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British Journal of Oral and Maxillofacial Surgery 58 (2020) 1017–1022

New World Health Organization classification of

odontogenic tumours: impact on the prevalence of
odontogenic tumours and analysis of 1231 cases from Turkey
M. Soluk-Tekkesin a,∗ , S. Cakarer b , N. Aksakalli a , C. Alatli a , V. Olgac a
a Institute of Oncology, Department of Tumour Pathology, Istanbul University, Istanbul, Turkey
b Dentistry Faculty, Department of Oral and Maxillofacial Surgery, Istanbul University, Istanbul, Turkey

Accepted 19 June 2020

Available online 16 July 2020

Abstract

The aims of this study were to describe the frequency of odontogenic tumours (OT) based on the World Health Organization’s (WHO)
4th edition of Head and Neck Tumours in Turkey, to compare the results with other regions and to assess the frequency changes of OT
worldwide after the new WHO classification. OT were selected from the pathology department’s files between 1971-2018. In a total of 1231
OT, 1215 (98.7%) were benign, whereas malignant OT were only 16 cases (1.3%). The three most common tumours were ameloblastoma
(n = 366, 29.7%), odontoma (n = 335, 27.2% both complex and compound types), and odontogenic myxoma (n = 190, 15.4%), respectively.
After the 2017 classification, the decrease of OT frequency was found among 20%-42% in the selected epidemiological series because of
re-classification of some lesions. The pattern of incidence in the Turkish population is similar to that in other populations. However, there
are some differences in the frequency of the tumour types. It is obvious that the relative frequency of odontogenic tumours worldwide will
change based on the new classification. It should be kept in mind that this is not a real decrease of OT cases. These marked changes in the
frequency and prevalence of OT is just related to reclassification of some entities.
© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: Odontogenic tumours; WHO; update; ameloblastoma; odontogenic keratocyst; classification

Introduction ter understanding of the interactions between odontogenic

Odontogenic tumours (OT) are a heterogeneous group of
lesions derived from epithelial and mesenchymal elements
of the tooth-forming apparatus that make these lesions
unique to the jaws. They show diverse clinical behaviour and
histopathological types, which range from hamartomatous
lesions to malignancy.
The first World Health Organization (WHO) classifica-
tion of odontogenic tumours was published in 1971.1 This
dynamic classification is constantly renewed with the bet-
∗ Corresponding author at: Institute of Oncology, Istanbul University,
34093 Capa- Istanbul, Turkey, Tel: +90 532 748 70 57.
E-mail address: msoluk@istanbul.edu.tr (M. Soluk-Tekkesin).
epithelium and ectomesenchyme and update of the new
genetic and molecular data. The origin based subclassifica-
tion (epithelial, mixed, and mesenchymal) was first defined
in 1992, and this was continued in the 2005 classification and
the last WHO classification which was published in January
2017.2,3 The new edition includes newly described or newly
added lesions (sclerosing odontogenic carcinoma, primordial
odontogenic tumour, odontogenic carcinosarcoma, cemento-
ossifying fibroma), reclassified entities (ameloblastomas,
odontogenic carcinomas/sarcomas, ameloblastic fibromas)
and removal of tumours (keratocystic odontogenic tumour,
calcifying cystic odontogenic tumour, odontoameloblas-
toma). 2,3

https://doi.org/10.1016/j.bjoms.2020.06.033
0266-4356/© 2020 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 1018
Table 1
Number, age, gender, and anatomical distribution of 1231 odontogenic tumours according to histopathological type.
WHO 2017 classification No. Percentage of all OT Mean age (years) M:F ratio Maxilla Mandible

Anterior Premolar Molar Anterior Premolar Molar

M. Soluk-Tekkesin et al. / British Journal of Oral and Maxillofacial Surgery 58 (2020) 1017–1022
Malignant odontogenic tumours (n = 16, 1.3%)
Ameloblastic carcinoma 3 0.24 50.6 2:1 0 0 0 1 0 2
Primary intraosseous carcinoma, NOS 5 0.41 46.8 1.5:1 2 0 0 0 0 3
Sclerosing odontogenic carcinoma 0 – – – – – – – – –
Clear cell odontogenic carcinoma 4 0.33 37.5 1:1 0 0 3 0 1 0
Ghost cell odontogenic carcinoma 0 – – – – – – – – –
Odontogenic carcinosarcoma 1 0.08 30 Woman 0 0 0 0 0 1
Odontogenic sarcomas 3 0.24 50 2:1 2 0 0 0 0 1
Benign odontogenic tumours (n = 1215, 98.7%)
Epithelial origin (n = 431, 35.01%)
Ameloblastoma, conventional 303 24.61 36.1 0.95:1 5 4 20 27 30 217
Ameloblastoma, unicystic type 52 4.2 34.6 0.5:1 1 0 5 8 3 35
Ameloblastoma,extraosseous/peripheral 11 0.9 39.7 1.7:1 1 0 1 1 2 6
Metastasising (malignant) ameloblastoma 0 – – – – – – – – –
Squamous odontogenic tumour 11 0.9 41.5 1.75:1 2 2 1 3 2 1
Calcifying epithelial odontogenic tumour 22 1.8 37.1 1:1 1 3 5 1 3 9
Adenomatoid odontogenic tumour 32 2.6 23.2 0.4:1 13 0 1 9 7 2
Mixed (epithelial-mesenchymal) origin (n = 394, 32.0%)
Ameloblastic fibroma 15 1.21 20.4 1.14:1 0 0 0 3 4 8
Primordial odontogenic tumour 0 – – – – – – – – –
Odontoma (all types) 335 27.21 26.85 1.17:1
Compound type 144 11.7 23.9 1.05:1 49 9 6 42 13 25
Complex type 191 15.51 29.0 1.27:1 31 1 26 23 8 102
Developing odontoma (ameloblastic fibrodentinoma/odontoma) 40 3.25 22.5 2.07:1 5 1 7 4 1 22
Dentinogenic ghost cell tumour 4 0.33 40.5 0.3:1 0 0 0 0 0 4
Mesenchymal origin (n = 360, 29.25%)
Odontogenic fibroma 9 0.73 32.5 1.25:1 1 1 1 0 5 1
Odontogenic myxoma/myxofibroma 190 15.44 34.9 0.6:1 34 20 19 28 33 56
Cementoblastoma 34 2.76 31.9 0.7:1 0 0 0 0 9 25
Cemento-ossifying fibroma 127 10.32 31.63 0.42:1 5 9 11 22 33 47
Peripheral odontogenic tumours (n = 30, 2.44%, excluding peripheral ameloblastoma)
Odontogenic fibroma 27 2.2 36.7 1.5:1 8 3 2 4 6 4
Calcifying epithelial odontogenic tumour 2 0.16 33.5 All men 1 0 0 0 0 1
Dentinogenic ghost cell tumour 1 0.08 15 Woman 1 0 0 0 0 0
Total 1231 100 32.1 0.9:1 162 53 108 176 160 572
 M. Soluk-Tekkesin et al. / British Journal of Oral and Maxillofacial Surgery 58 (2020) 1017–1022 1019

Table 2
The frequency differences in the studies of OTs in regard to different classification.
First author, year, and Country No. of OT cases No. of OT cases without Decrease of OT OKC order among OTs in
reference (2005 WHO) OKC and COC (2017 WHO) (%) the original series
Luo 200824 China 1.309 754 (OKC:522, C0C:26) 42 Most common
Tawfik 201013 Egypt 82 66 (OKC:16, COC:0) 20 Second most common
Servato 20128 Brazil 240 155 (OKC:76, COC:9) 35 Most common
Siriwardena 201212 Sri Lanka 1.677 1222 (OKC:431, COC:24) 27 Second most common
da Silva 20155 Brazil 289 167 (OKC:100, COC:22) 42 Most common
Nalabolu 201611 India 161 108 (OKC:53, COC:0) 33 Second most common
Ismail 20186 Malaysia 173 123 (OKC:38, COC:12) 30 Second most common

OT: Odontogenic tumour, OKC: Odontogenic keratocyst, COC: Calcifying odontogenic cyst.

One of the major changes in the last classification is
the removal of “keratocystic odontogenic tumour” from the
neoplastic category in the 2005 classification back into the
cyst category with “odontogenic keratocyst (OKC)” name.
Actually, the redefinition of OKC as a tumour in 2005 had
produced a relative increase in the prevalence and frequency
of OT4 and OKC occurred one of the most common OT in
many studies.5–7
The aims of the present study were to assess the frequency
of odontogenic tumours based on the new classification
within the Turkish population, to compare the results with
other regions and their geographic variation, and to show that
the relative frequency of OT will decrease worldwide after
the new classification.
ically in accordance with the 2017 WHO classification of
benign and malignant odontogenic tumours. Many epidemi-
ological studies of odontogenic tumours have been published
according to the 2005 WHO classification, so the numbers
were recalculated (the keratocystic OT and calcifying OT
data were removed) in those reported for comparative pur-
poses.
All data analysis and graphs were performed using
Microsoft Office Excel 2011. This retrospective study was
approved by the Research Ethics Committee of Istanbul Uni-
versity (Number: 795/2018) in compliance with the Helsinki
Declaration.

Results

Material and methods
A total of 1231 odontogenic tumours were selected from the
Oral and Maxillofacial Pathology Unit files between 1971-
2018. These tumours were identified using the clinical details,
including age, sex, and anatomical location. To analyse the
site distribution, the jaws were divided into the anterior,
premolar, and molar areas. The mandibular molar site also
included angle and ramus areas. The recurrent cases were
detected and calculated as one case. The cases with a lack of
clinical information were excluded from the study. All cases
were reviewed and, if necessary, reclassified histopatholog-
Among 53,869 oral biopsies in the records of the Depart-
ment of Tumour Pathology at Istanbul University between
January 1971- January 2018, 1231 cases (2.3%) were diag-
nosed as OT (Table 1). The three most common tumours
were ameloblastoma (n = 366, 29.7% including unicystic
and peripheral ameloblastomas), odontoma (n = 335, 27.2%
both complex and compound types), and odontogenic myx-
oma/fibromyxoma (n = 190, 15.4%), respectively. Malignant
(n = 16, 1.3%) and peripheral OT (n = 41, 3.3%) were a small
proportion of this series. The mean age was about 32 years
(range 2 - 91) and there was a slight female predilection
(53.5%). The most common site was the mandible molar

Table 3
Comparison of the present study with previous studies of OT series from different regions that updated in numbers based on the 2017 WHO classification.
First author, year, and Country No.* Period Most common The most Mean age* M:F ratio*
reference (years) OTs* common sites* (years)
Luo 200824 China 754 21 Ameloblastoma, odontoma Mand. molar, mand. anterior 34.48** 1.13:1
Tawfik 201013 Egypt 66 16 Ameloblastoma, odontoma Mand. molar, mand. premolar 29.57** 1.06:1
Servato 20128 Brazil 155 31 Odontoma, ameloblastoma Mand. molar, mand. premolar 29.0** 0.9:1
Siriwardena 201212 Sri Lanka 1222 30 Ameloblastoma, odontoma Mand. molar, mand. premolar 30.8** 0.9:1
da Silva 20155 Brazil 167 10 Ameloblastoma, odontoma Mand., max. (no subvision) 35.0** 1:1.3**
Nalabolu 201611 India 108 13 Ameloblastoma, odontoma Mand. molar, mand. anteior NA 1.91:1
Ismail 20186 Malaysia 123 8 Ameloblastoma, odontoma Mand. molar,max. anterior 33.5** 1.4:1**
Present study 2018 Turkey 1231 48 Ameloblastoma, odontoma Mand. molar, mand. anterior 32.1 0.9:1

NA: not applicable, Mand: mandible, Max: maxilla.

∗ The results were re-calculated by excluding the odontogenic keratocyst and calcifying odontogenic cyst from the series.
∗∗ The numbers were not re-calculated due to limited knowledge, used original numbers.
1020 M. Soluk-Tekkesin et al. / British Journal of Oral and Maxillofacial Surgery 58 (2020) 1017–1022
region, followed by the mandible anterior and maxillary ante-
rior sites.
Table 2 shows the frequency changes of OT after 2017
classification in some selected regional series that the
decrease of OT frequency was found among 20% - 42%.
Discussion
The last classification of OT was published in January 2017.
One of the most notable changes in the last classification
is that “keratocystic odontogenic tumour” and “calcify-
ing cystic odontogenic tumour” of 2005 are now classified
under the developmental odontogenic cysts with the name of
“odontogenic keratocyst” and “calcifying odontogenic cyst”,
respectively.2 Gaitán-Cepeda et al4 and Servato et al8 demon-
strated nicely that there was a huge increase in the frequency
of the OT in their series like 92% and 50%, respectively, after
the reclassification of OKC as a tumour in 2005.
Another study from Brazil also showed that after the
2005 classification, OKC occupied first place among the OT
and their study demonstrated a huge increase of 464.2%
in OT incidence.9 The present study did not include these
two cysts to reflect real incidence and they were also
excluded from the comparing studies due to a real compari-
son (Table 3). Recently a large, detailed epidemiological data
of OT from UK was published in the line with 2017 WHO
classification.10
The mandible was more commonly involved than the max-
illa by all tumours with a ratio of 2.74:1. The most common
sites were mandibular molar, anterior mandible, and anterior
maxillary areas, respectively. These results show similarity
with those reported by Nalabolou et al11 and Servato et al8
regarding the first and third common site. On the other hand,
Siriwardena et al12 reported that the second most common
site was the anterior maxilla, different from our results.
In the present study, the three most common tumours
were ameloblastoma, odontoma and odontogenic myx-
oma/myxofibroma, respectively. Ameloblastoma was found
as the most common tumour (29.7%) in our series agree-
ing with the results of Siriwardena et al,10 Nalabolu et
al,11 and Tawfik et al.13 Almost no gender predilection was
observed in our series in contrast with the previous reports of
South India,11 Egypt,13 and Nigeria14 that showed male pre-
dominance. The most frequently reported affected area was
mandibular posterior, and the conventional type was most
common type observed in the study.
Odontoma was found as the second most common tumour
(27.2%) in our series different from the series of USA,15
Canada16 , Mexio17 , Chile,18 and Estonia,19 which reported
that the odontoma was found as the most common tumour.
The important reasons for variability of most common
tumours in different populations can be associated with the
differences in the submission of lesion samples or limited
access to histopathology services,10 therefore the real fre-
quency may tend to be underestimated.
Odontoma were evaluated as complex and compound
types in the present study as reported in the series from
Chile18 and Estonia.19 The patients afflicted with compound
odontoma were younger than those with the complex type as
reported Tawfik et al,13 Fernandes et al,20 and Tamme et al.19
The patients in the second decade of life showed a higher fre-
quency of odontomas, which was in keeping with the previous
reports.11–20 Males were affected slightly more than females
in both types of odontomas, in contrast with the series from
Chile18 and Estonia19 that showed that females were affected
more commonly. Most complex odontomas were found in the
posterior mandible whereas compound odontomas were most
commonly observed in the anterior maxilla.
Odontogenic myxoma/myxofibroma was found as the
third commonest tumour (15.4%) in our series. The preva-
lence was higher than in previous reports. 11,13,21,22 On
the other hand, an African series reported that the odonto-
genic myxoma was found as the second common tumour
with a prevalence of 12%.23 In our series, females were
affected more than males (1.7:1) similar to the reports of
Siriwardena et al,10 Tawfik et al,13 Chrysomali et al,22 and
Luo and Li.24 The lesions were commonly observed at the
mandibular molar area, consistent with the results of reported
series.10,13,22,25
The mixed OT classification of 2005 had included
ameloblastic fibroma, ameloblastic fibrodentinoma, and
ameloblastic fibro-odontoma entities. The last two were
excluded from the 2017 classification because there is some
evidence that once dental hard tissues are formed, these
lesions are programmed to develop into odontomas.2,3 How-
ever, in our experience, there are some destructive, large cases
of these entities that are difficult to diagnosis them as a “devel-
oping odontoma”. This debate may be clarified by the next
classification.
Two of the 40 cases of “developing odontoma” were
ameloblastic fibrodentinoma, others were ameloblastic fibro-
odontomas in our study. However, we agree that some
“developing odontoma” cases histopathologically resemble
ameloblastic fibro-odontoma, especially associated with an
unerupted tooth, and these should be distinguished from true
ameloblastic fibro-odontoma. Therefore, the detailed evalu-
ation of history, clinical, radiological and histopathological
features are essential to make a proper diagnosis.
Cemento-ossifying fibroma was firstly included in the
odontogenic tumour classification in 1971 under the ‘cemen-
tomas’ group with the name of “cementifying fibroma”, then
excluded from the 1992 and 2005 OT classifications and men-
tioned under the bone-related lesions.1–3 In 2017, it was again
classified under the odontogenic tumours-mesenchymal ori-
gin and distinguished from the juvenile ossifying fibromas.
However, it is still a fibro-osseous lesion and discussed in
detail with the other ossifying fibromas in the fibro-osseous
lesions section of the last WHO edition.2,3 The prevalence of
cemento-ossifying fibromas in our series was found as 10.3%.
It is not possible to make a proper comparison between the
reported OT series and the present study due to classifica-
 M. Soluk-Tekkesin et al. / British Journal of Oral and Maxillofacial Surgery 58 (2020) 1017–1022
tion differences used, but our results were compatible with
the other series of fibro-osseous lesions of the jaws in terms
of female predominance in middle-age and location in the
posterior mandible region.26
When comparing odontogenic malignancies, the percent-
age of the malignant OT in our series was found as 1.3%,
differently than the reports from UK,10 Chinese,21,24 and
African27,28 populations which showed more than 5% of
prevalence. The studies from North and South America have
reported the percentage of OT malignancy as 1.6%.16–18,20
Primary intraosseous carcinoma was the most common
malignant tumour in our series (0.4%), in keeping with the
reports from China24 , Egypt,13 and Sri Lanka.12 The lesion
was found commonly at the posterior of the mandible, as
in previous reports.12,13,24 On the other hand, the report
from Brazil8 demonstrated that ameloblastic carcinoma was
the most common malignant tumour with a prevalence of
1.3%. In our series, clear cell odontogenic carcinoma was
found as the second common malignant tumour (0.32%) and
most of the lesions were located in the maxilla. The reports
from Brazil8 and Sri Lanka12 also showed that the clear cell
odontogenic carcinoma was the second most common malig-
nant tumour. The UK10 report showed 33 malignant OT, in
one of the largest malignancy series, and that the common-
est malignancies were ameloblastic carcinoma and primary
intraosseous carcinoma with 9 cases of each.
Peripheral/extraosseous types of odontogenic tumours are
rare OT and they have been updated in the last classification
but remain relatively unchanged. In our series, the total num-
ber of 41 peripheral cases was observed with a percentage
of 3.3%. Review of published reports reveals that periph-
eral odontogenic fibroma and peripheral ameloblastoma were
the most common peripheral odontogenic tumours.29 In our
series, the commonest tumour was found as peripheral odon-
togenic fibroma (2.2%) as reported by Daley and Wysocki.30
Eleven cases (0.9%) of peripheral ameloblastoma were
identified. The case number was found to be higher than the
reports of Luo and Li24 , Nalabolu et al11 , and Manor et al.29
The mean age was 39.7 years that was slightly younger than
the reports of Manor et al29 who reported that the mean age
was 50 years. In our series, it was observed that the lesion
commoner in males and located at the mandible, which agree
with the results of Manor et al.29
In the new classification, some new entities are described,
such as sclerosing odontogenic carcinoma and primordial OT.
On our review, none of them had been identified.
In conclusion, this study is one of the largest series of
OT to be described from Europe and one of the first studies
that has evaluated frequency of OT in accordance with the
2017 WHO classification. The location, gender, and age of
the patients are similar to that in other populations. However,
there are some differences in the frequency of the tumour
types. It is also obvious that the relative frequency and preva-
lence of odontogenic tumours in the world will decrease when
the studies will start to publish based on the new classifica-
tion. However, it should be kept in mind that as the increase
1021
in OT cases after the 2005 classification did not reflect real
increment of OT, this is not a real decrease of OT cases. These
marked changes in the frequency and prevalence of OT is just
related to reclassification of some entities.
Conflict of interest
We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission
This retrospective study was approved by the Research Ethics
Committee of Istanbul University (Number: 795/2018) in
compliance with the Helsinki Declaration. Patients’ permis-
sion was not necessary.
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