7 Tumors-Prof Ahmed El-Sabbagh - May 2021

5/25/2021
ORAL & MAXILLOFACIAL

TUMORS
BY: Prof. Ahmed Mostafa El-Sabbagh

Oral & Maxillofacial Surgery
Alexandria University - Egypt
Classification Of Tumors Of
Oral & Maxillofacial Tissue
I. Benign Tumors
A. Odontogenic
B. Non-odontogenic
I. Tumors of Bone & Cartilage

II. Tumors of Soft Tissue
II. Malignant Tumors
A. Odontogenic B. Non-odontogenic
Oral Tumors Prof. Ahmed M. El-Sabbagh
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I. Benign Tumors
Odontogenic
Tumors
Epithelial Mesodermal Mixed
Tumors of
Odontogenic Epithelium
a. Ameloblastoma
b. Adenomatoid Odontogenic Tumor ( AOT )
c. Calcifying Epithelial Odontogenic Tumor (CEOT)
( Pindborg Tumor)
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Ameloblastoma
• It is typically slow-growing, locally invasive and runs a
benign course.
• Ameloblastoma occur in 3 different clinico-radiographic

situations requiring different therapeutic considerations
and having different prognoses:
– Conventional Solid/Multi cystic (86 % of all cases)
– Unicystic (13 % of all cases)
– Peripheral or Extra osseous (1 % of all cases)
Solid or Multicystic Ameloblastoma

Clinical Features
• Gender (Sex Predilection): Approximately equal.
• Age Predilection: Approximately equal frequency from the

third through the seventh decades.
• Location Predilection: 80 % in mandible; 70 % in posterior

regions.
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Radiographic Appearance: Radiolucent lesion which is

usually well-circumscribed; multilocular (soap-bubble, or
honeycombed appearance); occasionally an ameloblastoma
will be ill-defined with a ragged border.

Treatment
• Treatments have ranged from simple enucleation
and curettage to en bloc resection.
• Marginal resection is the most widely used method

of treatment with the least recurrences reported (up
to 15 %).
• Segmental resection for larger sized tumor that

exceeds the borders.
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Treatment
• Most surgeons advocate a margin of at least

1.0 - 2.0 cm beyond the radiographic limits of the
tumor as the tumor often extends beyond the
apparent radiologic/clinical margins.
Unicystic Ameloblastoma
Clinical Features
• Gender (Sex Predilection): Same as for the solid
( multicystic ) type.
• Age Predilection : The patients are younger than

those with the solid/multicystic form.
• 50% are diagnosed during the second decade of life.
• Location: 90 % occur in the mandible usually in

the posterior region.
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Radiographic Features
Radiographic Appearance: Typically appears as a RL around

the crown of an unerupted tooth (most commonly a
mandibular third molar).
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Histologic Features
Three histopathological variants :
1. Luminal: the tumor is confined to the luminal

surface of the cyst.
2. Intraluminal/plexiform: the tumor projects
from the cystic lining; sometimes resembles
the plexiform type of solid/multicystic
ameloblastoma.
3. Mural: the tumor infiltrates the fibrous cystic
wall.
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Treatment and Prognosis
• Enucleation of the cyst is probably adequate for the

luminal and intraluminal/plexiform types.
• Treatment of the mural type is controversial with

some surgeons believing that local resection is best.
• 10-20 % recurrence after enucleation and curettage

with all unicystic ameloblastoma.
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Adenomatoid Odontogenic Tumor

(AOT)
• Formerly called an adenoameloblastoma, a

somewhat deceptive term that should be discarded,
the AOT represents about 3-7 % of all odontogenic
tumors.
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AOT: Clinical Features
Gender Predilection: Females – male 2:1
• Age Predilection: The peak age is in the second

decade with a mean around 17 years.
• Location: Sixty-five percent of the AOTs occur in

the maxilla with 65 % occurring in the canine
region. Seventy-five percent of the cases are
associated with the crown of an unerupted tooth.
On rare occasion the lesion is extraosseous.
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AOT: Radiographic Picture

• AOTs typically appear as pericoronal radiolucency,
which may have radiopaque material (“snowflake”
calcifications) within the lucency.
• These lesions are frequently asymptomatic and

therefore are discovered upon routine radiographic
examination. AOTs may also block the eruption of
a permanent tooth and be discovered when
radiographs are taken to “search for” the unerupted
tooth.
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AOT: Treatment and Prognosis

• Enucleation is the treatment of choice as the tumor
is easily removed from the bone.
• AOTs seldom recur.
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Calcifying Epithelial Odontogenic Tumor

(CEOT; Pindborg Tumor)
• Pindborg tumor accounts for < 1 % of all

odontogenic tumors.
• It is clearly of odontogenic origin but its

histogenesis is uncertain.
• The tumor cells are said to resemble cells of the

stratum intermedium.
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Calcifying Epithelial Odontogenic Tumor

(CEOT; Pindborg Tumor)
• Gender Predilection: There is no reported sex
predilection.
• Age Predilection: Patients ages range from the

second to the tenth decades with a mean around 40
years.
• Location: 75 % of the CEOTs occur in the mandible

with most occurring in the posterior region. A rare
peripheral CEOT does occur.
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CEOT: Radiographic Features

• CEOTs occur as radiolucent lesions with/without
opaque foci.They are usually well-circumscribed
and may be unilocular or multilocular.
• Slightly over 50 % of the CEOTs are associated

with an unerupted tooth.
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CEOT
• Bony lesions most commonly present as painless,
slow-growing swellings.
• Peripheral lesions typically appear as non-specific
sessile gingival masses.
• Conservative local resection is the treatment of
choice as these lesions are typically less aggressive
than the ameloblastoma.
• With this treatment the recurrence rate is
approximately 15 % and the overall prognosis is
good.
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Mesenchymal Odontogenic Tumors
• Odontogenic Myxoma
• Odontogenic Fibroma
• Dentinoma
• Cementoma
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Odontogenic Myxoma
• Originates from dental papilla or follicular
mesenchyme
• Slow growing, aggressively invasive
• Multilocular, expansile; impacted teeth?
Radiology – radiolucency with septae of radio-opacity
Treatment – en bloc resection, curettage may be attempted if fibrotic

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Odontogenic Fibroma
• Originates from dental papilla or follicular
mesenchyme
• Slow growing, aggressively invasive
• Multilocular, expansile; impacted teeth?
• Types
• Central
• Peripheral
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Odontogenic Fibroma
Radiology – radiolucency
• Treatment – Surgical removal or curettage
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Cementoma
• True neoplasm of cementoblasts
• Cortex expanded without pain
• Involved tooth ankylosed.
• Radiology – apical mass; lucent or solid,
radiolucent halo with dense lesions
• Histology – radially oriented trabeculae from

cementum, rim of osteoblasts
• Treatment – complete excision and tooth sacrifice
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Mixed Odontogenic Tumors
• Ameloblastic Fibroma
• Ameloblastic Odontoma
• Odontome
• A. Compound Composite Odontome
• B. Complex Composite Odontome
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Odontoma
• The odontoma is the most common odontogenic tumor.
• It is not a true neoplasm but rather is a developmental

anomaly (hamartoma).
• Two types of Odontoma are recognized:
– Compound: this type of odontoma is composed of

multiple small tooth-like structures.
– Complex: this lesion is composed of a conglomerate mass

of enamel and dentin, which bears no anatomic
resemblance to a tooth.
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Odontoma:
Clinical Features
• Gender Predilection: Approximately equal.
• Age Predilection: Most cases are recognized

during the second decade of life with a mean of 14
years.
• Location: Somewhat more common in the maxilla.

The compound type is more often in the anterior
maxilla while the complex type occurs more often in
the posterior regions of either jaw.
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Odontoma
• Most odontomas are small and do not exceed the size of a
normal tooth in the region.
• However, large ones do occur, and these may cause

expansion of the jaw.
• Most odontomas are asymptomatic and as a result are

discovered upon routine radiographic examination.
• Odontomas may block the eruption of a permanent tooth

and in these cases are often discovered when “searching for”
the “missing” tooth radiographically.
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Odontoma:
Radiographic Features
• Early lesions are radiolucent with smooth, well-
defined contours.
• Later a well-defined radiopaque appearance

develops.
• The compound type shows apparent tooth shapes
• while the complex type appears as a uniform opaque

mass with no apparent tooth shapes present.
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Odontoma:
Histologic Features
• The compound odontoma is composed of enamel, dentin and

cementum arrange in recognizable tooth forms; some
enamel matrix may be retained in immature and hypo-
mineralized specimens.
• The complex odontoma is composed of enamel, dentin and

cementum but these tissues are arranged in a random
manner that bears no morphological resemblance to a tooth.
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Odontoma:
• Odontomas are treated by simple local excision and

the prognosis is excellent.
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B. Classification of Non-Odontogenic Tumors

I. Neoplasm of Bone tissue & Cartilage
Benign
Osteoma
Exostosis and Tori
Osteogenic Fibroma
Osteogenic Myxoma
Chondroma
Fibrous dysplasia and Ossifying Fibroma
Central giant cell lesions
Non-odontogenic Tumors Prof. Dr. Ahmed M. El-Sabbagh
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Benign
Osteoma
Central osteoma arises from the inner surface of the cortex and
consists of dense compact bone ( Ivory-like ) microscopically.
Peripheral ( periosteal ) osteoma arises from periosteum and is

composed of compact and cancellous bone (spongy) and may
have some foci of cartilage ( osteochondroma ).
Radiologically,
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Benign
Osteoma
Treatment
May be unnecessary until pain or interference with function takes place.
Surgical removal
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Benign
Osteogenic Fibroma
Osteogenic Myxoma
Chondroma
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Benign
Fibro-osseous lesions
(Non-neoplastic)
Cemento – osseous lesions
1. Periapical Cemento-osseous dysplasia
2. Florid Cemento-osseous dysplasia
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Periapical Cemento - osseous Dysplasia
Florid Cemento – osseous Dysplasia

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Benign
Fibro-osseous lesions
Fibrous dysplasia
It is a group of central lesions in which normal bone is replaced by
fibrous tissue.
1. Monostotic fibrous dysplasia
2. Polystotic fibrous dysplasia ( Albright`s syndrome )
3. Familial fibrous dysplasia ( Cherubism )
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1. Monostotic fibrous dysplasia
43

2. Polystotic fibrous dysplasia ( Albright`s syndrome )
Triad of:
1.Sexual precocity
Pituitary adenoma
Hyperthyroidism
2. Bone changes
3. Cafe` au lait
3. Familial fibrous dysplasia ( Cherubism )
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Neoplastic lesions
Ossifying Fibroma
A rare benign fibro-osseous neoplasm of the jaw
characterized by substitution of normal bone by fibrous
tissues and newly formed calcified products such as
bone, cementum or both.
Radiologically
It is well-demarcated lesion that differentiates from fibrous
dysplasia.
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Neoplastic lesions
Juvenile Ossifying Fibroma
A rare benign fibro-osseous tumor which involves maxilla

more than mandible. It usually occurs in children below 15
years of age.
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II. Tumors of the oral soft tissues
1. Epithelial 2. Connective Tissue

Benign Benign
Papilloma Fibroma
Papillomatosis Giant Cell Fibroma (fibrous Epulis )
Pigmented Cell Nevus Peripheral Ossifying Fibroma
Myxoma
Lipoma
Peripheral Giant cell Granuloma
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3. Vascular Tissue 5. Muscle tissue

Hemangioma
Benign
Lymphangioma Leiomyoma
Rhabdomyoma
4. Nerve Tissue
Benign
Neuroma
Neurofibroma
Neurolemmoma (
Non-odontogenic Schwannoma
Tumors ) Prof. Dr. Ahmed M. El-Sabbagh
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Epithelial
Benign
Papilloma ( Squamous Cell Papilloma )
Occurs at any age , any where in the oral cavity
Predisposing factors: Irritation, infection (Bacterial or viral )
Attached to the underlying tissues by narrow or broad pedicle
and projects in a cauliflower-like pattern.
Treatment
Excision, including the pedicle and base
49

Epithelial
Benign
Papillomatosis ( Inflammatory Papillary Hyperplasia )
The lesion arises as several tiny tumors scattered over the
mucosa as numerous papillary projections.
Common age between 30 – 40 years.
Possibly caused by chronic inflammation, chronic irritation,
poor oral hygiene and poor ill-fitting denture.
Treatment
Excision by surgery, electrosurgery or cryosurgery
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Epithelial
Benign
Pigmented Cell Nevus
It appears in the buccal mucosa, gingiva and tongue.
It contain melanin pigment and vary in color from light blue to black.
It may appear flat, sessile or papillary in form.
May exhibit malignant transformation ( malignant melanoma ).
Treatment : wide excision with a consideration to regional lymph

nodes
51

# Connective Tissue
Benign
Fibroma
The most common, often related to chronic irritation.
It is a slowly growing, deep or superficial , sessile or
pedunculated lesion, arise from the periosteum or
connective tissue of sub-mucosa.
Treatment : excision
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# Connective Tissue
Benign
Giant Cell Fibroma (Fibrous Epulis)
It occurs around the gingiva due to chronic irritation

of the periosteum or periodontal ligament.
Treatment
Complete excision, the involved tooth should be
considered.
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# Connective Tissue
Benign
Peripheral Ossifying Fibroma
Myxoma (Fibromyxoma)
Lipoma (Fibrolipoma)
Peripheral Giant Cell Granuloma
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Vascular Tissue
Hemangioma
It is a proliferation of blood vessels, considers as developmental
malformation rather than neoplasm.
Capillary or Cavernous
Peripheral or Central
Commonly present at birth or arise at an early age
Clinically, it is dark reddish – blue or purple, smooth soft surface and

compressible ( peripheral type ) or pulsating ( central ).
Radiologically, negative (peripheral) and honey–combed radiolocency

with fine fibrillar network.
55

Vascular Tissue
Hemangioma
Treatment
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Vascular Tissue
Hemangioma
Lymphangioma
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Oral Malignancy
Premalignant lesions
Leukoplakia
Erythroplakia
Errosive Lichen planus
Chronic ulcers or fissures (not respond to treatment for more

than 2 weeks)
Intraepithelial Carcinoma or Carcinoma in situ
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Oral Malignancy
Malignant
Osteosarcoma
Multiple myeloma
Ewing`s Sarcoma
1. Epithelial 2. Connective Tissue

Malignant Malignant
Squamous cell carcinoma Fibrosarcoma
Basal Cell Carcinoma Liposarcoma
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Oral Malignancy
4. Nerve Tissue 6. Lymphatic tissue
Malignant
Malignant Lymphoma :
Malignant Schwannoma
• 1. Hodgkin’s Disease
• 2. Non-Hodgkin’s Lymphoma
5. Muscle tissue
Malignant • Burkitt’s Lymphoma
Leiomosarcoma
Rhabdomyosarcoma
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Oral Malignancy
Squamous cell carcinoma
Basal Cell Carcinoma
61
1. Osteosarcoma Oral Malignancy

2. Fibrosarcoma
3. Multiple myeloma
4. Ewing`s Sarcoma
5. Kaposi Sarcoma
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1. Osteosarcoma Oral Malignancy

2. Fibrosarcoma
3. Multiple myeloma
4. Ewing`s Sarcoma
3
5. Kaposi Sarcoma
5
4
sunray pattern in a patient with Ewing`s sarcoma
63
Oral Malignancy
Staging of cancer
It is the system that describe how far the primary cancer has spread
anatomically and attempt to put the patients with similar prognosis
and treatment in the same staging group.
TNM Staging
T Tumor ( T0 – T 4 )
T1 < 2 cm in diameter T2 2 – 4 cm T3 > 4 cm
N Lymph Nodes ( N0 – N 4)
M Metastasis ( M0 - M1 )
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Oral Malignancy
Principles of Treatment
Surgical Radiotherapy Chemotherapy

Combination
Choice of treatment based on

1. Tumor factors that include subsite,
T stage, N stage, histologic characteristics,
endophytic vs. exophytic morphology, and proximity to bone.
2. Patient factors include the patient’s age, co-morbidities,

convenience, rehabilitation potential, and the patient’s wishes.
3. Resource factors include the availability of a well-trained

surgeon or radiotherapist with a dedicated interest in head and
neck cancer.
65
Oral Malignancy
Treatment
Surgery
A generous margining of normal tissue at least 1 – 2 cms
should be included with the lesion.
Types of Resection
1. Segmental
2. Marginal
3. Partial Resection without or ….
4. Total Resection with disarticulation
5. Composite
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Oral Malignancy
Treatment
Radiotherapy
Cells in stage of active growth are more susceptible to ionizing
radiation than adult tissue.
(Normal tissues as Bone marrow and Hair follicle)
Types of irradiation
1. External
2. Interstitial irradiation ( Brachytherapy )
67
Oral Malignancy
Treatment
Chemotherapy
Infusion of cytotoxic agents into the major blood vessels that
supplying the area with the tumor.
They are synthetic anti-metabolites having predilection for the
anaplastic cells.
Interfering with the metabolism of the rapidly growing and
dividing cancer cells, thus destroying the tumor.
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Oral Malignancy
Treatment
Chemotherapy
Drugs
1. Bleomycin
2. Cis – Platin
3. Methotrexate
4. Fluorouracil (5FU)
5. Carboplatin
6. Combination
69
Oral Malignancy
Role of the dentist in

prevention, detection and
treatment
Prevention
o Smoking
o Alcoholism
Detection
oEarly diagnosis and screening
oReferral
Treatment
o Dental care prior to Radiotherapy
o Post-treatment care
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Detection
o Early diagnosis and screening
o Referral
All patients with oral lesions of unknown origin and more than 2
weeks’ duration should immediately be referred to an Oral &
Maxillofacial Surgery specialist , these lesions include:
● White or red spots anywhere on the oral mucosa

● A mucosal defect or ulceration
● Swelling anywhere in the oral cavity
● Loosening of one or more teeth for no known reason, not
connected with periodontal disease
● Pain
● Difficulty or pain in swallowing
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Detection
o Early diagnosis and screening
o Referral
cont….
● Speech difficulties
● Reduced mobility of the tongue
● Numbness of the tongue, teeth, or lips
● Bleeding of unknown origin
● Neck swelling
● Fetor
● Altered dental occlusion.
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5/25/2021

ORAL & MAXILLOFACIAL

BY: Prof. Ahmed Mostafa El-Sabbagh

I. Tumors of Bone & Cartilage

II. Malignant Tumors

Epithelial Mesodermal Mixed

Oral Tumors Prof. Ahmed M. El-Sabbagh

b. Adenomatoid Odontogenic Tumor ( AOT )

c. Calcifying Epithelial Odontogenic Tumor (CEOT)

Oral Tumors Prof. Ahmed M. El-Sabbagh

• Ameloblastoma occur in 3 different clinico-radiographic

– Conventional Solid/Multi cystic (86 % of all cases)

– Unicystic (13 % of all cases)

– Peripheral or Extra osseous (1 % of all cases)

Oral Tumors Prof. Ahmed M. El-Sabbagh

Solid or Multicystic Ameloblastoma

• Gender (Sex Predilection): Approximately equal.

• Age Predilection: Approximately equal frequency from the

• Location Predilection: 80 % in mandible; 70 % in posterior

Oral Tumors Prof. Ahmed M. El-Sabbagh

Solid or Multicystic Ameloblastoma

Radiographic Appearance: Radiolucent lesion which is

Oral Tumors Prof. Ahmed M. El-Sabbagh

Solid or Multicystic Ameloblastoma

• Marginal resection is the most widely used method

• Segmental resection for larger sized tumor that

Oral Tumors Prof. Ahmed M. El-Sabbagh

Solid or Multicystic Ameloblastoma

• Most surgeons advocate a margin of at least

Oral Tumors Prof. Ahmed M. El-Sabbagh

• Gender (Sex Predilection): Same as for the solid

• Age Predilection : The patients are younger than

• 50% are diagnosed during the second decade of life.

• Location: 90 % occur in the mandible usually in

Radiographic Appearance: Typically appears as a RL around

Oral Tumors Prof. Ahmed M. El-Sabbagh

Oral Tumors Prof. Ahmed M. El-Sabbagh

Three histopathological variants :

1. Luminal: the tumor is confined to the luminal

Treatment and Prognosis

• Enucleation of the cyst is probably adequate for the

• Treatment of the mural type is controversial with

• 10-20 % recurrence after enucleation and curettage

Adenomatoid Odontogenic Tumor

• Formerly called an adenoameloblastoma, a

Oral Tumors Prof. Ahmed M. El-Sabbagh

AOT: Clinical Features

Gender Predilection: Females – male 2:1

• Age Predilection: The peak age is in the second

• Location: Sixty-five percent of the AOTs occur in

AOT: Radiographic Picture

• These lesions are frequently asymptomatic and

AOT: Treatment and Prognosis

• AOTs seldom recur.

Oral Tumors Prof. Ahmed M. El-Sabbagh

Calcifying Epithelial Odontogenic Tumor

• Pindborg tumor accounts for < 1 % of all

• It is clearly of odontogenic origin but its

• The tumor cells are said to resemble cells of the

Oral Tumors Prof. Ahmed M. El-Sabbagh

Calcifying Epithelial Odontogenic Tumor

• Age Predilection: Patients ages range from the

• Location: 75 % of the CEOTs occur in the mandible