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Radiographic analysis of ameloblastoma: A retrospective study

Article  in  Indian journal of dental research: official publication of Indian Society for Dental Research · September 2012
DOI: 10.4103/0970-9290.107436 · Source: PubMed

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Original Research

Radiographic analysis of ameloblastoma: A retrospective study

Chandramani More, Mansi Tailor, Hetul J Patel, Mukesh Asrani1, Krushna Thakkar2, Chhaya Adalja

Department of Oral Medicine &


Radiology, K. M. Shah Dental
ABSTRACT
College & Hospital, Sumandeep Background: Ameloblastoma is benign odontogenic tumor, usually affecting the posterior region
Vidyapeeth, Piparia, Vadodara,
1
Department of Oral Medicine &
of mandible. It is seen in the third to fifth decades of life. Radiographically the lesion is variable
Radiology, Karnavati School of in appearance and may be unilocular or multilocular, with well-defined cortical borders in the
Dental Sciences, Gandhinagar, mandible and ill-defined margins in the maxilla.
Gujarat, 2Department of Oral
Objective: To analyze cases of ameloblastoma, with emphasis on the radiographic findings. We
Medicine & Radiology, J. G.
Dental College & Hospital, also review the current literature briefly and discuss the clinical and radiographic findings.
Akola, Maharashtra, India Materials and Methods: The present hospital-based retrospective study was conducted by
reviewing the clinical and radiographic records of ameloblastoma cases from 2009 to 2011,
available in the archives of the department. The data of a total of 14 patients were analyzed.
Results: We observed that the patients affected with ameloblastoma were in the age-group of 19–
68 years. The male: female ratio was 1.3:1. The mandible (78.57%) was more commonly affected
than the maxilla (14.28%). Six patients (42.86%) had unilateral involvement and eight cases
(57.14%) had bilateral involvement. The multilocular and unilocular types of ameloblastoma
were noted in 12 (85.72%) and 2 cases (14.28%), respectively. The soap-bubble (50.00%), spider-
web (21.43%), and honeycomb (14.28%) appearances were seen in the multilocular variety.
Root resorption of variable degree was distinctly observed in 11 cases (78.57%).
Conclusion: Radiographs are an important aid for the diagnosis of oral lesions of various types,
especially those that involve bone. It is important for the practicing clinicians to know the salient
Received : 15-06-11 features of ameloblastoma which are peculiar to the local population.
Review completed : 23-12-11
Accepted : 14-02-12 Key words: Ameloblastoma, multilocular, radiographic analysis, root resorption

Ameloblastoma (from the English word amel, meaning odontogenic in origin is largely based on the histologic
enamel, and the Greek word blastos, meaning germ)[1] is similarities of the tumor with the developing enamel
a rare, benign epithelial odontogenic tumor, representing organ.[2,6,7]
1% of all oral ectodermal tumors and 9% of odontogenic
tumors.[2] It was recognized in 1827 by Cusack.[3] This type Ameloblastoma appears most commonly in the third to
of odontogenic neoplasm was designated as ‘adamantinoma’ fifth decades of life, but it has been reported in patients
in 1885 by the French physician Louis-Charles Malassez.[4] with age ranging from 10–90 years.[5,8,9] It commonly affects
It was first detailed and described by Falkson in 1879. The the mandible and only rarely the maxilla or the soft tissue
term ameloblastoma was coined by Ivey and Churchill in (peripheral ameloblastoma).[8] Over 80% of these lesions
1930.[2,3,5] It is considered as a true neoplasm and, as the occur in the mandible, with 70% of these arising in the
name implies, it resembles the cells of the enamel-forming molar-ramus area; they are occasionally associated with
organ. The general agreement that ameloblastomas are unerupted third molar teeth.[2,6,8–10] They are slow-growing
tumors and are usually asymptomatic until a large size is
achieved. These tumors characteristically expand within
Address for correspondence:
Dr. Chandramani More the jaw and displace bone, teeth, and roots. Occasionally,
E-mail: drchandramanimore@rediffmail.com infiltrating tumors may erode through the bone and extend
into the soft tissue.[9]
Access this article online
Quick Response Code: Website:
Radiographically, ameloblastoma appears either unilocular
www.ijdr.in or multilocular and, histologically, as unicystic or
multicystic. Both forms have been shown to recur,
PMID:
*** particularly following inadequate surgical treatment. The
periphery of the lesion may be smooth or scalloped. The
DOI: cortical plate may become thin, expanded, and may even
10.4103/0970-9290.107436
be perforated if the lesion is in its advanced stage. An
Indian Journal of Dental Research, 23(5), 2012
Radiographic analysis of ameloblastoma More, et al.

occlusal radiograph may demonstrate cyst-like expansion, CASE REPORTS


with thinning of the adjacent cortical plate leaving only a
thin ‘eggshell’ of bone.[11] Case 1
A 44-year-old male with unilateral involvement of the body
The structure of this lesion can be detected on panoramic and ramus of mandible. The panoramic radiograph reveals a
radiographs. Therefore, panoramic radiographs may be single, well-defined, circumscribed, corticated multilocular
preferred over computed tomograms (CT). However, radiolucency extending from 35 to the ramus of mandible.
panoramic radiographs are inadequate for localization Knife-edge and complete root resorption, respectively, are
of such lesions because of the nature of panoramic seen in 35 and 36. The neurovascular bundles are affected.
radiography, with its inherently less-sharp image and The lesion mimics a ‘soap bubble.’
ghost image. CT is usually helpful for determining the
contours of the lesion, its contents, and its extension into Case 2
soft tissues. Ameloblastoma typically shows expansive A 60-year-old female with unilateral involvement of the
growth with an osseous shell. On CT there are cystic areas symphysis and body of mandible. The panoramic radiograph
of low attenuation along with isoattenuating solid regions. reveals a single, well-defined, circumscribed, corticated
Contrast-enhanced CT shows an enhancement effect in the multilocular radiolucency extending from the midline to the
solid components. Although there are no major differences retromolar region, with thinning of the inferior border of the
between MRI and CT in the ability to detect the cystic mandible. The root apices from 41 to 43 show multiplanar
component of the tumor, MRI is slightly superior. MRI is resorption. The neurovascular bundles are affected. The
essential for establishing the exact extent of an advanced lesion has a spider-web-like pattern.
maxillary ameloblastoma.[2,9]
Case 3
It has been stated that, radiographically, ameloblastoma A 52-year-old female with involvement of bilateral
may be mistaken for keratocystic odontogenic tumor, symphysis; unilateral body, ramus, coronoid, and condyle
fibroma, fibromyxoma, fibrosarcoma, hemangioma, of mandible; and maxillary tuberosity. The panoramic
aneurysmal bone cyst, and giant cell tumor. [11,12] The radiograph and CT scan show a single, extensive, well-
desmoplastic ameloblastoma is especially deceptive defined, circumscribed, multilocular radiolucency extending
radiographically, as it may mimic fibro-osseous lesions or from 44 to the left ramus, condyle, and coronoid process, and
globulomaxillary cyst.[12] The purpose of the present study the left maxillary tuberosity. The antrum floor is displaced
was to analyze cases of ameloblastoma, with emphasis superiorly. Lower anteriors and unerupted 38 are displaced
on radiographic findings. We also review the current within the lesion. The inferior border of the mandible is
literature and discuss the clinical and radiographic findings severely thinned. The neurovascular bundles are severely
that may aid in diagnosis and the strategies for preventing destructed. The lesion appears like a soap bubble.
recurrences.
Case 4
MATERIALS AND METHODS A 60-year-old male with bilateral involvement of premaxilla
and the canine fossa of maxilla. The occlusal and panoramic
The present hospital-based retrospective study was radiographs show a single, well-defined, circumscribed,
conducted by reviewing the clinical and radiographic corticated unilocular radiolucency associated with horizontally
records of ameloblastoma cases for the years 2009–2011, impacted 23; the radiolucency is seen extending from 11 to
available in the archives of department. Permission to the 24 region. Multiplanar root resorption is present in 21.
undertake this study was obtained from the institutional
ethics committee. A total of 14 cases that were diagnosed Case 5
clinically, radiographically, and histopathologically A 22-year-old female with bilateral involvement of the body
were included in the study. The intraoral and panoramic and symphysis of mandible. The panoramic radiograph and
radiographs and computed tomograms formed the basis of CT scan reveal a single, well-defined, corticated unilocular
the present study. Radiographs with any type of artifact or radiolucency extending from 36 to 44. All these teeth
fault were excluded from the study. All the radiographs and are displaced and have multiplanar root resorption. The
images were taken by standard techniques, were processed neurovascular bundles are displaced inferiorly.
under standardized conditions, and viewed on a standard
illuminated screen by three oral radiologists to prevent Case 6
inter-observer bias. The descriptive data of these patients A 40-year-old male with bilateral involvement of the body
was evaluated and compared with previously documented of mandible. The panoramic radiograph and CT scan reveal a
data in the literature. The study variables included age, single, well-defined, circumscribed, corticated multilocular
gender, site of lesion, type, radiographic appearance, radiolucency extending from the right body of the mandible
neurovascular bundle, and root resorption. to 36, expansion of the cortical plate, and thinning of the
Indian Journal of Dental Research, 23(5), 2012
Radiographic analysis of ameloblastoma More, et al.

inferior border of the mandible. The neurovascular bundles inferior border of the mandible and inferior displacement
are affected. The lesion mimics a soap bubble. of the neurovascular bundle is observed. The lesion mimics
a soap bubble.
Case 7
A 28-year-old male with bilateral involvement of the body Case 13
and symphysis of mandible. The panoramic radiograph A 21-year-old male with bilateral involvement of premaxilla
reveals a single, well-defined, circumscribed multilocular and the lateral part of the left maxilla. Panoramic radiograph
radiolucency with scalloped margins and corticated borders, and CT scan reveal a single well-defined multilocular
extending from 43 to 37. The root apices from 43 to 36 show radiolucency extending from 11 to 26. There is displacement
multiplanar root resorption. The neurovascular bundles are of 21 and 23. The antrum floor is displaced superiorly. The
affected. The lesion mimics a soap bubble. lesion shows a honeycomb pattern.

Case 8 Case 14
A 55-year-old male with bilateral involvement of the body A 68-year-old old female with unilateral involvement of the
and symphysis of mandible. The panoramic radiograph symphysis, body, and ramus of mandible. The panoramic
reveals a single, well-defined, circumscribed multilocular radiograph and CT scan reveal a single, well-defined,
radiolucency with scalloped margins and corticated borders, multilocular radiolucency extending from 31 to anterior third
extending from 47 till 34. Knife-edge root resorption is of the ramus of the mandible. The roots of 32, 33, and 34 show
present in 44 to 47, and multiplanar type of root resorption knife-edge resorption, while the root of 35 shows multiplanar
is seen in 43 to 33. The neurovascular bundles are destructed. type of root resorption. Thinning of the inferior border of
The lesion mimics a soap bubble. the mandible and destruction of the neurovascular bundle is
observed. The lesion shows a spider-web-like pattern.
Case 9
A 42-year-old male with unilateral involvement of the
RESULTS
body and ramus of mandible. The panoramic radiograph
shows a single, well-defined, circumscribed multilocular In the present study, the patients affected with ameloblastoma
radiolucency with corticated borders, extending from 36 to
were in the age range of 19–68 years, with a mean age of
the posterior border of the left ramus. The roots of 36, 37,
43.5 years. The maximum number of patients were in the
and 38 show knife-edge resorption. Thinning of the inferior
age-groups of 20–29 (28.57%) and 40–49 (28.57%). The male:
border of the mandible and destruction of the neurovascular
Female ratio was 1.3:1.
bundle is observed. The lesion mimics a soap bubble.

Case 10 Among these 14 cases, the mandible was the most affected
A 19-year-old female with unilateral involvement of the jaw: The mandible alone was involved in 11 cases (78.57%),
body of the mandible. The panoramic radiograph and CT the maxilla in two cases (14.28%), and the maxilla and
scan reveal a single, well-defined, corticated unilocular mandible together in one case (7.15%).
radiolucency extending from 36 to 38. All these teeth are
displaced and the roots show knife-edge resorption. The In the mandible, the body was involved in two cases (14.28%);
neurovascular bundle is displaced inferiorly. The lesion the symphysis and body in four cases (28.57%); the body
appears like a honeycomb. and ramus in two cases (14.28%); the parasymphysis, body,
and ramus in one case (7.15%); and the symphysis,
Case 11 body, and ramus in two cases (14.28%). In the maxilla, the
A 40-year-old male with unilaterally involved parasymphysis, premaxilla and the lateral part of maxilla were involved in
body, and ramus of mandible. Panoramic radiograph shows one case (7.15%) and the premaxilla and canine fossa in one
a single, well-defined, multilocular radiolucency extending case (7.15%). In one case (7.15%), the lesion involved the
from 33 to the middle third of the ramus of the mandible. maxilla and the mandible together.
Multiplanar type of root resorption is seen in 34 to 36. The
neurovascular bundle is displaced inferiorly. The lesion Out of these 14 cases of ameloblastoma, 6 cases (42.86%)
shows a spider-web-like pattern. had unilateral involvement of jaw and 8 cases (57.14%) had
bilateral involvement.
Case 12
A 20-year-old female with bilateral involvement of the The multilocular and unilocular type of ameloblastoma was
symphysis, body, and ramus of mandible. The panoramic noted in 12 (85.72%) and 2 cases (14.28%), respectively. In
radiograph reveals a single, well-defined, circumscribed, the multilocular type, the soap-bubble appearance was seen
multilocular radiolucency extending from 34 to the lower in seven cases (50.00%), the spider-web-like pattern was
third of the right ramus. The roots of associated teeth seen in three cases (21.43%), and the honeycomb pattern
show multiplanar type of root resorption. Thinning of the was seen in two cases (14.28%).
Indian Journal of Dental Research, 23(5), 2012
Radiographic analysis of ameloblastoma More, et al.

Root resorption of variable degree was distinctly observed In this study, ameloblastoma was observed to occur between
in 11 cases (78.57%). Six cases (54.55%) showed multiplanar the ages of 19 years and 68 years [Figure 3], with the mean
type of root resorption, 3 (27.27%) cases showed knife-edge age being 43.5  years. This finding is not consistent with
root resorption, and 2 cases (18.18%) showed a combination the studies conducted by Darshani et al., Fregnani et al.,
of multiplanar and knife-edge types of root resorption. Adeline et al. and Krishnapillai et al., where the mean age
of occurrence was 33.2 years, 33.2 years, 30.2 years, and
DISCUSSION 30.2 years, respectively.[15–18]
Ameloblastomas are an enigmatic group of oral tumors. They Various studies show inconsistent findings regarding
are usually benign in growth pattern but frequently invade gender predilection. The present study showed a slight
locally and occasionally metastasize. They have a persistent
male predilection, with a male: female ratio of 1.3:1. This
and slow growth, spreading into marrow spaces with
is similar to the findings of Krishnapillai et al. and Potdar
pseudopods, without concomitant resorption of the trabecular
et al.[18,19] However, the studies of Khan et al., Takahashi
bone. As a result, the margins of the tumor are not clearly
et al., and Olaitan et al. found a slight female predilection,
evident radiographically or grossly during operation and,
and Keszlar et al. and Takahashi et al. reported no gender
consequently, the lesion frequently recurs after inadequate
predilection for ameloblastoma.[20]
surgical removal, demonstrating a locally malignant pattern.[5]

In most cases, ameloblastoma present a characteristic, Numerous studies have concluded that the mandible
though not diagnostic, radiographic appearance. [2,5,13] is more commonly affected with ameloblastoma than
Radiographically, the margins of the lesion in the mandible the maxilla. In this study, the maximum number of
are usually well-defined, frequently corticated, and lesions were found in mandible (78.57%); the maxilla
occasionally scalloped; in contrast, in the maxilla, the margins was involved in only 14.28%. Lesion involving both
are severely ill-defined as the lesion tends to grow along the maxilla and mandible was seen in 7.15% of the cases
bone rather than expanding it. The internal structure varies [Figure 4]. Our observations are similar to the findings of
from totally radiolucent to mixed, with the presence of bony Gunawardhana et al., Ogunsalu et al., Adeline et al., and
septa creating internal compartments. The compartments in Chidzonga et al.[15,17,20,21]
bone are round and of varying size. The septae are usually
coarse and curved and originate from normal bone that has The most common site of occurrence of ameloblastoma is the
been trapped within the tumor. With growth or expansion body–ramus region.[2,6] Our observations in the present study
of the tumor, there may be coalescence and fusion of the showed presence of the lesion in the posterior mandible
compartments and, as a result, there may be transformation (28.57%), the anterior as well as posterior mandible
from a multilocular to a monolocular cystic space. Tumors in (50.00%), the maxilla (14.28%), and involving both maxilla
which the compartments are large and few in number may and mandible in the posterior region (7.15%). Our study
resemble a multilocular epithelium-lined cyst.[11] results contradict the studies of Fregnani et al. and Robinson
et al.[14,16] In the maxilla, ameloblastoma is mostly found in
The radiographic appearance of ameloblastoma is variable. the canine and antrum region.[2] In this study, anterior as
H. M. Worth has described four patterns[14] [Figures 1 and 2]: well as posterior maxilla was involved, and this finding is
• Unicystic type: This appears as a unilocular radiolucency consistent with the literature [Table 1].
resembling a cyst. However, unlike cyst, it causes a
break or discontinuity in the peripheral cortex and may
even show trabeculae within the lumen.
• Spider-web pattern : This is the most common
appearance, where the lesion is seen as a large
radiolucent area with scalloped borders. From the
center of the lumen coarse strands of trabeculae radiate
peripherally, giving rise to a gross caricature of a spider.
• Soap-bubble pattern: This lesion is seen as a multilocular
radiolucency with large compartments of varying sizes,
giving rise to the soap-bubble appearance, or a multi-
chambered or multi-cystic ‘bunch of grapes’ appearance.
• Honeycomb or solid pattern: This is also called a
beehive pattern. These are tumors that have not
undergone cystic degeneration. Hence, multiple small
radiolucencies are seen surrounded by hexagonal or
polygonal thick-walled bony cortices, giving rise to a
Figure 1: Schematic diagram showing radiographic appearance of
honeycomb appearance. ameloblastoma
Indian Journal of Dental Research, 23(5), 2012
Radiographic analysis of ameloblastoma More, et al.

a b

c d
Figure 2: (a) Maxillary occlusal radiograph showing unicystic type of ameloblastoma; (b) cropped panoramic radiograph showing spider-web
type; (c) cropped panoramic radiograph showing soap-bubble type; and (d) intraoral periapical radiograph showing honeycomb type

Figure 3: Graph showing age-wise distribution Figure 4: Graph showing jaw-wise distribution

Robinson et al. in his study observed that 10%–15% of


ameloblastomas are associated with an unerupted tooth.[2,8,10]
In our study, 14.28% of lesions were associated with an
impacted tooth and all these lesions were in the maxilla.

Various published articles have confirmed the pattern


of the lesion on the radiographs. In the present study,
radiographically, all our 14 cases had well-defined corticated
borders. Out of these cases, 85.72% tumors were multilocular
and 14.28% were unilocular [Figure 5]. In comparison,
Fregnani et al. and Adeline et al., observed multilocular
lesion in 60% and 83.2% of their cases, respectively.[16,17] It
Figure 5: Graph showing radiographic type wise distribution is pertinent to note that among the 14 cases discussed here,
Indian Journal of Dental Research, 23(5), 2012
Radiographic analysis of ameloblastoma More, et al.

12 cases were multilocular; of these 12 cases, 7 showed the not match the observations of Ogunsalu et al. who found
soap-bubble pattern, 2 showed the honeycomb pattern, and only 31.6% cases with root resorption.[20]
3 cases showed the spider-web pattern.
Tooth displacement, displacement or destruction of inferior
There is a pronounced tendency for ameloblastomas to alveolar canal, and displacement of the sinus membrane
cause extensive root resorption, either blunting of root are the common findings in ameloblastoma. [11] In the
apex/knife-edge root resorption or multiplanar or sharp present study, four (28.57%) cases radiographically showed
root edges. In our study, 11 cases (78.57%) showed root teeth displacement: inferiorly, superiorly, or laterally.
resorption [Table 2]. The multiplanar type was the most Neurovascular bundles were affected in 12 (85.71%)
common, followed by the knife-edge type. Our findings did cases. In this study, expansion of the cortical plate, with
resultant facial deformity, was a distinct feature of large
Table 1: Location wise distribution ameloblastomas [Figure 6].
Location No. of patients Percentage (%)
Body of mandible 02 14.28
Table 2: Type of root resorption
Body and symphysis 04 28.57
Body and ramus 02 14.28 Type Total Percentage (%)
Parasymphysis, body and ramus 01 07.15 Knife-edge type 03 27.27
Symphysis, body, and ramus 02 14.28 Multiplanar type 06 54.55
Maxilla and mandible 01 07.15 Combination of multiplanar and 02 18.18
Maxilla 02 14.28 knife-edge type

a b c

d e f
Figure 6: (a) Coronal section showing buccal cortical plate expansion and thinning; (b) axial section showing buccal cortical plate expansion
and thinning; (c) axial section showing both buccal and lingual cortical plate expansion and thinning; (d) 3D reconstruction showing destruction
of part of the maxilla and mandible; (e) axial section showing both buccal and lingual cortical plate destruction, with area of central necrosis;
(f) 3D reconstruction showing destruction of part of the madible

Indian Journal of Dental Research, 23(5), 2012


Radiographic analysis of ameloblastoma More, et al.

CONCLUSION p. 337-40.
10. Tozaki M, Hayashi K, Fukuda K. Dynamic multislice Helical CT of
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It is important for the practicing clinicians to know the tumours of the jaw. Fifth ed. Mosby an imprint of Elsevier; p. 419-22.
salient features of ameloblastoma which are peculiar to 12. Yacoob H. The radiographic appearance of ameloblastoma in
Malaysians. Singapore Med J 1991;32:70-2.
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Source of Support: Nil, Conflict of Interest: None declared.
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Indian Journal of Dental Research, 23(5), 2012

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