Odontogenic tumors

DEFINITION:
Odontogenic tumors
are the lesions
derived from
cellular elements
that are forming
the tooth
structure.

TOOTH FORMING APPARATUS

Neoplastic
Benign

Intersection

Hamartomatous

Malignant

Cystic
changes
Odontoma

Amelobl
Amelobl
astoma
astic
Calcifying
Cementoma Cementoma
odontogenic cyst
Ameloblastic fibro odontoma

CLASSIFICATION
NEOPLASM
A). Benign
1). Odontogenic epithelium
(i). Ameloblastoma
(ii). Squamous odontogenic tumor
(iii).Calcifying epithelial
odontogenic tumor
(iv).Clear cell odontogenic tumor

(Pindborgs tumor)

2). Odontogenic epithelium with

odontogenic ectomesenchyme
(i). Ameloblastic fibroma
(ii). Ameloblastic fibro dentinoma and
ameloblastic fibro odontoma
(iii). Odontoameloblastoma
(iv). Adenomatoid OdontogenicTumor
(v). Calclifying odontogenic cyst
(vi). Complex odontoma
(vii). Compound odontoma

3). Odontogenic ectomesenchyme

(i). Odontogenic fibroma
(ii). Myxoma / Odontogenic
myxofibroma
(iii).Benign cementoblastoma( True
Cementoblastoma)

MALIGNANT
1). Odontogenic carcinomas
(i). Malignant Ameloblastoma
(ii). Primary intraosseous carcinoma
(iii). Malignant variant of other
odontogenic epithelial tumor
(iv). Malignant changes in odontogenic
epithelial tumors
(v). Malignant changes in odontogenic
epithelial cyst

2). Odontogenic sarcomas

(i). Ameloblastic fibrosarcoma
(Ameloblastic sarcoma)
(ii). Ameloblastic fibrodentine
sarcoma & Amleoblastic fibro
odontosarcoma
3). Odontogenic carcinosarcoma

AMELOBLASTOMA

Definition

An epithelial tumor arising

from the odontogenic
apparatus or from cells with
a potentiality for forming
tissues of the enamel organ.

WHO Defined it as
Unicentric, non functional,
intermittent in growth,
anatomically benign and
clinically persist

Origin of the ameloblastic cells

1). Odontogenic epithelium
a). Remenants of Dental lamina
b). Reduced enamel epithelium
c). Rests cells of malassez
2). Basal cell layer o overlying surface
epithelium
3). Epithelial lining of odontogenic cyst

Three clinical subtypes

1). Common polycystic Ameloblastoma
(80% of all cases)

2). Unicystic Ameloblastoma (13% of all cases)

3). Peripheral (Extraosseous)
Ameloblastoma (1% of all cases)

A). Common polycystic ameloblastoma

Also called conventional, Intraosseous ,
Multicystic
Clinical features
Age - 20 to 40yrs
Site - mandible > maxilla
slow growing, painless, bony expansion
initially Tennis ball like consistency
Egg shell like cracking
Jaw bone enlargement & parasthesia

Radiographic features

Round cyst like radiolucency

Honey comb (if small loculations)

or soap bubble like consistency(if

large loculations)
Histopathology:
(Vickers and Gorlins criteria).

1). Hyperchromatism
2). Palisading cells
3). Vacuolization
4). Hyalinization

Histopathological variants
1). Follicular ameloblastoma
2). Plexiform ameloblastoma
3). Plexiform unicystic ameloblastoma
4). Acanthomatous ameloblastoma
5). Papilliferous keratoameloblastoma
6).Granular cell ameloblastoma
7). Desmolytic ameloblastoma
8). Basal cell ameloblastoma
9). Clear cell Ameloblastoma

Follicular Ameloblastoma
Consists of different
shapes & sizes of
epithelial islands in the
form of epithelial nests
or follicles.

Plexiform ameloblastoma
Consists of interlacing
strands of odontogenic
epithelial trabeculae

Acanthomatous
Ameloblastoma
central epithelial cells
squamous cell metaplasia
keratin deposition.

Desmoplastic
Ameloblastoma
Small epithelial islands
widely separated by dense,
scar like fibrous tissue.

Granular cell
Ameloblastoma
central cells appears
swollen & densely
packed with
eiosinophillic granules.

Basal cell pattern

Islands of uniform
basaloid cells.

Treatment options
1). Simple Curettage - high recurrence
rate. In mandible, wide marginal
resection leaving compact bone of
lower border intact provided the lower
border is not involved radiographically
Large tumors invading lower border of
mandible, segment resection using
bone grafts. In maxilla, wide excision
is treatment of choice

A 17-year-old girl with obvious facial expansion

(A) related to a multilocular radiolucency of the
left mandible associated with impacted tooth no.
17 (B). Note the aggressive nature of this tumor.
The incisional biopsy showed solid/multicystic
ameloblastoma.

Twenty years of undisturbed growth of a solid/multicystic

ameloblastoma led to significant facial disfigurement
(A), with an impressive radiographic appearance (B). A
segmental resection of the right mandible was
performed(C).

B). UNICYSTIC AMELOBALSTOMA

Definition :
Is defined as a single unicystic cavity that
shows ameloblastous differentiation in the
lining.
origin - a). De-novo as a neoplasm
b).result of neoplastic transformation.

Clinical features

age - 16 to 20yrs (younger patients).

Site - mandible > maxilla

Large lesions painless swelling in the jaw.

Radiographic features
Well-circumscribed,
radiolucent area that
surrounds the crown of
an unerupted molar.

3 histopathological
variants.
1). Luminal unicystic
2). Intaluminal
unicystic
3). Mural unicystic

Differential diagnosis
(1). Dentigerous cyst
(2). Residual cyst
Treatment and prognosis
(1). Enucleation and curettage (recurrence rate
- 10% to 20%) less recurrence as surrounding
fibrous connective tissue limits the lesion .
(2). If the lesion extends into fibrous cyst wall
Prophylactic measure
Local resection
of the area

A, Treatment of the ameloblastoma of the patient

in Figure 30-17 required a disarticulation
resection of the left mandible. B, The
effectiveness of the bony linear margin should
always be evaluated by intraoperative specimen
radiographs.

A, The luminal unicystic

ameloblastoma in Figure 30-21 is treated with
an enucleation and curettage surgery. B, The
5-year postoperative radiograph shows an
acceptable bony fill.

This 18-year-old presented with significant right facial expansion

(A) associated with the destructive radiolucency of the right
mandible noted on the panoramic radiograph (B). The incisional
biopsy documented the mural variant of unicystic ameloblastoma
(hematoxylin and eosin; original magnification 20) (C). A
disarticulation resection was performed (D).

3).PERIPHERAL OR EXTRAOSSEOUS
Incidence - 1%
origin - a). Remnants of dental lamina beneath the
oral mucosa
b). Basal epithelial cells of
surface epithelium
Clinical features

Age - middle age

site - posterior gingival &

alveolar mucosa Mandible > maxilla

Painless, nonulcerated, sessile or pedunculated

gingival or alveolar mucosal lesion.

Histopathology:

bear islands of ameloblastic

epithelium occupying lamina
propria underneath surface
epithelium.

Treatment & prognosis

Surgical excision (Recurrence
rate - 15 to 20%).
Earliest diagnosis

MALIGNANT AMELOBLASTOMA
Benign tumor that in the typical
intraosseous form has a tendency to
infiltrate cancellous bone

AMELOBLASTIC CARCINOMA
Ameloblastoma that has a
cytologic evidence of malignancy.

Clinical features:
swelling, pain and
inflammation
Ulceration of mucosa
& loosening of teeth
Epitaxis & nasal
obstruction.

Radiographic
features
unilocular or
multilocular
radiolucency, soap
bubble
appearance.

Treatment
Simple curettage (high
recurrence rate). In mandible, wide
marginal resection leaving compact bone
of lower border is not involved
radiographically.
Large tumors - segmental resection
followed by reconstruction using bone
graft.

A, The large destructive radiolucency

of the right mandible was present in a 22-year-old
man who complained of precipitous growth and
pain. The incisional biopsy showed benign
solid/multicystic ameloblastoma. B, A segmental
resection was performed. D and E, Final
histopathology of the resection specimen showed
ameloblastic carcinoma

ADENOMATOID ODONTOGENIC
TUMOR

Origin - Tumor cell derived from

a). Enamel organ epithelium
b). Remnants of dental lamina
Clinical features
Age - younger patient (10 to 19yrs).
Site - anterior portion of the jaw
maxilla > mandible
Asymptomatic, painless, slow growing.
large lesions causes expansion of
bone.

Sit e of occurance

A well circumscrbed
solid mass en velo pin g
t he cown of t his t oot h

of AOT

AOT variants
Central

Peripheral

(intraosseous)

(extraosseous)

1). Follicular type

rare, small

involves crown of

sessile masses on

an unerupted tooth

facial gingiva of
maxilla

2). Extrafollicular type

located b/w roots
of erupted tooth
DD: globulomaxillary cyst

DD: Gingival
fibrous lesion

Radiographic features

Usually unilocular with well defined corticated border

may or may not contain a tooth

often contains fine calcifications.

tubular or duct like structures

Follicular

Extrafollicular

Histopathology:
surrounded by fibrous capsule

Spindle shaped epithelial cells forming

sheets, strands or whorled masses of cells

epithelial cells

Calcification-

small foci as
well as larger
areas
Treatment
Surgical enucleation (recurrence is rare).

CALCIFYING EPITHELIUM
ODONTOGENIC TUMOR
( Pindborgs tumor )

Definition:
It is a locally aggressive tumor consist of sheets
& strands of polyhedral cells in fibrous stroma
with no inflammatory component & are often
accompanied by spherical calcifications &
amyloid staining hyaline deposits.
Origin -Rest of dental lamina
-Reduced enamel epithelium
1% of all odontogenic tumor

Clinical features
CEOT
Central
(intraosseous)
age - 40yrs
site - 2/3rd of
lesions in mandible
slow growing.
painless mass.

Peripheral
(extraosseous)
site - anterior gingiva
appears as superficial
soft tissue swelling
of gingiva in a tooth
bearing area or
edentulous area of
jaw

Radiographic features:

Early lesions - unilocular, old lesions multilocular or honey comb appearance.

Scalloped margins

entire radiolucency with calcified

structures of varying size & density
Snow driven appearance.

Histopathology:

sheets of polyhedral epithelial cells on fibrous

stroma

cells show pleomorphism, prominent nucleoli &

hyperchromatism.

Liesegang ring calcifications

amyloid stained by
congo red

A 40-year-old woman with a 5-year history of

an expansile mass of the left maxilla. The
patient with the Pindborg tumor in Figure 3038 is treated with hemimaxillectomy.

ODONTOMA
Most common type of odontogenic tumor
Hamartoma
Definition:
A non-neoplastic developmental anomaly or
malformation that contains fully formed
enamel and dentin.

Types:
1). Invaginated odontome(Dens invaginatus,
Dens in dente)
2). Evaginated odontome
3). Enamel pearl
4). Germinated odontome
5). Complex odontome
6). Compound odontome
Clinical features:
Age- 10 to 20yrs
Site - Maxilla > mandible
Slow growing , hard , painless mass

GARDNERS Syndrome is
associated with it
(a). Multiple odontomas
(b). Multiple osteomas
(c ). Intestinal polyps
(d). Epidermoid cyst
(e). Dermoid
tumor(fibrous)
2 Types
(1). Complex
(2). Compound

Compound odontoma
site - anterior part of maxilla
origin - repeated divisions of tooth
germs. By overgrowths multiple
budding of dental lamina with
formation of multiple tooth germ.
Radiographically Dense opacity with radioluscent rim
surrounding it.

Collection of tooth like structures of

varying size & shape surrounded by
narrow radiolescent zone.

Histolopathology
Numerous denticles having structures of normal
teeth embedded in fibrous connective tissue.

Complex odontoma
site - posterior part of maxilla
Consist of congomerated mass of enamel &
dentin which bears no anatomic resemblence to
a tooth.Cauliflower like mass of hard tissues.
Radiographically:
Calcified mass with the radiodensity of tooth
structures

Histolopathology:
Mass consist of enamel, mature tubular
dentine, cementum together with pulp &
PDL members in varying amount

CALCIFYING ODOTOGENIC CYST

(Odontogenic ghost cell cyst)
Definition:
A rare well circumscribed solid or cystic
lesion derived from odontogenic epithelium
that resembles follicular ameloblastoma but
consists ghost cells & spherical
calcifications.
Cutaneous counterpart- Benign calcifying
epithelioma of MALHERBE/ Pilomatrixoma

Clinical features
Origin - remnants of dental lamina
Site - areas anterior to molar
Age - most common in 2nd decade
painless asymptomatic slow growing
hard lesion
expansion of buccal cortical plate.

TYPES
Extaosseous
Focal localized
swelling

Intraosseous
generalized
expansion of buccal
cortical plates

DD. gingival fibroma Dentigerous cyst

peripheral giant
Ameloblastoma
Gingival cyst
Adenomatoid
odontogenic cyst

Radiographic feature
Well circumscribed unilocular radiolucency
containing.
Flecks of indistinct radiopacities.
Histolopathology:
Epithelium lining a cystic space.
Epithelium consist of pallisaded columnar
cells with reverse polarity of nuclei. Inner
layer of stellate reticulum.
GHOST cells present.
Multiple spherical & diffuse calcification.
Deposites of hyaline material.

1). Curettage
2). Recontouring
3). Resection with or without loss of
continuity.
Curettage
Scrapping of the tumor tissue away
from bone. Tumor usually comes out
in

A, The patient underwent a segmental resection of

his odontogenic tumor B, As with the ameloblastoma,
specimen radiographs should be obtained when
resecting to verify the bony linear margin. A better
depiction of the stepladder pattern of the
odontogenic myxoma is noted on this specimen
radiograph.

Ameloblastic fibroma
painless mixed tumor occurring in younger
patients in the premolar and molar region.
Sharply demarcated radiographic borders.
Microscopically epi. Cells lie in conn. Tissue
stroma. Enucleation and curettage

An enucleation and curettage surgery is

performed in the patient of 15-years of age.
The associated permanent teeth are removed
with the tumor.

Ameloblasticfibro - odontoma
Tumor with features of ameloblastic fibroma but
that also contains enamel and
dentin.histologically epi. Islands in conn. Tissue
stroma .Radiographically well circumscribed
unilocular. Treated by enucleation.

Ameloblastic fibrosarcoma

Malignant counterpart of ameloblastic

fibroma. Radiographically ill defined
destructive radiolucency.

Cellular mesenchyme shows hyperchromatism

and atypical cells with island of ameloblastic
epithelium