles
coming together towards central nidus
Grenz zone: separates lesion form overlying mucosa
CIC in CT
Epi: acnthosis with elongated rete pegs
Rx: excision

PERIPHERAL GIANT CELL GRANULOMA:

Mostly reactive lesion
Etiology: local irritation, periodontitis, poor restorations, ill fitting dentures
C/F:
F>M, 4th 6th decade
Aymptomatic rapidly growing
Ant mand gingiva
Dark red vascular pedunculated/sessile
H/F:
Noncapsulated
Reticular & fibrillar stroma with numerous ovoid /spindle fibroblasts
MNGC osteoclastic / endothelial origin
Capillaries and Spicules of osteoid / bone at periphery
R/F: superficial erosion peripheral cuffing
Rx: excision

CENTRAL GIANT CELL GRANULOMA:

Etiology:unknown
C/F:
Below 3rd decade. F>M, Mand > Maxilla
Mobility, displacement and resorption
2 types: non aggressive (slow growth with no destruction) and aggressive ( fast
growth, pain, perforation & resorption)
H/F:
Loose fibrillar stroma with proliferating capillaries and fibroblasts
Whorled pattern of fiborblasts
MNGC mainly osteoclastic origin
R/F: RL with faint trabeculae, expanded cortical plates
Rx: excision / curretage

OSTECLASTOMA:
Arise from undifferentiated cells
Giant cells fusion of mononuclear cells of histiocytic origin
C/F:
F> M, 3rd decade
Pain & swelling
H/F:
Round / oval / spindle shaped nucleus
Surrounding ill defined cytoplasm
Intercellular subst is absent
Giant cells: uniformly scattered. 40 60 number
Areas of infarction and foam cells
Rx: currettage
Secondary malignant change - osteosarcoma

LIPOMA: yellow epulis

Rare intra oral lesion
Etiology: developmental, trauma, genetic rearrangement
C/F:
Tongue, floor, BM, gingiva
a. diffuse: slight surface elevation. Fluid like feel
b. Superficial: lobulated, painless, sessile, yellow colored
c. Encapsulated
Multiple lipomas: neurofibromatosis, gardener syndrome, Proteus syndrome
H/F:
. Mature adipocytes in collagen
. Thin capsule with lobular pattern
. Types: infiltrating, fibrolipoma, angiolipoma, myxolipoma, spindle cell, pleomorphic,
myolipoma, angiomyolipoma, perineural osteo, adenolipoma

VERRUCIFORM XANTHOMA:
Reactive lesion
Etiology: damage to epi. and immunological
C/F:
4th 5th decade, whites >
Ridge / gingiva, palate and BM
Red / white with pebbly surface
Papillomatous / verrucous
H/F:
Hyperparakeratotic plugging in epithelial crypts
Uniform elongated rete pegs
CT papillae close to epithelial rete pegs
Large foam cells confined to CT papillae. Dont extend beyond rete pegs
CIC
Rx: excision

HEMANGIOMA:
Cell of origin: trophoblast
Not present at birth. Arise within 1st month
8 types:
1. Capillary
2. Cavernous
3. Angioblastic
4. Racemose
5. Diffuse systemic
6. Metastasizing
7. Port wine stain
8. HHT
C/F:
. F> M and whites commonly
. Mand>max> nasal bones
. Intramuscular - masseter

O/M:
Flat/raised, deep red/ bluish red
Lips, tongue, BM and palate
2 stages: rapid proliferation & involute
Central: honey comb with peripheral sun burst appearance & root resorption
H/F:
Capillary type: Numerous capillaries lined by single layer of endothelial cells in CT
Cavernous type: large dilated blood sinuses with thin walls
Rx: undergo spontaneous regression
Surgery, radiation and sclerosing agents

HHT / RENDU OSLER WEBER SYNDROME:

AD disorder
Common in whites
Triad:
1. telangiectasias: on lips, gingiva, BM, floor and tongue. Increases with age
2. Recurent epistaxsis
3. Positive family history
H/F:
. Intrinsic defect in blood vessels endothelial cells detach from basement
membrane / defect in perivascular supportive tissue
. BT &CT are normal
. Rx: cautery, excision and radiation

LYMPHANGIOMA:
Hamartomatous hyperplasia of lymphatics
Malformed vessels have poor communication with normal vessels
Types:
1. Simple
2. Cavernous
3. Cellular
4. Diffuse systemic
5. Cystic hygroma lateral neck
O/M:
. Papillary / diffuse nodules
. Tongue (macroglossia), palate, BM, gingiva, lip (macrochelia)

H/F:
Multiple intertwining lymph vessels
Loose fibrovascular stroma
Cavernous: dilated lymphatics. Flat single layer of cells with plump nucleus

1.
2.
3.

Variants:
Hemangio lymphangioma
Lymphangiomyoma
Lymphangioendothelioma

Rx:
. Excision
. Radioresistant and insensitive to sclerosing agents

MYXOMA:
True neoplasm composed of primitive mesenchyme
Mostly composed mainly of mucopolysaccharides hyaluronic acid
Stellate cells in loose mucoid stroma
Delicate reticulin fibers
Oral lesions are very rare
Surgical excision

CHONDROMA:
Tumor showing mature cartilage tissue
Rare to occur in maxilla and mandible due to secondary cartilages
Painless, slow growing with loosening of teeth
Ant maxilla and mandibular condyle & coronoid
Irregular RL / mottled appearance
Root resorption
H/F:
Hyaline cartilage with areas of calcification and necrosis
Cells small with single nuclei. No great cellular pleomorphism
Cartilagenous tumors are highly area variable
Rx: excision. radioresistant

CHONDROBLASTOMA:
Codmans tumor, epiphyseal chondromatous gaint cell tumor
Younger patients
M.>F
Mandibular condyle and ant maxilla
H/F:
Polyhedral cells uniform and closely packed
Foci of chondroid matrix
MNGC
Necrosis and calcification of chondroid
Rx: excision

LEIOMYOMA:
Rare to occur intra orally because of absence of smooth muscle except in bv
wall / circumvallate papillae

Post tongue, palate, BM, gingiva & lips

Slow growing, painless, pedunculated
c/o sore throat / lump in throat. Dont ulcerate
Central mand

H/F:
Interlacing bundles of smooth muscles with varying amount of fibrous tissue
Nucleus spindle with blunt ends vesicular
Whorled pattern
Rx: excision

RHABDOMYOMA:
Etiology: unknown. Translocation of 15 & 17 chromosomes
C/F:
Nodular/submucosal mass
Adult: male predominance, pharynx and mouth (floor, base of tongue, soft palate)
Fetal: male predominance, new born, pre and post auricular region
H/F:
Adult:
Large round cell
Granular eosinophilic vacoulated cytoplasm rich in glycoprotein and glycogen
Less cellular
Fetal:
Less mature pleomorphic cells
Spindle shaped
More cellular with myxoid stroma
Rx: excision

TRAUMATIC NEUROMA:
Not a neoplasm
Attempt to repair the nerve hyperplasia of nerve and adj tissues
Initial distal degeneration:
1. Swelling
2. Fragmentation and disintegration of axon cylinder and myelin sheath removed
by macrophages
3. Shrinkage of neurilemmal tubes
. Repair:
1. Proliferation of axon and cells of neurilemmal sheath and endoneurium
Unorganised bulbous / nodular mass - neuroma

O/M:
Swelling at mental foramen. Alveolar ridge /lips / tongue
Rarely central
Slow growth with pain on pressure application
PALISADED ENCAPSULATED NEUROMA:
Hyperplasia of fibers, axons and sheaths
Solitary benign
Mainly near mucocutaneous junction
H/F:
Irregular mass of interlacing neurofibrils and schwann cells
Scanty CT stroma perineurium
Fibrils appear as small bundles
Rx: excision

MULTIPLE ENDOCRINE NEOPLASIA (MEN):

AD & neuroendocrinal origin
Associated with:
1. Adrenal pheochromocytoma
2. Medullary thyroid carcinoma
3. Diffuse alimentary tract ganglioneuromatosis
4. Multiple small submucosal neuromas
O/M:
. Yellowish white
. Sessile painless nodule
. 2 8 neuromas. Lips (bumpy lips), commissures and tongue
. Raised calcitonin, altered epinephrine to norepinephrine ratio and VMA levels
H/F:
. Partially capsulated with proliferation of nerves
. Thick perineurium intertwined with plexiform pattern
. Tortous nerve pattern in loose endoneurium

NEUROFIBROMA:
Originates from perineural / fibroblasts
Neuroectodermal origin
Etiology: NF1 gene (neurofibromin) and NF2 gene (Schwanomin)
O/M:
Discrete nonulcerated nodules
BM, palate, alveolar ridge, tongue (diffuse involvement - macroglossia)
Central fusiform shape of mandibular canal
H/F:
o Proliferating spindle cells with thin wavy nuclei
o Mixed with neurites in irregular pattern
o Delicate lacing of CT fibers
Rx: excision. Recurrence is common and malignant transformation

NEURILEMMOMA: neurolemmoma, neurinoma, schwannoma

Derived from schwann cells
slow growing, painless growth
Tongue > palate > floor > BM and gingiva
Central mandible lytic lesion with cortical expansion, pain and paresthesia
H/F:
o 2 types of tissues:
1. Antoni A areas:
. Cell with elongated or spindle nuclei arranged in palisading pattern
. Intercellular fibrils are arranged parallely between the rows of nuclei
. Appears as swirls
2. Antoni B areas:
. Disordered arrangement of cells and fibers
. Edematous stromal fluid with micorcyst formation
. Verocay bodies small hyaline structures
Rx: excision. radioresistant

Schwannoma with alternating Antoni A

and B areas