Dx: Calcifying Epithelial Odontogenic Tumor

KEY FACTS

Terminology Calcifying epithelial odontogenic tumor (CEOT) Definition: Odontogenic epithelial tumor that produces mineralized substance Imaging CBCT: Shows extent of lesion, displacement of structures, and buccolingual extent Location: Posterior mandible, less common in posterior maxilla Border may be well defined or ill defined Unilocular or multilocular Scattered high-density foci of calcification of varying size and density: Described as "driven snow" May be pericoronal to impacted tooth Calcifications often cluster close to crown of tooth, impeding eruption Fine, sparse trabeculation may be present Top Differential Diagnoses
Adenomatoid odontogenic tumor (AOT)

Ameloblastic fibro-odontoma (AFO) Calcifying cystic odontogenic tumor

Dentigerous cyst

Clinical Issues Painless, slow-growing swelling of jaws Can occur at any age
Most common in 5th decade

M>F Diagnostic Checklist AOT most common in anterior maxilla AFO similar but in younger age group Early pericoronal lesions may be indistinguishable from pericoronal lesions that do not produce radiopacities: Most commonly dentigerous cyst
TERMINOLOGY

Abbreviations Calcifying epithelial odontogenic tumor (CEOT) Synonyms Pindborg tumor Definitions Odontogenic epithelial tumor that produces mineralized substance
IMAGING

General Features Best diagnostic clue: Unilocular or multilocular radiolucency with internal calcifications in posterior mandible Location

Posterior mandible, less common in posterior maxilla

May occur in anterior jaws, but rare May or may not be associated with impacted tooth Extraosseous variety has been described Size May be a small radiolucency surrounding crown of unerupted tooth May enlarge and extend into ramus of mandible or expand maxilla and into surrounding structures Imaging Recommendations Best imaging tool
CBCT

Shows extent of lesion, displacement of structures, and buccolingual extent CT Findings Border may be well defined or ill defined
Unilocular or multilocular

Scattered high-density foci of calcification of varying size and density: Described by some as having appearance of "driven snow" Calcifications may be clustered close to impacted tooth crown and impede eruption Fine, sparse trabeculation may be present Expansion of cortices of affected jaw Inferior displacement of inferior alveolar nerve canal if in posterior mandible
DIFFERENTIAL DIAGNOSIS

Adenomatoid Odontogenic Tumor (AOT) Anterior maxilla

Younger age group, 2nd decade More common in females

Ameloblastic Fibro-odontoma

Posterior mandible Tooth density calcifications

2nd decade of life Calcifying Cystic Odontogenic Tumor

Anterior to 1st molar Peaks in 2nd decade, with mean age of 36 years
Dentigerous Cyst

Most common pericoronal radiolucency Early pericoronal lesions of CEOT may be indistinguishable
PATHOLOGY

General Features Associated abnormalities: Single report of association of AOT component within CEOT Microscopic Features Islands, strands, or sheets of polyhedral epithelial cells in fibrous stroma Tumor islands enclose masses of amyloid-like material, giving cribriform appearance Calcifications develop within amyloid-like material in concentric rings (Liesegang rings)
CLINICAL ISSUES

Presentation

Most common signs/symptoms: Painless, slow-growing swelling of jaws Demographics Age: Can occur at any age, most common in 5th decade Gender: M > F Natural History & Prognosis Malignant transformation due to loss of P53 (tumor suppressor gene) transcriptional activity has been reported Treatment Conservative local resection Lesions in posterior maxilla should be treated more aggressively as they can extend intracranially Recurrence is about 15%
DIAGNOSTIC CHECKLIST

Consider AOT may appear similar, but most common in anterior maxilla Ameloblastic fibro-odontoma can show same appearance but in younger age group