INTRAOSSEOUS, OR HARD TISSUE BIOPSY TECHNIQUE AND SURGICAL PRINCIPLES
A lesion either on or within i:be osseous tissues of the jaws requires investigation. Frequently, problems related to the dentition are the primary cause” and osseous lesions resolve withroper treatment. However,
any lesion that seems unrelated to the dentition or does not respond to the customary treatment of the dentition should have tissue removed for definitive diagnosis.
The most’ common tntraosseous lesions the dentist wil lencounter are perias and cysts of the jaws. Because these have a ristiphic appearance and ale usually as-ymptoma.tic,: a presumptive,dialnosisis frequently How Crystal, treatment mayinvolve:surgical removal Of.the cyJt in the. form of an, .excisional biopsy. When alesion is large, perforating intosoft tissues, or Suspected of malignancy, tnctsional biopsy ,is indicated.
Hard tissue biopsies are no different in their surgical and pathologic principles from soft tissue biopsies; however, their location mandates some special considerations.
Aspiration Biopsy of Radiolucent Lesions
Any radiolucent lesion that requires biopsy should under go aspiration before surgical exploration. This provides the dentist with valuable diagnostic information regarding the nature of the lesion. The results of aspiration may make the dentist decide to refer the patient to another clinician. For example, brisk, pulsating blood may indicate
a vascular’ lesion; whiCh should not undergo surgical exploration by the general dentist. The return of strawcolored fluid would corroborate the presumptive dtagnosis of a cyst, and surgical removal can then be undertaken without hesitation. The aspiration of air may indicate
that the needle tip is within the maxillary sinus or a traumatic bone cavity. The ‘technique for aspiration was ‘outlined previously.
Because of their ‘location within or proximal to the jaws, most lesions of hard tissue must be approached through . a mucoperiosteal flap. Several varieties of mucoperiosteal flaps are available; the choice depends chiefly on the size’ andlpcatton of the lesion.
The principles of flap design outlined in Chapter 8 are the same for surgery for an impacted tooth or an osseous biopsy. The size of the lesion dictates how much access is necessary when excisional biopsy is indicated. Access
may necessitate extension of the mucoperiosteal flap. The location of the lesion dictates where the flap incisions are to be made. It is important to avoid major neurovascular structures when-possible and to keep incisionover sound bone for closure, Optimally the flap design
should provide 4 to 5 mm of sound bone around the anticipated surgical margins. A central lesion that may ‘have eroded the cortical plate of the jaw ‘is- always approached with flap elevation in an area away from the
lesion and.over sound bone. This technique allows establishment of the proper tissue plane for dissection. As the lesion is approached, fusion of the periosteum to the expanding lesion can more readily be ascertained. All
mucoperiosteal flaps for biopsies in or on the jaws sbould be full thickness and incised through mucosa, subrnucosa, and periosteum. The dissection to expose the bone is always performed subperiosteally.
Lesions within the jaws (i.e., central lesions) require the use of a cortical window. If expansion of iI central lesion has eroded the cortical plate to the point that an osseous void is seen once the flap has been elevated, this window
(if necessary) can be enlarged with rongeurs or burs. If the cortical plate is intact, a rotating bur should be used to remove an osseous window (fig. 21-14). The size of the window depends on the size of the lesion and the proxirr. iry of the window to normal anatomic structures such as roots and neurovascular bundles. Once the window has been created, it can be enlarged with a rongeur. The osseous window specimens should always be submitted for histopathologic examination along with the primary
Removal of Specimen
The technique for removal of the biopsy specimen depends on the nature of the biopsy. (excisional versus incisional) and the consistency of the tissue encountered. Most small lesions that have a connective tissue capsule’ (e.g., cysts) ca be removed in their entirety. A dental
curette i used to peel the connective tissue wall of the specimen from surrounding bone. The concave surface of the instrument should always be kept in contact with the osseous surfaces of the bone cavity (see Fig. 21-14).
The specimen should be handled exactly as outlined for soft tissue biopsies. The pathologist should be made aware that both hard and soft tissues have been submitted. Radiographs should always b~ included with the
specimen. It may take 2 weeks or longer before the pathology
report is available because of the delay required for decalcification of tissue, For any benign process excised with the biopsy procedure, the dentist must follow the patient – with serial radiographs to monitor osseous healing. In a .lesion that had only an incisional biopsy performed or in ‘
a lesion that requires further intervention, the dentist must see that definitive treatment of the lesion (if necessary) is undertaken.