Odontogenic tumors and

related jaw lesions

‫ارجعي للصور في الكتاب‬ 
 Neoplasms & other tumors may be
odontogenic or non-odontogenic ,it's
not obvious whether swelling is
odontogenic or not CLINICALLY in
many instances origin & nature of
lesion may be unclear until biopsy
 Odontogenic tumors are the most
common neoplasms of the jaws.
# The most common
 There are many types , and the majority are rare : cause : 1st is cyst , 2nd is
odontogenic odontogenic tumors
tumors according
to tissue of origin # The most common
type of tumor is
odontogenic ( due to
predominant dental
odontogenic odontogenic tissue )
mixed
epithelium mesanchyme
#the most common
odontogenic tumor is
ameloblastoma
dental lamina -1 dental follicle -1
# add to classification :
reduced ename -2 dental papilla-2 hamartoma & dysplasia
epithelium pulp -3
rest of serres -3 # tumors are also
PDL -4
rest of malessez -4 classified into benign
and malignant

 The dental follicle gives rise to the inner half of the lamina dura of the socket, so
lesions of bone can be odontogenic too.

A) Benign epithelial tumors :

AMELOBLASTOMA :
 Several types (conventional , desmoplastic , metastasising , unicystic ) , all are:
1- BENGIN EPITHLIAL NEOPLASM #but locally aggressive
2- Epithelium contain ameloblast like cells and stellate reticulum like cells 
odontogenic nature
 1) Conventional ameloblastoma :
 Also called solid , multicystic ameloblastoma
 This is the most common type and the most common neoplasm in the jaws
 AGE : 30 – 50 years , rarely in children & old people
 SITES : 1- 80% in mandible 2- 75% in post molar region 3- involve ramus
Ameloblastoma should be included in the differential diagnosis for any
radiolucency in the posterior alveolus and lower ramus of the mandible
# in post molar region
 Symptomless until swelling is noticed ( can grow to enormous size and expansion
may be both lingual and buccal )
 Radiographically :(#well defined multilocularity radiolucency )
- ameloblastomas typically form rounded, cyst-like, radiolucent areas with well-
defined margins.
- The smallest appear unilocular (Ameloblastomas with a single bony cavity
simulate many types of cyst and tumour radiographically)
- larger ameloblastomas may :
1-comprise a few large clustered cysts (‘soap-bubble’ multilocularity)
2-numerous small cysts a few millimeters across (‘honeycomb’ multilocular
pattern) ‫هاي الي حكاها الدكتور‬
3-a mixture of patterns

 Other multilocular lesions that may mimic ameloblastoma radiologically include(

question in exam what differential diagnosis of well defined radiolucency multilocular
in post mandible?):
1- odontogenic keratocyst
2- giant-cell
3- granuloma
4- odontogenic myxoma.

 Pathology :
- The cause of ameloblastoma is not known , although most have recently been
shown to #gene expression during teeth formation :
1- V600E mutation in the BRAF (activate MAP kinase  cell division &
proliferation )
2- Mutation SMO gene ( less frequent and activate hedgehog pathway )
# according to dr : 3 examples of abnormal gene expression ( heat shock
protein , matrix metalloproteinase , nitric oxide synthetase)
 Components are a mixture of solid neoplasm and cysts , and either component may
predominate:
- The solid areas comprise fibrous tissue containing :
1- islands or interconnected strands
2- sheets of epithelium with a peripheral layer of palisaded preameloblast-like
cells that
3- At least focally, have nuclei at the opposite pole from the basement membrane
(reversed polarity, a feature seen in ameloblasts just before secretion of enamel
matrix).
‫ هم اشكال بحملوا‬, ‫ يعني كل الي حيتم ذكرهم بعد‬ameloblastomas ‫ ل‬major pictures ‫ هدول هم الشكل األساسي‬#
‫ تمام ؟‬, ‫هاي الصفات مع صفات خاصة بكل شكل‬
  There are two histological patterns(These two histological patterns do not reflect
behaviour and are of no significance.) :‫الدكتور بدو بشكل سطحي عنهم‬
Follicular pattern plexiform pattern
the most common and most readily the epithelium forms strands and
recognizable type interconnected sheets surrounding islands of
connective tissue and the ameloblast cells
are often less prominent

there are islands with an outer layer( at Mixed , multiple of ameloblast like cell and
periphery ) of tall, columnar, ameloblast-like dark stain around ( which mean
cells with reversed polarity surrounding a core hyperchromatism that resembles a feature of
of loosely arranged polyhedral or angular cells, malignancy but here we don’t deal with
resembling stellate reticulum malignancy )
Cyst formation is common, and there are usually several large cysts as large as a few
centimeters in diameter. Even apparently solid ameloblastomas have numerous microscopic
cysts
the cysts develop in the stellate reticulum in the plexiform pattern the cysts are caused
inside the epithelial islands by degeneration of the connective tissu stroma

Other less common histological variants include:‫شوفي صور الكتاب‬

1- the acanthomatous type, in which prickle cells replace the stellate reticulum
( squamous metaplasia) and sometimes form keratin
2- The rare basal cell variant and consists of more darkly staining basal cells with
little evidence of ameloblasts. (#could be mistaken as basal cell carcinoma but
this is benign )
3- In the granular cell pattern the epithelium in the central areas of the tumour
islands (ameloblast & stellate like cells)
degenerates into sheets of large eosinophilic
(pink ) granular cells
 A much more important histological feature is that
islands of ameloblastoma can extend into the
medullary spaces of surrounding bone(The
islands of ameloblastoma may extend into bone
marrow spaces for several millimeters beyond the
edge of the main bony cavity):
 - This behavior is not expected in a benign neoplasm because it resembles
infiltration by a malignant neoplasm.
- Only a minority of ameloblastomas have this feature, but it determines the
necessary treatment( excised with a margin rather than curetted )
- If left behind after surgery, they will seed recurrence

 Behavior:
1- Ameloblastomas enlarge the jaw slowly
2- displacing and often resorbing tooth roots,
3- perforating the cortical bone
4- if large, expanding into soft tissue constrained only by the periosteum
5- Although benign, they can be difficult to eradicate.
6- Maxillary ameloblastomas are particularly dangerous, partly because the bones
(spongy bone ) are considerably thinner than those of the mandible and present
weak barriers to spread ( ameloblastoma here local aggressive ):
- Maxillary ameloblastomas tend to form in the posterior region and to grow
backwards and upwards to invade the sinonasal passages, pterygomaxillary
fossa, orbit and eventually the cranium and brainThey are thus occasionally
lethal despite being benign.
 Treatment ;
1- The diagnosis must be confirmed by biopsy:
- The permeation of adjacent medullary bone previously discussed cannot usually
be detected preoperatively but if seen in a biopsy indicates a need for more
aggressive treatment
2- In recent years there has been a tendency to try to treat ameloblastoma
conservatively to avoid the morbidity of large surgical excisions, especially in
adolescents
- Case selection for conservative treatment is paramount
Small mandibular lesions can sometimes be enucleated, the cavity curetted and
the lower border and much of the cortex preserved. Such treatment must be
undertaken in the expectation that there may be recurrence
- Advocates of conservative treatment point out that, for the few recurring lesions,
resection will be required but that the majority will benefit.
- Conversely, recurrence carries risks if ameloblastoma escapes into soft tissue or
extends posteriorly into the infratemporal fossa as these are potentially fatal
complications.
- Conservative management remains controversial
3- Marsupialization is ineffective.
4- The standard of care for ameloblastoma therefore remains wide surgical excision:
- removing 10 mm of apparently normal bone around the margin to ensure that
any extension into the medullary bone is removed.
- Complete excision of a large ameloblastoma may therefore require partial
resection of the jaw, often with the condyle and bone grafting.
- Smaller lesions may be excised, leaving the lower border of the jaw intact and
extending the resection subperiosteally.
- Bony repair then causes much of the jaw to re-form.
- These more extensive operations normally guarantee cure.
5- Regular radiographic follow-up is essential, and recurrence may not appear for
several years.
6- Spread of ameloblastomas into the soft tissues is difficult to manage.
# treatment of ameloblastoma in general should be Wide excision with safety margin(1-
2mm) of bone to assure the removal of any remnant and avoid recurrence then bone
grafting
‫ بس‬enucleation ‫ فبروح بعملها‬unicystic and others ‫ وهني‬cyst ‫ بتبين انها‬ameloblastoma ‫مرات بعض‬
recurrence ‫ فبصير‬tumor ‫هي‬
‫ هاد‬enucleation ‫ تمام ممكن اعملها‬unicystic ameloblastoma ‫ هس في حاالت بتكون‬, ‫ركزي شو بدي احكي‬
excision ‫ خلص نعمل‬mistaken of mural type ‫ بس عشان نتفادى‬theoretically applicable ‫الموضوع بس‬

2) Desmoplastic ameloblastoma: ‫ما حكى عنه الدكتور‬

 The desmoplastic ameloblastoma is a distinctive variant of conventional
ameloblastoma
 These ameloblastomas arise with equal frequency in both jaws and often present
in the anterior regions
 fine honeycomb radiolucency resembling a fibro-osseous lesion.
 The islands of epithelium are sparse, do not show obvious ameloblasts at
periphery ( may found focally ) and the lesion is dominated by densely
collagenous (‘desmoplastic’) tissue
 Behaviour and treatment are the same as for the conventional ameloblastoma

3) Metastasizing ameloblastoma:
 This is a very rare curiosity, a histologically typical ameloblastoma
 although apparently benign, gives rise to distant metastases ( false metastatic )
 The metastases are usually in the lung.
 Some cases appear to have resulted;
- from aspiration implantation at surgery
- others follow surgical disruption at the primary site or repeated incomplete
removal, suggesting that they result from surgical implantation into the circulation
and are not truly malignant.
 Both the primary tumour and the ‘metastases’ look histologically identical to
conventional benign ameloblastomas, and metastasis cannot be predicted.
 Because the ‘metastases’ are really benign, local excision of the secondary
deposit(s) should be curative

4) Unicystic ameloblastoma:
 Cyst like lesion
 The unicystic ameloblastoma is an ameloblastoma that has a single cyst cavity
 Such ameloblastomas present at a younger age than conventional
ameloblastoma, in the second and third decades and may account for 10% of all
ameloblastomas.
 Many present in a true dentigerous relationship to an unerupted third molar
 The remainder may simulate any odontogenic cyst type depending on location,
but often suggestive features of root resorption, cortical perforation or large size
may give clues
 In theory, the single cyst structure should mean that these ameloblastomas could
be treated by simple enucleation with a low risk of recurrence:
Unfortunately, making a preoperative diagnosis of unicystic ameloblastoma is
difficult, and there remains controversy about exactly what constitutes a unicystic
structure.
 An ameloblastoma with only one bony cavity radiographically can be a
conventional solid or multicystic ameloblastoma:
- This will not become apparent until the lesion has been opened or examined
histologically and the multiple cysts seen.
- It is therefore important to bear in mind the various configurations of an
ameloblastoma that could present radiologically as a single cyst

- An ameloblastoma where the epithelium is limited to a single layer lining the

lumen is termed a luminal type of Unicystic ameloblastoma
# lining of unicystic is not stratified squamous epithelium but it is ameloblast like
cells with reverse polarity sometimes thick and sometimes flattened!!
- If there are papillary projections into the cyst lumen, but no islands within the wall,
this is termed an intraluminal unicystic or plexiform unicystic ameloblastoma.
In these types, ameloblastoma epithelium is limited to the lumen or inner cyst
wall and the lesion may be enucleated.
- The danger of making this diagnosis(enucleation) on radiological grounds alone
is shown by the third diagram ,why?
Here a conventional ameloblastoma has developed one very large dominant
cyst. However, there is a focus of solid/ multicystic ameloblastoma in one area of
the wall that might penetrate its full thickness or even into surrounding bone. This
has been called the mural type of unicystic ameloblastoma, but in reality it is a
conventional ameloblastoma that could easily be misdiagnosed as a unicystic
one
# mural type ‫ خبيثثثثث‬ misdiagnosed
- The histological appearances of the true unicystic ameloblastomas are similar
and are shown in Fig. 11.14. The tumour cells forming the cyst wall are often
flattened and easily mistaken for those of a non-neoplastic cyst
 It is often said that unicystic ameloblastomas may be enucleated without
recurrence #‫غير قابل للتطبيق العملي الدكتور بحكي بس بحالة وحدة‬
- This may be true, but the difficulty is making the diagnosis preoperatively.
- The diagnosis can only be made confidently after removal because it requires
detailed histological examination of the whole wall.
lesion‫بس احنا منوخذ يا دوب جزء من ال‬, ‫ اذا ال بدنا نعيد‬, ‫ هون بتأكد شغلي صح وال ال‬#
 A single biopsy of a stretched cyst lining is insufficient for diagnosis
- In many cases unicystic ameloblastomas are not recognised before surgery and
are enucleated on the assumption that they are dentigerous or other types of
cyst.
 - After diagnosis, it is usually sufficient to monitor radiographically, and most will
heal without problems.  Any recurrence should be treated as conventional
ameloblastoma.
 There is insufficient evidence to give a recurrence rate for unicystic ameloblastomas,
but it is clear that they do have a low rate of recurrence, approximately 10%.
ADENOMATOID ODONTOGENIC TUMOUR
 Adenomatoid odontogenic tumour is uncommon
 completely benign and a hamartoma not a
neoplasm.
 Its name comes from its histological
resemblance to a gland because it contains duct-
like structures.
 Adenomatoid odontogenic tumours present in
late adolescence or young adulthood(<20years)
 more common in females than males
 Most develop in the anterior maxilla
 form a very slow-growing swelling resembling a
dentigerous or radicular cyst or are chance findings in
the follicle of an extracted unerupted tooth.
 When in the wall of a cyst, a subtle radiographic clue is ‫دكتور حكى هاي هون‬
fine speckled mineralisation around the wall. dentigerous ‫بتذكرنا ب‬
 Pathology :
- A well-defined capsule encloses sheets
- whorls and arcading strands of epithelium, among which
are microcysts, resembling glandular ducts cut in cross-
section and lined by columnar cells similar to ameloblasts
feature of island & strand‫ فبشوف نفس ال‬odontogenic ‫ عشانها‬#
- These microcysts may contain homogeneous eosinophilic
material
- Fragments of amorphous or crystalline calcification may
also be seen among the sheets of epithelial cells.
 Ttt;These lesions shell out readily, enucleation is curative and
recurrence is almost unknown

CALCIFYING EPITHELIAL ODONTOGENIC TUMOUR

 This rare tumour,

 also known as a Pindborg tumour
 is important because it can be mistaken for a carcinoma
microscopically
 It arises in middle-aged and elderly adults after the age of 40
years
 usually in the posterior body of the mandible, which is twice as
frequently involved as the maxilla
  Presentation is either with swelling or as an
asymptomatic chance radiographic finding
 There is a well-defined radiolucent area initially,
sometimes corticated, that may develop increasing
internal radiopacity when it mineralizesMost
present as a mixed radiolucency.
# ill defined radiolucency with multiple radiopacities ,
with maturation become more large and radiopacity

 Pathology :

- This unusual tumour resembles a carcinoma but is benign

- It comprises sheets or strands of epithelial cells in fibrous tissue(typical feature of
odontogenic epithelium)
- The epithelial cells have a prickle cell morphology with intercellular bridges and
appear very eosinophilic.
# have striking features( nuclear polymorphism & chromatism )
- Their nuclei, in a proportion of cases, show gross variation in nuclear size, including
giant nuclei, and hyperchromatism,, mimicking malignancy
- At the periphery these cells can extend into adjacent medullary spaces, appearing to
be infiltrative
- Despite these alarming features, mitoses are very rare.
# calcification of hyaline material
 The diagnosis is aided by areas of amyloid deposited in the connective tissue:
- This amyloid material is pink, homogeneous and often mineralises, producing
rounded densely mineralised masses with concentric ‘Liesegang’ rings.
- The amyloid may be sparse or a dominant feature and can be identified with Congo
Red staining
- It is a precipitated secretory product of the epithelial cells, a defective truncated
protein called odontogenic ameloblast-associated protein (ODAM) that is normally
found in tooth germs in small quantities, confirming the odontogenic nature of this
tumour.
- It is the mineralisation of the amyloid that produces the dense radiopacities seen on
radiographs
 Because the mineralisation is dystrophic and not actively caused by the tumour
cells, the amount of mineralisation is very variable. Some tumours remain
completely radiolucent, most are mixed radiolucencies and some become densely
radiopaque.

 Calcifying epithelial odontogenic tumours extend

into peripheral bone medullary spaces like
ameloblastomas(ill defined lesion )  ttt:
complete excision of the tumour with a border of
normal bone should be curative, but recurrence
will follow incomplete excision.

CALCIFYING (Ghost cell) ODONTOGENIC CYST

 The calcifying odontogenic cyst is rare
 has been considered both an odontogenic tumour and an odontogenic cyst, but it is
currently classified with cysts as it rarely if ever recurs on removal.
  it is easily confused with odontogenic tumours
radiographically and histologically .
# this is neoplastic make itself cyst
# unilocular
#in maxilla or mandible in any area anterior to 1st premolar
#striking feature is ghost cell
# have island & stands of epithelium at lining of cyst with thick
epithelium
#may have abnormal keratinzation  large swollen eosinophilic cells , paller in color
( ghost cells )
# 10% of this lesion related to hamartoma
# treatment is enucleation

SQUAMOUS ODONTOGENIC TUMOUR

 rare tumour mainly affects young adults
 involves the alveolar process of either jaw, close to
the roots of teeth(periosteum ).
 Radiographically, the squamous odontogenic
tumour can mimic severe bone loss from
periodontitis if high in the alveolus or produce a
unilocular or multilocular cyst-like cavity if more
deeply placed.
scaling ‫ما بخف مع العالج ع انها التهاب لثة من نظافة و‬#
 Histologically(have different material ):
- it is composed of rounded islands of squamous epithelium with flattened peripheral
cells (not elongate ameloblasts) in a fibrous stroma
- No keratin should be present in the epithelium, which may also contain laminated
calcifications or globular eosinophilic structures(and keratin ???)
keratin or Para keratin ‫منشوف فيه‬#
- Unfortunately, the histology is not very specific, and squamous odontogenic tumour
is prone to overdiagnosis ,why? because there are histological mimics found next to
cyst and in inflammatory lesion
 Ttt:This tumour is benign and removed by curettage and extraction of any teeth
involved

B) Benign epithelial & mesenchymal tumors :

#here we see island & strand with abnormality in underlyning connective tissue
AMELOBLASTIC FIBROMA
 Rare
 Only tumor is mixed
 Called else ameloblastic fibro-odontoma
 More common in children (7-20 years)  very
destructive in growing facial bones
 Post mandible
  They form multi or unilocular radiolucencies that expand the jaw slowly and displace
teeth or prevent their eruption.

 Pathology :
- Ameloblastic fibroma comprises interconnected strands and small islands of
odontogenic epithelium in a cellular mesenchymal tissue resembling dental papilla
- Unusually, it is considered that both epithelium and connective tissue are neoplastic.
- The epithelial strands and islands are composed of cuboidal cells where the strands
are thin, but they broaden out and have peripheral buds resembling cap stage tooth
germs, with central stellate reticulum and peripheral elongate ameloblast-like cells
#this island & strand of epi make invagination into loose CT  mushroomed like
extension with intact basement membrane
# connective tissue are loose , highly cellular( high number of fibroblast ) and
fibromyoxid (high amount of collagen fiber & myxoid material )
# may have calcified tissues (usually calcified dental tissue )  ameloblastic fibro
odontoma
# in rare cases may have malignant variant ameloblastic fibrosarcoma
 Ameloblastic fibroma is benign and separates readily from the surrounding bone
Treatment (just enucleation , in some cases due to invagination do conservative
resection ) :
- conservative resection is effective but, if incomplete, recurrence follows
- In the maxilla, an excision margin of bone is often taken because the bones are thin
and confident excision is more difficult than in the mandible.
- There is a potential for malignant change following repeated incomplete removal.
(have malignant variants)

C) Benign mesenchymal tumors:

 These tumours do not contain any true mesenchyme, that is an embryonic tissue,
but rather are tumours of its derivatives: the fibroblasts and osteoblasts of dental
follicle, pulp, periodontal ligament and cementum.

ODONTOGENIC MYXOMA ‫صور الكتاب‬

 The odontogenic myxoma is a benign neoplasm
  the third commonest odontogenic tumour after odontomes and ameloblastoma
 10-30 years
 produce asymptomatic swellings of the jaws
 usually posteriorly in the mandible
 Myxomas cause ill defined radiolucent areas with
scalloped indistinct margins or a soap-bubble or
honeycomb appearance multilocular
 They displace teeth after destroying their
supporting bone and are more extensive than is
appreciated radiographically.
 Expansion is usually prominent (invading
surrounding bone )
 Pathology :
This is the odontogenic tumour that most deserves the
name of a mesenchymal tumour because its
appearance is exactly that of the mesenchyme of the
developing dental follicle and papilla:
- The bulk of the myxoma is loose myxoid (mucous)
ground substance, containing dispersed spindle-
shaped or angular fibroblasts with long, fine,
anastomosing processes
- The ground substances is hyaluronic acid and
chondroitin sulphate, as in normal tissue, but
excessive in amount
- A few collagen fibres may also form
- there may be small, scattered epithelial rest
 The margins of the tumour are ill-defined, and peripheral bone is progressively
resorbed.
 Myxomas are benign, but grow by secretion of the ground substance by the
fibroblasts rather than cell proliferation
 The gelatinous consistency allows the tumour tissue to permeate widely between
medullary bone trabeculae without a clear marginmaking removal very difficult.
 Have malignant variant  odontogenic myosarcoma
 Ttt: Excision with a margin of normal bone and removal of associated teeth is
required but, in spite of vigorous treatment, some tumours recur.

Normal dental follicle: ‫ما حكى عنه‬

- The normal dental follicle resembles odontogenic myxoma histologically and sometimes
shows enlargement, often on impacted unerupted teeth (‘hyperplastic follicle’).
-If removed on suspicion of a dentigerous cyst or other odontogenic tumour, it can be
mistaken for myxoma if the pathologists not aware of the clinical presentation.
-The shape and location are diagnostic and should prevent misdiagnosis and
overtreatment

ODONTOGENIC FIBROMA
 The odontogenic fibroma is a benign neoplasm of fibrous tissue
 Clinically, odontogenic fibroma arises across a wide age range
#Pain , may be biting by pt
 more frequently affects the mandible
 forms a slow-growing asymptomatic mass that may
eventually expand the jaw.
 appears as a sharply defined, rounded radiolucent area in a
tooth-bearing region (periosteum ).
 Pathology :
- Odontogenic fibromas consist of spindle-shaped fibroblasts
and abundant bundles of whorled collagen fibres
- Some lesions contain (traces ) rests of odontogenic
epithelium, apparently by chance.  These islands are not
required for diagnosis; they just reflect the odontogenic
origin.
 Ttt: Odontogenic fibromas are benign, enucleate (shield out ) easily from
surrounding bone and do not recur.
 Granular cell odontogenic tumour odd and very rare tumour shares many features
with odontogenic fibroma

Tumors and dysplasia of cementum

1) CEMENTOBLASTOMA:
 Cementoblastoma is a benign neoplasm of cementoblasts that
forms a mass of cementum on a tooth root.
 Some authorities, considering cementoblasts to be no more
than osteoblasts, prefer to classify this lesion as an
osteoblastoma( a neoplasm of osteoblasts normally found in
long bones and vertebral column)
BUT Cementoblasts are unequivocally odontogenic, and
the presentation and behaviour of cementoblastoma is
distinct from osteoblastoma, even though the histopathology
is almost identical.

 Clinically, cementoblastomas mainly affect young adults,

particularly males, typically younger than 25 years
 They are slow growing, sometimes painful and expand the
jaw or are chance radiographic findings.
 The lower first permanent molar is the tooth that is
almost always affected.
 Radiographically, there is a radiopaque mass, with a
thin radiolucent margin or rim , attached to the root
of a tooth
 The mass may be rounded or irregular in shape and
mottled in texture.
 Resorption of related roots is common, but the tooth
remains vital
 Pathology :
-start radiolucent  mineralization with long standing
- The mass consists of cementum fused to a resorbed tooth root
- The cementum often has many reversal lines, resembling Paget’s disease centrally
and a radiating structure of unmineralised matrix at the periphery
#Have mainly bone cells (osteoclast & osteoblast like material ) in center while
unmineralized with ct capsule at periphery
#rarely infected
- The cementoblasts are larger and more darkly stained than normal osteoblasts, and
often several cell layers lie on the surface of the matrix.
- Outside the actively growing rim is a thin fibrous capsule
 Ttt(excision & extraction ): Cementoblastomas are benign and treated by extraction
of the tooth and enucleation and curettage of the bony cavity.
 Recurrence is unusual, but incomplete removal leads to regrowth

 ‘Cementomas’: ‫ما حكى عنهم الدكتور‬

- Some sources refer to a group of lesions called cementomas.

- This historic designation used to be applied to all localized cementum lesions, but it
is no longer used because the causes have become better characterised and
require different treatments. Current terms for ‘cementomas’ are shown in Box
11.11.

2) CEMENTO-OSSIFYING FIBROMA:
 Is fibroosseous odontogenic lesion(lesions can be
neoplasms, dysplasias, odontogenic or non-
odontogenic lesions )
 The name cemento-osseous fibroma has recently
been reinstated for this lesion to emphasise its
odontogenic nature
- In the past is has been called a type of ossifying
fibroma, but the presentation and restriction to the
jaws confirm the odontogenic origin
 These lesions are presumed to originate from periodontal ligament or lamina dura
bone of the socket, part of which is odontogenic in origin
 The name cemento-ossifying fibroma also has the advantage of avoiding confusion
with the ossifying fibromas of the facial skeleton
 Uncommon
 arise exclusively in the jaws and typically cause a painless swelling in the
mandibular premolar or molar region(post mandible nearby ).
 Patients are usually between 20 and 40 years of age on diagnosis, but the range is
wide.
 Females are affected several times more frequently than male
 Like other fibro-osseous lesions, the cemento-ossifying fibroma starts as a small
radiolucency (cellular and fibrous tissue at begin with well defined cortical border ,
after dystrophic and dense calcification become radio-opaque ) and expands slowly
Calcification develops centrally while the lesion enlarges.
Most become densely calcified given time and then appear largely radiopaque
At all stages, the lesion has a sharply defined margin, often with a thin radiolucent
rim surrounded by a narrow zone of cortication.
 This circumscription is a key diagnostic feature and can be detected both
radiographically and histologically .
 Roots of related teeth can be fused to the lesion or displaced.
 Microscopy :

- Being a fibro-osseous lesion, it has histological similarity to fibrous dysplasia and

cemento-osseous dysplasias, and it cannot always be differentiated from them on
the basis of its microscopic appearances alone
One key distinguishing feature is the well-demarcated periphery, sometimes with a
fibrous capsule between the lesion and surrounding bone.(Clinical and radiographic
findings are required for definitive diagnosis)
- The histological appearances vary widely and range from predominantly fibrous
tumours to densely calcified masses depending on size and duration.
- Both trabeculae of woven bone with osteoblastic rimming and dense rounded
islands of acellular bone are seen, usually a mixture of both . Foci of bone gradually
grow, fuse and, ultimately, form a dense mass
#have cementum like material (dystrophic calcification )
 Management (enucleation due to circumstances or cortication large one need jaw
resection &grafting ) :
- Cemento-ossifying fibromas can
usually be readily enucleated,
separating from bone in the plane of
their capsule
- Occasionally, large tumours that have
distorted the jaw require local resection
and bone grafting.
- Recurrence is rare.
- Densely mineralised lesions are
relatively avascular and can become a
focus(center ) for chronic osteomyelitis
following dental extraction.

hamartoma & dysplasia ‫ هون حيبلش يشرح الدكتور عن‬#

Non - neoplastic odontogenic lesions:

1- CEMENTO-OSSEOUS DYSPLASIAS:
 These poorly understood diseases are non-neoplastic disturbances of growth and
remodeling of bone and cementum.
 They are, by far, the most common fibro-osseous diseases of the jaws and are
common enough to be seen from time to time in
general dental practice.
 It is unclear whether the various
subtypes(periapical , florid ,focal ) are all truly
related:
- They have similar histological and radiological
features and differ mainly in their extent and radiographic appearances.
 All types have a strong predilection for females, accounting for more than 90% of
cases, particularly those of African descent
  Patients tend to be seen between 30 and 50 years, but
probably after many years of asymptomatic disease
 Previously these diseases have been known as osseous
dysplasias:
- However, because they affect only the alveolar bone
and appear odontogenic, the name cemento-osseous
dysplasia has been reinstated.
- This avoids confusion with several inherited osseous dysplasia syndromes of long
bone
Periapical cemental Florid cemento- Focal cemento-osseous
dysplasia osseous dysplasia dysplasia
 In the periapical form,  Is type of periapical  This term is given to
several adjacent teeth  In the florid form, changes similar to florid
are affected, usually multiple teeth are osseous dysplasia but
lower incisors. affected in more than forming a single lesion on
 The condition is one quadrant. The one tooth.
asymptomatic and often affected areas are  The lesion resembles a
a chance radiographic frequently symmetrically cemento-osseous
finding of rounded distributed and may fibroma radiographically,
radiolucent areas related involve all teeth in all but shows the maturation
to the apices of the teeth four quadrants sequence typical of this
These simulate  although the mandibular group of lesions.
periapical granulomas or teeth are more  Lesions are usually in the
cyst but the related teeth commonly and more posterior mandible
are vital severely affected in most
 During a period of years cases
the separate lesions  Individual lesions
enlarge, may fuse and develop around the root
develop internal apices exactly as in the
calcification. periapical form but
 Mineralisation starts become larger and
centrally and gives each occasionally expand the
lesion a target-like jaw
appearance  The target-like
radiographically.  appearance with central
Eventually the lesions sclerosis resembling
cease to enlarge, rarely cementum on the root
exceeding 8–10 mm, and apex, surrounded by a
become densely radiolucent trim with a
radiopaque further outer zone of
 All stages of sclerosis in the
development may be surrounding bone is
seen at the same time in characteristic.
different lesions in the  Eventually dense
same patient. radiopaque, somewhat
 The teeth remain vital irregular masses of
throughout sclerotic bone without a
radiolucent border
develop, producing a
radiographic appearance
 similar to chronic
osteomyelitis .
 As in the periapical
form, tooth vitality is not
affected.
 The florid form becomes
the most sclerotic and is
particularly liable to
become infected after
extraction
 Some patients also
develop solitary bone
cysts in association with
the lesions

 Microscopy :
- It must be emphasised that biopsy should not be performed for diagnosis.
- The diagnosis should be made radiographically, and biopsy avoided because it risks
introducing infection into the sclerotic bone
- All types are fibro-osseous in nature with cellular fibrous tissue containing woven
bone trabeculae and islands of dense cementum-like bone.
- Progressive calcification leads to the formation of a solid, bony mass with prominent
resting and reversal lines
 Management : ‫ما نتدخل هون‬
- Osteomyelitis starting in these lesions following extraction must be avoided because
the widespread sclerosis of the late stages makes the infection difficult to treat.
- Wide excision may then be required to allow resolution.
- Treatment is otherwise not indicated except, rarely, for cosmetic reasons if there is
expansion or if solitary bone cysts develop.‫يعني بس سببين بسمحولي اتدخل‬
Familial gigantiform cementoma: ‫ما حكى عنه‬
- This extremely rare autosomal dominant condition causes extremely large and
disfiguring lesions, usually in all quadrants and presenting in childhood.
- In at least some cases, the origin appears to be at the tooth roots.
- Lesions grow progressively and recur after incomplete removal, so that it is unclear
whether the condition is one of multiple cemento-ossifying fibromas or a type of
cemento-osseous dysplasia.
- The term gigantiform cementoma must not be
used for florid cemento-osseous dysplasia
with expansion, and is best reserved for the
inherited condition in which the multiple
tumours reach 10 or 20 cm in diameter.
- Conventional ossifying fibromas can be
multiple and reach a large size, but not all
such cases are gigantiform cementoma.
-

2- ODONTOMES (ODONTOMAS):

 In the UK, the term odontome is traditionally used, but the international terminology
is odontoma. Odontoma incorrectly suggests a benign neoplasm. These lesions are
hamartomatous and show no progressive growth
 Odontomes are developmental malformations (hamartomas) of dental tissues and
not neoplasms
#remember the differen between hamartoma and teratoma (abnormal formation in
abnormal site as ovarian cyst )
 They are the commonest odontogenic tumours and are chance radiographic findings
or present having prevented tooth eruption in children and adolescents
 In their early stages they are radiolucent, developing opaque flecks and then dense
opaque masses as enamel and dentine form internally
 Occasionally they may erupt and then often become infected because of their
convoluted shape and because no organised epithelial attachment forms
 The two common types of odontome are compound and complex odontomes:
- Both are easily enucleated (well defined )and do not recur.
- If odontomes are left untreated in the jaw, cysts of dentigerous type may form by
separation of reduced enamel epithelium from enamel.
 Multiple odontomes are a component of Gardner’s syndrome
 There is an ill-defined borderland between odontomes and some malformed teeth.
(Dens in dente, invaginated odontomes, tuberculate mesiodens, dilated odontomes
and connate teeth are distinctive minor tooth malformations )
Compound odontoma Complex odontoma
 These are clusters of many  Complex odontomes consist of a
separate, small, tooth-like structures single irregular mass of hard and soft
(denticles) within one crypt, the dental tissues, having no
whole lesion usually no larger than morphological resemblance to a
20 mm in diameter tooth and frequently forming a
 This type is usually found in the cauliflower shaped disorganized
anterior maxilla and causes minimal nodule of enamel and dentine
swelling  These may reach several
 Histologically: centimetres in size and often expand
- The denticles are embedded in the jaw.
fibrous connective tissue and have a  Radiographically, when calcification
fibrous capsule around the entire is complete, an irregular radiopaque
lesion mass is seen containing areas of
 - Each denticle has densely radiopaque enamel
an organized 
structure with pulp
centrally and an
enamel cap over
the abnormally
shaped dentine
- The denticles
develop like Histologically:
normal teeth, mineralise fully and - the mass consists of all the dental
once mature, stop growing tissues in a disordered arrangement,
but frequently with a radial structure.
- The pulp is usually finely branched
so that the mass is perforated, like a
sponge, by small branches of pulp

‫ممكن يصيرلها التهاب او تمنع نمو االسنان‬ 

 Other types of odontome:
- Ameloblastic fibrodentinoma and ameloblastic fibroodontome are mixed lesions with
a component of complex odontome and a major component of soft tissue resembling
ameloblastic fibroma.
- In the fibrodentinoma, only dentine is present, and in the fibro-odontome, both
enamel and dentine are present.
- Both lesions share many features with odontomes, presenting in the first and early
second decade, usually in the posterior mandible.
- Initially radiolucent, they progressively develop radiopacity within while the hard
tissues grow and mineralise .
- In the past these have been considered benign neoplasms in their own right, but it
is now thought that they are just odontomes with a prominent soft tissue component
and that, if untreated, they will eventually cease growing and mineralise.
- They can be treated by enucleation and do not recur, and may be suspected
preoperatively by their radiopaque element

MALIGNANT ODONTOGENIC TUMOURS

 Malignant odontogenic tumours are very rare, and there are many histological types
 A malignant equivalent exists of most of the odontogenic tumours except
adenomatoid odontogenic tumour and odontome
 The malignant tumours, either carcinomas or sarcomas, can present with typical
signs of malignancy, such as
1- Progressive growth of a swelling of the jaw
2- pain
3- ulceration
4- loosening of teeth
5- nerve signs
6- invasion beyond bone into soft tissues
 However, they are not necessarily clinically evident as malignant, and sometimes
the diagnosis is not suspected until a biopsy is examined
 The main significance is to be aware of their existence and be alert for minor
features of malignancy in the clinical and radiographic appearance of jaw tumours:
nerve signs, an indistinct moth-eaten outline and tooth root resorption
 Most arise in the posterior jaws, more frequently in the mandible. All are more
common in the elderly
 Malignant neoplasms in the jaws are much more likely to be metastatic than
odontogenic to develop in the bone marrow below the inferior dental canal in the
mandible.
 The malignant odontogenic tumours usually develop in the alveolar bone or
retromolar region

1- Ameloblastic carcinoma : is a carcinoma that resembles an ameloblastoma

histologically, with palisaded basal cells
excision & ‫ فيصبح العالج‬metastasis ‫ وتعمل‬loss of differentiation ‫ هنا الخاليا‬, ‫ نادرة جدا‬#
radiotherapy

2- Primary intraosseous carcinoma:

- is a carcinoma arising in the jaws with no resemblance to a specific odontogenic
tumour.
- Almost all are squamous carcinomas, and approximately 40% appear to arise in
odontogenic cysts, radicular, dentigerous or odontogenic keratocyst .
- Sclerosing odontogenic carcinoma is a primary intraosseous carcinoma that induces
a dense collagenous stroma
3- Clear cell odontogenic carcinoma is a carcinoma comprising sheets and islands
of cells with clear cytoplasm
#only epithelial odontogenic tumor
#old people (>60 years )
#around teeth (tooth bearing lesion )
#aggressive & rate rage radiolucency (irregular )
#central nucleus & prominent cellular membrane
#metastasis to distant area (lymph nodes , nervous system )
#ttt is excision & chemoradiotherapy (systemic treatment )
4- Ghost cell odontogenic carcinoma is a carcinoma containing scattered islands of
ghost cells. It is the malignant counterpart of dentinogenic ghost cell tumour.
5- Ameloblastic fibrosarcoma
- is the rare malignant counterpart of ameloblastic fibroma.
- It is invasive and destructive but has little tendency to metastasise.
- As many as half of cases seem to develop in ameloblastic fibromas that have been
repeatedly inadequately treated.
- In these sarcomas the epithelial component remains benign, but the dental-papilla
like component becomes very cellular and atypical .
- Those that contain mineralisation are known as ameloblastic fibro-dentinosarcoma
or odontosarcoma, but behave similarly.