REVIEW PAPER
Odontogenic Cysts and Tumors
Dana Rioux-Forker, MD,* Allyson C. Deziel, MD,*
Larry S. Williams, DDS,† and Arshad R. Muzaffar, MD*
Abstract: Odontogenic cysts and tumors are mandibular and maxillary lesions that
occur across all patient demographics across age, sex, race, and social economic
status, as altered remnants of dental development. They may be incidental findings
from routine imaging in any office or found through workup for craniofacial sur-
gery or injury. Many of these patients present with asymptomatic lesions, whereas
others may be symptomatic. In this article, we review the literature on the most
common odontogenic tumors and cysts and discuss their presentation, their de-
fining traits, and how to approach diagnosis and definitive management.
Key Words: odontogenic cyst, odontogenic tumor, periapical cyst, radicular cyst,
dentigerous cyst, eruption cyst, paradental cyst, botryoid cyst, gingival cyst,
glandular odontogenic, ameloblastoma, keratocytic odontogenic tumor,
gorlin cyst, myxoma, odontoma
(Ann Plast Surg 2019;82: 469–477)
T he World Health Organization classifies neoplasms of the mandible
as odontogenic cysts, nonodontogenic cysts, and pseudocysts.1,2 A
true cyst is defined as an epithelial lined cavity, whereas pseudocysts
lack an epithelial lining.3 Odontogenic and nonodontogenic cysts are
differentiated by the origin of their epithelial lining. Odontogenic cyst
epithelium originates from the tooth forming organ. These include the
reduced enamel epithelium, rests of Malassez, and rests of Serres.2,3
Odontogenic cysts can be further classified into developmental cysts
(gingival, dentigerous, odontogenic keratocysts, lateral periodontal, cal-
cified odontogenic, and glandular odontogenic cysts) or inflammatory
cysts (radicular, paradental, residual cysts).1
The true prevalence and distribution of odontogenic cysts and tu-
mors is not known. Odontogenic cysts are thought to comprise the vast
majority of jaw cysts, accounting for approximately 90%.4 Johnson
et al5 did a systematic literature review and found that odontogenic cysts
were 2.25 times more common than odontogenic tumors. They reported
that the most common cyst found was the radicular cyst, which comprised
54.6% of the odontogenic cysts. The next most common types found were
the dentigerous cysts comprising 20.6% and the keratocystic odontogenic
tumor (KCOT) comprising 11.7% of the reported odontogenic cysts.
Other cysts including calcifying odontogenic cysts, lateral periodontal
cysts, eruption cysts, botryoid odontogenic cysts, and residual cysts
were reported infrequently enough to limit further analysis. Combined,
these were thought to comprise less than 10% of odontogenic cysts.5
Johnson et al5 also reported on the incidence of odontogenic tu-
mors in the literature. They found that ameloblastomas were the most
prevalent at 37.9%, followed by KCOT at 36.6%, odontogenic myxomas
at 3.8%, adenomatoid odontogenic tumor at 3.2%, and ameloblastic fi-
bromas at 1.1%. Finally, odontoma classification remains disputed, with
some including them as odontogenic tumors with a frequency of up
to 45.8%.5
Received March 7, 2018, and accepted for publication, after revision October 5, 2018.
From the *Division of Plastic Surgery, University of Missouri; and †Department of Oral
Surgery, Truman VA, Columbia, MO.
Conflicts of interest and sources of funding: none declared.
Reprints: Dana Rioux-Forker, MD, Division of Plastic Surgery, University of Missouri,
One Hospital Dr, Columbia, MO 65212. E-mail: Riouxforkerd@Missouri.edu.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0148-7043/19/8204–0469
DOI: 10.1097/SAP.0000000000001738
Annals of Plastic Surgery • Volume 82, Number 4, April 2019
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
DIAGNOSIS AND TREATMENT
Preoperative clinical assessment and imaging are vital for devel-
oping a provisional diagnosis of any jaw lesion. Initial imagining typically
includes an x-ray series or panorex. Often, plain radiographs are insuf-
ficient, and more advanced imaging including cone beam computed to-
mography (CT), CT, magnetic resonance imaging, or ultrasound is needed
to further characterize the lesion, surrounding tissue, or even vascularity.
Chapelle et al6 and Stoelinga7 reviewed jaw tumors and cysts and
developed recommendations based on provisional diagnoses and treat-
ment outcomes (Fig. 1). They recommended avoiding preoperative bi-
opsy in unicystic lesions, unless a solid tumor is expected. Enucleation
with histologic assessment was the recommended initial treatment of
unicystic lesions, unless the lesion was in the mandibular third molar
region with extension onto the ramus. This extension tends to be more
consistent with odontogenic keratocysts and ameloblastomas. In the
past, they have recommended adding mucosal excision with applica-
tion of Carnoy's solution or liquid nitrogen, which will overtreat some
odontogenic or pseudocysts but may spare morbidity in odontogenic tu-
mor patients. Unfortunately, obtaining Carnoy's solution has become
difficult because chloroform has been classified as a carcinogen and
there is often soft tissue damage that can be seen with liquid nitrogen.
A suggested alternative method involves decompressing the lesion with
a drain followed by surgical enucleation, after which long-term follow-
up is critical because recurrent cases have been reported. Multiloculated
and multicystic tumors were recommended to be treated more aggres-
sively. They recommended performing an incisional biopsy to differen-
tiate ameloblastomas from odontogenic keratocytes in multilocular or
multicystic lesions with expansion. Those without expansion were di-
agnosed by aspiration.6,7 Final pathologic diagnosis then directs
any further lesion specific treatment. Long-term follow-up and repeat
imaging are necessary given the high recurrence rates and possible
malignant conversion.
Odontogenic Cysts
Periapical (Radicular) Cyst
These are the most common odontogenic cysts (52%–70% of all
jaw cystic lesions) (Fig. 2) and are commonly found in the maxilla in about
60% of cases (Fig. 3).3,8 They are usually asymptomatic unless they be-
come infected. The epithelium of periapical cysts develops from the rests
of Malassez, from an inflammatory process associated with a nonvital
tooth (caries, trauma, periodontal space extension), and a precursor
periapical dental granuloma.1,9,10 These cysts typically present with a
unilocular radiolucency at the apical portion of a tooth root. However,
they can develop lateral to a tooth system (lateral radicular cyst). They
typically have well-defined borders and are often under 1 cm in diame-
ter.11 The sensitivity and specificity of radiographs in detecting periapical
cysts are low (33.3% and 61.5%, respectively).12
Treatment for these lesions is simple enucleation given their be-
nign pathology. These may resolve with endodontics (root canal therapy);
however, if a periapical cyst is incompletely removed; it may develop
into progressively expanding residual cysts and result in significant bone
destruction. Some have hypothesized that periapical cysts may sponta-
neously resolve once apical periodontitis is treated.1
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FIGURE 1. Odontogenic cyst and tumor initial management flow chart. Reprinted with permission from Elsevier from Chapelle KA et al.
Copyright Elsevier. All permission requests for this image should be made to the copyright holder.

Dentigerous (Follicular) Cyst
These are the second most common developmental odontogenic
cysts, which make up about 20% of all mandibular cysts (Fig. 4).1
Dentigerous cysts are noninflammatory and form when fluid accumu-
lates between a tooth crown and the enamel epithelium, which dilates the
tooth follicle and prevents tooth eruption.13 These cysts are associated with
the crown of an unerupted tooth, developing tooth, or an odontoma. The
third molars and maxillary canines are most frequently involved. Dentigerous
cysts are commonly diagnosed in teenage years and early adulthood and are
typically asymptomatic, unless they cause local swelling or become infected.

FIGURE 2. Odontogenic cyst and tumor chart.

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Annals of Plastic Surgery • Volume 82, Number 4, April 2019
FIGURE 3. Periapical cyst.
Radiographically, patients have a unilocular radiolucency associ-
ated with an unerupted tooth. These cysts typically have well-demarcated
borders and display an origin from the cemento-enamel junction.14 Iden-
tifying the crown of a tooth projecting into the cystic cavity is pathogno-
monic15; however, definitive diagnosis still requires histologic analysis.
The affected tooth may be displaced large distances or even be re-
sorbed.13 These cysts have shown malignant degeneration, and both squa-
mous cell carcinoma and mucoepidermoid carcinomas arising from
dentigerous cysts have been reported. Simple enucleation is curative.
Tooth sparing marsupialization has been used, but with higher
recurrence rates.16
FIGURE 4. Dentigerous cyst.
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Odontogenic Cysts and Tumors
FIGURE 5. Eruption cyst. Reprinted with permission from
Wolters Kluwer from Nagaveni NB et al.17 Copyright Wolters
Kluwer. All permission requests for this image should be made
to the copyright holder.
Eruption Cysts
Eruption cysts are a form of dentigerous cyst associated with
erupting teeth (Fig. 5). These cysts form at the time of deciduous or per-
manent tooth eruption and can even be seen in newborns. They develop
from the crown of a tooth when it is within the soft tissue.2 Eruption cysts
overlie the tooth, presenting with a swelling on the alveolar ridge, often hav-
ing a bluish hue.13 The erupting tooth typically expands through and ruptures
the cyst. Rarely is unroofing required because of delayed eruption.17
Paradental Cysts
Many consider paradental cysts to be a variant of dentigerous
cysts (Fig. 6). Food-induced periodontitis, impaction, and subsequent
occlusion of a pericoronal tooth pocket are thought to result in cystic
formation leading to the inflammatory cyst. They originate from the
cemento-enamel junction, often on the buccal side of the tooth, rarely
on the mesial surface, and never on the lingual. Mandibular molars
FIGURE 6. Paradental cyst. Reprinted with permission from Elsevier
from Lacalta MG et al.42 Copyright Elsevier. All permission
requests for this image should be made to the copyright holder.
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Rioux-Forker et al
FIGURE 7. Lateral periodontal cyst. Reprinted with permission from Wolters Kluwer from Meseli SE et al.43 Copyright Wolters Kluwer. All
permission requests for this image should be made to the copyright holder.
are often involved. Tooth extraction is typically performed for any third
molar paradental cyst, as opposed to enucleation in other locations.18
Lateral Periodontal Cyst
These lesions develop on the lateral surface of a vital tooth from
dental lamina and comprise less than 3% of odontogenic jaw cysts (Fig. 7).
They can displace tooth roots and appear as a swelling in the interdental
gingival papilla.1 They retain neoplastic potential but are typically found
incidentally in the interproximal area between tooth roots.2 Lateral peri-
odontal cysts are typically diagnosed in the fifth and sixth decades and
more often in males.
Radiologically, these are unilocular and well corticated. Histology
differentiates these cysts from KCOT, odontogenic cysts of undetermined
origin, and lateralized periapical cysts.
Simple enucleation is indicated for unilocular lesions. If
multilocular, the lesion is likely a botryoid odontogenic cyst, and light
curettage is indicated.2
Botryoid Odontogenic Cyst
Some describe this as a variant of the lateral periodontal cyst, but
multiloculated and occasionally multicystic (Fig. 8). Others differentiate
it from lateral periodontal cysts because of its larger size, minor histo-
logic differences, and increased recurrence risk. They are found in
FIGURE 8. Botryoid odontogenic cyst. Reprinted with
permission from Wolters Kluwer from Arora P et al.44 Copyright
Wolters Kluwer. All permission requests for this image should be
made to the copyright holder.
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Annals of Plastic Surgery • Volume 82, Number 4, April 2019
alveolar bone of erupted vital teeth and treated with enucleation with
bone curettage.19
Gingival Cyst of the Adult
This is the soft tissue equivalent of the lateral periodontal cyst
(Fig. 9).2 This lesion is derived from dental lamina remnants but found
in the gingiva. These may be blue in color and are commonly found in
the fifth and sixth decades.1 Radiographically, superficial cortical cup-
ping may occur, along with bone erosion.13 Treatment with local exci-
sion and histopathologic analysis is recommended.
Gingival Cyst of the Newborn
These are small lesions, being only a few millimeters in diameter,
present on the alveolar ridge, and seen only in the first few months of
life. They are isolated to the soft tissue only, with no bony component.
Histologic analysis is unnecessary. These lesions nearly always rupture
spontaneously before 3 months of age and rarely require intervention.1
Enucleation or deroofing may be indicated when a lesion significantly
disrupts feeding.20
Keratinizing Odontogenic Cyst (Orthokeratinized
Odontogenic Cyst)
Originally, these lesions were not differentiated from KCOTs
(Fig. 10). However, they have a significantly different prognosis, with
FIGURE 9. Gingival cyst of the adult. Reprinted with permission
from Hindawi from Brod JMM et al.45 Copyright Juliana Mancano
Melhado Brod. All permission requests for this image should be
made to the copyright holder.
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Annals of Plastic Surgery • Volume 82, Number 4, April 2019
FIGURE 10. Keratinizing odontogenic cyst. Reprinted with
permission from Wolters Kluwer from Kulkarni M et al.46
Copyright Journal of Oral and Maxillofacial Pathology. All
permission requests for this image should be made to the
copyright holder.
little to no neoplastic potential and low recurrence rates. Keratinizing
odontogenic cysts have variable presentations, with no unifying clinical
trait. They may present on erupted or unerupted dentition and in vari-
able locations often adjacent to the crown.2 They may become very large
and are often found in the third to fifth decades of life. Radiologically,
they are uniloculated, well-corticated lesions. Surgical enucleation, histo-
logic assessment, and follow-up are sufficient treatment for these lesions.21
Glandular Odontogenic (Sialoodontogenic) Cyst
This lesion is poorly understood (Fig. 11). It typically presents
asymptomatically but can be very large and destructive. Radiographi-
cally, this lesion may be unilocular or multilocular, and often anteriorly
positioned. The margins are generally well defined with a sclerotic rim.
Aggressive growth and expansion may lead one to consider this rare cyst.2
Aggressive features include multilocularity, cortical expansion, scalloped
FIGURE 11. Glandular odontogenic cyst. Reprinted with
permission from Wolters Kluwer from Shah AA et al.47 Copyright
Wolters Kluwer. All permission requests for this image should be
made to the copyright holder.
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Odontogenic Cysts and Tumors
or sclerotic borders, root resorption, or tooth displacement.22 This lesion
can be confused with other odontogenic cysts or mucoepidermoid carcino-
mas. Clear or red-brown viscous fluid on aspiration may help lead to a clin-
ical diagnosis.23 Surgical treatment should include enucleation with bone
curettage and follow-up, as high recurrence rates up to 25% are reported.1
Odontogenic Tumors
Ameloblastomas
Ameloblastomas are the most common jaw neoplasm and are of-
ten asymptomatic, arising from the enamel organ (Fig. 12).13 Generally,
they are the most aggressive benign neoplasm. They are typically slow
growing but can reach large and destructive sizes.1 Preoperative CT or
magnetic resonance imaging may help to direct biopsy, guide resection,
clarify soft tissue involvement, and guide surgical margins. Surgical re-
section is typically the treatment of choice, with wide margins from 1 to
1.5 cm to 2 cm for more aggressive solid subtypes. Curettage and enu-
cleation result in high recurrence rates, 55% to 100% for solid, 18% to
25% for unicystic, and 8% for peripheral. Ameloblastomas have malig-
nant potential and may metastasize. Metastasis occurs in under 1% of
ameloblastomas, which are then termed malignant ameloblastoma.1 The
histologic features of metastatic ameloblastomas are identical to benign
ameloblastomas. Subsequently, diagnosis in a distant or regional site is
required to label an ameloblastoma as malignant. Metastatic sites include
lungs (70%–85%), bone, liver, and brain. Malignant ameloblastomas
can also be found regionally, as up to 35% of malignant ameloblastomas
have metastasized to the neck. Metastases are preferentially treated with sur-
gical excision or radiotherapy in nonoperable tumors. Chemotherapy and ra-
diotherapy are yet to be validated as treatment options.24 Ameloblastic
carcinoma conversely is any ameloblastoma with anaplastic cytopathologic
features without apparent metastasis. Anaplastic features may include in-
creased mitotic activity, nuclear/cytoplasmic ratio, and hyperchromatism.2
Unicystic Ameloblastoma
These lesions are usually asymptomatic and found incidentally,
unless they become secondarily inflamed. They comprise 15% of all
FIGURE 12. Ameloblastoma.
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Rioux-Forker et al Annals of Plastic Surgery • Volume 82, Number 4, April 2019

overlying mucosa are typically sent with the specimen. Soft tissue mar-
gins should be assessed with preoperative advanced imaging and
intraoperative frozen sections. The goal is to include 2 biologic barriers
in your resection.

Peripheral (Extraosseous) Ameloblastoma

These soft tissue lesions may arise from the dental lamina or from
basal cells of the overlying mucosa. By definition, these do not infiltrate
adjacent bone. Surgical excision with histologically confirmed margins
is the treatment of choice.2 Some advocate for 1 cm intraoperative mar-
gins with negative frozen sections to obtain complete excision. Often a
marginal mandibulectomy is performed with resection of a cuff of un-
involved alveolar bone.24

FIGURE 13. Ameloblastic fibroma. Reprinted with permission
from Wolters Kluwer from Verma N.48 Copyright Wolters
Kluwer. All permission requests for this image should be made to
the copyright holder.
ameloblastomas and are often found in the second or third decades of
life.1 These ameloblastomas are differentiated by their unilocular,
unicystic nature, and lack of connective tissue invasion, giving them a
better prognosis.
Radiologically, they appear similar to dentigerous cysts (radiolu-
cent, unilocular, with well-corticated borders) but are not confined to
unerupted teeth or the crown region. Up to 80% of these tumors further
mimic dentigerous cysts by enclosing a tooth crown.13 Performing a
biopsy with curettage is advocated for diagnosis given the similarities
shared with dentigerous cysts. Aspiration is typically nondiagnostic. If
the pathology returns positive for ameloblastoma, then any surgically
violated mucosa or gingiva would require resection. For unilocular
and unicystic ameloblastomas with no soft tissue involvement and mea-
sure less than 2 cm in diameter, the ideal surgical treatment continues to
be debated. Simple enucleation with or without curettage is performed
by many but at the expense of an increased recurrence rate of 10% at
10 years.13 Others have added cryotherapy, Carnoy's solution, drilling,
or electrocautery to help decrease recurrence rates. Some advocate an
even more aggressive approach at the expense of additional morbidity.
This includes en bloc resection with margins 1 to 1.5 cm beyond the ra-
diographic margin and negative frozen sections of any soft tissue involve-
ment. Immediate vascularized bone reconstruction typically follows
this approach.24
Ameloblastic Fibroma
These are benign neoplasms with proliferating mesenchyme and
ameloblastic cells (Fig. 13). They are differentiated from fibroodontomas
or odontomas by their lack of enamel, detin, or cementum.2 They are slow
growing and asymptomatic unless they become secondarily inflamed.
Once large enough, they may cause an expansion of the overlying buc-
cal cortex. Ameloblastic fibromas are commonly diagnosed before the
age of 20 or during middle age. Radiologically and clinically indistinct,
they appear as a well-defined radiolucency with a corticated (or sclerotic)
border and may be unilocular or multilocular.1 Histopathology is required
to differentiate these lesions from ameloblastomas. Fine needle aspiration
or biopsy may help identify this lesion preoperatively. Surgical enucle-
ation often with curettage is the treatment of choice, with low recurrence
rates and a favorable prognosis.25 Follow-up remains important because
there are cases of malignant transformation into ameloblastic fibrosar-
comas.26 There remains no indication for more extensive surgical treat-
ment unless there is recurrence or malignant change.
Ameloblastic Fibroodontomas
These are rare odontogenic tumors that are similar to ameloblastic
fibromas but display radiographic or histopathologic mineralization
and contain enamel and dentin (Fig. 14).1 They are benign and are

Intraosseous Ameloblastoma
These comprise the majority of ameloblastomas, making up
about 80%.2 Prognosis is often related to tumor location. The more su-
perficially located or cortically confined lesions often have better out-
comes. These lesions can readily invade soft tissue and medullary bone;
however, cortical bone and periosteum often act as barriers. Radiologi-
cally, these lesions have a classic soap bubble or honeycomb appear-
ance; however, smaller lesions may be unilocular and indistinguishable
from other lesions of the jaw.2 The lesion itself may displace teeth or
cause root resorption.24
Treatment of intraosseous ameloblastomas with enucleation with
or without curettage has shown a high recurrence rate. Subsequently,
surgical resection with negative radiographic margins and negative his-
tologic margins is the treatment of choice. Even with en bloc resection
beyond the radiologic margins, recurrence rates of 10% to 15% have
been reported. To ensure complete removal, many advocate surgical
margins of 1.5 to 2 cm past the radiographic margin as well as negative
frozen margins intraoperatively.24 Others recommend an excision 1 cm
past the radiologic margin.2 Soft tissue, except alveolar mucosa, is pre-
served unless there is periosteal involvement. Teeth, gingiva, and FIGURE 14. Ameloblastic fibroodontoma.

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Annals of Plastic Surgery • Volume 82, Number 4, April 2019
FIGURE 15. Keratocystic odontogenic tumors (4) in a patient
with Gorlin syndrome.
typically diagnosed in patients before the age of 20 years. Like
ameloblastic fibromas, these lesions can be locally expansive and de-
structive. Surgical enucleation is the treatment of choice, with curettage
for multilocular lesions. In many cases, adjacent dentition can be pre-
served.27 There are isolated cases of malignant transformation requiring
more aggressive resection, but recurrence and malignant transformation
are atypical and highlight the importance of long-term follow-up.28
KCOT (Odontogenic Keratocyst, Parakeratizing
Odonotogenic Keratocyst)
These lesions make up 10% to 12% of odontogenic cysts
(Fig. 15).1 Debate exists on whether to classify these lesions as cysts
or neoplasms, but the general trend is toward neoplastic classification.
Often asymptomatic, KCOTs can cause symptoms of swelling, pain,
trismus, sensory deficits, or infection. They have a peak incidence in
the second and third decades of life. Radiologically, these lesions can
be unilocular or multilocular with well-defined borders. They can be
found at any site of odontogenesis and may extend significant distances
and aggressively invade tissue planes.2
Gorlin syndrome (basal cell nevus syndrome) is commonly asso-
ciated with KCOT and should be considered in any patient with multiple
KCOTs. Gorlin syndrome typically results from an autosomal domi-
nant PTCH gene mutation. Patient history may include numerous basal
cell carcinomas, KCOTs, cleft lip, hypertelorism, ovarian fibromas,
FIGURE 16. Calcifying cystic odontogenic tumor. Reprinted with
permission from Springer Nature from Masuda K et al.49
Copyright Masuda et al. 2005. All permission requests for this
image should be made to the copyright holder.
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Odontogenic Cysts and Tumors
macrocephaly, frontal bossing, palate abnormalities, palmar pits, bifid
ribs, polydactyly, and syndactyly among other findings.29
Optimal treatment is currently debated. The goal of surgical
treatment is removal of the cyst and lining, including satellite cysts
and dental lamina rests. Enucleation alone has high recurrence rates of
about 62.5%. Enucleation with thorough curettage decreases recurrence
rates down to 10%.2 Many have included cryotherapy, electrocautery, or
chemical cautery for decreased recurrence rates.30 Some advocate a more
aggressive approach with enucleation, excision of overlying mucosa, pe-
ripheral osteotomy, and chemical cautery. Pogrel31 has suggested a
treatment protocol that was developed due to the difficulty of obtaining
Carnoy's solution and the soft tissue damage that can be seen with liquid
nitrogen. His method involves decompressing the lesion with a drain
until it is 2 to 3 cm in size, after which he performs surgical enucleation
with peripheral ostectomy.31 Marginal mandibulectomy or segmental
resection may be indicated with aggressive tumor invasion or penetra-
tion.32 Long-term follow-up is crucial because recurrence can be seen
decades after initial treatment.
Calcifying Cystic Odontogenic Tumor (Gorlin Cyst)
There is debate on whether to classify calcifying cystic odontogenic
tumors as neoplasms or cysts (Fig. 16). Thought to arise from dental
lamina rests, this lesion may occur intraosseously or peripherally in the
gingiva.2 It may be unilocular or multilocular and is radiolucent (with
occasional opacities).33 These are benign in nature but are thought to
have rare neoplastic potential. Cases have been reported of recurrent
calcifying cystic odontogenic tumors and progression into Ghost cell
odontogenic carcinoma.34 Enucleation with curettage is the advocated
treatment for these lesions with extended clinical follow-up.35
Odontogenic Myxoma
This benign neoplasm arises from the dental papilla or dental sac
(Fig. 17). They are often locally aggressive tumors but without malig-
nant or metastatic potential. Clinical examination often shows a smooth,
bony, hard expansion of the alveolus. Odontogenic myxomas are often
identified in the second or third decades of life. As with most odontogenic
neoplasms, these may be unilocular or multilocular and are radiolucent.
Cortical penetration can occur, and a periosteal reaction can result giving
a honeycomb or tennis racket appearance. Grossly, the contents of the
myxoma are gelatinous, which makes surgical enucleation difficult.
For noninvading smaller lesions (<3 cm), enucleation and curettage of
medullary bone going 0.5 to 1 cm past radiographic margins (+/− marginal
resection) with negative histologic margins may be performed.2
FIGURE 17. Odontogenic myxoma. Reprinted with permission
from College of American Pathologists from Li TJ et al.50 Copyright
College of American Pathologists. All permission requests for this
image should be made to the copyright holder.
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Rioux-Forker et al Annals of Plastic Surgery • Volume 82, Number 4, April 2019

FIGURE 18. Adenomatoid odontogenic tumors. Reprinted with permission from Wolters Kluwer from Belgaumi U et al.51 Copyright
Annals of Medical and Health Sciences Research. All permission requests for this image should be made to the copyright holder.

However, the recurrence rate for this is thought to be as high as 25%.1
For more invasive or larger lesions, a more aggressive approach includ-
ing segmental, en bloc resection, or hemimandibulectomy with recon-
struction is advocated by some.36,37
Adenomatoid Odontogenic Tumor
Adenomatoid odontogenic tumors represent 3% to 7% of all
odontogenic tumors (Fig. 18).1 This tumor develops from either the enamel
organ or dental lamina and is histologically similar to ameloblastomas.2
It is known as the two-thirds tumor, because two thirds occur in female,
two thirds occur in maxilla, two thirds are associated with impacted teeth,
and two thirds occur in teenagers. Adenomatoid odontogenic tumors are
often associated with impacted canine teeth. Radiographically, these le-
sions may be mistaken for dentigerous cysts because they are often asso-
ciated with impacted teeth, blend into the tooth follicle, are radiolucent,
and are unilocular. Adenomatoid odontogenic tumors often contain fine
calcifications.1 Surgical enucleation is the treatment of choice because
these lesions are typically well encapsulated.38,39 Aggressive behavior
and recurrence are not typical, and associated dentition can often be
preserved.39
Odontomas
The classification of odontomas is debated, with some consider-
ing them hamartomas and others considering them odontogenic tumors
(Fig. 19). They are the most commonly diagnosed odontogenic tumor.1
They consist of masses of enamel, enamel matrix, dentin, and cemen-
tum arranged either chaotically (complex odontoma) or in an organized
tooth-like fashion (compound odontoma). Grossly, compound odontomas
may have small, malformed, identifiable teeth. Odontomas may be as-
sociated with other odontogenic cysts or tumors. They can also deform
adjacent teeth or alter eruption.2 Radiographically, these lesions have a
central radiopaque region with a sack of teeth or disorganized aggregate
appearance. There is a peripheral radiolucent area and a well-defined
and visible corticated border. Treatment is indicated only if the diagno-
sis is uncertain or the odontoma is disrupting adjacent dentition.1

FIGURE 19. Compound odontoma. Reprinted with permission from Wolters Kluwer from Sreedharan S et al.52 Copyright Wolters Kluwer.
All permission requests for this image should be made to the copyright holder.

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Annals of Plastic Surgery • Volume 82, Number 4, April 2019
Treatment is simple enucleation with preservation of adjacent anatomy
and dentition.40,41
CONCLUSIONS
Odontogenic cysts and tumors represent a diverse group of path-
ologic lesions of the jaw. Physical examination along with imaging is the
best initial tool for developing a differential diagnosis. Final diagnosis is
made from the surgical pathology, and it dictates whether further treat-
ment is required. Long-term follow-up is usually indicated after any sur-
gical excision because of high recurrence rates of many of the lesions.
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