Effect of Geographic Variation in Bioarcheology: A Forensic Odontology Perspective.

How to cite this article: Yukta HN, Augustine D, SV Sowmya. Effect of Geographic Variation in Bioarcheology: A Forensic Odontology Perspective. J Contemp Dent Pract 2024;25(1):1-2.

Artificial intelligence systems in dental shade-matching: A systematic review.

PURPOSE: Uses for artificial intelligence (AI) are being explored in contemporary dentistry, but artificial intelligence in dental shade-matching has not been systematically reviewed and evaluated. The purpose of this systematic review was to evaluate the accuracy of artificial intelligence in predicting dental shades in restorative dentistry. METHODS: A systematic electronic search was performed with the databases MEDLINE (PubMed), Scopus, Cochrane Library, and Google Scholar. A manual search was also conducted. All titles and abstracts were subject to the inclusion criteria of observational, interventional studies, and studies published in the English language. Narrative reviews, systematic reviews, case reports, case series, letters to the editor, commentaries, studies that were not AI-based, studies that were not related to dentistry, and studies that were related to other disciplines in dentistry, other than restorative dentistry (prosthodontics and endodontics) were excluded. Two investigators independently evaluated the quality assessment of the studies by applying the Joanna Briggs Institute Critical Appraisal Checklist for Quasi-Experimental Studies (non-randomized experimental studies). A third investigator was consulted to resolve the lack of consensus. RESULTS: Fifty-three articles were initially found from all the searches combined from articles published from 2008 till March 2023. A total of 15 articles met the inclusion criteria and were included in the systematic review. AI algorithms for shade-matching include fuzzy logic, a genetic algorithm with back-propagation neural network, back-propagation neural networks, convolutional neural networks, artificial neural networks, support vector machine algorithms, K-nearest neighbor with decision tree and random forest, deep learning for detection of dental prostheses based on object-detection applications, You Only Look Once-YOLO. Moment invariant was used for feature extraction.  XG (Xtreme Gradient) Boost was used in one study as a gradient-boosting machine learning algorithm. The highest accuracy in the prediction of dental shades was the decision tree regression model for leucite-based dental ceramics of 99.7% followed by the fuzzy decision of 99.62%, and support vector machine using cross-validation of 97%. CONCLUSIONS: Lighting conditions, shade-matching devices and color space models, and the type of AI algorithm influence the accuracy of the prediction of dental shades. Knowledge-based systems and neural networks have shown better accuracy in predicting dental shades.

Nanohydroxyapatite in dentistry: A comprehensive review.

Enamel, being the hardest and the highest mineralized tissue of the human body, contains nearly 96% inorganic components and 4% organic compounds and water. Dentin contains 65% inorganic components and 35% organic and water content. The translucency and white appearance of enamel are attributed to Hydroxyapatite (HA), which constitutes the major part of the inorganic component of dental hard tissue. With the advent of nanotechnology, the application of Nanohydroxyapatite (nHA) has piqued interest in dentistry due to its excellent mechanical, physical, and chemical properties. Compared to HA, nHA is found to have superior properties such as increased solubility, high surface energy and better biocompatibility. This is due to the morphological and structural similarity of nanosized hydroxyapatite particles to tooth hydroxyapatite crystals. These nanoparticles have been incorporated into various dental formulations for different applications to ensure comprehensive oral healthcare. To prevent dental caries, several nHA based dentifrices, mouth rinsing solutions and remineralizing pastes have been developed. nHA-based materials, such as nanocomposites, nano impression materials, and nanoceramics, have proven to be very effective in restoring tooth deformities (decay, fracture, and tooth loss). The nHA coating on the surface of the dental implant helps it bind to the bone by forming a biomimetic coating. A recent innovative strategy involves using nHA to reduce dentinal hypersensitivity and to reconstruct periodontal bone defects. The purpose of the present review is to discuss the different applications of nHA in dentistry, especially in preventive and restorative dentistry, dental implantology, bleaching and dentine hypersensitivity management.

Inverse correlation of CD3 & vascular endothelial growth factor in incisional oral squamous cell carcinoma biopsies predicts nodal metastasis & poor survival of patients.

Background & objectives: Oral squamous cell carcinoma (OSCC) is widely prevalent in the Indian subcontinent mainly due to habit-associated aetiologies. Immune regulation and angiogenesis are the part of tumourigenesis that play a crucial role in metastasis and survival. However, the concurrent expression of vascular endothelial growth factor (VEGF) and CD3 (immune regulator receptor on T-lymphocyte) in the same OSCC tissue samples has not been reported in the Indian population. The present study evaluated the expression of CD3+ T-cells and VEGF in OSCC tissue samples and studied the clinicopathological correlation and survival analysis in an Indian population. Methods: This was a retrospective study conducted on 30 formalin-fixed and paraffin embedded sections which were histologically diagnosed as OSCC cases comprising of 15 metastatic OSCC and 15 non-metastatic OSCC with available clinical data and survival status. Results: Reduced expression of CD3+ T-cells and increased VEGF expression were observed in metastatic OSCC samples. The correlation of expression of CD3+ T-cells and VEGF with clinicopathological parameters showed a significant association between these markers with age, nodal status, site of the lesion and survival. Interpretation & conclusions: Reduced expression of CD3+ T-cells in OSCC was found to be associated with a significantly poor survival. VEGF was found to be over expressed in metastatic OSCC as compared to that in non-metastatic OSCC. The study findings suggest that the evaluation of CD3 and VEGF in incisional OSCC biopsies can be considered for predicting the survival outcome and metastasis.

Digital microscopy: A routine mandate in future? A leaf out of Covid-19 pandemic laboratory experience.

The COVID-19 pandemic has brought out lot of changes among the way people and organisations function. It has also reduced social gatherings and hence social relations considerably, forcing people to adjust to new ways of work and life. An outstanding difference between the current COVID-19 pandemic and previous epidemics or pandemics is the increased availability and use of technology currently, which has been validated by various reports from across the globe. Thus, even with the ensuing pandemic, lockdown and decreased social gatherings, with the technology support we have devised ways to keep in contact with friends, family and work place, so as to continue our lives. Social distancing guidelines and regulations have put pressure on a great many organisations to find new ways of keeping employees and students connected while working remotely. For more deskbound occupations and roles, this can be relatively straightforward, but it is challenging if not impossible for lab-based quality control, research and study. The answer to this is digital remote microscopy which enables sharing of data online, carrying out collaborative work through multi-viewing in real time and facilitates remote training functions.

Panoramic view of key cross-talks underpinning the oral squamous cell carcinoma stemness - unearthing the future opportunities.

The clinical management of oral cancer is often frequented with challenges that arise from relapse, recurrence, invasion and resistance towards the cornerstone chemo and radiation therapies. The recent conceptual advancement in oncology has substantiated the role of cancer stem cells (CSC) as a predominant player of these intricacies. CSC are a sub-group of tumor population with inherent adroitness to self-renew with high plasticity. During tumor evolution, the structural and functional reprogramming persuades the cancer cells to acquire stem-cell like properties, thus presenting them with higher survival abilities and treatment resistance. An appraisal on key features that govern the stemness is of prime importance to confront the current challenges encountered in oral cancer. The nurturing niche of CSC for maintaining its stemness characteristics is thought to be modulated by complex multi-layered components encompassing neoplastic cells, extracellular matrix, acellular components, circulatory vessels, various cascading signaling molecules and stromal cells. This review focuses on recapitulating both intrinsic and extrinsic mechanisms that impart the stemness. There are contemplating evidences that demonstrate the role of transcription factors (TF) in sustaining the neoplastic stem cell's pluripotency and plasticity alongside the miRNA in regulation of crucial genes involved in the transformation of normal oral mucosa to malignancy. This review illustrates the interplay between miRNA and various known TF of oral cancer such as c-Myc, SOX, STAT, NANOG and OCT in orchestrating the stemness and resistance features. Further, the cross-talks involved in tumor micro-environment inclusive of cytokines, macrophages, extra cellular matrix, angiogenesis leading pathways and influential factors of hypoxia on tumorigenesis and CSC survival have been elucidated. Finally, external factorial influence of oral microbiome gained due to the dysbiosis is also emphasized. There are growing confirmations of the possible roles of microbiomes in the progression of oral cancer. Given this, an attempt has been made to explore the potential links including EMT and signaling pathways towards resistance and stemness. This review provides a spectrum of understanding on stemness and progression of oral cancers at various regulatory levels along with their current therapeutic knowledge. These mechanisms could be exploited for future research to expand potential treatment strategies.

Leveraging technology-driven strategies to untangle omics big data: circumventing roadblocks in clinical facets of oral cancer.

Oral cancer is one of the 19most rapidly progressing cancers associated with significant mortality, owing to its extreme degree of invasiveness and aggressive inclination. The early occurrences of this cancer can be clinically deceiving leading to a poor overall survival rate. The primary concerns from a clinical perspective include delayed diagnosis, rapid disease progression, resistance to various chemotherapeutic regimens, and aggressive metastasis, which collectively pose a substantial threat to prognosis. Conventional clinical practices observed since antiquity no longer offer the best possible options to circumvent these roadblocks. The world of current cancer research has been revolutionized with the advent of state-of-the-art technology-driven strategies that offer a ray of hope in confronting said challenges by highlighting the crucial underlying molecular mechanisms and drivers. In recent years, bioinformatics and Machine Learning (ML) techniques have enhanced the possibility of early detection, evaluation of prognosis, and individualization of therapy. This review elaborates on the application of the aforesaid techniques in unraveling potential hints from omics big data to address the complexities existing in various clinical facets of oral cancer. The first section demonstrates the utilization of omics data and ML to disentangle the impediments related to diagnosis. This includes the application of technology-based strategies to optimize early detection, classification, and staging via uncovering biomarkers and molecular signatures. Furthermore, breakthrough concepts such as salivaomics-driven non-invasive biomarker discovery and omics-complemented surgical interventions are articulated in detail. In the following part, the identification of novel disease-specific targets alongside potential therapeutic agents to confront oral cancer via omics-based methodologies is presented. Additionally, a special emphasis is placed on drug resistance, precision medicine, and drug repurposing. In the final section, we discuss the research approaches oriented toward unveiling the prognostic biomarkers and constructing prediction models to capture the metastatic potential of the tumors. Overall, we intend to provide a bird's eye view of the various omics, bioinformatics, and ML approaches currently being used in oral cancer research through relevant case studies.

A multicentric case study of fibroblastic and myofibroblastic oral spindle cell lesions.

Context: Spindle cell lesions comprise a vast plethora of benign and malignant lesions with similar clinical and radiographic features. Their overlapping histopathologic features ensure a diagnostic dilemma. Aim: The current multicentric study aims to delineate fibroblastic and myofibroblastic oral spindle cell lesions based on cytomorphology and comprehensive immunohistochemical analysis. Settings and Design: The experimental study was conducted at MS Ramaiah University of Applied Sciences, Bangalore, and All India Institute of Applied Sciences, Delhi. Methods and Material: A comprehensive histological scoring criteria and panel of immunohistochemical makers (STAT6, CD31, CD34, S100, SMA, vimentin, pan-CK, HHF-35, Ki67, ALK, desmin, HMB-45, SATB2, ERG, EMA and CD99) were employed concurrently for the first time for fibroblastic and myofibroblastic oral spindle cell lesions. The data obtained was tabulated and studied. Statistical Analysis Used: NA. Results: Using cytological scoring criteria and panel of immunohistochemical makers, the cases analysed and characterized were desmoplastic fibroma, fibrosarcoma, leiomyosarcoma, nodular fasciitis, neurofibroma and epithelioid inflammatory myofibroblastic sarcoma (EIMS). Conclusions: The diagnostic strategies need to be upgraded for the diagnosis of spindle cell lesions. Emphasis must be placed on cytomorphology, an immunohistochemistry (IHC) panel of markers is imperative for the accurate diagnosis of fibroblastic and myofibroblastic oral spindle cell lesions.

Micrometastasis detection using modified papanicolaou stain in nodal tissues of oral squamous cell carcinoma - A histological study.

CONTEXT: Cervical lymph node metastasis is the most important prognostic factor in Squamous Cell Carcinoma of Head and Neck (SCCHN). Detection and evaluation of micro-metastasis forms the basis for diagnosis, staging, treatment options and prognosis. Lymph node prognostic factors are extremely important for the survival and recurrence in the patient. Assessing lymph node metastasis in the absence of clinical enlargement is challenging. AIM: To evaluate micrometastasis and individual tumor cells (ITC) in regional lymph nodes of oral squamous cell carcinoma (OSCC) by modified papanicolaou (PAP) stain and re-evaluate the tumor staging. SETTINGS AND DESIGN: The retrospective study was executed at MS Ramaiah University of Applied Sciences. METHODS AND MATERIALS: The current study constituted a total of 40 lymph nodes from OSCC patients, metastatic (n=20) and non-metastatic lymph nodes (n=20). All sections were stained with H & E followed by modified PAP stain. Modified PAP was used for identification of micrometastasis deposits. STATISTICAL ANALYSIS USED: The Chi square test was employed to analyze significance. RESULTS: Modified PAP stain proved to be more accurate (p = 0.006) than H and E stain in detecting micrometastasis which accounted for 15% of non-metastatic lymph node sections used in our study. CONCLUSION: Special stain like modified PAP stain is valuable and sensitive in detecting micro-metastasis over H and E stain. Detection of micrometastasis in OSCC patients is advantageous for the patient as it influences staging, it modifies the treatment plan in terms of both radiotherapy and chemotherapy.

Role of Nanozymes in Oral Cancer the Road Ahead.

Oral cancer is a result of diverse interactions in the tumor microenvironment (TME), genetic alterations along with associated risk factors such as lifestyle and microbial infections. Various modalities are employed in the diagnosis and therapeutics of oral cancer. Nanozymes which are artificial enzymes have a great potential in the diagnostic and therapeutic approach of tumors. They have enormous advantages compared to natural enzymes and possess inherent biological and physical properties. A web-based search was performed via the Google scholar, PubMed database, Web of Science with keywords nanozymes, nanoparticles in cancer and oral cancer. The other keywords used were diagnosis, therapy, TME, microbiome, molecular alterations, biosensor, targeted therapy, imaging and tissue regeneration. Original research studies, reviews, case reports published from 2012 to 2022 were included to appraise different subsections. An absolute lack of literature on nanozymes was observed in oral cancer. The present review is the first attempt to describe the role and application of nanozymes in oral cancer by correlating its outcome in tumor biology and biomedical research. Rapid development of nanotechnology has created a paradigm shift in cancer diagnosis and therapeutics. Nanozymes with novel designs can be anticipated in the future in oral cancer management. Supplementary Information: The online version contains supplementary material available at 10.1007/s11244-022-01729-9.

Immunology of Oral Squamous Cell Carcinoma-A Comprehensive Insight with Recent Concepts.

This review aims to understand the concept of oral cancer immunology through the notion of immune profiling, immunoediting and immunotherapy, and to gain knowledge regarding its application for the management of oral cancer patients. Oral cancer is an immunogenic tumor where the cells of the tumor microenvironment play an important role in tumorigenesis. Understanding the mechanism of these modulations can help design immunotherapeutic strategies in oral cancer patients. This article gives an overview of immunomodulation in the oral cancer tumor microenvironment, with concepts of immune profiling, immunoediting and immunotherapy. English literature searches via Google Scholar, Web of Science, EBSCO, Scopus, and PubMed database were performed with the key words immunology, tumor microenvironment, cells, cross talk, immune profiling, biomarkers, inflammation, gene expression, techniques, immunoediting, immunosurveillance, tumor escape, immunotherapy, immune checkpoint inhibitors, vaccines in cancer, oral cancer, and head and neck cancer. Original research articles, reviews, and case reports published from 2016-2021 (n = 81) were included to appraise different topics, and were discussed under the following subsections. Literature published on oral cancer immunology reveals that oral cancer immune profiling with appropriate markers and techniques and knowledge on immunoediting concepts can help design and play an effective role in immunotherapeutic management of oral cancer patients. An evaluation of oral cancer immunology helps to determine its role in tumorigenesis, and immunotherapy could be the emerging drift in the effective management of oral cancer.

Modified Mineral Trioxide Aggregate-A Versatile Dental Material: An Insight on Applications and Newer Advancements.

Mineral Trioxide Aggregate (MTA) has been a material of revolution in the field of dentistry since its introduction in the 1990s. It is being extensively used for perforation repairs, apexification, root-end filling, obturation, tooth fracture repair, regenerative procedures, apexogenesis, pulpotomies, and as a pulp-capping material because of its desired features such as biocompatibility, bioactivity, hydrophilicity, sealing ability, and low solubility. Even though its application is wide, it has its own drawbacks that prevent it from reaching its full potential as a comprehensive replacement material, including a long setting time, discoloration, mud-like consistency, and poor handling characteristics. MTA is a material of research interest currently, and many ongoing studies are still in process. In this review, the newer advancements of this versatile material by modification of its physical, chemical, and biological properties, such as change in its setting time, addressing the discoloration issue, inclusion of antimicrobial property, improved strength, regenerative ability, and biocompatibility will be discussed. Hence, it is important to have knowledge of the traditional and newer advancements of MTA to fulfill the shortcomings associated with the material.

The Anticariogenic Efficacy of Nano Silver Fluoride.

Dental caries is a common chronic disease, and anyone can be at threat of it throughout their lifespan. In school-aged children, dental caries is the most frequent disease related with oral health. Contemporary dental caries management focuses on non-restorative, non-invasive, and micro-invasive therapeutic techniques that effectively eliminate the caries progression at the lesion level and decrease the loss of healthy tooth structure. One of these strategies is to use caries apprehending agents with antibacterial and remineralizing characteristics. Due to recent regulatory approval in the United States, the use of silver diamine fluoride (SDF) for the therapy of dental caries has received substantial interest. SDF has successfully prevented and reversed both primary tooth caries and permanent teeth root caries. Even though SDF is an effective anti-caries agent, but it is associated with certain drawbacks like gum irritation, metallic taste, and irreversible dark stains on applying on cavities. As an alternative agent Nano Silver Fluoride (NSF) is preferable because it performs like SDF without tooth staining. It has comparable preventive and antibacterial activities as SDF. Further, it is ergonomic, economic and safe in children and adults. The current article aims to highlight the superior properties of NSF as a better anti-caries agent outstripping the limitations of discoloration of SDF.

Alternate Special Stains for the Detection of Mycotic Organisms in Oral Cyto-Smears-A Histomorphometric Study.

In the wake of the COVID-19 pandemic, fungal infections of the maxillofacial region have become prevalent, making their accurate diagnosis vital. Histopathological staining remains a simple, cost-effective technique for differentiation and diagnosis of the causative fungal organisms. The present study aims to evaluate the staining efficacy of Periodic Acid-Schiff (PAS), Alcian Blue, Safranin-O and Gomori's Methenamine Silver (GMS) on fungal smears. This research work also attempts to study the morphometric characteristics of Candida albicans, Aspergillus flavus, Rhizopus oryzae. Candida albicans, Aspergillus flavus and Rhizopus oryzae, 10 smears each, were stained using PAS, Alcian Blue, Safranin-O and GMS. The morphological characteristics and staining efficacy were examined, and semi-quantitative scoring was performed. Candida albicans, Aspergillus flavus and Rhizopus oryzae were stained for the first time with Safranin-O. The morphometric traits were then analyzed using an image analysis software. Safranin-O provided the most reliable staining efficacy amongst the stains and optimum morphological definition for all three organisms. Safranin-O was found to be superior to PAS and GMS, ensuring detection of even the most minute mycotic colonies. The hyphae of Aspergillus flavus to be the largest, and the spores and fruiting body of Rhizopus oryzae were found to be the largest amongst the three organisms compared. Early and accurate diagnosis of fungal infections can significantly reduce morbidity in orofacial fungal infections.

Zinc Oxide Nanoparticles: A Review on Its Applications in Dentistry.

Nanotechnology in modern material science is a research hot spot due to its ability to provide novel applications in the field of dentistry. Zinc Oxide Nanoparticles (ZnO NPs) are metal oxide nanoparticles that open new opportunities for biomedical applications that range from diagnosis to treatment. The domains of these nanoparticles are wide and diverse and include the effects brought about due to the anti-microbial, regenerative, and mechanical properties. The applications include enhancing the anti-bacterial properties of existing restorative materials, as an anti-sensitivity agent in toothpastes, as an anti-microbial and anti-fungal agent against pathogenic oral microflora, as a dental implant coating, to improve the anti-fungal effect of denture bases in rehabilitative dentistry, remineralizing cervical dentinal lesions, increasing the stability of local drug delivery agents and other applications.

Cytogenetics in Oral Cancer: A Comprehensive Update.

AIM: To evaluate the application of cytogenetic techniques in determining the diagnosis, prognosis, and therapeutics in oral cancer. BACKGROUND: Genetic aberrations that play an important role in oral oncogenesis demand substantial research for in-depth characterization of the tumor. Cytogenetic techniques have the potential to detect these aberrations. This review highlights about various cytogenetic approaches in cancer and how these findings support its application in the field of oral oncology. METHODS: Google scholar search was done for articles on cancer cytogenetics, and in particular, PubMed database was queried for articles published from 2015 to 2020 using keywords cytogenetics, chromosomal aberrations, conventional cytogenetics, karyotyping, banding techniques, molecular cytogenetics, fluorescent in situ hybridization, spectral karyotyping, comparative genomic hybridization, multiplex ligation probe analysis, and next-generation sequencing (NGS) in oral cancer. Abstracts were reviewed, and relevant full text was accessed to extract the cytogenetic findings in oral cancer. RESULTS: Data regarding various cytogenetic approaches from conventional to molecular techniques have been published in oral cancer. They convey a highly complex cytogenetic finding from gross chromosomal aberrations to specific gene mutations in oral cancer. CONCLUSION: Crucial information in the development and progression of oral cancer is achieved through cytogenetic findings in particular with the molecular cytogenetic techniques. Novel technologies like NGS have emerged in recent years that hold promise in the detection of these alterations more efficiently. CLINICAL SIGNIFICANCE: An appraisal of cytogenetic analysis in oral cancer helps to determine the diagnosis and the most important prognosticators. It assists in building targeted therapies for patient benefit.

Nanopore Sequencing Technology in Oral Oncology: A Comprehensive Insight.

AIM: To review the principles and application of Nanopore Sequencing Technology (NPST) in oral cancer. BACKGROUND: Oral cancer is a disease caused by aberrations in the genes. Substantial research at the genomic level is still required for in-depth understanding of the molecular mechanism in oral cancer. The advent of the novel nanopore sequencing technique has the potential to detect the alterations at the genomic level. This review highlights nanopore sequencing, its advantages and disadvantages, and how research supports its application in the field of oral oncology. MATERIALS AND METHODS: Web-based search via PubMed database, internet sources using keywords "nanopore sequencing, third-generation sequencing, next generation sequencing, cancer, oral squamous cell carcinoma, genetic, epigenetic, oncogenic viruses" was performed in this review. Original research, reviews, and short discussions published from 2008 to 2020 were included. The findings are discussed with emphasis on common gene mutations, epigenetic alterations, and oncogenic viruses in oral cancer. A brief mention regarding translational nanopore sequencing research in oral cancer and future perspectives is also discussed. RESULTS: The results obtained reveal that cost-effectiveness and rapid turnaround time make nanopore sequencing an enticing platform to resolve the ambiguity of genomes, epigenomes, and transcriptomes. CONCLUSION: The findings will encourage researchers to further adopt NPST in their studies and give an overview of the latest findings of oral squamous cell carcinoma (OSCC) management. To highlight the importance of NPST application in OSCC studies, this paper not only discusses the use of NPST in identifying the behavior of malignancy but also implies the need for further research using this technique. CLINICAL SIGNIFICANCE: The review suggests that nanopore sequencing can be utilized for diagnosis and achieving personalized treatment in each oral cancer patient.

Histopathologic Feature of Hyalinization Predicts Recurrence of Conventional/Solid Multicystic Ameloblastomas.

The histologic properties of tumors seem to affect their biological behavior, and the same holds good for solid multicystic ameloblastoma (SMA), a benign, locally destructive lesion. Hyalinization is one such histological factor that has been demonstrated to correlate with the biological behavior of neoplasms. The present study aimed to analyze the correlation between the severity of hyalinization (SOH) and the recurrence potential of SMAs. The study was performed on formalin-fixed, paraffin-embedded (FFPE) diagnosed archival cases of SMA, follicular SMA (n = 35) and plexiform SMA (n = 25). The cases were evaluated for SOH and scored from 0-3, and the correlation between SOH and recurrence was analyzed for statistical significance. The clinical parameters of the lesion were analyzed for statistical correlation with recurrence. The SOH significantly correlated with the recurrence of SMA (p = 0.001). The histologic type did not influence the biological behavior of SMA. The location of SMA in the body of the mandible (p = 0.036), multilocular radiolucency (p = 0.001) and root resorption (p = 0.002) also showed strong statistical correlation with recurrence. It is evident from the present study that hyalinization strongly correlates with the biological behavior of SMA. Future studies with advanced investigations could validate the presence of hyalinization and identify the origin of the hyalinized product in SMAs.