BENIGN TUMORS OF THE JAW

BENIGN TUMORS OF THE JAW

A – GENERAL INFORMATION:

1 / INTRODUCTION
Benign tumors of the jaws, very polymorphic pathological entities, are divided into:
Odontogenic tumors: original and specific affection of the jaws whose subdivisions are based on odontogenesis and the induction phenomena which accompany it.
Non-odontogenic tumors, some of which are common to the rest of the skeleton and others electively located at the level of the jaws.

2/REMINDER OF ODONTOGENESIS:

The embryological development of the dental bud results from the interaction between the dental lamina and the ectomesenchyme.
The enamel is born under the induction of the ectomesoderm of the dental lamina comprising 04 layers of cells:
– an external dental epithelium with cubic cells,
– a stellate reticulum,
– an intermedian stratum,
– an internal layer of preameloblasts.
The peripheral reflection zones of these layers represent the future Hertwig sheath.
The preameloblasts induce in the mesenchymal papilla the differentiation of fibroblasts into odontoblasts which will form dentin, moreover the Hertwig ridges induce the edification of the root dentin.
The secretion of dentin in turn induces the maturation of preameloblasts into ameloblasts responsible for the secretion of enamel and the appearance of cementoblasts forming the cementum.
The mesenchymal papilla becomes the dental pulp lined with functional odontoblasts.

These different interactions are reproduced in most odontogenic tumors.

3 / Specific clinical and radiological signs:
3.1. Clinical signs
Bone swelling most often summarizes the symptomatology; it is not painful, sometimes follows an inflammatory episode, it is part of the bone.
Inspection and palpation highlight the integrity of the covering cutaneous-mucosal plane, and note the firm or depressible consistency of the swelling; they allow the extension to be assessed in relation to the cortices.
No or few dental signs.
In the absence of inflammatory flare-ups or malignant transformation, there is no cutaneous-mucosal alteration or cervical adenopathies.

BENIGN TUMORS OF THE JAW

3.2. Signes radiologiques

From a radiological point of view, the panoramic scan assesses the extension of the tumor, its uniqueness as well as the analysis of the bone structure.
Other, more specific views are often necessary.

The radiological characteristics to be studied are:
The tone of the image:
radiopaque, indicating the odontogenic, cemento- or osteoformative component of the tumor;
or radiolucent, proof of the osteolytic or cystic character. The image can be mixed, indicating even more the odontogenic character of the tumor.
The outline of the image:
clear border underlined by a thick or thin line, otherwise with a cloudy and irregular outline.
The mono or polygeodic character.
Dental signs:
displacement, repression of the tooth or dental germ.
The relationship of the tumor with the peripheral anatomical elements

(dental canal, maxillary sinus, nasal cavities) which will guide the extension radiological assessment (CT scan).

B/ Benign odontogenic tumors of the jaw:

WHO classification (1992)
distinguishes between:
1- epithelial tumors without induction of mesenchyme
2- epithelial-connective tissue tumors with or without formation of hard dental tissue
3- ectomesenchymal tumors with or without inclusion of odontogenic epithelium.

WHO Classification (2005)
1- Epithelial odontogenic tumors without induction of odontogenic ectomesenchyme:
Ameloblastoma (unicystic, solid-multicystic, desmoplastic, extraosseous-peripheral).
Squamous odontogenic tumor (Benign epithelial odontogenic tumor).
Calcifying odontogenic tumor (Pindborg tumor).
Keratocystic odontogenic tumor “TOK”.
Adenomatoid odontogenic tumor (adenoameloblastoma).
2- Mixed odontogenic tumors (epithelial with odontogenic ectomesenchyme) with or without formation of hard dental material:
Ameloblastic fibroma.
Ameloblastic fibro-odontoma and ameloblastic fibro-dentinoma.
Odontoameloblastoma.
Odontomas (compound odontomas, complex odontomas).
Calcified cystic odontogenic tumor “TOKC”.
Ghost cell dentinogenic tumor.
3-Ecto-mesenchymal odontogenic tumors with or without inclusion of odontogenic epithelium:
Odontogenic fibroma.
Myxoma / Myxofibroma.
Benign cementoblastoma.
4-Bone-related lesions:
Ossifying fibroma, Fibrous dysplasia, Bone dysplasia, Central giant cell granuloma,
Cherubism, Aneurysmal bone cyst, Simple bone cyst.
5-Other benign tumors:
Neuroectodermal melanotic tumor of childhood.

Epithelial odontogenic tumors
1/ AMELOBLASTOMA:
11- Clinical signs:
Tumor common in the +++ between the 4th and 5th decade.
The mandible is affected in (80%) especially at the level of the angular region, then comes the PM and incisor region.
In the maxilla: the floor of the nasal fossae and the molar region (50%).
Ameloblastoma is characterized by a remarkable latency.
It generally manifests itself by a masseteric swelling with thickening of the BM
. Little or no trismus.
12-the radiographic image:
variable appearance
A-polygeodic image:
This is the most evocative.
*Rounded or oval geodes, unequal, with a clear and homogeneous background, bordered by a fine peripheral border. By superimposing, these geodes create the classic “soap bubble” image, the cortices are progressively thinned or even blown in places
*sometimes the image is vast, with a polycyclic outline, finely partitioned.
B – monogeodic image:
a vast single geode, with a scalloped outline, blowing and thinning the cortex at the mandibular level, pushing back the sigmoid notch but preserving the condyle.

CT scans can be used to specify the nature of the tissue (guide the diagnosis)

13- anapath:
Macroscopy:
Grayish-white mass or cyst containing clear fluid or gelatinous material.
Microscopy:
Proliferating odontogenic epithelium within a fibrous stroma
. Base of preameloblast-type cells.

BENIGN TUMORS OF THE JAW

14-Evolution :

In the absence of treatment, ameloblastoma develops slowly in stages.
Ameloblastoma is particularly aggressive, which explains its spread and recurrence.

15- treatment:
Enucleation and bone curettage in monogeodic forms Partial or interruptive mandibular resection as first intention in polygeodic forms

2°/ EPIDEMOID ODONTOGENIC TUMOR (Pullon 1975)

without sex predilection with predisposition for the 3rd decade.
Rarely asymptomatic, it induces dental mobility with spontaneous or provoked sensitivity to axial percussion.

21-Radiologically:
The tumor appears as a triangular or semi-circular radiolucent area bordered by a radiopaque border, most often unilocular, affecting the alveolar processes opposite a root which is sometimes rhizalysed
.
22-Histologically:
islands of well-differentiated epidermoid cells in a fibrous stroma.

23- Treatment:
Enucleation with or without tooth extraction.

3-CALCIFIED ODONTOGENIC EPITHELIAL TUMOR (PINDBORG TUMOR) (PINDBORG 1955)
31 – clinical
Rare
Affects both sexes between the 2nd and 6th decade (peak frequency at 40 years)
Painless swelling, slow-growing, sometimes related to several impacted teeth

32 radio:
Irregular osteolysis interspersed with fine opacities. Sometimes it resembles an ameloblastoma.

33- anapath:
*Macroscopy: hard, friable, grayish tumor.
*Microscopy: dense sheets of polyhedral cells, multinucleated cells with calcification deposits.

34- treatment
Healing after complete enucleation

4/ Adenomatoid odontogenic tumor (adenoameloblastoma) (Philipsen and Bern 1969)
Represents between 2 and 7% of odontogenic tumors; It is encountered more frequently in Africa (Nigeria in particular).
It affects both sexes equally and can be encountered at any age, but with a peak in the 2nd decade.
The regions involved are most often maxillary, in the incisor-canine sector.
Radiologically: a homogeneous, perfectly limited, clear radiographic lesion, the location of which in relation to the dentoalveolar arch may suggest:
A dentigerous cyst, on a lateral incisor or an included canine: this is the “follicular” variety of adenoameloblastoma, the most frequent.
A paradental cyst, globulomaxillary, or essential depending on whether the lesion is located near the apex, latero-radicular, or punched into the bone, without dental connection. This clinical form is called “extra follicular”.
Finally, there is a rarer “peripheral” form, taken for an epulis.
Histology finds a dense, yellowish lesion, surrounded by a thick fibrous capsule.
Complete excision of this lesion ensures healing.

B/ MIXED ODONTOGENIC TUMORS:

1°/ AMELOBLASTIC FIBROMA:
Occurs before the age of 21 with a preferred location: mandibular PM region.
Most often monogeodic image with a well-defined outline.

Histology:
compact, white-grey tumor;
the mesenchyme is abundant, and contains epithelial structures reminiscent of the dental organ.

Treatment:
enucleation.

2°/ FIBRODENTINOMA and AMELOBLASTIC FIBRO-ODONTOMA

Similar to ameloblastic fibroma, these tumors are the site of epithelial-connective induction leading to the formation of:
dentin: fibrodentinoma
*or dentin + enamel: fibro-odontom).

Radiologically:
the non-specific image of osteolysis with the presence of opacities.

3°/COMPLEX ODONTOMAS AND COMPOUND ODONTOMAS
They result from developmental anomalies and do not constitute a real tumor entity
. All normal dental tissues are represented but arranged in an anarchic manner.
Often diagnosed in children during the 2nd decade, they can be revealed by swelling of the maxillary and mandibular PM and M regions or by delayed dental eruption. They are sometimes discovered by chance.

COMPLEX ODONTOMA:
Revealed by an irregular opacity surrounded by a radiolucent border (lesional tissue in the process of mineralization).
Histology shows an anarchic arrangement of normal and mineralized dental tissues (Enamel-Dentine-Cement) and pulpal connective tissue.

COMPOUND ODONTOMA:
Radiologically:
opacity of the anterior seat, consisting of the accumulation of several rudimentary dental bodies. The whole being surrounded by a clear halo with well-defined contours.
Histology:
the compound odontoma is limited by a connective tissue sac and contains multiple small teeth, each consisting of mineralized tissue.

TREATMENT:
excision + curettage.

5/ghost cell odontogenic tumor
First described in 1932 by Rywkind
Revisited in 1962 by Gorlin et al. (Gorlin cyst)
WHO (1992) classifies TOKC among the “benign odontogenic tumors”.
WHO (1995) distinguishes 2 varieties:
a cystic one (calcified odontogenic cyst or KOC)
and a tumoral form (neoplastic ghost cell odontogenic tumor)
OTHER NAMES
Gorlin cyst (cystic variety)
This tumor, representing less than 2% of all odontogenic tumors,
occurs rather during the 2nd decade.
without gender predominance.
It equally affects the mandible or the maxilla, especially in their anterior region.
Besides the usual intraosseous forms, rarer peripheral forms (epulis) are described.
The clinical discovery modalities are unremarkable; imaging reveals a clear, perfectly limited, generally unilocular radiographic lesion.
Calcifications are often associated, ranging from punctuation outlining the cortex to more voluminous formations such as odontomas.
Histological examination reveals a cavity lined by an epithelium that mimics the stellate reticulum of the enamel organ. Mummified ghost cells can be identified in this cell layer.
In rare cases, this component predominates, resulting in a more aggressive, solid tumor called a “ghost cell odontogenic tumor.”
Finally, an odontoma already mentioned, an ameloblastoma fibroblastoma or, more exceptionally, an ameloblastic fibroodontoma can be encountered in the calcified odontogenic cyst.

BENIGN TUMORS OF THE JAW

III°/MESENCHYMAL ODONTOGENIC TUMORS

1°/ ODONTOGENIC FIBROMA:
located asymptomatically in the mandibular body in children and young adults.
The radiological image is polygeodic and finely trabeculated, however the presence of small opacities of dental tone differentiates it from ameloblastoma.

Histologically:
it associates fibroblasts and collagen fibers frequently sparse with islands of odontogenic epithelium.
Treatment:
excision (conservative treatment)

2°/MYXOMA (ODONTOGENIC MYXOMA) OR MYXOFIBROMA
Locally invasive tumor, found before the age of 30 in both sexes.
Affects the mandible more than the maxilla .
Clinically: slowly progressive swelling with abnormal dental development.
The radiograph shows a polygeodic image with sharp or right-angled compartmentalization.

Macroscopically:
the myxoma is grayish, of gelatinous consistency without a clear boundary compared to neighboring structures (bone + soft parts).
Histology
reveals triangular or stellate connective cells embedded in abundant mucoid material,

Treatment:
Treating things as conservatively as possible sometimes carries the risk of recurrence.

3°/BENIGN CEMENTOMA, CEMENTOBLASTOMA (TRUE CEMENTOMA)
Characterized by the formation of proliferating cementum tissue with authentic functional cementoblasts.
Especially in young people (20-30 years) with a slight male predisposition, it is located almost exclusively in the mandibular PM-M region, less often in the maxillary.
The tumor is slow-growing and asymptomatic, associated with possible displacement of teeth remaining alive despite possible insensitivity to the pulp test.

The radiological image
is characteristic: rounded and opaque mass, attached or fused to the root of a tooth.

Histology:
The central area consists of extensive areas of cementum. The unmineralized connective tissue consists of cementoblasts.
Treatment:
Enucleation

C – NON-ODONTOGENEOUS TUMORS AND PSEUDOTUMORS OF THE MAXILLA

I/ BONE-FORMING TUMORS:
Uncommon compared to their malignant counterparts, TBs originating in the bone are sometimes difficult to diagnose with histology.

1°/ TRUE OSTEOMA:
Resulting from the proliferation of compact or trabecular bone within a membranous bone of periosteal or central location.

Often asymptomatic in subjects over 40 years old, slow growing, it is discovered late by a hard and well-defined swelling.

The radiological image is radiopaque, dense, unique and homogeneous with a tone similar to that of the tooth from which it remains independent.
Treatment: excision

2°/ PALATINE and MANDIBULAR TORUS
Exophytic bone neoformation and limited growth, frequently observed
PALATINE TORUS:
located in the midline of the palatine vault, it creates a hard, oval swelling,

MANDIBULAR TORUS:
In adults, it is a bony swelling formed at the expense of the internal cortex, above the mylohyoid line opposite the PM. Most often bilateral and symmetrical. Appears in the form of dense radiopacity, in continuity with the internal cortex.

Histologically:

adult bone whose center is occupied by a mass of spongy bone.

Treatment:
sometimes hindering the wearing of an adjunct prosthesis, their removal by modeling surgery is indicated.

II°/OSTEOCEMENTOGENIC TUMORS:
Cemento-ossifying fibroma, Cementing fibroma, Ossifying fibroma WALDRON 1970
1°/CEMENTO-OSSIFYING FIBROMA (FCO)

It is a neoplasia consisting of fibrous tissue containing varying amounts of mineralized material resembling bone and/or cementum.
It mainly affects the maxilla and especially the mandible at the PM level.
Exceptional in long bones.
Slight female predisposition between 20 and 30 years of age, in the form of slowly progressive swelling of the affected bone sector with dental displacement and sometimes rhizalysis.

*radio
In the early stage, the radiological image is essentially radiolucent, even pseudocystic. Fine opacities appear later and gradually thicken.
In a more advanced stage, the image is made up of concentric bony trabeculae delimited at the periphery by a shell deforming the bony tables, the center of the image contains more regular opacities.
Later the image will be entirely radiopaque

*Histology:
Cemento-ossifying fibroma is formed of connective tissue rich in fibroblasts without mitosis with inclusion of calcified substance whose exact cement or bone nature is often difficult to assess.

BENIGN TUMORS OF THE JAW

III°/ CARTILAGINOUS TUMORS
CHONDROMA:
common in men and exceptional in the maxilla, it is preferentially located in the region:
Upper incisor, symphysis, mandibular body and condyle.
It manifests as a painless bone swelling that develops slowly.
Radiology:
no typical image has been described, the chondroma presents in the form of a + or – polycyclic osteolysis without peripheral osteocondensation.
Histology:
the macroscopic appearance is firm and translucent. *The histology of this tumor is dominated by the presence of small, rounded or stellate chondrocyte cells without nuclear atypia.

IV°/FIBROBLASTIC TUMORS

1°/ DESMOID FIBROMA
painless swelling, of variable evolution, poorly defined.
Rapid growth, it spreads in the soft parts.
Radiology:
single or multilocular osteolytic image with sometimes rhizalysis.
Treatment:
the macroscopic appearance is such that enucleation is technically impossible justifying a large resection. Histogenesis:
the desmoid fibroma is currently considered not as a true tumor but as an anarchic repair process following a trauma.

V°/TUMORS AND PSEUDOTUMORS RICH IN GIANT CELLS

1°/TRUE GIANT CELL TUMORS: (MYELOPLAX T.)

Usually located in the long bones, exceptionally in the jaws.
Occur between 20 and 40 years of age in the form of bone swelling, sometimes painful.
Radiology:
image of mono or polygeodic osteolysis.
Histology:
macroscopy = reddish-brown tumor, partly necrotic, hemorrhagic, pseudocystic; histological examination shows numerous very large giant cells with a very large number (40 to 50) of nuclei bathed in a matrix poor in collagen.
Treatment:
wide excision in healthy bone with or without restoration of bone continuity, in order to avoid the significant risk of recurrence or malignant transformation.

2°/CENTRAL GRANULOMA WITH GIANT CELLS (REPAIRING GRANULOMA): Jaffé 1953

Localization exclusively at the level of the maxillae; frequent in the symphysis region in 20-30 year olds.
Manifests by a bony swelling covered with a brownish mucosa with modifications at the level of the adjacent teeth (mobility, displacement)

Radio.:
large geode with a rounded or scalloped outline, often furrowed by a few cottony or, on the contrary, very fine (honeycomb) partitions.

Histology:
Macroscopically, the enucleation product appears reddish-brown, granular, and hemorrhagic.
The histological appearance varies depending on the quantity and arrangement of giant cells; presence of hemorrhagic foci and hemosiderin deposits. Trabeculae of bone or osteoid tissue may be observed peripherally.

Treatment:
Enucleation is the treatment of choice for central giant cell granuloma, followed by careful curettage.*

The outcome
is often favorable even after incomplete excision.

. 3°/BROWN TUMORS OF HYPERPARATHYROIDISM
Clinical
Brown tumors are bone lesions inherent to secondary hyperparathyroidism in the context of chronic renal failure complicated by osteodystrophy located at the level of the maxillae and the rest of the skeleton.
(Dystrophy = abnormality of shape)
X-ray: image of finely partitioned lacunae without specificities, elsewhere disappearance of the lamina dura and the trabecular structure of the adjacent bone.
Histology similar to that of central giant cell granuloma.
Treatment:
*local: enucleation *general: specific treatment for hyperparathyroidism and the phosphocalcic disorders it causes.

4°/ CHERUBISM (cherubism): familial multilocular cystic disease of the jaws

It is a genetic condition in which the spongy tissue of the jaw is replaced by vascularized fibrous tissue, containing a variable quantity of giant cells.
It is familial and is transmitted in an autosomal dominant manner; with variable expression.
Mandibular angles and rami are hypertrophied.
It begins around the age of 1 to 3 years, progresses during childhood and stabilizes then regresses at puberty, possibly disappearing at the age of 30.
In its mandibular location it appears as a deformation of the bilateral masseteric region, painless and without neurological deficit giving a chubby appearance.
In its maxillary location, the eyeballs are displaced upwards.
Dental malpositions are common as well as monstrous deformities in extreme cases.

Radiography:
multiple areas of osteolysis with preservation of the condyles + agenesis of the 2nd and 3rd molars.

Histology;
appearance varies depending on the progression:
young lesions: connective tissue rich in fibroblasts and numerous multinucleated giant cells is found.
Old lesions: dense fibrous connective tissue, poor in giant cells, with trabeculae of newly formed bone.
Treatment:
therapeutic abstention with control biopsies to monitor progression. In some cases, remodeling surgery may be proposed.

BENIGN TUMORS OF THE JAW

VI°/ OTHER CONNECTIVE TUMORS. NERVE TUMORS

1°/TRUE ANGIODYSPLASIA AND VASCULAR TUMORS:

HEMANGIOMA:

Rarer in the jaws than in the skull and vertebrae.
Mainly affects females in their first decades.
Affects the mandible more than the maxilla (2/3 of cases).
Latent, it is revealed by hemorrhages (gingival bleeding or even cataclysmic hemorrhage after extraction of a mobile tooth).
It must be systematically considered in the presence of an angiomatous appearance of the mucosa, a pulsating bone swelling.

Radio.:
appearance of a poorly defined, single or multi-geodic, non-specific osteolysis. Only angiography will allow a correct exploration of the lesion
Ana-path.:
macroscopy: dark red mass, hollowed out with microcavities and dotted with fibrous or bone tissue.
Histology:
structure of cavernous angioma, with large lacunae lined with endothelium and filled with blood.

OTHER VASCULAR TUMORS:
Among these, capillary lymphangioma is exceptional in the mandibular bone. It consists of an assembly, probably hamartomatous, of distended and cystic lymphatic cavities.

TREATMENT:
The treatment of high-flow angiodysplasia has truly evolved with the advent of hyperselective embolization

2°/LIPOMAS AND LEIOMYOMAS:
They are exceptional in the skeleton and in particular in the jaws.

3°/NERVE TUMORS
Particularly frequent in the cervicofacial sphere.
Among the mandibular locations, SCHWANNOMAS, also called NEURINOMAS, are the most common; they derive from the inferior dental nerve and are usually benign.
They are observed at any age without gender predisposition.
Clinically latent, they sometimes result in a bone swelling.
X-ray: reveals a monogeodic radiolucent image sometimes pushing back the dental canal.

4/ NEUROECTODERMAL MELANOTIC TUMOR. (MELANOTIC PROGNOMA)

Rare tumor, deriving from the neural crest, it occurs in infants between 1 and 3 months and is never observed beyond 1 year.
Its usual location is the maxilla in its anterior portion and some cases have also been described in the mandible or in other locations.
More or less pigmented lesion located in the bone or externalizing in the gum
X-ray:
the appearance realized is that of an osteolysis with poorly defined contours, frequently compartmentalized by bone septa; the developing dental germs are often displaced.
Histopathology:
the tumor is made up of two types of cells:
* some resemble epithelial cells,
* others are small, round, very chromophilic, pseudo-lymphocytic.
Treatment and evolution:
despite the sometimes extensive nature of the lesion, excision is not followed by recurrence .

BENIGN TUMORS OF THE JAW

VII/LANGERHANSIAN HISTIOCYTOSIS (HISTIOCYTOSIS X):

Under the term histiocytosis X have been grouped (according to Lichtenstein 1953) three clinical syndromes having the same histological substratum:

eosinophilic granuloma located mainly in the skeleton,
Hand-Schuller-Christian disease associating cranial lesions with diabetes insipidus and exophthalmia,
Abt-Letterer-Siwe disease, highly progressive, observed in infants.

The condition is characterized by the proliferation of Langerhans cells, hence its current name of Langerhans cell histiocytosis.
The meaning of this condition remains controversial: for some, it would be a genuine tumor developed at the expense of Langerhans cells; but, most authors consider it as a dysimmune disease that could result either from excessive stimulation of Langerhans cells or from a dysfunction of immunosuppressive T lymphocytes.

VIII – Bone and/or cementing dysplasias
1-fibrous dysplasia:
Start 2nd decade, sex F++
Slow progression starting in childhood, stabilization at the end of growth, sometimes occasional progression
Rx:
Appearance Rx differs according to the progression stage:
Decalcification or radiolucency (young lesions)
Gradually “ground glass” appearance
Dense foci with a “cotton” appearance
Major characteristic: absence of demarcation line/healthy bone
Histology
Connective tissue rich in fibroblasts + trabeculae of dystrophyic bone with irregular
contours TTT:
Modeling surgery
2-cemento-osseous dysplasias:

a-periapical cemental dysplasia (periapical fibrous dysplasia)
It affects middle-aged women (40-50 years old) and is located mainly in the region of the mandibular incisors; it sometimes affects several neighboring teeth.

Radiography:
results in periapical osteolysis simulating an apico-dental cyst. However, the tooth in contact is healthy. Then an increasingly compact opacity is observed.
Histopathology: microscopic study shows connective tissue dotted with more or less large lumps of a substance close to cementum.
Evolution: the lesion is usually left in place due to the vitality of the adjacent tooth.

b-florid cemento-osseous dysplasia:

(Giant cementoma, multiple familial cementoma)
These cementomas are observed almost exclusively in middle-aged women of black ethnicity.
X-ray:
images of radiopaque masses disseminated in both jaws, causing bone deformities that are often ulcerated and complicated by osteitis.

Histopathology:
Areas of highly basophilic acellular cementum merging with the dental roots are observed.
This lesion must be distinguished from simple radicular hypercementosis more regularly arranged concentrically to the root.
TTT
Therapeutic abstention in the absence of disorders
Surgical TTT, when necessary, involves large en bloc resections.

END

BENIGN TUMORS OF THE JAW

Deep cavities may require root canal treatment.
Interdental brushes effectively clean between teeth.
Misaligned teeth can cause chewing problems.
Untreated dental infections can spread to other parts of the body.
Whitening trays are used for gradual results.
Cracked teeth can be repaired with composite resins.
Proper hydration helps maintain a healthy mouth.
 

BENIGN TUMORS OF THE JAW