Biopsy Techniques in Maxillofacial Surgery
Biopsy Techniques in Maxillofacial Surgery
Biopsy Techniques in Maxillofacial Surgery
maxillofacial surgery
Dr Tegegne,RI
12/19/2023 1
Outline
• Introduction
• Indications and contraindications
• Types of biopsy
• Tissue processing in biopsy
• Special considerations
• Summary of biopsy
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Introduction
• Biopsy is removal of representative &viable
tissue sample from a living body for histo
pathologic examination & Dx .
• The clinician should know the types of biopsy
methods &detail Hx of the lesion prior to
taking the Biopsy.
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• These are :
• The location ,site , color
• Consistency & texture of lesion
• DDx can help the clinician to select
better biopsy type for the lesion.
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Indications
• Clinical suspicion of malignancy
• Rapid growth, ulceration,bleeding
• Induration ,fixation ,erythroplakia
• Duration of lesion for more than 2 weeks with no
known etiological basis
• Any inflammatory lesion not responding to local Rx
after 2weeks
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• Bone lesion not specifically identified by
clinical &radiographic findings
• Any persistent tumescence ,either viable or
palpable below normal tissue
• New or enlarged pigmened lesion that has
irregular border and non homogenous color to
rule out melanoma
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• Lesions clinically appearing benign or
reactive lesion (mucocele ,pyogenic
granuloma) may be excised for esthetic or
functional purpose but the excised specimen
should be sent for histologic analysis to
confirm the clinical impression
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• Lichen planus ,mucous membrane
pemphigoid,pemphigus vulgaris and other
immune mediated diseases may present with
wide spread mucosal ulceration and erythema
• There is no need to biopsy normal structures
• No need to biopsy to inflammatory and
infectious lesion responding to local
Rx(pericoronitis,gingivitis,periodontal abscess
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Contraindication of biopsy
• Vascular lesions significant bleeding may follow
biopsy of vascular lesions
• Caution has to be exercised in the biopsy of any
lesion with red,purple or blue discoloration
– Has blanching & pulsation on palpation
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• Aesthetic region: location of lesion on
esthetic area(vermillion border of lip) is
relative contraindication but referral to
specialist should be considered for such cases
• Medically compromised patient medical
clearance is important in critically ill patients
including poorly controlled
CAD,CLD, endocrinopathies
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• Bleeding diasthesis : Caution should be exercised for
pt on
• Anticuagulant
• Thrombocytopenic purpura
• Hemophilia
• VWB diseases
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• Radiotherapy or bisphosphonate therapy pt
• Caution in taking biopsy of these pt as biopsy
procedure may expose bone that leads to
osteonecrosis
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Types of biopsy techniques
• Incisional
• Excisional
• Punch biopsy
• Electro surgery & laser biopsy
• Oral biopsy
• FNAC
• Frozen section biopsy
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Incisional biopsy
• Provides representative sample of tissue from a
large lesion for histologic analysis
• Its accuracy is relative as it doesn’t allow study
of entire lesion
• The sample should be taken from the part of
lesion that has been severely &significantly
affected
• Multiple biopsy sample may required for
extensive & variety of clinical presenting lesions
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• It is a method of choice for malignant
differential lesions
• The site of biopsy is chosen after completing
clinical ,laboratorical and imaging examination
• Aspiration should always be tried before
incisional biopsy
• Representative area of lesion incised in wedge
fashion including some amount of normal
tissues
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• Sufficient amount of tissue sample should be
obtained
• Ulcerated , necrotic tissue should be avoided
• Incision is planned not to damage
neurovascular structures
• Deeper biopsy is preferred over superficial
one
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Indication of incisional biopsy
• For large and extensive lesions
• Late stage malignancy
• Esthetic concern
• Lesion near to vital structures
• When entire extent of lesion is not accessible
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Technique for incisional biopsy
• 15 size scalpel blade is used
• Elliptical incision with L / W ratio of 3:1
• Facilitate 1ry intention healing
• Inferior incision made fist to obscure bleeding
• The anterior tip of ellipse is gently lifted with tissue
forceps and the base is severed
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Excisional biopsy
• Complete removal of entire lesion for
functional,esthetic purpose and histologic
analysis of lesion
• Is used for entirely benign lesions
• Small ,pedunculated and exophytic lesion in
accessible area are excellent candidate for
excisional biopsy
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• Wedge incision towards the centre of lesion
made to excise it
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Punch biopsy
• Used for excisional or incisional biopsy of
small lesion at accessible site.
• The punch device approach the mucosal
surface perpendicularly
• The punch placed on the lesion tissue and
down ward ,twisting motion is applied
• The tissue core is severed at base with curved
scissors
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• It is not used for vesiculobullous lesions as
twisting motion detach epithelium and
prevent proper assessment of interface
between epithelium and connective tissue
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Electro surgery &laser biopsy
Electro surgery biopsy –
• Used with caution for diagnostic biopsy or
• When information from the margin is required
• Produce thermal artifact hampering histologic
interpretations
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Laser biopsy
• Laser biopsy produce thermal coagulation
smaller than electrosurgery
• Produce good local hemostasis &minimal post
operative discomfort
• Has great value in skin biopsy but
inappropriate to manage wound left by scalpel
biopsy in area of mouth because suture
closure is very difficult here.
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Oral cytology
• Is adjuvant to Incisional or Excisional biopsy
but not substitute to them
• Allow examination of individual surface cells
but can’t provide accurate &definitive
histologic features
• Is diagnostic Screening tools to monitor large
tissue area for dysplastic changes
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• Monitoring tools for chronic mucosal changes
• Doesn’t require any topical or local anesthesia
• Results in minimal tissue discomfort or
bleeding
• Can be exfoliative & brush biopsy
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Exfoliative cytology
• Is scrapping of oral mucosal cells for diagnostic
screening tool
- Using wooden spatula
- Moistened tongue depressor
• If the site to be scrapped is dry,wooden
spatula or tongue depressor should be
moistened to prevent dehydration
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Brush biopsy
• Screening modality for innocuous lesions with
stiff brush by rotational movement including
basal membrane for adequate sampling
• Nuclear stain &light source stain used to
detect early cancerous changes
• Metachromic stain defines erythroplakia
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FNAC
• The use of needle and syringe to penetrate a
lesion for aspiration of its contents
• The use of needle to determine whether a
lesion contains fluid or air and the use of
needle to aspirate cellular material for
diagnostic examinations
• Aspirated fluid( color ,smell)
• Anesthesia usually not required
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• 18-25 gauge needle &5-10ml syringe is used
for aspiration
• The needle is connected to 5ml or 10ml &is
inserted into center of the mass via a small
hole in the lesion
• The syringe is aspirated and tip of the needle
may need to be positioned in multiple
directions to locate a potential fluid center
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• The inability to withdraw fluid or air indicates
that the lesions is probably solid
• For deep lesion , U/S or radiological guidance
may be used to ensure that the needle enters
the lesions
• A radiolucent lesion in jaw that yields straw –
colored fluid on aspiration is most likely a
cystic lesion
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• If purulent exudates –pus-is withdrawn , then
an inflammatory or infection process should
be considered
• Traumatic bone cyst will yield an air aspiration
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• Aspiration of blood indicate vascular
malformation-hemangioma,aneurysmal bone
cyst,CGCG
• Intrabony radiolucent lesion should aspirated
to rule out vascular lesion
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Armamentarium for FNAC
• 22-27 gauge needle
• 10ml syringe
• Pistol grip syringe holder
• Pad or skin swab
• Glass slide
• Gauze sponge
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Frozen Section Biopsy
• Allows for stained slide to be examined within
10 minutes of taking specimen
• Fresh tissue is sent to laboratory to be quickly
frozen to about 70 degrees by immersing in
liquid nitrogen/ dry ice
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• Specimen is cut into slice on refrigerator
microtome & stained and examined
• Establish whether excised margin is malignant
or free of tumor cells
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Tissue processing in Biopsy
It has 7 series of steps
Fixation
Dehydration
Clearing
Impregnation
Embedding &blocking
Section cutting
Routine staining
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• Any tissue taken out of the body will decompose due
to
• Loss of blood supply &oxygen
• Accumulation of metabolic products
• Action of autolytic enzymes
• Putrefaction by bacteria
Fixation prevents all these changes
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• Tissue get fixed in complete physical and
partial chemical states
• The principle of tissue fixation is
• Denaturation or precipitation of cell protein
• Make soluble substance into insoluble
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Function of Fixation
• Prevent putrefaction & autolysis
• Harden tissue slice helping sections cutting
• Make cells insensitive to hypotonic or
hypertonic solutions
• Acts as mordants
• Induce optical contrast for good microscopic
examinations
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Types of fixative compound
• Two types : Type A &Type B fixative
• Type A fixative
• Simple …. Formalin 10%
• Compound…..Bouin’s & Zenker’s solution
Type B:alcohols (carnol’s solution)
• Micro anatomical….preserve anatomy
• Cytological….cytoplasmic &nuclear features
• Histo chemical….. Constituents of enzymes
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Commonly used fixatives
• Formalin….routinely used in light microscope
• Glutaraldehyde ….electron microscope
• Pieric acid(bouin’s solution)..renal and testicular tissues
• Carnol’s solutions…endometrial sampling, cytologic smears
• Osmium tetraoxide .. CNS tissue and Electron microscopy
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Dehydration
• Water is removed from tissue and cells &
space is occupied by wax
• Tissue passes through grades of alcohols-
70%,80&,90% % 100%
• Ethyl ,methyl ,isopropyl alcohol and acetone
can be used
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Clearing
• Alcohol from the tissue and cells is removed –
de-alcoholisation and
• Tissue is replaced by wax soluble fluids
making tissue transparent
• Xylene ,tolune,benzene, chloroform and cedar
wood oil can be used
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Impregnation
• Empty space in tissue and cells - after removal of
clearing agents –are taken by molten wax.
This process is Paraffinization
• Hardens tissue that helps for tissue sectional cutting
• Melting point of wax - 54 to 64 degree Celsius
• Paraffin wax is used for impregnation
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Tissue Processor
• Automatic tissue processor
Open(hydraulic )
Closed(vacuum)
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Embedding & blocking
• Is deparaffinazation process where molten
wax is made out of tissue
• Allow water soluble dyes to penetrate tissue
section and make molds of blocking tissue
• Xylene –water soluble solution- is used
embedding process
• No paraffin contained tissue is stained
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Section cutting
• Specimen is cut into slice of pieces
• Decalcification is removal of calcium from
calcified tissues and making tissue suitable for
sectional cutting
• Unless decalcification is made,the sample
tissue is hard and brittle that make tissue
section difficult
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Routine staining
• We use hematoxylin(basic) & eosin(acidic)
• Eosin ..cytoplasmic stain
• Hematoxylen …nuclear stain
Nucleus,cytoplasm,muscle & collagen
-Stained blue pink
RBC, keratin & colloid protein stained pink
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Special considerations of biopsy
• Ulcerated malignant lesion - rapid
proliferation of cancer cells can out place the
nutrient supply leading to necrosis and
ulcerations
• Biopsy of adjacent intact mucosa is advised as
that from the ulcer or its bases result in non
specific diagnosis
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• Palatal &gingival biopsy - the hard bound
tissues of palate and gingiva make suturing
difficult leading wound healing by 2nd ry
intention
• Denuded bone and discomfort may last for
several weeks
• Gingival biopsy may lead to recession and root
exposure
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• Lip &tongue biopsies - this biopsy may
accompany by hemorrhage &mobility that
complicate the biopsy procedures
• Managed by assistant firmly grip the tissue by
thumb and finger on each side of the lesion
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General guidelines of biopsy
• Armamaterium
• No 15 blade and holder
• Fine tissue forceps
• LA and syringe
• Retractor
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• Sutures
• Curved scissors
• Hemostatic agent-AgNo3,gelatin foam,gauze
• Specimen bottle containing 10% neutral
buffered formaline
• Biopsy data sheet
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• Consent verbal or written consent should be
obtained before any biopsy procedure and explains
about
• The potential complications
Infection,swelling,discomfort,bleeding
Surgery near to nerve may result in transient or
permanent paraesthesia
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Procedure in floor of mouth can damage or
obstruct salivary ducts
Reactive lesions may recur & re excision may
be required
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• LA with adrenaline may be used (1.8ml)
• Infiltration of LA deep into lesion or
• Field or regional block around the biopsy site
can be used
• Intra lesional injection is not good as it distorts
tissue or produce artifact
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Tissue Artifacts
Can be originated from varieties of sources
• Suction induced artifact
– Use suction carefully
– Gauze on hemostat is enough
• Crush artifact ….excessive force
• Cautery artifact around periphery of specimen
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Tissue Orientation
• Is accomplished by placing one or more
sutures on a known margins
• When more than one specimen is collected ,
specimen should be clearly distinguished by
sutures in each specimen or submitting them
by different containers
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Tissue Fixation
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• The sample must be received by lab within 48 hrs
• Because the fixation solution is water based and
doesn’t preserve the tissue
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Hemostasis for Biopsy
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Post op instructions
Standard postoperative instruction should be
provided to the patient that includes
Eating guidelines
Brushing guidelines
Pain control guidelines
Bleeding controlling mechanism
Emergency contact information should
be available
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Submission of Biopsy Specimen
The specimen should always contain
Pertinent clinical history &demographic data
Clinical appearance &location of lesions
Relevant medical Hx in relation to lesion
Colour photograph of the lesion
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Follow up &Reporting of
Biopsy Results to Patient
o Patient should be seen within 1 or 2weeks
post operatively to ensure healing &discuss
the result of biopsy
o The is responsibility of the clinician only
o If the microscopic diagnosis is inconsistent
with clinical impressions ,the clinician should
discuss any concern directly with the
Pathologist
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Summary of Biopsy
Tissue biopsy is very important investigation tool
Proper management of lesions start with the Dx
The final goal of different types of biopsy technique
is to obtain representative tissue sample to facilitate
histologic interpretation
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References
• Caw son essentials of oral pathology & oral
medicine, 7th edition
• Robert E-max maxillofacial pathology,2nd
edition
• Robbins basic principles of pathology
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Thank you
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