Odontogenic tumors

Dr.Haytham Issa
Ass.Professor and Head of OMFS
department
 classifications
• Benign
• Tumors of odont. Epi :-
Ameloblastoma
Calcifying epi odont. Tumor
Squamous odont. Tumor
Clear cell odont . Tumor
• Tumors of odont. Epi &ectomesenchyme
Ameloblastic fibroma
Ameloblastic fibro-odontoma
Odonto ameloblastoma
Adenomatoid odont . Tumor
Complex odontome
Compound odontome
 tumors of odontogenic ectomesenchyme ± included odontogenic
epithelium

• Odontogenic fibroma
Granular cell odontogenic tumor
• Odontogenic myxoma
• Cementoblastoma
• Malignant
Odontogenic ca .
Malignant ameloblastoma
1ry central ca
Malignant variants of other odont. Epi. Tumors
Malignant changes in odont . Cysts
Ameloblastic ca .
Odontogenic sarcomas
Ameloblastic fibrosarcoma
 Ameloblastoma
• The most common clinically significant and potentially
lethal odontogenic tumour
• It’s incidence equals or exceeds the combined total of
all other odontogenic tumours excluding odontomas
• Origin : It may arise from :-
*rests of the dental lamina
*developing enamel organ
*epi. lining of odontogenic cyst
*basal cells of the oral mucosa
 Clinical picture

 Painless expansion of
the jaws
 neurosensory changes
are uncommon even with
large tumours
 Slow growing , locally
invasive , benign course
in most cases
 Classifications &Management

 Conventional solid or multicystic (92%)

 unicystic (6%)

 peripheral (extraosseous) (2%)

 Solid or multicystic ameloblastoma

• Age : _ wide range (3rd to 7th decades )

_ rare in children
• no gender predilection
• more common in black Americans & west
Africans
• 85% in the mandible (molar / ramus reion)
15% in the maxilla ( posterior region )
 Radiographicaly

• Multilocular radiolucency
• buccal and lingual cortical
expansion is common
• root resorption is common
• often associated with
unerrupted tooth (3rd
molar)
 Histologic patterns
• most common:-
follicular
plexiform
• less common:-
acanthomatous
granular cell
desmoplastic
basal cell variant
 follicular
The most common

Islands or follicles of tumor cells

resemble the normal dental follicle
(enamel organ epi ) in a mature
fibrous CT stroma

Thse nests consist of a single layer of

tall columnar or cuboidal ameloblast
like cells
Their nuclei are located at the opposit pole to the
basement membrane

Central to these cells are loosely arranged angular cells

resembling the stellate reticulum of an enamel organ
 plexiform
Long anastomosing cords or larger sheets of odont. Epi .that are
bounded by ameloblast like cells sorrounding more loosely
arranged stellate reticulum like cells

The supporting stroma tends to be loosely arranged & well

vascularized
• acanthomatous : squamous differentiation of the odontogenic
epi. (In the central portion of the island may confused with SCC )

• granular cell : the tumour islands exhibit cells that demonstrate

abundant granular eosinophilic cytoplasm
• desmoplastic : extremely dense collagenized stroma that support
the tumor may not appear radiolucent
• basal cell variant :nest of uniform basaloid cells (CUBOIDAL
NOT COLUMNAR ) are present and the stellate reticulum is not
present in the central portion of the nest
 Treatment &Prognosis

• the most controversial

• ranging from simple enucleation and curettage

to resection
• the solid or mulicystic A.B tends to infiltrate
between intact cancellous bone trabeculae at
the periphery of the tumour before bone
resorptiom become radiographically evident

• so the conservative treatment may result in a

very high recurrence rate
• It is recommended that the best treatment for
the solid or multicystic A.B. is resection with
1cm linear bony margins .
• this linear bony margin should be confirmed
by intra operative specimen radiographs
• soft tissue margins are best managed
according to the anatomic barrier margin
principles (one uninvolved surrounding barrier
is sacrificed.
 unicystic
ameloblastoma
most commonly
seen in young patients
(50% in the 2nd decade

 more than 90% of

this type are found in
the mandible
(molar/ramus region )
unilocular
radiolucency
mimicking dentigerous
cyst
 Histopathologic variants
 luminal unicystic A.B.

 Intraluminal unicystic A.B.

 Mural unicystic A.B.

 luminal A.B.
• the tumour is confined to the luminal surface
of the cyst
• the lesion consist of fibrous cyst wall with a
lining that consist totally or partially of
ameloblastic epi.
 Intraluminal A.B.
• contains one or more nodules of A.B.
projecting from the lining to the lumen

• it resemble the plexiform pattern of the multi

cystic A.B.
 mural A.B.
• the fibrous wall of the cyst is infiltrated by
typical follicular or plexiform A.B.

• the extent and infiltration may vary from case

to case
 Treatment &prognosis
• since the clinical and the radiographical pictures
of the unicystic A.B. and the cyst are nearly the
same the surgeon should :
-request the pathologist to obtain multiple
sections through many levels

- histopathologic examination should occur with

frozen sections especially in large lesions
The enucleation &
curettage has
probably curative
treatment in case of
luminal and
intraluminal
unicystic
ameloblastoma .
 in case of mural A.B. The management is
controversial :
.....if the Dx is made post op. :close follow up is
very important
......if the Dx is made pre op. : the best treatment
is by resection because this variant has a
higher rate of persistence
• The recurrence rate of all unicystic
ameloblastoma following enucleation &
curettage has been reported as 10 to 20 %
which is significantly lower than that of
enucleation & curettage of solid or multicystic
ameloblastoma
Absolute indications for resection
 Solid or multicystic A.B.
 recurrent unicystic A.B.
 mural A.B.
 Very large tumour in which enucleation &
curettage will result in resection of the
involved jaw
 Peripheral Ameloblastoma
 The most rare variant
 May arise from rest of dental lamina or basal
epi. Cells
 Clinically : nonulcerated sessile or
pedunculated gingival lesions
 Wide age range (average 52 year )
 Treatment and prognosis : wide local
excision ....malignant transformation is very
rare
 Malignant Ameloblastoma & Ameloblastic
ca
 Very rare
 Most common sites of mets are the lungs
(may be aspiration phenomena ) followed BY
cervical lymph nodes &visceral organs
 Mostly arise from solid A.B.
 Histopathologically :features of malignancy
 Radiograph : more aggressive
 Treatment : resection
 Prognosis : very poor 50% die in 5 years
 D.Dx
• Multilocular RL
- kertocyst
- Aneurysmal bone cyst
- Myxoma
- CGG
- Cherubism
- Central mucoepidermoid Ca .
- Central Hemangioma
• UNILOCULAR periapical RL :-

- PA granuloma
- PA cyst
- Chronic PA abscess
- Early cementoma
 Squamous odont . Tumor
• Rare, benign , locally invasive tumor
• This tumor appear to originate within the PDL of
the lateral root surface of erupted tooth
• Mandible = maxilla
• Favoring ant. Maxilla & post mandible
• Age :- wide range ….40 years (mean )
• No gender predilection
• Asymptomatic ( some times tenderness & tooth
mobility
• Radiographically :-

usually well defined semilunar RL between roots

• RX & prognosis

- Coservative
- Maxillary lesion >>> more serious ( porous &
spongy bone )
 CEOT( Pindborg tumor )
• 1% of all odont tumor
• Locally aggressive
• Mostly between 30-50 years old pt
• No gender predilection
• Mandible affected twice as often as the
maxilla ( molar – ramus )
• Painless slow growing
 R. G

• Uni or multi locular RL. That are frequently

associated with impacted teeth
• Frequently contains RO foci of varying sizes &
density
 DDx
• When it is RL
- Dentigerous cyst
- OKC
- Unicystic AB
- Benign non odontogenic jaw tumors
- Early stage COC OR AOT
- Ameloblastic fibroma
- Odont. Fibroma
• When a mixed RL\RO pattern
- COC
- AOT
- Odontoameloblastoma
- Ossifying fibroma
- Osteoblastoma
• Histopathology
- Islands , strands of large polyhedral epi cells in fibrous
stroma with distinct cellullar outline & intercellular
bridges
- Their nuclei show considerable variation in size , shape
& numbers
- The tumor sheets frequently enclose masses of
amyloid like materials
- Concentric calcific deposits ( liesegang rings )may be
seen in the amyloid material
 Rx & prognosis

• Recurrence rate < 20%

• Mets have not been reported
• Enucleation to resection
 Clear cell odont tumor
• Rare benign locally aggressive tumor
• Clear cells are the prominent feature
• Mostly > 50 yrs old pts
• Mand = max.
• Symptoms free or bone swelling and loose
teeth
 RG

• Poorly defined uni or multi locular RL

 HISTOPATHOLOGY
• Large sheets of clear cells with central nuclei
• Well defined cell membrane
• Tumor cells invade the sorrounding tissues
• Area of hemorrhage may be seen
 DDx
• Central 1ry malignant neoplasm
• Mets tumors
 Rx & prognosis

• Should be treated as malignant lesion since it

is aggressive lesion with local & distant mets
 • Tumors of odont epi &
ectomesenchyme in origin
 Ameloblastic fibroma
• Uncommon benign True mixed odont. Tumor
• Mostly in the 1st 2 decades ( 12 yrs mean )
• No gender predilection
• 70% in the posterior mandible
• Either asymptomatic or associated with slowly
growing painless swelling
 RG

• Well defined uni or multilocular RL

• Usually surrounded by a sclerotic ring
• 50% of cases associated with unerupted tooth
 Histopathology

• Primative myxoid CT that resembles the

dental pulp or immature dental papilla
• Mashroom like proliferation of odont. Epi
• A definite capsule may or may not be present
 DD
• Dentigerous cyst
• OKC
• Unicystic Ameloblastoma
• COC early stages
• AOT early stages
 AOT
• 3-7% of the odontogenic tumors
• Duct – like or gland - like structures (not clear
but more likely due to the secreory activity of
the tumor cells )
• Commonly in the 2nd decades
• Females are twice as frequently as males
• Mostly in the anterior maxilla ( generally
associated with impacted canine
 RG

• Well defined unilocular radiolucency arround

the crown of impacted tooth
• It may have fine opaque foci which
deferentiate it from the dentigerous cyst
 DD

• Odontoma
• COC
• CEOT
• odontoameloblastoma
 Histopathology
• Solid lesion or may show varying degree of
cystic change
• Well defined fibrous capsule encloses sheets ,
or strands of spindle epi cells
• Microcysts resembling ducts , tubules in cross
section lined by columnar or cuboidal cells
• Small foci of calcificatins may also scattered
throughout the tumor ?? Enamel formation
 odontoameloblastoma
• Extremely rare
• Contain ameloblastomatous component with
odontoma like elements
• More often in the mandible of younger pts
• Pain , delayed eruption & expansion may be
noted
• RG :-mixed
 Microscopically
• Epi has features of the ameloblastoma
( follicular or plexiform )
• Immature dental tissue as odontoma

• RX : as AB
 ODONTOMA
• Most common odont. Tumor
• Mixed tumors ( epi & mesnchymal tissues )
• Deposition of enamel by the ameloblast &
dentin by the odontoblasts >>> abnormal
organization of otherwise normal mature
sructures
• Subdevided into :-
- Compound odontoma :- multiple small tooth
like structures
- complex odontoma :- mass of enamel &
dentin . No anatomic resemblance to a tooth
- Both of them occur in equal frequency
• Mostly in the 2nd decade of life
• No gender predilection
• Maxilla more than mandible
- Compound more often in the anterior maxilla
- Complex in molar reigon of either jaws
 most of them are small in size & rarely exceed the
size of the tooth
 Clinical signs :- retained primary tooth . Impacted
tooth . Alveolar bone swelling
 RG
• INITIALLY crypt like … RL phase
• Intermediate stage :-mixed
• Finally RO

• Compound odontoma :- several mature teeth

in single focus usually in the teeth bearing
area ( between roots or over impacted tooth )
• COMPLEX:- appear in the same area but as a
RO mass
 Histopathology
• Developing odontoma :- structures that
resemble tooth germ are present

• Compound :- normal dental structures in a

regular pattern

• Complex :- all dental structures are present in

disordered manner
 RX

• SIMPLE EXCISION
TUMORS OF ODONTOGENIC MESENCHYME

• ODONT. FIBROMA :-
- Uncommon
- Central more than peripheral
- Originate from PDL , dental papilla or dental follicle
- All age groups
- Marked female predilection
- Mostly in the maxilla ( anterior to the first molar). In
the mandible mostly posterior to the first molar .
- May cause expansion and loosening of teeth
 RG
• SMALL …. Unilocular RL
• LARGE ….multilocular
• Root resorption is common
 Histopathology

• Proliferating fibroblast with fine collagen fibrils

& considerable ground substance
• Calcifications are present in some
cases(dentinoid or cementum like materials
 RX

• CONSERVATIVE TREATMENT
• RECURENCE >>> UNCOMMON
 ODONT. MYXOMA
• Benign locally aggressive tumor with
moderate recurrence rate
• Young are more affected
• No gender predilection
• Mandible more than maxilla
• Large lesions may cause expansion
 RG
• Multilocular RL ( HONY –COMB APPEARANCE )
• Well or ill defined
• Cortical expansion and root displacement

• RX :- aggressive treatment
 Cementoblastoma
• Rare
• Origin is the cementoblast
• Typically before 25 years of age
• Mc site >> post mand
• Associated with roots of vital teeth
• Cortical expansion
• RG L: RO mass surrounded by RL rim

• RX :- CONSERVATIVE