Oral Pathology 2 Benign, No recurrence potential

Odontogenic Tumors – Epithelial Odontogenic  AOT

Tumors  PCOD
 SOT
I. Odontogenic Tumors  Cementoblastoma
A. Epithelial Odontogenic Tumors  Odontoma
1. Ameloblastoma Benign, Some recurrence potential
a. Unicystic  CEOT
b. Malignant Ameloblastoma  Cystic Ameloblastoma
c. Peripheral Ameloblastoma  Central Odontogenic fibroma
d. Pituitary Ameloblastoma  FCOD
e. Adamantinoma of Long  Ameloblastic fibroma
Bones Benign Aggressive
2. CEOT  Ameloblastoma
3. AOT  Clear cell odontogenic tumor
4. DGCT  Odontogenic ghost cell tumor
5. SOT  Odontogenic myxoma
6. CCOT  Odontoameloblastoma
Malignant
I. ODONTOGENIC TUMORS  Odontogenic ghost cell
 Carcinoma
 From Epithelial (enamel) or mesenchymal  Malignant ameloblastoma
(dentin and pulp) elements in origin.  Ameloblastic Carcinoma
 Involves tooth forming tissues.  Primary intraosseous carcinoma
 Clinically, they are usually asymptomatic  Ameloblastic fibrosarcoma
and discovered through routine radiograph
or noticeable jaw expansion. A. EPITHELIAL ODONTOGENIC
 Has a tendency to swell (but not inflamed). TUMORS
 Bony hard when palpated.
 Histologically mimic tooth tissue 1. AMELOBLASTOMA
appearance.
 Most common tumor
 Talks about ameloblast (which forms the
enamel).
 Aka Adamantinoma, adamantoblastoma
 Locally aggressive, high occurrence,
metastatic

Etiology
 Cell rests of enamel organ
o Remnants of dental lamina
o Hertwig's sheath
o Rests of malassez
 Epithelium of odontogenic origin
o Dentigerous cyst and
o Odontomas
SOURCES
 Disturbances of developing enamel
Epithelial rests of Serres
organ
Epithelial rests of Malassez
 Basal cells of the surface epithelium of
Reduced enamel epithelium the jaws
 Heterotropic epithelium of other body
BIOLOGIC CLASSIFICATION OF parts
ODONTOGENIC TUMORS
Clinical features
 Adults: 4th-5th decade (35 - 45 y.o.)
 No gender predilection
 Md M-ramus area > Md PM > Md Ant/
Mx Post > Mx PM > Mx Ant
 Asymptomatic, detected through x-ray,
jaw expansion or tooth movement.
o It can displace teeth and cause
malocclusion, mobility and/or pain
upon biting.
 Slow growing oOsteolytic
 Typically found in tooth-bearing
areas of the jaws.
o Multilocular
o Unilocular
 Cystic
 Margins are well-defined and sclerotic.
 Tooth resorption

Clinical features

Histopathology
 Follicular
o Most common islands of tumor cells
appearing like dental follicle.

Radiographic features
 Soap bubble appearance or
honeycombed

 Microcystic
o Central cystic degeneration of
follicular islands.
 Plexiform
o Neoplastic cells in a network of
epithelium.
 Desmoplastic
o Stroma is desmoplastic and the
tumor islands become squamous
appearing (squamoid) or elongated.
 Basal Cells/Basaloid
o Similar to basal cell carcinoma of
the skin, there's proliferation of
basal cells.
o The epithelial tumor cells are more
primitive, less columnar, generally
arranged in sheets.
o The least common subtype.
 Granular/Granulomatous
o Central neoplastic cells exhibiting
prominent cytoplasmic granularity. TYPES
o Darkly stained ameloblastoma. Solid
Multicystic
Unicystic
Peripheral ameloblastoma
Malignant ameloblastoma
Ameloblastic carcinoma

a. UNICYSTIC AMELOBLASTOMA

 Common to all subtypes: Polarization of
cells on one side
o Palisading of columnar cells around
epithelial nests.
o Cells similar to ameloblasts.
o Loosely-arranged cells that mimic
stellate reticulum.
o Some ameloblasts are seen with
ghost cells.
o Budding of tumor cells from
neoplastic foci.
Clinico-radiographic features
 Younger patients (2nd decade)
 Mandible (posterior)
 Asymptomatic, painless swelling
 Circumscribed radiolucency
Histologic features
 Luminal unicystic ameloblastoma
 Intraluminal unicystic meloblastoma
 Mural unicystic ameloblastoma

Treatment
 Enucleation
 Patient kept under long-term follow-up.
Recurrence rate: 10% to 20%
b. MALIGNANT AMELOBLASTOMA
 Md > Mx, younger (30’s yo)
 Long standing lesions which metastasize to
lymph nodes and distant organs.
 Malignant Amelo: well-differentiated with
the characteristic histologic features of
ameloblastoma while
 Ameloblastoma Carcinoma: poorly
differentiated, less microscopic
differentiation, cytologic atypia and mitotic
figures.
 Can extend towards the lungs > regional
lymph nodes > skull, liver, spleen, kidney,
skin- (rare).
Treatment
 Excision, curettage
c. PERIPHERAL/ EXTRAOSSEOUS
AMELOBLASTOMA
 Older adults, 40-60 yo
 Gingiva, rarely in buccal mucosa.
 Surface epithelium or remnants of dental
lamina.
 Arise from overlying epithelium or rests of
Serres.
 Non-invasive (does not invade underlying
bone), rare, do not recur (following local
excision).
 Benign, nonaggressive and noninvasive on
underlying bone.
 Recurrence is rare.
Clinical features
 Painless, nonulcerated sessile or
pedunculated.
 Represent fibroma or pyogenic
granuloma.
 Wide age range (52 years)
 Posterior gingival and alveolar mucosa
 Mandibular
Histologic Features
 Same features as the intraosseous form.
 Islands of ameloblastic epithelium that
occupy the lamina propria underneath
the surface epithelium.
Treatment
 Local surgical excision
Recurrence rate: 15% - 20%
Further excision
d. PITUITARY AMELOBLASTOMA
 Comes from craniopharyngiomal/ Rathke's
pouch tumor.
 Can enter CNS and destroys the pituitary
gland (which control many hormones).
e. ADAMANTINOMA OF LONG BONES
 Happens 90% in tibia, ulna, femur, fibula.
 Not related to ameloblastoma of the jaw.

DIFFERENTIAL DIAGNOSIS
CEOT
Odontogenic myxomas (luscent)
Dentigerous cysts
Keratocysts
Non-odontogenic: Central giant cell
granuloma, ossifying fibroma, central  Snow flaked (luscent or with
hemangioma, idiopathic histocytosis calcifications)
Treatment and prognosis  Unilocular or multilocular radiolucent.
 Solid and multicystic: Surgical  Margins: scalloped, well-defined
excision up to resection (for larger  Associated with an impacted tooth.
lesions).  Calcified structures
 Unicystic: Enucleation up to excision

Recurrence rate: 50-90%

2. CALCIFYING EPITHELIAL
ODONTOGENIC TUMOR (CEOT)
 Pindborg Tumor
 Histologically, NO resemblance to
ameloblastoma but similar in other clinical
features.
Etiology
 Unknown. Although dental lamina
remnants and the stratum intermedium
of the enamel organ have been
suggested.
 Peripheral: cupped-out erosion of the
underlying bone.
Histopathology
 Polygonal epithelial cells with nuclei in
varying shapes and number.
 Abundant cytoplasm, eosinophilic
 Amyloid, extracellular product
(droplets)
o (+) for amyloid under Congo Red
stain under polarized light w/
thioflavin T CUV

Clinical features
 2nd — 10th decade, 40 y.o.
 No gender predilection
 Md (2x more prone) molar-ramus area>
mx.
 If there are peripheral lesions, they are  Leisegang rings (concentric calcified
usually seen in the anterior gingiva. deposits)
 Noted through jaw expansion or o Characteristic annular staining
radiograph. pattern.
 Usually associated with impacted tooth. o The calcified deposits cause it to be
 Painless, slow-growing swelling. radiopaque.

Radiographic features
 Honeycombed (uni or multilocular)

Differential Diagnosis
 If Luscent: dentigerous cyst, keratocyst,
ameloblastoma, myxomas
 If Mixed: COC
 AOT, amelo fibroodontoma, ossifying
fibroma, osteoblastoma
Treatment and Prognosis
 Has invasive potential but apparently
not to the extent of ameloblastoma.
 Conservative local resection (including
a narrow rim of surrounding bone).
Posterior maxilla - more aggressively
 Rare malignant transformation.
 Metastasis not reported.
Recurrence rate: <20%
3. ADENOMATOID ODONTOGENIC
TUMOR (AOT)
 2-7% of all odontogenic tumors.
 Epithelial odontogenic hamartoma
containing pseudoducts and enameloid.
 Initially thought to be a subtype of
ameloblastoma.
 Benign
 Unknown etiology
 Thought to behave more like a hamartoma
than neoplasm.
Clinical features
 5-30 y.o., 2nd decade
 F>M
 Mx>Md
 Anterior maxilla (2/3), associated with
impacted tooth (mostly canine).
 Mx anterior (50%) > Md Anterior (35%),
Mx posterior > Md posterior.
 Peripheral type is rare.
 Tumor tissues proliferate into lumen.
 Well encapsulated cyst like spaces.
 Asymptomatic painless expansion of the
bone.
 Discovered on routine radiographic
examination.
Radiographic features
 Enameloid island: small opaque foci
 Well circumscribed unilocular lesion
with impacted tooth.
Histopathology
 Polyhedral to spindle shaped cells.
 Lobular > syncytial arrangement
 Rosettes or duct like structures with
columnar epithelial cells.
 Foci of enameloid.
Differential Diagnosis
 Dentigerous cyst (because of frequent
association with impacted teeth)
 Lateral cyst (because of its occasional
location adjacent to roots of anterior
teeth)
 CEOT, COC (if opacities are evident)
o Higher tendency to occur on
anteriors.
Treatment and Prognosis
 Enucleation: depends on the
size/extent; do biopsy first (more well-
defined border).
 Conservative treatment (enucleation) is
all that is required since AOTs are
o Benign
o Encapsulated
o Usually do not recur
 Histopathology
 Lining of cystic areas consists of
squamous epithelium with cuboidal or
ameloblast-like basal cells.
 Ghost cells:
o Large, eosinophilic cells that
contain the outline of a nucleus
centrally and represent aberrant
keratinization.
o Dentin formation is seen as masses
4. DENTINOGENIC GHOST CELL of hard tissue within the wall and
TUMOR assoc with epithelial component.
 Formerly known as Calcifying Odontogenic
Cyst.
o Calcifying cystic odontogenic tumor
(cyst)
o Dentinogenic ghost cell tumor
o Dentinogenic ghost cell carcinoma
 Considered as a developmental lesion,
occasional aggressive behavior.
 Ameloblastomatous epithelium containing
"ghost cells" within the epithelial
component.

Etiology
 Believed to be derived from
odontogenic epithelial remnants within
Treatment
the gingiva or within the mandible or
 Local resection
maxilla.
 Extraosseous variant is treated by
enucleation.

Radiographic features
 Circumscribed with a mixed lucent and
opaque quality.

5. SQUAMOUS ODONTOGENIC TUMOR

Clinical features
 Rare tumor affecting mainly young
adults, 2nd-7th decade, mean age 40.
 No gender predilection
 Involves alveolar process: Mandible
(post) and/or Maxilla (ant).
 Usually found close to the roots of
erupted teeth.
  No symptoms
Etiology
 From neoplastic transformation of the
rests of Malassez.
Radiographic feature
 Well circumscribed, often semilunar
lesion associated with the cervical
region of roots of teeth.
 Not specific or diagnostic
 Mimic severe bone loss from
periodontitis.
 Consist of a triangular radiolucent defect
lateral to the root or roots of the teeth.
 Exceed 1.5 cm
Histopathology
 Circumscribed/ rounded or more
irregular islands of squamous epithelium
with flattened peripheral cells are set in
a fibrous stroma.
 Foci of keratin or parakeratin, which
may contain laminated calcifications or
globular eosinophilic structures.
Treatment
 Curettage and extraction of involved
teeth
o Benign, but maxillary lesions may
invade adjacent structures
occasionally.
Recurrence: few instances
6. CLEAR CELL ODONTOGENIC TUMOR
 A carcinoma, rare neoplasm of the jaws
 Etiology unknown
 Age > 60y.o., women more affected
 Either jaw
 Occasionally painful
 Locally aggressive, poorly circumscribed
neoplasm composed of sheet of cells with
relatively clear cytoplasm.
 Recurrence as high as 50%
 Metastases to lung and regional lymph
nodes.
Histopathology
Differential Diagnosis
 CEOT
 Central mucoepidermoid carcinoma
 Metastatic acinic cell carcinoma
 Metastatic renal cell carcinoma,
 Hyalinizing clear cell carcinoma
  Ameloblastoma

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