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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
Vidyapeeth, Piparia, Vadodara,
1
Department of Oral Medicine &
Radiology, Karnavati School of
Dental Sciences, Gandhinagar,
Gujarat, 2Department of Oral
Medicine & Radiology, J. G.
Dental College & Hospital,
Akola, Maharashtra, India
Received : 15-06-11
Review completed : 23-12-11
Accepted : 14-02-12
Background: Ameloblastoma is benign odontogenic tumor, usually affecting the posterior region
of mandible. It is seen in the third to fifth decades of life. Radiographically the lesion is variable
in appearance and may be unilocular or multilocular, with well-defined cortical borders in the
mandible and ill-defined margins in the maxilla.
Objective: To analyze cases of ameloblastoma, with emphasis on the radiographic findings. We
also review the current literature briefly and discuss the clinical and radiographic findings.
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
features of ameloblastoma which are peculiar to the local population.
Key words: Ameloblastoma, multilocular, radiographic analysis, root resorption

Ameloblastoma (from the English word amel, meaning
enamel, and the Greek word blastos, meaning germ)[1] is
a rare, benign epithelial odontogenic tumor, representing
1% of all oral ectodermal tumors and 9% of odontogenic
tumors.[2] It was recognized in 1827 by Cusack.[3] This type
of odontogenic neoplasm was designated as ‘adamantinoma’
in 1885 by the French physician Louis-Charles Malassez.[4]
It was first detailed and described by Falkson in 1879. The
term ameloblastoma was coined by Ivey and Churchill in
1930.[2,3,5] It is considered as a true neoplasm and, as the
name implies, it resembles the cells of the enamel-forming
organ. The general agreement that ameloblastomas are
Address for correspondence:
Dr. Chandramani More
E-mail: drchandramanimore@rediffmail.com
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DOI:
10.4103/0970-9290.107436
odontogenic in origin is largely based on the histologic
similarities of the tumor with the developing enamel
organ.[2,6,7]
Ameloblastoma appears most commonly in the third to
fifth decades of life, but it has been reported in patients
with age ranging from 10–90 years.[5,8,9] It commonly affects
the mandible and only rarely the maxilla or the soft tissue
(peripheral ameloblastoma).[8] Over 80% of these lesions
occur in the mandible, with 70% of these arising in the
molar-ramus area; they are occasionally associated with
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
the jaw and displace bone, teeth, and roots. Occasionally,
infiltrating tumors may erode through the bone and extend
into the soft tissue.[9]
Radiographically, ameloblastoma appears either unilocular
or multilocular and, histologically, as unicystic or
multicystic. Both forms have been shown to recur,
particularly following inadequate surgical treatment. The
periphery of the lesion may be smooth or scalloped. The
cortical plate may become thin, expanded, and may even
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,
with thinning of the adjacent cortical plate leaving only a
thin ‘eggshell’ of bone.[11]
The structure of this lesion can be detected on panoramic
radiographs. Therefore, panoramic radiographs may be
preferred over computed tomograms (CT). However,
panoramic radiographs are inadequate for localization
of such lesions because of the nature of panoramic
radiography, with its inherently less-sharp image and
ghost image. CT is usually helpful for determining the
contours of the lesion, its contents, and its extension into
soft tissues. Ameloblastoma typically shows expansive
growth with an osseous shell. On CT there are cystic areas
of low attenuation along with isoattenuating solid regions.
Contrast-enhanced CT shows an enhancement effect in the
solid components. Although there are no major differences
between MRI and CT in the ability to detect the cystic
component of the tumor, MRI is slightly superior. MRI is
essential for establishing the exact extent of an advanced
maxillary ameloblastoma.[2,9]
It has been stated that, radiographically, ameloblastoma
may be mistaken for keratocystic odontogenic tumor,
fibroma, fibromyxoma, fibrosarcoma, hemangioma,
aneurysmal bone cyst, and giant cell tumor. [11,12] The
desmoplastic ameloblastoma is especially deceptive
radiographically, as it may mimic fibro-osseous lesions or
globulomaxillary cyst.[12] The purpose of the present study
was to analyze cases of ameloblastoma, with emphasis
on radiographic findings. We also review the current
literature and discuss the clinical and radiographic findings
that may aid in diagnosis and the strategies for preventing
recurrences.
MATERIALS AND METHODS
The present hospital-based retrospective study was
conducted by reviewing the clinical and radiographic
records of ameloblastoma cases for the years 2009–2011,
available in the archives of department. Permission to
undertake this study was obtained from the institutional
ethics committee. A total of 14 cases that were diagnosed
clinically, radiographically, and histopathologically
were included in the study. The intraoral and panoramic
radiographs and computed tomograms formed the basis of
the present study. Radiographs with any type of artifact or
fault were excluded from the study. All the radiographs and
images were taken by standard techniques, were processed
under standardized conditions, and viewed on a standard
illuminated screen by three oral radiologists to prevent
inter-observer bias. The descriptive data of these patients
was evaluated and compared with previously documented
data in the literature. The study variables included age,
gender, site of lesion, type, radiographic appearance,
neurovascular bundle, and root resorption.
Indian Journal of Dental Research, 23(5), 2012
CASE REPORTS
Case 1
A 44-year-old male with unilateral involvement of the body
and ramus of mandible. The panoramic radiograph reveals a
single, well-defined, circumscribed, corticated multilocular
radiolucency extending from 35 to the ramus of mandible.
Knife-edge and complete root resorption, respectively, are
seen in 35 and 36. The neurovascular bundles are affected.
The lesion mimics a ‘soap bubble.’
Case 2
A 60-year-old female with unilateral involvement of the
symphysis and body of mandible. The panoramic radiograph
reveals a single, well-defined, circumscribed, corticated
multilocular radiolucency extending from the midline to the
retromolar region, with thinning of the inferior border of the
mandible. The root apices from 41 to 43 show multiplanar
resorption. The neurovascular bundles are affected. The
lesion has a spider-web-like pattern.
Case 3
A 52-year-old female with involvement of bilateral
symphysis; unilateral body, ramus, coronoid, and condyle
of mandible; and maxillary tuberosity. The panoramic
radiograph and CT scan show a single, extensive, well-
defined, circumscribed, multilocular radiolucency extending
from 44 to the left ramus, condyle, and coronoid process, and
the left maxillary tuberosity. The antrum floor is displaced
superiorly. Lower anteriors and unerupted 38 are displaced
within the lesion. The inferior border of the mandible is
severely thinned. The neurovascular bundles are severely
destructed. The lesion appears like a soap bubble.
Case 4
A 60-year-old male with bilateral involvement of premaxilla
and the canine fossa of maxilla. The occlusal and panoramic
radiographs show a single, well-defined, circumscribed,
corticated unilocular radiolucency associated with horizontally
impacted 23; the radiolucency is seen extending from 11 to
the 24 region. Multiplanar root resorption is present in 21.
Case 5
A 22-year-old female with bilateral involvement of the body
and symphysis of mandible. The panoramic radiograph and
CT scan reveal a single, well-defined, corticated unilocular
radiolucency extending from 36 to 44. All these teeth
are displaced and have multiplanar root resorption. The
neurovascular bundles are displaced inferiorly.
Case 6
A 40-year-old male with bilateral involvement of the body
of mandible. The panoramic radiograph and CT scan reveal a
single, well-defined, circumscribed, corticated multilocular
radiolucency extending from the right body of the mandible
to 36, expansion of the cortical plate, and thinning of the
Radiographic analysis of ameloblastoma More, et al.
inferior border of the mandible. The neurovascular bundles
are affected. The lesion mimics a soap bubble.
Case 7
A 28-year-old male with bilateral involvement of the body
and symphysis of mandible. The panoramic radiograph
reveals a single, well-defined, circumscribed multilocular
radiolucency with scalloped margins and corticated borders,
extending from 43 to 37. The root apices from 43 to 36 show
multiplanar root resorption. The neurovascular bundles are
affected. The lesion mimics a soap bubble.
Case 8
A 55-year-old male with bilateral involvement of the body
and symphysis of mandible. The panoramic radiograph
reveals a single, well-defined, circumscribed multilocular
radiolucency with scalloped margins and corticated borders,
extending from 47 till 34. Knife-edge root resorption is
present in 44 to 47, and multiplanar type of root resorption
is seen in 43 to 33. The neurovascular bundles are destructed.
The lesion mimics a soap bubble.
Case 9
A 42-year-old male with unilateral involvement of the
body and ramus of mandible. The panoramic radiograph
shows a single, well-defined, circumscribed multilocular
radiolucency with corticated borders, extending from 36 to
the posterior border of the left ramus. The roots of 36, 37,
and 38 show knife-edge resorption. Thinning of the inferior
border of the mandible and destruction of the neurovascular
bundle is observed. The lesion mimics a soap bubble.
Case 10
A 19-year-old female with unilateral involvement of the
body of the mandible. The panoramic radiograph and CT
scan reveal a single, well-defined, corticated unilocular
radiolucency extending from 36 to 38. All these teeth are
displaced and the roots show knife-edge resorption. The
neurovascular bundle is displaced inferiorly. The lesion
appears like a honeycomb.
Case 11
A 40-year-old male with unilaterally involved parasymphysis,
body, and ramus of mandible. Panoramic radiograph shows
a single, well-defined, multilocular radiolucency extending
from 33 to the middle third of the ramus of the mandible.
Multiplanar type of root resorption is seen in 34 to 36. The
neurovascular bundle is displaced inferiorly. The lesion
shows a spider-web-like pattern.
Case 12
A 20-year-old female with bilateral involvement of the
symphysis, body, and ramus of mandible. The panoramic
radiograph reveals a single, well-defined, circumscribed,
multilocular radiolucency extending from 34 to the lower
third of the right ramus. The roots of associated teeth
show multiplanar type of root resorption. Thinning of the
inferior border of the mandible and inferior displacement
of the neurovascular bundle is observed. The lesion mimics
a soap bubble.
Case 13
A 21-year-old male with bilateral involvement of premaxilla
and the lateral part of the left maxilla. Panoramic radiograph
and CT scan reveal a single well-defined multilocular
radiolucency extending from 11 to 26. There is displacement
of 21 and 23. The antrum floor is displaced superiorly. The
lesion shows a honeycomb pattern.
Case 14
A 68-year-old old female with unilateral involvement of the
symphysis, body, and ramus of mandible. The panoramic
radiograph and CT scan reveal a single, well-defined,
multilocular radiolucency extending from 31 to anterior third
of the ramus of the mandible. The roots of 32, 33, and 34 show
knife-edge resorption, while the root of 35 shows multiplanar
type of root resorption. Thinning of the inferior border of
the mandible and destruction of the neurovascular bundle is
observed. The lesion shows a spider-web-like pattern.
RESULTS
In the present study, the patients affected with ameloblastoma
were in the age range of 19–68 years, with a mean age of
43.5 years. The maximum number of patients were in the
age-groups of 20–29 (28.57%) and 40–49 (28.57%). The male:
Female ratio was 1.3:1.
Among these 14 cases, the mandible was the most affected
jaw: The mandible alone was involved in 11 cases (78.57%),
the maxilla in two cases (14.28%), and the maxilla and
mandible together in one case (7.15%).
In the mandible, the body was involved in two cases (14.28%);
the symphysis and body in four cases (28.57%); the body
and ramus in two cases (14.28%); the parasymphysis, body,
and ramus in one case (7.15%); and the symphysis,
body, and ramus in two cases (14.28%). In the maxilla, the
premaxilla and the lateral part of maxilla were involved in
one case (7.15%) and the premaxilla and canine fossa in one
case (7.15%). In one case (7.15%), the lesion involved the
maxilla and the mandible together.
Out of these 14 cases of ameloblastoma, 6 cases (42.86%)
had unilateral involvement of jaw and 8 cases (57.14%) had
bilateral involvement.
The multilocular and unilocular type of ameloblastoma was
noted in 12 (85.72%) and 2 cases (14.28%), respectively. In
the multilocular type, the soap-bubble appearance was seen
in seven cases (50.00%), the spider-web-like pattern was
seen in three cases (21.43%), and the honeycomb pattern
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 11 cases (78.57%). Six cases (54.55%) showed multiplanar
type of root resorption, 3 (27.27%) cases showed knife-edge
root resorption, and 2 cases (18.18%) showed a combination
of multiplanar and knife-edge types of root resorption.
DISCUSSION
Ameloblastomas are an enigmatic group of oral tumors. They
are usually benign in growth pattern but frequently invade
locally and occasionally metastasize. They have a persistent
and slow growth, spreading into marrow spaces with
pseudopods, without concomitant resorption of the trabecular
bone. As a result, the margins of the tumor are not clearly
evident radiographically or grossly during operation and,
consequently, the lesion frequently recurs after inadequate
surgical removal, demonstrating a locally malignant pattern.[5]
In this study, ameloblastoma was observed to occur between
the ages of 19 years and 68 years [Figure 3], with the mean
age being 43.5  years. This finding is not consistent with
the studies conducted by Darshani et al., Fregnani et al.,
Adeline et al. and Krishnapillai et al., where the mean age
of occurrence was 33.2 years, 33.2 years, 30.2 years, and
30.2 years, respectively.[15–18]
Various studies show inconsistent findings regarding
gender predilection. The present study showed a slight
male predilection, with a male: female ratio of 1.3:1. This
is similar to the findings of Krishnapillai et al. and Potdar
et al.[18,19] However, the studies of Khan et al., Takahashi
et al., and Olaitan et al. found a slight female predilection,
and Keszlar et al. and Takahashi et al. reported no gender
predilection for ameloblastoma.[20]

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

Figure 5: Graph showing radiographic type wise distribution
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
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
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 features of ameloblastoma which are peculiar to
the local population. Although very often the diagnosis of
ameloblastoma is made on the basis of radiographic features,
one should never rely on it alone. All such lesions should
be biopsied and an accurate histologic diagnosis should be
obtained before definitive treatment is commenced.
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How to cite this article: More C, Tailor M, Patel HJ, Asrani M, Thakkar K,
Adalja C. Radiographic analysis of ameloblastoma: A retrospective study.
Indian J Dent Res 2012;23:698.
Source of Support: Nil, Conflict of Interest: None declared.
Indian Journal of Dental Research, 23(5), 2012