You are on page 1of 16

Odontotgenic tumors arise frome odontogebic tissue .

Odontogenic tissue is odontogenic epithelium and odontogenic mesnchyme

.odontogenic epitheliume is represented by the enamel organ and you
remember the enamel organ which contain columnar cells at the periphery
which are the ameloblast and stellaet reticulm at the center .dentine originate
from connective tissue (mesenchymel tissue ) because we have reciprocal
indaction then dental papilla produce dentine. So we have epithelium and
mesenchyme either of these tow component may give rise to tumors. so we
have odontogenic tumors which originates completely from epithelial origin
and we have odontogenic tumors which originates from mesenchemal origin
and we have odontogenic tumors which arise from both epithelial and
mesenchymal together this is the bases of calcification of odontogenic tumors
.WHO calcification lately2003 changed the name of OKC to keratinizing cystic
odontogenic tumor another change to a cyst was call coc (calcifying
odontogenic cyst to calcifying cystic odontogenic tumor. These tow cyst has
been changed to odonotogenic tumors due to their clinical behavior.

Odontogenic tumors of epithelial origin

Epithelial lesions:
(1) Without odontogenic mesenchyme (epithelial origin)
Squamous odontogenic tumor not included
Calcifying epithelial odontogenic tumor
Adenomatoid odontogenic tumor
Keratinizing cystic odontogenic tumor
Now we have tumors of epithelial and mesenchymal origin :

(2) With odontogenic mesenchyme (mixed epithelial and nesenchymal)

Ameloblastic fibroma and fibrodentinoma
Ameloblastic fibro-odontoma
Calcifying odontogenic cyst and dentinogenic ghost cell tumor
Calcifying cystic odontogenic tumor (calcifying odontogenic cyst) and
dentinogenic ghost cell tumor
Complex odontome*
Compound odontome*

According Ameloblastic fibroma and fibrodentinoma here we have fibroma

which mean mesenchymal origin and ameloblastic which mean epithelial origin
so if we say that ameloplastic fibroma or fibroodontoma is mesenchymal origin
or epithelial origin only that is false because its mixed origin . but if we say
amelobalstoma alone its epithelial origin ,when we say ameloplastic something
its most likely mixed .complex and compound odontoma are of mixed origin
because they contain enamel(epithelial ORIGIN) and dentine (mesenchymal
origin )odontoms are surrounded by dental follicles so they contain
connective tissue ,there is a debate on the odontoma that its may be
considered as hamertomma (normal tissue in normal position but in abnormal
organization ).

Mesenchymal lesions
Odontogenic fibroma


Melanotic neuroectodermal tumor of infancy
Congenital gingival granular cell tumor) (congenital epulis
Their sources arent well known they arise in the jaw according to the
melanotic neuroectodermal tuomr of infancy mostly its arise from
neuroectoderm .congenital epulis the infant come with a lesion on the
gingiva polyop on the gingiva we call it congenital because it arise with
the birth of the infant ,and becuse its on the gingival we call it epulis so
(congenital epulis)also called granular cell tuomar . Now Dr.saied what
do we understand about clacification ? clacification is based on the
tissue of origin of the tumor either epithelial alone or mesenchymal
alone or mixed.
Now we will start with first lesion which is the most common
odontogenic tumor (ameloblastoma)benign
Ameloblastoma : when we have un erupted third molar and if this impactrd 8
has a pericoronal radiolucency so we will consider in our differentiation
diagnoses dentogerous cyst ,odontogenic kerato cyst and anyloblastoma .the
most common presentation of ameloblastoma is in the posterior region of the
mandible with or without association un erupted tooth .the best location is
the posterior part of the mandible posterior to the molars it may occurs in the
angle or in the ramus of the mandible and if you look at the radiograph

You will see the most likely presentation of amelobastoma which is the multi
locular radiographic presentation but it may be unilocular just like
dentogerous cyst .so when you find a pericoronal radiolucency try to take
biopsy because it maybe ameloblastoma
So ameloblastoma is odontogenic tumor of an epithelial origin most
likley occurring in the mandible in the posterior part maybe associated
with un erupted tooth or without association of any maybe multi locular
or uni locuolar .ameloblastoma extends through the marrow spaces if it
occurs in the maxilla it will extend to the maxillary sinus and in the
cancellous marrow spaces so it may reach bigger sizes in the maxilla
before bone expansion compared to the mandible because it has the
whole maxillary sinus to expand in it .but also in the mandible after it
spread thorough the marrow spaces it will start causing bony expansion
.usually the expansion is fussiy form meaning that it doesnt have well
defined margin and usually egg shell cracking may not occur unless the
tumor reaches very big sizes so the perforating of the bone not common
.there is a very important feature of ameloblastoma despite its benign
its locally invasive as you seen in the radiograph so it needs aggressive
treatment it has a high recurrence rate from 50to90 percent high
recurrence rate is to due it extention through the marrow spaces ,the
tumor extend beyond the safe margins so the surgent cannot remove it
completely .less than 1% of oral tumors ,80%in the mandible but it still
can be in the maxilla ,majority of the mandible lesions occur posteriorly
the majority of maxillary lesions also occur in posterior areas

,15%involves the ant rum . As it gets larger, there may be gradual facial
deformity and bone expansion.
Enlargement is usually bony-hard, non-tender, and ovoid to fusiform.
In advanced cases, egg-shell crackling may be felt due to thinning of
Perforation of bone and extension into soft tissue are late findings.
the teeth may get lose due to the tumor according to its size but pain is a
seldom feature because it doesnt relly grow fast as it involve the inferior
dental nerve or the surrounding nerve so its not like the malignant tumor
which grow fast and involve the nerve and metastasize along the nerve ,root
resoption may occur un erupted teeth may be associated.
*dentogerous cyst unilocluar *
Ameloblastoma present usually as multilocuolar ,less frequently unilocuolar

Histology of ameloblastoma

Its almost the same of enamel so we have columnar cells at the periphery and
stellate reticulum at the center and we are talking about these follicles so
ameloblastoma is composed of multiple follicles ,follicles composed of
epithelial cells ,follicles(epithilum) are the neoplastic component ,each follicle
is surrounded be columnar cell which are darker in color nuclei are darker and
they are tall and columnar each follicular is composed of columnar cells at the

periphery and stellate reticulum like cell at the center .follicular cells are open
Nuclei of peripheral cells are polarized away from the basement membrane.
the stroma is fibrocollagenous stroma.
Several change can occure
like cystic changes in the center of the follicles because it may reaching big
sizes and the nutrient stope reaching the center of the island and we may have
granular cell change in the center meaning the stellate reticulum like cells may
have granular or cystic changes or it may start producing keratin
(acanthomatus change ,squamous metaplasia).histologicaly there are different
patterns but they dont affect the prognosis of the patient .
there is a different variance of follicular ameloblastoma from the follicular
pattern in the plexi form pattern we dont have big islands or follicles we have
strands of epithelial cells and each strands is surrounded by columnar cells
with Nuclei of peripheral cells are polarized away from the connective tissue
and each strands has a stellate reticulum cells at the center . cystic changes
occur in the connective tissue surround the strand in contrast to the follicular

pattern .

origin and pathogenesis of the ameloblastoma

it may be from dental lamina reminant ,lining of the odontogenic cyst either it
was dentogerous cyst or okc ,may be from basel cell of oral epithiluim if
ameloblastoma is peripheral or may be from odontogenic remnants in the
Q:peripheral cells why they dont secret enamel ?because they are consider to
be pre ameloblast they are not functioning ameloblastoma
Behavior: its aggressive its locally invasive, shows high recurrence rate up to
90%, it spread through marrow spaces.
*through the oral surgery aspiration of ameloblastoma may occur and it may
go to the lunge so later on maybe there ameloblastoma in the lymph node of
the lung or in lunge if it not due to aspiration it called malignant
ameloblastoma .when we have metastasis regardless if there are cytological
changes or not we use the word malignant (malignant ameloblastoma) ,but if
we have cytological changes(neoplastic chnges ) regardless if we have
metastases or not we use the word carcinoma (ameloblastic carcinoma ) but
the most commen is aspiration ameloblastoma .

Ameloblastoma has a small range of polymorphism and of hyperchromatic

Truly malignant ameloblastomas are rare.

Now we have tow sub types of ameloblastoma that should metiond

Unicystic ameloblastoma
suppose we have impacted tooth or any un erupted tooth and there is a
big radiolucency around it that maybe cyst or ameloblastoma or
odontogenic kerato cyst

Suppose that this was a big cyst and the ameloblastic changes collomuner
layer +stellate reticulum layer are only lining the cyst so we call it unicyst
ameloblastoma ,they arent forming folliculs invading the walls of the cyst
Treatment for the unicystic ameloblastoma
Will be conservative treatment by inoculation while the treatment of
ameloblastom is aggressive by block resection and having safe margins
*suppose that the lining of ameloblastoma start to form nodules protruding
inside the cyst which we call it neural ameloblastoma and the treatment is the
same but when the lining changing invading the tissue of the cyst wall it
needs aggressive treatment
So they concider that unicystic ameloblastoma has three histological variance
*the ameloblastoma only lining the cyst
* the ameloblastom is protruding inside the cyst lumen only and these tow are
treatment conservatively

*the third variance is that the ameloblastic changes are invading the cyst wall
and in this case the treatment is aggressive like the regular ameloblastoma
*the last variance of the ameloblastoma is the peripheral ameloblastoma on
the gingival the origin of epithelial is either the basal cells of the oral
epithelium or odontogeinc epithelial remnants, its much less invasive its need
much less conservative treatment so ,its treated like pyogenic granuloma by

Q:i didnt hear it but its about cyst ?the answer was based histologicaly on the
lining epithelium if we see stellate reticulm cells and basel collomuner layer
polorised away from the underlining tissue its ameloblastoma but if we see
basel collomuner layer polorised away from the underlining tissue but with
uniform thikness and keratin and no stellate reticullm cell its okc if we see
only blind epithelial tissue maybe dentogeirous cyst or other types of cyst so
the lining epithilum is the bases

Squamous odontogenic tuomr is not included in the exam ????very short

essay inthe book
Calcifying epithelial odontogenic tuomrs : calcifying meaning that we have
calcifying mineralized tissue epithelial meaning that its from epithelial origin
tumour means its a mass no cystic component in the lesion usually ##in the
exam if there are 2 true option chose them together.

Calcifying Epithelial Odontogenic Tumor: we use to call it COET

CEOT its odontogenic tumor of epithelial origin >>>what do we know by heart

abouth this tumor
1-it behaves aggressively so it needs aggressive treatment like ameloblastoma
2- It occurs in the posterior part in the mandible this is the best location for the
tumor like ameloblastoma
3-it may appear radiographicly completely radiolucent so I may put
ameloblastoma in its diffrintional diagnoses or vi versa because at cretin
period of time it appears radiolucent but it may also appear mixed radiolucent
radio opaque because of this it called calcifying because it may have
calcifications .

4- it maybe locally aggressive so its need aggressive treatment and it looks

histological aggressive but its benign .
Histological features
Its aggressive but benign do you know its aggressive when we look at
the histological picture of COET will se hyper chromatic cells and there is
pleomorphism and we can see varation in the size and shape ,prominent
intercellular bridges (spaces between the cells ) it may mismatch with
malignat tumors due to this features but its actually benign .what happens in
this tumour that the cells secret amyloid like material which may become
calcifyid later on and after it calcifyid it will appear radio opaque
radiographicly.for this its got the name .these epithelial cells are polyhedral
,eosinophilic cytoplasm ,some of them are paled but most are deeply

eosinophilic bridges are prominent and pleomorphism is a feature but they

arent malignant .
*it maybe associated with unerupted crowns 50% like ameloblastoma
*it has extraseous variant like peripheral component like ameloblastoma
*its less aggrissve than ameloblastoma
*it may not clearly demarcated like ameloblastoma
*varying amount of radio opaque bodies

Adenomatoid Odontogenic Tumor:

Adenoma mean a benign tumor of epithelial origin histologically we see
gland like structures so we call it adenamatoid but this type of tumor is good
because it well defined and treated conservatively ,it occurs in young age ,it
occurs anteriorly in the maxilla its the best location in association with un
erupted tooth , its treated conservativly,it has a extraceous varaient .

Histologicaly :
Its well encapsulated its consist of epithelial cell some cells are spindled and
spirling and some of these epithelium cells will form gland like structures
these cells are cuboidal or colomuner cells which has epithelial origin they are
forming gland like structures ,calcification may occur enamel product may be
seen ,there is sheets of polyhedral cells these polyhedral cells show eosiniphilc
cytoplasm.,hyperchromatsim .pleomorphism sometimes multinuclation ,they

show pronounced inter cellular bridges ,they dont have stellate reticulum like
cells ,they dont have cuboidal cells with polarization nuclei a way from the
surrounding tissue ,we have amyloid like materials which may be calcified
later on ,it doesnt metastasize ,its not malignant ,its just locally invasive and
destructive but less than ameloblastoma .
Ameloblastic Fibroma:
It has mixed origin ,it has much better prognosis than ameloblastoma ,its
treated conservatively not aggressively ,its not invasive ,its occure most
frequently in the posterior part of the mandible sometimes in association with
un erupted third molar .now if you have an impacted third molar with
precoronal radiolucency what are the differential diagnoses?OKC ,dentigerous
cyst ,ameloblastoma,CEOT,ameloblastic fibroma.. .THESE diffirination in case
the lesion isnt multilocular ,recurrent rate is approximately 18% only it
mimics dentigerous cyst .
Histologicaly :we should focus on stroma supporting stroma which is
fibroblast with high cellularity compared to ameloblastoma for this reason its
named ameloblastoma .if you look at the follicles they have the same
columnar cells polarized away from the tissue but they are smaller than the
follicles in the ameloblastoma ,enamel ,dentine may be formed and when they
form it called ameloblastic fibro odontoma(enamel and dentine)or ameloblasic
fibro dentinoma (dentin only formed)both same treatment ,
*dental follicals are compose of mysenchemal tissue +remenants of epithelial
*stroma +epithelial =neoplastic .

Calcifying Cystic Odontogenic Tumor (Calcifying Odontogenic Cyst or Gorlin

Cyst) & Dentinogenic Ghost Cell Tumor:
Previously it was called Calcifying Odontogenic Cyst but now its called
calcifying odontogenic cystic tumor ,its also known as gorlin cyst or pind board
tumor (not sure of the name ) .it has a pronounced cystic component if it

hasnt cystic component bot with same pathological features we call it tumor(
Dentinogenic Ghost Cell Tumor)

Dentinogenic ghost cell tumor and calicifyaing odontogenic cyst both

have the same histological features but the DGCT dosent have cystic

Both have the same features except the cystic component :now
CCOT .. in the basal layer contain columnar cells with nuclei polarizing a way
from the connective tissue and going up we will see stellate reticulum like cells
like the ameloblastoma and we said if the cyst was lined with these tow layer
we will call it unicystic ameloblastoma but here we dont have only these tow
features we also have ghost cells these are odontogenic cell which gave some
cretin changes that will show only the outline if the nucleus this may be a form
of apoptosis or cellular changes thats why its called the ghost ,we see pink
eosinophilc cytoplasm and outline of the nucleus but we dont see the nucleus
,these ghost cells may go under calcifications and for this reason its called
calcifying ,its show ghost cells keretenazation .
Radiographicaly there will be radioopeaqu mases due to the calcification of
the ghost cells

Now spouse that there is no cyst or cavity meaning all the lesion composed of
these types of cells we will call it tumor Dentinogenic Ghost Cell Tumor why

Dentinogenic ?because dentine may be formed within the tumor and also
dentine with enamel may be formed with in cyst variance .

Odontogenic Fibroma
Clinical Features differences
1-The dentinogenic ghost cell tumor tends to occur in an older age group
than the calcifying cystic odontogenic tumor.
2-Both occurs centrly in the jaws but peripheral component may occure
3-They occure latly in the life 40+
4-They occur anteriorly to molar region in the mandible mostly
5-Maybe associated with un erupted teeth ,may be copletly
radiolucens,maybe radiolucenc radio opaque.dependind on the amount of
calcification of ghost cells
conservative treatment.for the cystic component but more aggrasseive
fore the solid component

mysenchemal tuomrs :
-odontogenic fibroma
-odontogenic myxoma
What is the difference between fibroma and myxoma ?in the type of fibres if
the fibers are collagen dens its fibroma but if they are loose contain high
amount of glucose amino glaycan >>gelatinous material >>less fibrous tissues
..its myxoma .
Myxoma goes more in the marrow spaces so its need more aggressive
treatment than fibroma ,,,fibroma has better prognosis .

The location of myxom in the mandible posteriorly related to roots or crowns

or it may be replace a tooth .origin is from PDL or dental papilla or dental
follicle...Dental follicle is the most.
Odontogenic fibroma may occurs in the gingival and it has a peripheral variant
called peripheral odontogenic fibroma .
Treatment: by inculcation because its fibrous it doesnt leak into the marrow
spaces ..
*No recurrencs rate in the odontogenic fibroma
*odontogenic tuomr is cellular and contain high amount of fobroblast and
cells and contain a remnant of odontogenic epithelial.
*True tumours are cellular
Myxoma is benign but its locally invasive because of the nature of the
gelatinous component of the tumour ,its more commen than
odontogenic fibroma ,more in the maxilla. Multilocualr radiolucency,
soap-bubble, or tennis-racket appearance, often with well-defined
margins but its not always well-defined.

*when we have both

dens collagenous and loose golagenouse fiber we call it

fibromyxoma or myxofibroma .