BENIGN ODONTOGENIC AND NON ODONTOGENIC TUMOURS

DR.SOORAJ S.

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• Introduction
• Classification
• Etiology
• Clinical features
• Radiographic features
• Histopathology
• Differential diagnosis
• Treatment modalities
• Prognosis
• References

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CONTENTS

BENIGN ODONTOGENIC AND

NON ODONTOGENIC TUMOURS

An imprecise term that encompasses a wide spectrum of variants depending upon embryologic stage of initiation, histologic and gross appearance of lesion

ODONTOGENIC TUMOR

• Uncommon lesions that are derived from specialised dental tissues.

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• Primarily intraosseous lesions (central).

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• Occassionally occurs extraosseously (peripherally).

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• These tumors have varied clinical & radiographic appearance,can consist

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• Entirely soft tissue
• Mixture of soft & calcified tissues.
• Entirely calcified tissues.
• Wide range of biologic behaviour &b’coz of this various treatment methods have been described : from conservative to very aggressive treatment.

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Classification based on tissue of embryonic origin & the epithelial- ectomesenchymal interactions.

A] Epithelial Origin-:

i) Tumours producing minimal inductive change in c.t

a) Ameloblastoma

b) CEOT [Pindborg Tumor]

c) Adenoameloblastoma [Odont.Adenomatoid Tumor]

ii) Tumours producing extensive inductive changes

a) Ameloblastic Fibroma

b) Ameloblastic Fibro-odontoma

c) Ameloblastic Odontoma

d) Odontoma :- Compound & Complex Composite.

B] Mesodermal Origin. -:

i) Central Odontogenic Fibroma

ii) Odontogenic Myxoma

iii) Dentinoma

iv) Cementoma

a. Periapical Cemental Dysplasia

b. Cementifying Fibroma

c. Benign Cementoblastoma

C] Tumours of unknown origin -:

i) Melanotic neuroectodermal tumor of infancy

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D] Malignant Origin. -:

i) Odontogenic Carcinoma -:

a. Primary Intraosseous Ca.

b. Malignant Ameloblastoma.

ii) Odontogenic Sarcoma -:

a. Ameloblastic Fibrosarcoma.

b. Ameloblastic Odontosarcoma.

WHO-2003

• Benign
• Odontogenic epithelium with mature, fibrous stroma; odontogenic ectomesenchyme not present

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• Ameloblastomas
• Squamous odontogenic tumor
• Calcifying epithelial odontogenic tumor
• Adenomatoid odontogenic tumor
• Keratinizing cystic odontogenic tumor

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• Odontogenic epithelium with odontogenic ectomesenchyme with or without dental hard tissue formation

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• Ameloblastic fibroma
• Ameloblastic fibrodentinoma
• Ameloblastic fibro-odontoma
• Complex odontoma
• Compound odontoma
• Odontoameloblastoma
• Calcifying cystic odontogenic tumor

• Mesenchyme and/or odontogenic ectomesenchyme with or without included odontogenic epithelium

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• Odontogenic fibroma
• Odontogenic myxoma or fibromyxoma
• Cementoblastoma

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• Malignant tumors (odontogenic sarcomas)

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• Ameloblastic fibrosarcoma
• Ameloblastic fibrodentino- and fibro-odontosarcoma

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• Malignant tumors (odontogenic carcinomas)

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• Metastasizing, malignant ameloblastoma
• Ameloblastic carcinoma
• Primary intraosseous squamous cell carcinoma
• Clear cell odontogenic carcinoma
• Ghost cell odontogenic carcinoma

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• True neoplasm of enamel organ type tissue not matured enough to the point of enamel formation.

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• Unicentric, non-functional, intermittent in growth, anatomically benign, clinically persistent.

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• Intra osseous & Extra osseous ameloblastoma

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AMELOBLASTOMA

INTRA OSSEOUS AMELOBLASTOMA

PATHOGENESIS

• Cell rests of enamel organ / dental lamina.
• Disturbance of developing enamel organ.
• Basal cells of surface epithelium of jaws.
• Heterotopic epithelium, e.g.; Pituitary –Rathke pouch
• Lining of odontogenic cysts.

Clinical Features-:

• Forms 1% of all tumours of maxillofacial region.
• 20-40 years, Equal predilection in both sexes.
• 80% in mandible – ¾ in ramus area.
• Maxilla - tuberosity
• Grows in all direction invading soft tissue & destroying bone - direct pressure & distension / osteoclastic resorption
• Swelling, Pain, Sinus & Ulcers
• Maxilla – Nasal Obstruction, Bleeding, Trismus, Sinus Involvement.

RADIOGRAPHIC FEATURES

• Depends on nature of local bone reaction.
• Classically multilocular radiolucency termed Soap bubble or Honey- comb appearance.
• Growth within medullary cavity causing scalloping of inner cortex by pressure erosion.
• Classification :
• Multilocular- Multicystic
• Unilocular
• Septate- Trabeculated
• Solid Type
• Root resorption more frequent than displacement of teeth.

UNICYSTIC AMELOBLASTOMA

• 10 to 15% of all intraosseous ameloblastoma
• Originates de nova or neoplastic transformation of non neoplastic cyst epithelium.
• A high percentage of these lesions are associated with an impacted tooth, and the most commonly cited provisional diagnosis is dentigerous cyst.
• Often seen in younger patients
• Depending on the stage of devlopment – 3 types

UNICYSTIC AMELOBLASTOMA

Intraluminal ameloblastoma

• The devoloping ameloblastoma is growing into the lumen & has not violated the wall of the cyst.

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Mural ameloblastoma

• The devoloping ameloblastoma is growing in the wall of a cyst & confined within the limits of the wall

Conservative surgical approach is often advocated

UNICYSTIC AMELOBLASTOMA

Invasive ameloblastoma

• When the tumor has extended beyond the wall of a cyst & into the adjacent bone or soft tissue or when the neoplasm develops from the epithelium other than the cystic epithelium.
• Radical approach is advocated.

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Extra osseous ameloblastoma

• Develops entirely outside the bone.
• Etiology
• Dental lamina or
• From basal cells of oral epithelium or
• From cells that have undergone SMITH 1968 differentiation to mimic the ameloblast
• Nodular swelling within the soft tissues adjacent to mandible or maxilla
• Slow growing lesion.

Surgical considerations

• The maxillary ameloblastoma is not confined by the strong cortical plate found in the mandible. In addition, the posterior maxilla lies in close relationship to many vital structures.
• In the mandible, 1-cm clear margins are considered the standard.
• For peripheral ameloblastoma, a more conservative excision with close clinical follow-up is the standard of care.

Treatment

• High recurrence rate , controversy, individual surgeon’s philosophy

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• Curettage: Removal of tumour by scraping from surrounding normal tissue.

Least desirable.

90% recur(Sehdev 1974).

More severe in maxilla. Nests of tumour extend much beyond clinical and radiological margin.

En Bloc resection

Kramer 1963,

• Diffuse invasion of cancellous marrow but not haversian system of compact bone
• compact bone of mandible is eroded but not invaded.
• Removal with rim of uninvolved bone, maintaining continuity.
• 1-2 cm safe margin.
• Mandible -no recurrence (Sehdev 1974).
• Maxilla- not successful (Bjorklund1979, Chaudhuri 1975)

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Segmental resection

• Most commonly used- hemimaxillectomy/hemimandibulectomy
• Mehlisch- 33% recurrence in tumours of diameter more than 5cms
• Sehdev- 21%

Other modalities

• Cautery: desiccation / electrocoagulation, secondary ischemia and necrosis for some distence. Mehlisch, Dahlin (1972)-50% recur.
• Carbon di-oxide laser
• Cryosurgery

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PINDBORG’S TUMOR (CEOT)

• Uncommon, benign, odontogenic neoplasm that is exclusively epithelial in its tissue of origin
• Pindborg 1958
• Arises from REE, based on the close proximity of the tumour to embeded or unerupted teeth
• Gon 1965
• In instances of retained teeth, the REE fails to fuse with the oral epithelium, which then may possibly result in abnormal proliferation of stratum intermedium in an attempt to carry out its function
• Intra osseous & Extra osseous variants

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• Expansile slow growing mass with a rather slow growing rate
• No age / sex predliction
• Mandibular molar/premolar region
• All intra osseous CEOT of maxilla- posterior region
• Associated with an unerupted or impacted tooth

Clinical Features

• Unilocular radiolucent lesion which may progress to multilocular lesion with minute calcified masses
• Chaudhry 1972 – 3 stages
1. Similar & cannot be differentiated from dentigerous cyst
2. Minute calcifications appear [ dentigerous cyst / cystic odontoma ? ]
3. Honeycomb appearance – bone destruction& calcium deposition

Radiographic findings

• WHO : "As a fibroblastic neoplasm containing variable amounts of apparently inactive odontogenic epithelium"
• Relatively rare,< 10% of all odontogenic tumors
• Origin - Dental follicle – associated with unerupted teeth Periodontal ligament – not associated with unerupted teeth.
• Females ,wide age range (mean, 37 years).
• Mandible ,anterior portions of the jaws.
• Its association with impacted teeth is uncommon.

CENTRAL ODONTOGENIC FIBROMA

• The unique presence of a palatal cleft when combined with the characteristic radiographic finding is highly suggestive of a codf.
• Radiographically: well demarcated unilocular radiolucencies, but multilocular and mixed-density lesions can occur.
• Locally aggressive,but tend to be separated from surrounding bone.

CENTRAL ODONTOGENIC FIBROMA

• Histolopathologic features

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(1) Fibrous tissue of variable cellularity and density;

(2) Variable amounts of inactive-appearing odontogenic epithelium; and

(3) Variable presence of calcifications resembling dysplastic dentin, cementum-like tissue, or bone

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• Enucleation followed by thorough curettage, unless the clinical behavior is unusually aggressive

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• The recurrence rate - 26%

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CENTRAL ODONTOGENIC FIBROMA

• Gingival counterpart of the COdF
• Ectomesenchymal in origin
• Rare , 1.2 %
• Gingival or alveolar ridge tumor
• Histolopathologic features
• unencapsulated proliferation of cellular fibrous or fibromyxomatous connective tissue that exhibits variable amounts of odontogenic epithelium and sometimes foci of calcification in the form of dentinoid, cementicles, or bone

PERIPHERAL ODONTOGENIC FIBROMA

• WHO :"As a locally invasive neoplasm consisting of rounded and angular cells that lie in an abundant mucoid stroma".
• Myxomas of the facial skeleton can be derived from primordial odontogenic mesenchyme or from nonodontogenic (osteogenic) embryonic connective tissue.
• <40 years, males.
• 2:1 for mandible, molar & premolar regions
• Painless expansion of the involved bone – growth may be rapid – due to accumulation of myxoid ground substance

Myxoma

(odontogenic myxoma,fibromyxoma)

• Radiographic features:multilocular radiolucencies with characteristic soap-bubble or wispy pattern.
• Cortical expansion or perforation & root displacement or resorption
• Histolopathologic features
• Bland myxoid
• No epithelial rests
• Variable amounts of collagen

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Myxoma

(odontogenic myxoma, fibromyxoma

• Complete surgical removal by conservative treatment can be difficult to achieve because the myxoma readily infiltrates the surrounding bone tissue without its immediate destruction.
• There is a high recurrence rate after inadequate surgical treatment

Myxoma (odontogenic myxoma, fibromyxoma

• Rare odontogenic tumour of C.T forming cementum like calcification, fused to a tooth root.
• Due to abnormal periodontal membrane growth & devolopment
• Teenage, no sex prediliction
• Mandibular-premolar & molar regions
• Slow growth & lack of symptoms
• Attached to vital tooth root
• Expansion of buccal & lingual cortical plates
• Occasionally , pain or parasthesia

CEMENTOBLASTOMA

• R/f- mottled or radiopaque mass attached to a tooth root rimmed by radioplucent halo.
• H/f-
• Encapsulated mass of osteocementum entrapping fibrous tissue
• Surrounding tooth root – sleeve
• Separate area of cementogenisis may be seen
• Enucleation

CEMENTOBLASTOMA

• True mixed tumor arising from a combination of 2 embryonic tissues
• The epithelial component is able to induce mesenchyme but not to the extent of developing dental hard tissues
• Relatively uncommon tumor of young people (aged 5-20 y)
• 75% -posterior mandible in the area of a developing tooth
• It is benign and expansile, growing as a pushing front rather than invading surrounding tissues.

AMELOBLASTIC FIBROMA

• Uniocular or bilocular radiolucency-posterior mandible
• H/F : composed of neoplastic epithelium & neoplastic myxomatous connective tissue
• Block excision with a border of normal bone
• Recurrence rate- 20-40%
• Sarcomatous change (ameloblastic fibrosarcoma) also has been reported with recurrence or inadequate excision

AMELOBLASTIC FIBROMA

Ameloblastic Fibro-odontoma

• WHO : " A neoplasm having general features of an ameloblastic fibroma while containing dentin & enamel".
• Abnormal proliferation of odontogenic epithelium from a permanent tooth germ.
• Expansile lesion, slow growth, attains large sizes.
• Swelling and mild pain, Altered occlusion, delayed eruption of teeth.
• X-ray shows radiopaque material in a well circumscribed radiolucency, smooth and even border.
• Aggressive and invades adjacent tissues
• Wide radical excision

• Broca 1866 -odontome
• Thoma & Goldman –odontoma
• "Benign tumors of dental hard tissues with the word 'composite' used to designate the presence of the four dental tissues.
• Anywhere in the jaws, frequent in third molar and incisor-canine region.

ODONTOMAS

• Odontomas with calcified structures & some degree of anatomical resemblence to normal teeth
• Hopper 1970
• Enamel organ or dental lamina in place of a normal tooth or from supernumerary lamina in association with follicle of unerupted tooth.
• Hitchin 1971
• Inherited or mutant gene or interference in post natal tooth devolopment
• Maxillary incisor – canine region
• 2^nd -3^rd decade

COMPOUND-COMPOSITE ODONTOMA

• Slow growing, noninfiltrating, nonaggressive self limiting
• Most common cause for failure of permanent tooth eruption
• Enucleation if capsule intact
• May recur if removed during soft tissue stage

COMPOUND-COMPOSITE ODONTOMA

• Abortive attempt at tooth formation
• Poor structural differentiation & disorderly arranged calcific masses
• Little resemblence to normal teeth
• 2^nd -3^rd decade
• 2nd -3rd molars region
• Less common, small lesion
• Enucleation & curettage
• May undergo cystic transformation

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COMPLEX-COMPOSITE ODONTOMA

EPITHELIAL TUMORS

NON-EPI/ MESENCHYMAL TUMORS

MIXED TUMORS

TUMOURS OF EPITHELIAL ORIGIN

PAPILLOMA

• Common neoplasm ----- from surface epithelium
• Similar to that of fibroma

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Clinical features :

• Exophytic growth --- small finger like projections.
• Roughened, verrucous or “cauliflower like” surface.
• Well circumscribed pedunculated / sessile.

• Tongue, lips, buccal mucosa, gingiva and palate
• Few mm --- several cm.
• Any age
• M= F
• Common wart --- skin analogous to oral papilloma.
• Auto inoculation by finger sucking or fingernail biting.

H/P

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Rx

• Excision--- with pedicle / stalk
• Recurrence is rare
• Malignant degeneration -- unlikely

NAEVUS

• (Pigmented mole, Benign melanocytic nevus)
• ORIGIN- cells migrating from NCC to epithelium/dermis or from altered resident melanocytes

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• Types of nevi
• Congenital
• Acquired.

I/O nevi

• Rare
• Occur at any age
• Small elevated papules/nodules
• <0.5 cm
• Palate common site
• Other– buccal/labial mucosa, gingiva, alv ridge, vermillion

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• H/P
• Junctional nevus
• Compound nevus
• Intradermal nevus (common mole)
• Blue nevus.

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• D/D
• Amalgam tattoo
• Melanoma
• Hematoma
• Kaposi’s sarcoma
• Hemangioma

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• Rx
• Excisional biopsy
• Recurrence unlikely
• Malig. Trans… melanoma... rare

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NON EPITHELIAL (MESENCHYMAL)

LIPOMA

• Tumor of mature adi. Tiss.
• Most common mesenchymal Tumor
• H& N lipoma… 13 % of all lipoma
• Pathogenesis uncertain🡺 common in obese

C/F

• 40 yrs/ >
• F> M
• Buccal mucosa, vestibule common site
• < in tongue, floor of mouth, lips

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• Asymptomatic
• 3 cm/ >
• smooth nodular masses
• Sessile/ pedunculated
• Yellow hue
• Soft, fluid like

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Variants of lipoma

Fibrolipoma

Fibrous+

Fat cells

Intramuscu

lar

Spindle

Spindle cell

+fat

Angiolipoma

Blood ves

+fat cells

Myxoid

Mucoid+ fat

H/P

• Well circumscribed--- thin fibrous capsule
• Lobular arrangement of cells

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TREATMENT

• Local excision
• Recurrence – 5%

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FIBROMA

• Irritation fibroma, traumatic fibroma, fibrous nodule
• Most Common tumor of oral cavity
• Reactive hyperplasia of fibrous CT🡺 local irritation

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C/F

• 4- 6 decade
• M- F 1:2
• Buccal Mucosa..Along bite line--- cheek bite
• Labial mucosa, tongue, gingiva

• Smooth surfaced pink nodule
• White surface --- hyperkeratosis 🡺 irritation
• Sessile, some pedunculated
• Mm- cm
• Asymptomatic until ulceration of surface

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• H/P
• Mass of fibrous con.tissue covered by str. Sq. epi
• Con tissue dense and collagenised
• Collagen bundles arranged in radiating, circular, haphazard pattern

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• Epi– atrophy of rete ridges( fibrous mass)
• Scattered infl---- lymphocytes and plasma cells
• TREATMENT
• Excision
• H/P evaluation– rule out malignancy
• Recurrence - rare

CHONDROMA

• Rare tumor
• originating from meckel's cartilage within the mandible or from cartilaginous rests
• Trauma from dentures – inducing agent
• Slow growing but locally invasive
• Extra osseous chondroma
• 6^th decade
• M=f
• Lateral margin of tongue
• Firm nontender nodules beneath an intact mucosa

Intra osseous chondroma

• 3^rd -4^th decade
• Mandible-posterior to lower cuspid or within coronoid or condylar process
• Body of mandible- swelling & loosening of teeth
• Coronoid or condyle- swelling in region of zygoma, malocclusion or limitation of mandibular movement
• R/f: well defined or extensive destruction of bone with root resorption
• H/f: greyish masses with bluish cartilagenous areas intermixed with cystic spaces
• Radical excision with wide cuff of normal tissue
• Multiple recurrences - malignant

OSTEOMA

• Benign tumor containing mature compact/cancellous bone
• True neoplasm/ bone response to stimuli
• Restricted to craniofacial skeleton

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C/F & radiologic features

• Young adults
• Asymptomatic, solitary lesions
• cranial bones > facial bones
• Body of mandible/ condyle--- common area
• Most occur post to premolars on lingual surface

Types

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• Periosteal osteomas
• Slow growing mass on surface of mand/max
• Polypoid/ sessile mass
• Some--↑ size🡺 facial deformity
• Cosmetic reconturing
• Endosteal osteomas
• In medullary bone
• Small – asymptomatic
• Large– enlargement of affected area
• Periodic observation

Condylar osteoma

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• Osteoma-🡪 mand condyle
• Shift in occlusion
• Shift in midline
• Facial swelling ,pain, limited mouth opening
• Lobulated growth (hyperplasia– condyle normal shape)
• Surgical excision

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H/P

• Compact osteomas– normal appearing dense bone with minimal marrow tissue
• Cancellous--- trabecular bone+ fibrofatty tissue
• Osteoblastic activity

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LEIOMYOMA

• Benign neoplasm of smooth muscles in uterus, GIT, skin
• 3 types
• Solid
• Vascular - common in oral cavity
• Epithelioid
• C/F
• Any age
• Slow growing firm mucosal nodule
• Asymptomatic
• Lips, tongue, palate, cheek--- 80%
• Intraosseous – rare, Unilocular radiolucencies

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• H/p
• Well circumscribed with interlacing bundles of smooth muscle cells
• Nuclei– elongated, pale staining, blunt ended
• TREATMENT
• Surgical excision
• No recurrence

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RHABDOMYOMA

• Neoplasm of skeletal muscle.
• H & N
• Adult
• Fetal
• C/F
• Adult type- Middle age & older pt
• 70% in men
• Pharynx, oral cavity, larynx
• I/O– FOM, soft palate, base of tongue
• Nodule/ mass.. Grows to many cm
• Multinodular or multicentric also
• Fetal – children in face & preauricular region

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• H/P
• Well circumscribed lobules of large polygonal cells with abundant granular, eosinophilic cytoplasm
• Peripheral vacuolization🡺 spider web
• TREATMENT
• Surgical excision

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HEMANGIOMA

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• Developmental vascular anomaly
• Benign tumor of infancy
• Rapid growth phase--- endothelial cell proliferation.
• Gradual involution
• Recognized during 1^st 8 weeks of life

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• Classification
• Type of vessel involved
• Capillary
• Venous
• Arterial
• Hemodynamic features
• low flow
• High flow

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C/F

• 5-10%-- in 1 yr old
• F:M 3:1
• H & N---- 60%
• At birth– pale macule on skin
• 1^st few weeks rapid development
• Bright red color
• Firm and rubbery to palpate
• Compression– mass doesn’t regress
• Deep lesion- slightly raised, bluish

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Proliferative phase

6- 10 months

Less firm to palpate

Involution phase

Color change to dark

purple hue

Age 5– most of red color

disappears

Complete resolution by 5

Yrs age

90% resolving by age 9

• Complications
• 20% of hemangioma
• Ulceration with/ without sec infection
• Hemorrhage
• Pt with multiple cutaneous hemangioma ---- ↑ risk of visceral hemangioma
• Tumors in neck– airway obstruction

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LYMPHANGIOMA

• Benign, hamartoma– lymphatic vessel
• Dev malformation from sequestered lymph tissue that do not communicate with rest of lymphatic system
• 3 types
• Lymphangioma simplex ( capillary lymphangioma)
• Cavernous lymphangioma
• Cystic lymphangioma/ hygroma

C/F

• 50- 70%-- H & N
• 50% Noted at birth,90% by 2 yrs of age
• Cervical lymphangioma
• Common --- post triangle
• Soft fluctuant masses
• Occasionally extend into mediastinum
• Tumor enlargement– 2ry to URTI
• Oral lymphangioma– ant 2/3 tongue 🡺 macroglossia

MCGILL & MUILIKEN CLASSIFICATION

• Type I
• Developing below mylohyoid m.
• Involving ant. & post. ∆
• CT- Sharp cystic demarcations
• Type II
• Develop above mylohyoid m.
• Involve tongue & lips
• CT- poorly demarcated mass, obscured in fat & muscle tissues

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H/P

• Dilated lymphatic vessels or cyst like structures
• Endothelium --- thin
• Spaces – proteinaceous fluid
• Lymphocytes
• RBC

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TREATMENT

• Surgical excision
• Choice- Type 1
• Difficult – Type 2
• Radiation , sclerosing agent – little effect
• Recurrence rate – 5-10%

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NEURILEMMOMA

• Uncommon Neoplasm of schwann cell
• 25- 48%-- H & N
• C/F
• F>M
• 3-6^th decade
• Asymptomatic, pain & tenderness may present
• Few mm- cm
• Lateral neck, middle ear & pharynx
• Tongue– common

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• Slow growing encapsulated
• Arises from nerve trunk
• Pushes nerve aside during growth
• Within bone– expansion

H/P

• Encapsulated tumor
• 2 microscopic patterns
• ANTONI A
• Fascicles of spindle shaped schwann cells
• Palisaded arrangement around central acellular ,eosinophilic areas– VEROCAY BODIES

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• ANTONI B
• Less cellular, less organised
• Spindle cells randomly arranged within loose myxomatous stroma
• TREATMENT
• Surgical excision – maintaining neuronal integrity
• Recurrence rare

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NEUROFIBROMA

• Most common Peripheral nerve noeplasm
• Origin- Mixed cell type
• Schwann cell
• Perineural fibroblasts
• C/F
• Solitary tumors in young adults
• Slow growing, soft, painless lesions
• Size– small nodule– large mass
• Skin– common location

• Tongue and buccal mucosa
• Can arise within bone
• Uni/ multilocular radiolucency
• H/P
• Well circumscribed
• Tumor--- interlacing bundles of spindle shaped cells--- wavy nuclei
• Delicate collagen bundles+ variable myxoid matrix
• RX
• Surgical excision
• Recurrence is rare

REFERENCES

• Oral and maxillofacial surgery– DANIEL M LASKIN
• Oral and maxillofacial pathology– NEVILLE
• Oral and maxillofacial pathology– MARX & STERN
• oral pathology – clinical pathologic corelations-REGEZI
• Text book of oral pathology– SHAFER
• OMSCNA 2004
• Contemporary Oral and maxillofacial pathology– SAPP
• Surgical pathology- FONSECA
• OCNA – 1986
• Odontogenic Tumors and Allied lesions-RICHARDS &PHILLIPSEN