4. Odontogenic Bone Tumors Flashcards
Traumatic bone cyst
Now that lesion is NOT going to cause resorption of the ____, not going to cause displacement of the teeth and certainly will not cause ____ of the bone.
• It is strictly an intraosseous condition that is the result of a ____ within the jaw bone or any bone for that matter, that while that resolved the bone itself did not heal around it and that is why radiographically it still appears lucent, but it won’t cause any other disturbances to the ____ or to the teeth around it.
roots
expansive
hematoma
bone
Odontogenic tumors
Derived from ____, ectomesenchymal and/or ____ elements of tooth-forming apparatus
• Or ____ tissue which is the mesenchymal tissue found in ____ during development or any combination thereof
epithelial
mesenchymal
ecto-mesenchymal
neural crest
Odontogenic ____ with mature, fibrous stroma without odontogenic ectomesenchyme
Ameloblastoma, solid/multicystic type Ameloblastoma, extraosseous/peripheral type
Ameloblastoma, desmoplastic type Ameloblastoma, unicystic type
Calcifying epithelial odontogenic tumor Adenomatoid odontogenic tumor Keratocystic odontogenic tumor
Beginning with the most common subset of tumor which are epithelial in origin. These tumors whereby the
tumor cells are epithelial in nature, not mesenchymal, not ecto-mesenchymal.
• The most common of these is ____. We will go thru the categories and we have already gone over ____ at the end.
• This is based on the previous WHO description whereby they include OKC in this category of epithelial
____. In the current update, it is still there but it is there with a question mark as to whether it truly is a tumor but none the less I have characterized it as an epithelial proliferation
epithelium
ameloblastoma
OKC
neoplastic
Odontogenic epithelium with odontogenic ____ with or without hard tissue formation
Calcifying cystic odontogenic tumor
Ameloblastic fibroma Ameloblastic fibro-odontoma
Odontoma, complex type Odontoma, compound type
The second category are tumors composed of epithelium and mesenchymal tissue where both components are neoplastic the epithelium component and ____ component.
ectomesenchyme
mesenchymal
Mesenchyme and/or odontogenic ectomesenchyme with or without odontogenic ____
Odontogenic myxoma Cementoblastoma
The last group, which are much more limited in scope in terms of different neoplasia.
• These are tumors derived from neoplasia of ____ or mesenchymal cells and NOT epithelial cells.
• They may contain epithelium, but the epithelium contained is not ____.
• The epithelium is some ____ or carrier-type tissue(idk what he is referring to?). What is causing the
tumor is the ____ that has become neoplastic. There are two within this category that we will discuss (indicated below). We will primarily discuss epithelium tumors
epithelium
fibroblasts
neoplastic
reactive
fibroblast
Ameloblastoma
most common ____ tumor
____ > 80-90%
– includes ____ variant
unicystic > 10-15%
____ > < 1%
The most common type of epithelial tumor
This is the most common benign jaw bone tumor that we see in clinical practice
It is seen in one of three histologic shapes: either a ____ tumor, a ____ tumor or a tumor that occurs only within the soft tissue, in this case as a ____ tumor
Most commonly in the solid form also called conventional or multi-cystic is found in the jaw bone as unilocular or ____ lucency and always as a ____ (this is an important distinction because some of these mixed tumors are mixed radiographically.) These tumors are always radiolucent.
odontogenic
conventional/multicystic
desmoplastic
peripheral
solid
unicystic
peripheral
multilocular
lucency
Ameloblastoma
The unicystic form is always and only ____ where as conventional is maybe unilocular or ____ radiographically, unicystic is always unilocular, by definition, radiographically and unicystic is always a cystic tumor. It takes the shape of a cyst, microscopically, except the cyst- lining is a tumor-lining/____-lining
Lastly, peripheral ameloblastoma is strictly within the ____ tissue and in this case, that is soft tissue only of the ____ because you don’t get tooth development in the buccal mucosa or tongue so where the teeth develop is where these tumor will occur either within the jaws or gingiva, but radiographically the conventional tumors or unicystic tumors may look like ____ in that they may be beneath teeth, around teeth, in between teeth, away from teeth much like OKC. In this image here, this is a multilocular lesion (arrow) between these two teeth here What are you thinking, first and foremost?____….. Except in this case this was an ameloblastoma. I showed you a case before when I showed you OKC of a very similar lesion that was an OKC.
These warrant a ____ for diagnosis because the treatment for BOC is very different from ameloblastoma. The treatment for this ameloblastoma is required removal of this ____ tooth and the tissue in between, that is a true tumor and that can potentially be an aggressive tumor.
unilocular
multilocular
neoplastic
soft
gingiva
anything
BOC
biopsy
two
Ameloblastoma
____, locally aggressive tumor
____ / unilocular radiolucency May be associated with ____ tooth
• These are benign but locally aggressive tumors
• These can cause local destruction and local invasive into adjacent structures, so maxillary tumors can be
quite debilitating as they can directly extend into the ____.
So going back to the yellow text listed at the bottom of that slide about with dentigerous cysts: Dentigerous cysts are NOT radiographical diagnosis, they are part of the differential because OKCs and ameloblastomas commonly manifest around crowns of ____ teeth.
So if you have a lesion around the crown of an impacted tooth, you are typically thinking those 3 lesions for differential diagnosis: ____, ____ and ____
benign
multilocular
impacted
orbit impacted OKC ameloblastoma dentigerous cyst
Ameloblastoma
So these can be quite extensive.
• This is a massive lesion in the mandible.
• This goes up to coronoid process all the way down to body.
• This is not that dissimilar to the OKC I showed you before, except that patient had massive expansion of
this mandible. So this is the same patient you see radiographically, whereas in the OKC case, that patient had almost no evidence of anything ____ beyond the radiographic presentation.
Can OKCs look like this? They can, very rarely. So in this case, my best guess diagnosis would be ____ in this case and NOT OKC.
clinically
ameloblastoma
Ameloblastoma
So this is the same image from the first slide, I showed you
This is a ____ lucency, this is like soap bubbles (green arrow, he mentioned this earlier)
Image on the right, a lesion between two teeth causing ____ of the roo
multilocular
displacement
Molecular genetics of odontogenicneoplasia
• Mice expressing ____-G12V transgene developed odontogenic tumors
HRAS, KRAS and NRAS
- ____
- promote ____
- suppress apoptosis
- modulate ____ microenvironment, stimulate ____
- enhance metabolism
- immune ____
These are true tumors & these tumors harbor mutations that are characteristic of them.
• In particular, these tumors harbor a mutation one of 3 or more genes.
• Most of the proteins these tumors harbor mutations in are all part of the same ____. Back
in the early 1990’s they were studying a form of lung cancer in mice.
• Back then they already knew some cancers expression HRAS. HRAS is an oncogene that is mutated and
this mutation called G12V (glycine-12) is oncogenic in that tumor. They created mice to overexpress the same oncogene to see where these tumors develop beyond the lung and unexpectedly, they found these mice developed tiny jaw tumors. At that point they did not characterize them further except to say they are jaw tumors, subsequently they looked and found they were ameloblastomas
HRAS plasma membrane GTPases proliferation cellular angiogenesis evasion
molecular pathway
Molecular genetics of ameloblastoma
• Beyond that these same tumors also harbor other mutations one of which is in the same pathways as HRAS, NRAS and KRAS and that protein being BRAF which we are familiar with. ____ mutations have been seen in melanomas and lung cancer.
• BRAF mutations have been seen in a pretty significant subset of ameloblastomas as well and primarily in those tumors that found in the ____.
• Maxillary ameloblastomas do not harbor mutations in BRAF but rather mutations called ____.
• This is interesting because it is the same tumor but in the maxilla they harbor one type of mutation and
in the mandible they harbor another type of mutation. ____ is not in the pathway that HRAS, NRAS or even BRAF is found in, but found in a whole different pathway. We do not know how those tumors develop, we just know that the mutation is found in a good subset of maxillary ameloblastomas
BRAF
mandible
SMO
SMO
BRAF is not associated with cancer in the jaw bone but rather it is associated with ameloblastoma which is a ____ tumor.
benign
Histologic variants
- ____
- Plexiform
- ____
- Granular cell
- ____
- Basal cell
- ____ epithelial cells (ameloblasts)
- Reversed nuclear polarity
- Subnuclear ____
- Stellate-shaped cells (stellate reticulum)
follicular acanthomatous desmoplastic columnar vacuolization
FOLLICULAR VARIANT
You should see 2 things:
• Periphery of tumor islands (here outlined is one distinct tumor island – outlined in green arrows)
• Around the periphery of the island, you should see ____ cells with palisading nuclei. These nuclei are
____ polarized away from the basal membrane (this essentially means the nuclei is pushed away from
the basal membrane and the nuclei are arranged in a palisading pattern)
• Between the nucleus and basal membrane you have a clear ____ in which, under normal circumstances,
these cells would be producing ____ (the same cells which give rise to enamel), except in this context they are neoplastic
These cells look like/mimic ameloblasts histologically, but do not function like ameloblasts (hence the term ameloblastoma). They do not produce ____ and are neoplastic. The dark cells seen in purple are the ameloblasts
Internally, within the tumor island you something called ____ (listed in last line on previous slide). Stellate reticulum is tissue found during normal tooth development.
Ameloblastoma is reproducing structures formed during normal tooth development, except in a neoplastic manner
So the follicular form is islands/small packets with all these features in each packet
columnar cells
reversibly
vacuole
enamel
enamel
stellate reticulum
PLEXIFORM VARIANT
Plexiform appearance is the same features except they go all over the ____. One ____ proliferation of tumor. he points out in the image on the left that there are cords & strands of interconnected tumor cells, that is the plexiform subtype
They are not discrete tumor islands, but rather one long strand of interconnected tumor that is going all over the place
place
continuous
Acanthomatous ameloblastoma is characterized by ____ of the stellate reticulum
Metaplasia is conversion of one normal cell type to another
Now, these aren’t normal cells but what is happening is that the stellate reticulum is being converted to squamous cells so you get acanthomatous change, squamous cell change of the islands. So if you see a cell that has mostly squamous metaplasia we call it acanthomatous variant
sqaumous metaplasia
Then we have granular cell variant
recall what a granular cell tumor is > tumor cells have a ____ appearance
These cells in the image on the right have a very grainy/sandy appearance like what you would see in a granular cell tumor so, in this context, they are called granular cell ameloblastoma
grainy
DESMOPLASTIC VARIANT
• The basal cell variant is pretty rare, so we are not discussing that
• This variant shown is not as rare
• This variant of the tumor has a distinctive radiographic presentation beyond the histology
• It is called desmoplastic ameloblastoma because all the ____ stuff represents the tumor islands
(follicular islands), around it (the pink stuff) is dense ____ so you have dense ____ of the connective tissue hence desmoplastic ameloblastoma
dark/purple
collagen
fibrosis
DESMOPLASTIC VARIANT
This version of the tumor may have a very distinctive radiographic presentation as well
You may see ____ or multi-locular type lucency or you may see as you do in the image on the left below, more of an ill-defined, poorly-defined, almost a mixed appearance radiographically where it is not really radiolucent and not really radiopaque, it has an in between presentation.
Image on the left: it is not really radiolucent, it is not completely dark as it was in some of the other cases, it has an in between appearance. This is sometimes called a ____ appearance, radiographically this is sometimes called a ____ appearance or a mixed type description
ground-glass
mixed
Unicystic ameloblastoma
• < ____ years
• Always ____ radiolucency
• Frequently associated with ____ tooth
Image shows a patient with ____ fracture due to bone being weakened. Anytime you have pathology in the bone (any bone) that inherently weakens the structural integrity of the bone
Even ____ could cause fracture in the bone and that is called pathologic fracture. In this case, the kid developed a pathologic fracture in his bone secondary to unicystic ameloblastoma which is what this lesion (green arrows) was.
30 unilocular impacted pathologic mild trauma
Right image: this lesion was most likely confused to be a ____ because there was a history of tooth extraction. The lesion is well-defined, unilocular which is why it was confused as well. Upon biopsy it was found to be an ameloblastoma
Left image: nice, well-defined unilocular lesion here (green). Again equally ____ there
residual cyst
well-defined
LUMINAL v. INTRALUMINAL
Microscopically, there are two types of unicystic ameloblastoma
Light blue represents the lining of the cystic structure/tumor, except the lining is not just regular epithelium it is ____ epithelium. The lining is made up of the same tumor cells that form the ____ part of the tumor
If only the cyst lining is ameloblastic then that is ____ unicystic ameloblastoma, if the tumor cells are growing into the space of the lumen we call that ____ unicystic ameloblastoma. They are still unicystic because the tumor is still within the cyst-lining
ameloblastic
solid
luminal
intraluminal
Treatment • Conventional – \_\_\_\_ / peripheral ostectomy • Unicystic – \_\_\_\_ / peripheral ostectomy
If it is a solid tumor, you would treat it pretty significantly with resection and if not resection then peripheral ostectomy which is when you take a big chunk of bone out
If it is unicystic, they may treat very differently. All you may need to o is remove the ____ structure and that may be enough. You rarely need a ____ surgery for unicystic
The image shows a patient who had a large conventional tumor in their mandible
resection
enucleation
cystic
significant
A peripheral ameloblastomas is strictly a ____ mass that looks like the ____, except in this case this was an ameloblastoma which is a very different diagnosis since 3 P’s are ____ lesions thus if you remove the source of the trauma and the lesion and that should resolve so there aren’t any reoccurrences.
In this case, this is a tumor and this will keep ____.
Either it will keep growing into the soft tissue or it may invade into the bone underlying the gingiva. These are true tumors that can be locally aggressive but microscopically they are just ameloblastoma
soft tissue
3P’s
reactive
Adenomatoid odontogenic tumor
Usually ____ decade; ____ > M
____ region
– Usually associated with crown of unerupted ____
____ radiolucency
– “snow-flake”–like calcifications
These tumors may also tend to have a ____ appearance radiographically in that they are radiolucent primarily with some degree of calcification. This tumor may be found around the crown of an impacted canine or independently of the tooth itself, but around the canine region
These tumors are pretty ____ so once you treat they tend not to reoccur
2nd F MX cuspid canine unilocular mixed non-aggressive
AOT
- These tumors are pretty microscopically and they are characterized by a couple of features:
- They have ____ (green arrow). They are tubes that have a ____ end to them, they are not thru and thru tubes or cylinders. At some point, if you cut deep enough, you will end up with some solid piece of tissue (indicated with blue arrow). These blind-end ducts are ____ for this tumor
- This tumor may also ____ which is what gives rise to the mixed appearance radiographically
blind ended ducts
solid
pathognomonic
calcify
Calcifying epithelial odontogenic tumor
• > ____ years
• ____ or mixed
radiolucent – radiopaque
• ____ region
- Distinctive in that the age predilection is much older (> 30)
- These can be lucent or mixed radiographic (not very distinctive)
- Location: it is not unique to the mandible so that is not a distinctive feature either
30
radiolucent
mandibular molar - ramus region
CEOT \_\_\_\_ cells with intercellular bridging Sheets of \_\_\_\_-like material – Odontogenic \_\_\_\_-associated protein \_\_\_\_ rings
- • •
- What is distinctive is that this is the only epithelial tumor that is not derived from ameloblastic type epithelium.
- This is derived from ____ during tooth development. Stratum intermedium is a layer of epithelial cells that look like ____ cells to an extent. They have bridging like squamous cells have bridging between one another. They are not exactly squamous cells but they are most close to squamous cells as you can see in developing tooth structure. That is the 1st distinctive feature about these structures.
polyhedral amyloid ameloblast liesegang stratum intermedium squamous
The second distinctive feature is that these tumors produce ____.
• This is the only tumor that occurs in the jaw bone that produces amyloid.
• Amyloid is an extracellular protein, it is a protein deposition.
• There are different types of amyloid and all amyloids have the same extra structural appearance, they are
characterized by ____, the protein is arranged in a unique morphology (we will not discuss morphology)
In dark field microscopy, ____stained amyloid will stain ____ under polarized light These tumors always and only produce amyloid and this is ____ for these tumors
amyloid sheets congo-red green pathognomonic
CEOT
These tumors also produce these rings called ____ (a ____) which are also pathognomonic for these tumors
Radiographically, nothing about these tumors is distinctive, they may be mixed radiolucent, radiopaque, uni or multi-locular, what is distinctive is their histology and that is how these things get diagnosed
liesegang rings
calcification
Odontogenic epithelium with odontogenic ectomesenchyme with or without hard tissue formation
Calcifying cystic odontogenic tumor
Ameloblastic fibroma Ameloblastic fibro-odontoma
Odontoma, complex type Odontoma, compound type
xt, category are those tumors that epithelial in nature but they do have neoplastic mesenchymal components, so they are ____ tumors. Both the epithelial and connective tissue are in fact tumor
mixed
Calcifying cystic odontogenic tumor
Calcifying odontogenic cyst
• \_\_\_\_ mutation • < \_\_\_\_ yrs of age • May be mixed \_\_\_\_ - radiopaque • Most common \_\_\_\_ tumor • Histology – \_\_\_\_ – like epithelium – \_\_\_\_ cells
These lesions are characterized my mutations in beta-catenin which is an important protein that plays a role in ____ and patients who develop sporadic mutations will get these in their jaw bone
These also occur in young population of patients and these tumors do not have any distinctive appearance ____ (can be radiolucent, radiopaque, uni or multi-locular). It will be mixed radiolucency most likely because they produce calcifications
Of all the jaw tumors, this is the only one that occurs most commonly outside of the ____ bone. You are more likely to see a peripheral ____ than a peripheral ameloblastoma
Of all the jaw bone tumors, this has a greatest predilection to occur either inside or outside the gingiva/soft tissue
b-catenin 30 radiolucent extraosseous ameloblast ghost
tooth development
radiographically
jaw
COC
These are all examples of lesions that were mixed radiographically (radiolucent or radiopaque)
Radiopacity implies ____
calcification
COC
What is pathognomonic for these tumors is that they are ____ (the epithelium is ameloblastic and the epithelium mimics ameloblastomas
What differentiates this form ameloblastoma is “ghost cells”. The presence of ____ (arrow) is pathognomonic for this tumor.
ameloblastic
ghost cells
COC
They are called ghost cells because they have an outline of a cell with nucleus but they are not ____ cells
These ghost cells are pathognomonic for COC
Over time, ghost cells ____
The dark purple in the images represents calcification within a ghost cell area
These are ____ tumors that are innocuous so once you treat them, they should not come
functional
calcify
benign
Ameloblastic fibroma
Ameloblastic fibro-odontoma
• \_\_\_\_, young adults • \_\_\_\_ region – Often with crown of \_\_\_\_ tooth • Uni– or \_\_\_\_ radiolucency – \_\_\_\_ radiolucent – radiopaque for AFO
Both the epithelial and the connective tissue are neoplastic the difference is that one tumor has ____ while the other does not
These tumors also have a distinct site predilection that they almost always occur in the posterior mandible, but radiographically, by definition, The lucent is always ____, the mixed OR radiopaque lesion is potentially ____
kids
mandibular molar-ramus
impacted
multilocular
calcifications
ameloblastic fibroma
ameloblastic fibro-odontoma
AF AFO
This is a patient that has a small lesion in the mandible (arrow), except it is overlying a developing first molar. This is the ____ most common reason a patient is sent to a pediatric dentist for evaluation of a missing first or second molar. So you have a 7 year old patient who has 3 of his 4 molars in place and they are sent to the dentist to figure out why the fourth molar hasn’t erupted and most times what happens is that the 4th molar is being impeded by one of two pathologies: either this pathology or the one we will talk about in a few minutes
The mandibular second molar was impeded with a large lesion above the molar blocking its ____
second
eruption
AF/AFO
This is tumor looks very much like ____, the epithelial islands look like ameloblastoma except the connective tissue does not (he points only to the image on the left)
ameloblastoma
AMELOBLASTIC FIBROMA v AMELOBLASTOMA
Ameloblastoma > the connective tissue is just ____ mature connective tissue. This is because the ameloblastoma is not neoplastic in ameloblastoma, it is just the ____
Ameloblastic fibroma > the epithelium looks identical to ameloblastoma except the ____ is not. In ameloblastic fibroma, the connective tissue (arrows) is ____, neoplastic connective tissue. So the fibroblast that make up the connective tissue are in fact neoplastic and ____. That is what defines this tumor, mechanistically and microscopically
regular
epithelium
connective tissue
immature
proliferative
AF/AFO
Ameloblastic fibro-odontoma is the exact same ameloblastic fibroma except odontoma implies that it is forming ____
That is the hard tissue calcified portion of ameloblastic fibro-odontoma. The odontoma portion is actual real tooth structure, not well-formed but still real tooth structure; ____, dentin and/or cementum
The dark pink stuff represents ____ (he will NOT ask us to recognize this microscopically, but do know that this tumor is composed of abnormal tooth structure + ____ together
tooth structure
enamel
dentin
ameloblastic fibroma
Compound odontoma
Complex odontoma
- ____ patients
- ____ mass
- May overly ____ tooth
This is a hamartoma of tooth structure, not a choristoma because a choristoma is normal tissue occurring in an abnormal site. So a choristoma in the tongue is bone occurring in the tongue, which is NOT normal, but it is normal bone
Hamartoma is ____ tissue occurring in an area where you would ____ find it
Complex odontoma implies abnormal arrangement of ____ developing in the jaw bone where you normally find tooth structure.
Hamartomas occur almost exclusively in young patients, kids, young adults. These are radiopaque masses and this is the most common reason why a patient may be missing an ____ tooth.
Image on the right, this patient is a young teenager who is missing the second molar being the eruption is being impeded by this massive radiopaque lesion (arrow) that is diagnosed as a complex odontoma
young
radioopaque
impacted
abnormal
normally
tooth structure
erupted
Compound odontoma
Complex odontoma
• Compound variant
– ____
– Multiple tiny, well-formed teeth
• Complex variant
– Usually ____
– Irregular mass of ____ material
anterior maxilla
posterior regions of MD and MX
tooth-like
This is a complex odontoma
He is not going to ask us to recognize it microscopically except to say that in a complex odontoma what you are seeing is irregular, aberrant organization of normal ____
So he is not going to ask us to identify but for our own knowledge is he points out enamel (green arrow) at the top, dentin (orange arrow) and cementum (yellow arrow). None of this looks like a tooth but it is all normal tooth structure which is why this is a ____. Sometimes they say the enamel, microscopically, looks like fish scales. Normal enamel but without the normal enamel ____
tooth structure
hamartoma
arrangement
Mesenchyme and/or odontogenic ectomesenchyme with or without odontogenic epithelium
Odontogenic myxoma Cementoblastoma
These are mesenchymal tumors in which mesenchymal cells are neoplastic not the epithelium
Two types:
• Odontogenic myxoma > neoplastic cells are ____
• Cementoblastoma > neoplastic cells are ____. Cementoblasts are ____ cells
fibroblasts
cementoblasts
mesenchymal
Odontogenic myxoma
< \_\_\_\_ years • \_\_\_\_>MX – NEVER directly associated with \_\_\_\_ • Histology – Widely spaced \_\_\_\_ – \_\_\_\_ – Minimal \_\_\_\_
If he were to show us a radiograph with a lesion around the crown of a tooth and it looks like it is attached to the tooth, that is never going to be a ____. This is because myxomas aren’t ever attached to tooth structure
Radiographically, they may be mistaken for ____, ameloblastomas, OKCs, so there is nothing distinct about the radiograph appearance except it is never physically attached to a tooth
30 MD teeth fibroblasts mucopolysaccharides collagen
myxoma
radicular cysts
Odontogenic myxoma
These are tumors so they can be locally ____
This is a patient who has almost half of his mandible, one big tumor
You see here (orange arrows) a large multi-locular lucency
The CT scan shows it had perforated thru the buccal cortex (yellow arrow)
The image on the right most is his mandible, not sure why they took out the whole mandible. Shows the massive tumor this guy has that took up a good chunk of his mandible
These may require pretty extensive & significant surgery
aggressive
Microscopically, it is the most distinctive of all tumors, lots of empty space, ____ space with only scattered pink. The scattered pink represents ____, dark blue dots represent tumor cells. This has a myxoid appearance microscopically & it is essentially ____ for this tumor
It is not really white space, the white space represents jelly aka ____ aka proteoglycans
So if you cut into the tumor shown on the previous slide with a scalpel what you would see would be a big blob of ____ that would pop-out. These tumor cells produce lots of mucopolysaccharides aka proteoglycans
white
collagen
pathognomonic
mucopolysaccharides
jelly
Cementoblastoma
• > MX
– ____region
• Well-____ mass
– Physically attached to ____
A tumor that is derived from neoplastic cementoblasts
This tumor is always and only ____ and this tumor is almost always found in the mandible, almost always in the first molar region and always physically attached to the tooth because cementum is always on the tooth root so cementoblasts produce cementum and so these tumors are producing neoplastic cementum
30 mandible first molar circumscribed root radiopaque
Cementoblastoma
This was treated inappropriately with the assumption that this was an ____ pathology
would require a significant effort since you can’t get extract the tooth because the tooth is physically fused to
the lesion so you have to surgically extract the tooth and then ____ up the underlying mass of tissue (lesion) and pull it out at the same time
inflammaotry
chop
