Odontogenic tumours

BY : Dr.Madhulaxmi.M Mod : Dr.Satish

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Deviation from normal odontogenesis serves as basis for formation of odontogenic tumours Reichart & reis 1983 possible stem cells of odontogenic tumour. Epithelial cells Ectomesenchymal cells Mesenchyme Neuroectodermal cells

WHO classification of odontogenic tumors-(2005)

Benign Tumours
Odontogenic epithelium with mature fibrous stroma,without odontogenic ectomesenchyme

Ameloblastomas Squamous odontogenic tumour Calcifying epithelial odontogenic tumour Adenomatoid odontogenic tumour Keratinocystic Odontogenic Tumor

Odontogenic epithelium with odontogenic ectomesenchyme, with or without tissue formation Ameloblastic fibroma / fibrodentinoma Ameloblastic fibro-odontoma Odontoma, complex type Odontoma, compound type Odontoameloblastoma Calcifying cystic odontogenic tumour Dentinogenic ghost cell tumour

Mesenchyme and/or odontogenic ectomesenchyme,with or without odontogenic epithelium

Odontogenic fibroma Odontogenic myxoma / myxofibroma Cementoblastoma

Classification
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As proposed by pindborg 1971 Benign ectodermal tumours ameloblastoma Adenomatoid odontogenic tumour Calcifying epithelial odontogenic tumour Benign mesodermal tumours odontogenic myxoma cementomas Benign tumours having ectodermal & mesodermal elements ameloblastic fibroma ameloblastic fibro odontome odontoameloblastoma Odontomes complex compound Melanotic neuro-ectodermal tumour of infancy

Histological classification of odontogenic tumours WHO 1992

1. Odontogenic epithelium without odontogenic ectomesenchyme Ameloblastoma Squamous odontogenic tumour Calcifying epithelial odontogenic tumour Clear cell odontogenic tumour

2. Odontogenic epithelium with odontogenic ectomesenchyme with or without dental hard tissue formation Amelobastic fibroma Amelobastic fibrodentinoma Amelobastic fibro odontoma Calcifying odontogenic cyst Complex odontoma Compound odontoma

3. odontogenic ectomesenchyme with or without included odontogenic epithelium Odontogenic fibroma Myxoma Benign cementoblastoma

Ameloblastoma
* In 1885 Malassez introduced the term Admantinoma. * In 1934 Churchill changed the name into Ameloblastoma. * Unicentric , nonfunctional,Locally invasive, anatomically benign, clinically persistent. * About 1% of odontogenic tumors and cysts are estimated to be ameloblastoma.

Pathogenesis
1. Rests of dental lamina
2. Developing enamel organ

3. Epithelial lining of an odontogenic cyst

4. Basal cells of oral mucosa

Classification
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Clinical variants Solid/multicystic 92% Unicystic 6% Peripheral 2% Histological Follicular Plexiform Acanthomatous Granular cell Basal cell desmoplastic

Examination
Mandibular - Molar ramus area Swelling Contd growth Local tooth mobility occlusal alterations failure of eruption of tooth

Radiographic features
multicystic

unicystic

Peripheral ameloblastoma
Firm , exophytic , diagnosed as fibrous epulis. Radiographic feature cupping with superficial erosion of bone

Different treatment modalities in ameloblastomas

Enucleation Curettage with or without mechanical/chemical fulguration of margin Cryotherapy Block resection

Enucleation is the separation of a lesion from bone, with preservation of bone continuity, by virtue of the lesion's containment within an encapsulating or circumscribing connective tissue envelope .
Curettage is removal of a lesion from bone, with preservation of bone continuity, by scraping of the lesion or absence of an intact encapsulating or circumscribing connective tissue envelope derived from the lesion or surrounding bone. Resection the excision of a lesion that includes a measurable perimeter of investing bone. In the mandible segmental, marginal or extend into a disarticulation if the temporomandibular joint is involved. In the maxilla it would be defined by the anatomic extension of the excision in subtotal (partial) or total maxillectomy.

Marginal resection

Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, & Endodontics Volume 81(4), April 1996

Surgical management of the ameloblastoma basis of anatomic location as Gardner et al

Anterior mandible (cuspid to cuspid ) The use of a marginal resection is made possible because the thickness of cortical bone in the symphyseal region is more resistant to infiltration by tumor.
Sachs et al suggested that anterior mandibular lesions and recurrences could be treated by a conservative approach that included peripheral ostectomy without continuity defect as long as there was close follow-up of the patient.

Mehlisch et al. suggested that small lesions (less than 3 cm in diameter) located in the anterior part of the jaws could be treated by excision with cautery whereas larger lesions required segmental or en bloc resection. Gardner et al reported that treatment of ameloblastoma in the anterior body of the mandible could be approached conservatively because of the distance from major anatomic structures

Posterior mandible (bicuspid to condyle)

Gardner and Pecak indicated that small lesions of the posterior mandible should be treated by marginal resection leaving the posterior border intact, whereas more extensive lesions should be treated by segmental resection

Treatment of solid or multilocular ameloblastomas of the body and posterior mandible requires radical therapy. Marginal resection without continuity defect with 1 to 2.0 cm margins
When the tumor has perforated bony cortices, overlying soft tissue should be removed and intraoperative frozen sections should be considered.

Anterior maxilla (cuspid to cuspid)

Ameloblastoma of the anterior maxilla could be treated less aggressively than those of the posterior maxilla as sufficient distances from vital structures allow for less radical treatment conservative management has the risk of recurrence with potential extension to the orbits, nasal cavity, and ethmoid cells

Posterior maxilla (bicuspid to pterygoid plates)

47% to 50% of maxillary ameloblastomas are found in the molar region and 15% to 30% in the maxillary sinus and floor of the nose
Posterior maxillary tumors are not well confined by the thin maxillary cortical bone and can easily spread outside maxillary boundaries. Gardner and Pecak suggested resection with 1 to 2.0 cm margins of clinically normal bone.

Squamous odontogenic tumour

Benign locally infilterative intraosseous tumour composed of well differentiated squamous epithelium in a fibrous stroma Origin from Rests of malassez Gingival surface epithelium Remnants of dental lamina Rests of serres

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Squamous odontogenic tumour

C/F deep pocketing, pain & swelling of adjacent gingiva R/F Triangular semicircular with scalloped margin

Treatment
Enucleation Curettage Recurrence rare - local curettage with extraction of adjacent teeth.

CEOT(Pindborgs tumour)
Uncommon From reminiscence of sequestered cells in stratum intermedium layer. C/F age & site of occurrence similar to ameloblastoma Lack of symptoms

Radiographic
Unilocular or multilocular Expansion & Thinning of buccal & Lingual cortical plates Wind driven snow appearance

Treatment of CEOT
Enucleation Curretage Segmental resection partial/hemimandibulectomy/hemimaxillect omy Adjuvant radiotherapy/chemotherapy

Adenomatoid odontogenic tumour

Adenoameloblastoma Hamartoma Vs Neoplasm Origin enamel organ remnants of successional dental lamina ( gubernaculum dentis)

Clinical features
<30yrs,common in teenage Maxillary antr region Delayed/unerupted permanent tooth Slow growing bony expansion

Impacted permanent tooth Unilocular radiolucency Divergence/displacement of tooth

Treatment
Enucleation & curettage No recurrances Gross specimen soft, roughly spherical with discernable fibrous capsule. Section white to tan brown fine hard gritty granular.

Ameloblastic fibroma
Rare <20yrs, painless,slow Growing,expansile neoplasm Do not infiltrate bone 75% of cases associated with impacted tooth R/F Well defined uni / multi Locular radiolucency with Sclerotic border TTT conservative excision modified block resection

Ameloblastic fibro odontoma

Similar to AF but shows inductive changes formn of dentin & enamel 98% before 20yrs Postr mandible Exclusive intraosseous R/F well circumscribed Expansile radiolucency With radioopaque foci TTT Enucleation Removal of tooth

ODONTOME
Most common odontogenic tumour COMPLEX COMPOUND Compound more common than complex odontomes Pathogenesis unknown trauma / infn from hypoplastic tooth germ genetic mutation

Small , Hard , painless mass Impacted permanent tooth or retained deciduous tooth. Conservative surgical excision No chance of recurrence

Complex odontoma

Compound odontoma

Odontogenic fibroma
Fibroblastic neoplasm with inactive odontogenic epi Average 37 yrs(5-80yrs) Mandible more common Antr to 1st molar Asymptomatic In maxilla palatal cleft R/F well defined with sclerotic border TTT curettage , enucleation Xn of teeth

MYXOMA
< 40yrs More common in mandible Molar premolar region Origin from odontogenic mesenchyme or osteogenic embryonic cells Spindle shaped tumour cells myxoblast

Unilocular to multilocular with displacement of teeth honeycomb Soap bubble Wispy Tennis racket Spider web No calcifications

Treatment
Recurrence 10 33% Surgical excision Enucleation & curettage with or without electrical or chemical cautery En bloc resection with or without immediate grafting.

Cementoblastoma
< 25yrs Mandibular 1st molar region Associated tooth vital Slow growing,expn of cortical plates Tumor mass attached to tooth root,resorption Xn of tooth with removal of tumour mass

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