Odontogenic tumors /certified fixed orthodontic courses by Indian dental academy

ODONTOGENIC TUMORS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


INTRODUCTION
• Uncommon lesions
• Derived from the specialized dental tissues
• Primarily Intra Osseous (Central)-although
some are Extra Osseous (Peripheral)
• Varied clinical and radiological appearance
• Can consist entirely of soft tissue, mixture of
soft and calcified tissue or entirely of hard
tissue.
• Express wide range of biological behavior.various methods of treatment modalitiescons to very aggressive (radical).

– The permutation
of different cells
of different origin
makes
odontogenic
tumors a highly
complicated
group of lesions

Odontogenic tumors
Normal odontogenesis
Epithelium

undifferentiated
mesenchymal cells of dental papillae

odontoblasts

dentin

enamel matrix formation by the ameloblasts

Classification
1.WHO

2.KRAMER, PINDBORG
AND SHEAR 1992

Classification
Based on the extent of connective tissue changes
induced by epithelial tissue.

I. Epithelial odontogenic tumors
1.Tumors producing minimal inductive change
connective tissue
a. Ameloblastoma (adamantinoma)
b. Calcifying epithelial odontogenic tumor(pindborg)
c. Odontogenic adenomatoid tumor (AOT)

2.Tumors causing extensive changes
a. Ameloblastic fibroma
b. Ameloblastic fibro-odontoma
c. Odontoameloblastoma
d. Odontoma 1. Compound composite odontoma
2. Complex composite odontoma

II Mesodermal odontogenic tumors
1. Central odontogenic fibroma
2. Odontogenic myxoma (myxofibroma)
3. Cementoma a.Peripheral cemental dysplasia(Cementoma)
b. Cementifying fibroma
4. Dentinoma

c Benign cementoblastoma


III Tumors of unknown origin
1. Melanotic neuroectodermal tumor of infancy
(melanotic progonoma, retinal anlage tumor)
IV Malignant odontogenic tumors
1. Odontogenic carcinoma
a. Primary intro osseous carcinoma
b. Malignant ameloblastoma
2. Odontogenic sarcoma
a. Ameloblastic fibrosarcoma
b. Ameloblastic odontosarcoma

Classification
• 2.KRAMER, PINDBORG AND
SHEAR 1992


ODONTOGENIC EPITHELIUM
WITHOUT ODONTOGENIC
ECTOMESENCHYME
–AMELOBLASTOMA.
–CEOT (PINDBORG’S)
–CLEAR CELL
–SQUAMOUS ODONTOGENIC

ODONTOGENIC EPITHELIUM WITH
ECTOMESENCHYME WITH OR WITHOUT
DENTAL HARD TISSUE

•
•
•
•
•
•

Ameloblastic fibroma
Ameloblastic fibro-odontoma
Odontoameloblastoma
AOT
Complex odontoma.
Compound odontoma

Odontogenic Ectomesenchyme
with or without O.Epithelium :

–O.Fibroma
–O.Myxoma
–Benign Cementoblastoma


MALIGNANT
•
•
•
•
•
•

Odontogenic carcinoma
Malignant ameloblastoma
Primary intra osseous carcinoma
Malignant changes in cyst
Odontogenic sarcomas
Carcinosarcomas

AMELOBLASTOMA


• WHO (1992)
“Is a true neoplasm of

enamel organ like tissue
which does not undergo
differentiation to the point
of enamel formation”

Robinson described it
as

• A TUMOUR THAT IS USUALLY
UNICENTRIC,
NONFUNCTIONAL
INTERMITTENT IN GROWTH
ANATOMICALLY BENIGN
CLINICALLY PERSISTENT

Synonyms :
–Adamantinoma
–Multilocular cyst
–Adamantoblastoma
–Eve’s Diesease

History :
• CUZACK (1827)- FIRST
RECOGNIZED
• FALKSON (1879) – DESCRIPTION
• MALASSEZ (1885) –
ADAMANTINOMA
• IVY &CHURCHILL (1934) –
AMELOBLASTOMA
• Unicystic ameloblastoma- Robinson
and Martinez in 1977

Pathogenesis: stimulus is unknown,source of
epithelium is from
1.Cell rests of enamel organ,remnants of dental lamina
or Hertwig’s sheath and epithelial rests of malassez.
2. Developing enamel organ
3. Basal cell of the surface epithelium of the jaws
4. Heterotrophic epithelium of the other parts of the
body
5. Epithelium of the odontogenic cyst (dentigerous cyst
and odontomas)

extra osseous
• Dental lamina
ameloblast
• Oral epithelium


Incidence
–1% of oral tumors
–18-20% of odontogenic
tumors


Clinical features
–20-50 years
–Number of cases reported in
children
–Youngest reported one month
old
–Oldest 98 yrs

– Frequent in
mandible than
maxilla(80% in
mand.20% in
max.
– 3:1
– In mandible75% in molar &
ramus
– In maxillacommon in
tuberosity www.indiandentalacademy.com
area

• Often associated with Impacted tooth.
• Start to grow in the cancellous bone of
the mand & may attain a substantial
size before the outer contour is altered.
• Later both lingual & buccal cortical
plates expand
• They can reach to enormous size
without either invading or ulcerating
thro’ soft tissue
• Pain or sensory nerve damage occur
only if infection supervenes.

Signs & symptoms
–Asymptomatic
–Asymmetry
–Slow growing
– non tender
–Later stages
pain

–Secondary infection
–Ulceration
–Egg shell crackling
–Extra osseous Small nodule
–Draining sinuses

Clinical classification
Anatomic site
– Central /intraosseous
• Conventional/Multicystic
• Unicystic
• solid
– Peripheral/ extra osseous
– Malignant
– Pituitary ameloblastoma
(craniopharyngioma,or Rathke’s pouch
tumour)

Radiographic appearance

Lagundoye et al (1975) classified
ameloblastoma in 4 types
1.Multiloculated, multicystic
2. Unilocular
3. Septate-trabeculated
4. Solid type

Radiological features
• Numerous well defined radioluscency
of varying diameter
• Honey comb or Soap bubble
appearance
• Unicystic radiolucent lesion
indistinguishable with cysts
• Root resorption without displacement
of other teeth

Ameloblastoma
With in medullary cavity
Scalloping of inner cortex
Pressure erosion.
Shell of the original cortex remains.


C T SCAN
• Show edge definition.
• Extensions
• Involvement of the vital structures
MRI
Show soft tissue involvement & extensions


–When maxillary sinus involved
–Cloudiness of sinus
–Destruction of wall
–Nasal obstruction
–Bleeding & trismus
–Unicystic in maxilla

Histopathology
–Follicular
–Plexiform
–Acanthomatous
–Granular cell
–Desmoplastic
–Basal cell type

Pathological features
Grayish firm tissue exhibiting cystic area
containing clear to yellow fluid.
Two major forms
1..Follicular : (Common)Epithelial islands
consisting of 2 Different components
1.Central and 2.Peripheral portion
2. Plexiform : Sheets and Cords of collumunar
epithelial cells in slender double collumns

plexiform


acanthomatous


Granular cell


desmoplastic


Basal cell


Unicystic ameloblastoma
Ackerman in 1988
–Type-I Intra Luminal
–Type-II Mural ameloblastoma
–Type-III Invasive ameloblastoma

DIFFERENTIAL DIAGNOSIS
– Multilocular cyst
Dentigerous cyst
odontogenic kerato cyst
– Giant cell granuloma, cherubism
– Brown’s tumor
– Central hemangioma
– odontogenic myxoma

Management
of
Ameloblastoma

• Radical treatment
– En-bloc or marginal
mandibular
resection
– Segmental
mandibular
resection including
hemi-mandiblectomy
– Marginal (partial)
maxillectomy
– Maxillectomy
Cautery (not common mode of therapy)
Radiotherapy and laser therapy
Reconstruction and rehabilitation.

• Conservative
treatment
– Curettage
– Cryotherapy

• CURETTAGE – Removal of tumor by scraping
it from the surrounding normal tissue.

• CAUTERY-Desiccation or electro
coagulation of the lesion,including
various amounts of the surrounding
normal tissue and
• EXCISION - Local surgical removal with an
attempt to include a rim of uninvolved tissue.


• ENBLOC RESECTION - Removal of
tumor with a rim of uninvolved bone but
maintaining the continuity of the jaw.
• SEGEMNTAL RESECTION -Removal
of segments of mandible or maxilla,up to
and including hemi section or more.

• combination of these procedures.


CONSERVATIVE TREATMENT

Complications
• Extension into vital
structures
• Seeding into lungs
• Direct extension into brain
• Malignant transformation

CONSERVATIVE TREATMENT

En-Bloc Resection


Segmental Resection


Partial Maxillectomy


Treatment Protocol
1. Definitive & offer best cure
2. Curettage and enucleation –
recurrence
3. Curettage condemned
4. Cancellous bone – readily
infiltrated resorbed by tumor
5. Dense cortical bone - temporary
barriers

A safe margin of uninvolved bone is
2 cm for solid and multicystic
lesion
1-1.5 for unicystic and peripheral
lesions
Resorption of cortical bone –
periosteum involved –
surrounding soft tissue and
muscle
Post treatment follow up 15-20 yrs

– IMMEDIATE
RECONSTRUCTION
–DELAYED
RECONSTRUCTION

Unicystic ameloblastoma
– Initial diagnosis
- Dentigerous cyst or OKC
– Enucleation or marsupialization?
– Careful assessment
– Biopsy may not confirm
– Microscopic section R without CD or
R with CD

A cystic
ameloblastoma
associated
with an unerupted
and displaced
molar tooth
in a child. Note the
hint at
compartmentalizati
on
(multilocularity). It
resembles an
ordinary
dentigerous cyst
except that
dentigerous
cysts are ordinarily
unilocular

Peripheral ameloblastoma
– Enmass excision
– With overlying mucosa periosteum
alveolar bone and adjacent teeth
– 1-1.5 resection margin
This tumor
arises from rests of
Serres or alternately from
basal epithelial cells in
the gingiva in a manner
analagous to cutaneous
basal cell carcinoma.

Cautery
• Chemical agents
• Electro cautery
• Cryotherapy


Carnoy’ solution
• Culter & Zollinger 1933
• Composition
–Glacial acetic acid-6 ml
–Absolute alcohol -3 ml
–Chloroform -3 ml
–Ferric chloride -1 gm
• Depth of penetration 1.5-1.8 mm

Unicystic ameloblastoma – use
of Carnoy’s solution after
enucleation
–P K Lee N Samman
–Int J Oral Maxillofac Surg
2004; 33 ; 263-7


EXTRAORAL EXAMINATION


INTRAORAL EXAMINATION
• PERICORNITIS WITH 48


RADIOGRAPHIC EXAMINATION


HISTOPATHOLOGY


FOLLICULAR( CYSTIC)
AMELOBLASTOMA


RESECTED HEMIMANDIBLE WITH TUMOR MASS


POSTEROMEDIAL VIEW

SUPEROLATERAL VIEW


RECONSTRUCTION


RECONSTRUCTION PLATE WITH
CONDYLE


RADIOTHERAPY
– Inoperable cases
– Invasion into cranium
– Primarily intraosseous- resistant
– Extra osseous ameloblastoma reduced
– Possible osteoradionecrosis
– Cause of metastasis

conclusion
•
•
•
•
•

Careful examination
Appropriate treatment
Complete cure
Reconstruction
Follow up


ADENOMATOID ODONTOGENIC TUMOR
(AOT),ADENOAMELOBLASTOMA
• This is a tumor mostly of teenagers.
• It occurs in the middle and anterior portions
of the jaws in contrast to ameloblastoma
which is found mostly in the posterior
segment
• Two-thirds occur in the maxilla. Anterior
• more common in females.
• This tumor is encapsulated.
• It is treated by curettage with a recurrence
rate approaching zero
• The radiographic appearance is a unilocular
radiolucency,
• often around the crown of an unerupted
tooth in which case they resemble a
dentigeous cyst www.indiandentalacademy.com

Adenomatoid
odontogenic tumor
(AOT)
associated with an
unerupted tooth #13. It
resembles a
dentigerous
cyst. Some AOTs
produce
calcifications that
may appear as
“snowflake”
densities.

Adenomatoid odontogenic tumor
Histologic examination reveals a thick
capsule of fibrous connective tissue.
The tumor fills the central
cavity, there is little stroma.
Tumor cells frequently
form ball-like structures referred to as
“rosettes”

Adenomatoid
odontogenic
tumor
Note how the
tumor cells
form balls of
cells that are
called
rosettes.
Another identifying feature is the presence of ductlike
structures

Calcifying epithelial odontogenic
tumor (CEOT,Pindborg tumor)
Rare. First desribed by JJ Pindborg in 1958.
This is the most “unodontogenic”
tumor of the group, the tumor cells do not resemble
odontogenic tissue.
Pathogenesis:
1.From reduced enamel epithelium - Pindborg 1958
2. From the stratum intermedium of the enamel organ- Gon 1965


• Clinical features:
• 1. Associated with unerupted or
impacted or embedded tooth.
• 2. Painless mass and slow growth.
• 3. Mandible > maxilla, Men > women,
Seen in range of 8-82 years
• 4. More often in molar region.

Pathological features:
- Polyhedral epithelial cells seen
-Amyloid, basal lamina, dentin and keratin
appear as a homogenous substance
(Characteristic feature of CEOT)
-Calcification are seen. It calcifies in a
concentrically lamellated“tree-ring”
pattern known as Liesegang
calcifications.This explains the name of
calcifying epithelial odontogenic tumor.

CEOT, high
power view. The tumor
cells resemble squamous
epithelium more than
odontogenic epithelium.
There is some variation
in nuclear size and
shape, but this is not a
malignant tumor.
Calcifications
(extreme left) in a CEOT
account for the density
noted on radiographs.
These are thought to be
calcified amyloid or
amyloid-like material,
some of which can be
seen right of center as a
pale eosinophilic globule
(arrow).

Radiological features:

• Chaudary (1972) -three stages of
development of CEOT
• I stage: Radiolucent appearance same
like dentigerous cyst
• II stage: Minute calcifications appear.
• III stage: Honey combed appearance
Calcifying epithelial
odontogenic tumor in
the body of the
mandible. It appears as
a radiolucent lesion with
www.indiandentalacademy.com dense areas.
smokey

Treatment
CEOT lacks a capsule but apparently does not infiltrate
as deeply into surrounding tissues as does
ameloblastoma. Excision with a small margin of
surrounding bone is usually curative.

Intraosseous lesions: Marginal or segmental resection

Extraosseous lesion : Simple local excision


AMELOBLASTIC FIBROMA
• This is a tumor of childhood, the typical
patient is about 12 –14 years old, seldom is it
seen beyond age 20.
• The posterior segment of the mandible is the
most common location.
• Local swelling or failure of teeth to erupt on
time or improper alignment may call attention
to the tumor.
• Ameloblastic fibromas are
purely radiolucent.

Ameloblastic
fibroma in and around
the crowns of lower
molar teeth. It is subtle,
the second deciduous
molar tooth has been tilted
downward by the
tumor. Patient was a 5
year old boy.

Small lesions may be unilocular but larger
lesions are ordinarily multilocular.

• Both odontogenic epithelium and
odontogenic ectomesenchyme
contribute to this tumor
• (an odontogenic mixed tumor not to be
confused with the mixed tumor of
salivary gland).
• The epithelium grows in small islands
Ameloblastic
and cords
fibroma, medium power.
Islands of odontogenic
epithelium exhibit
peripheral columnar cells.
The stroma is cellular
ectomesenchyme that
resembles the dental
papilla, the forerunner of
the dental pulp.

Ameloblastic
fibroma, high
power.
Cords of epithelium
lie in an
ectomesenchyme
stroma.


ODONTOMA:
COMPOUND AND COMPLEX
TYPES
• Defined as benign tumors of the dental hard
tissues with the word composite used to
designate the presence of the four dental
tissues – enamel,dentin,cementum,pulp.
• The tumors in which odontogenic
differentiation is fully expressed are the
odontomas
• In these tumors, the epithelium and
ectomesenchyme realize their potential and
make enamel and dentin respectively.
• As a result,these tumors are mostly
radiodense.

Compound composite odontoma
• Odontomas with calcified structures
bearing some degree of resemblance
anatomically to normal teeth.
• Occurs in second or third decade of life.
• Slow growing, non infiltrating malformation
• Occurs primarily in incisor and canine
region of maxilla
• Non aggressive, self limiting growth.

RADIOGRAPHIC FEATURES
In the compound
odontoma,
multiple small
and malformed
tooth-like
structures are
formed creating
a “bag of
marbles”
radiographic
appearance .


Compound odontoma in the body of the mandible
of a 17 year old boy

These lesions are generally sit. between the
roots of the erupted teeth.
The lesion is well demarcated from surrounding bone
by a thin radiolucent line representing the follicular capsule

PATHOLOGIC FEATURES
• It consist of mostly dwarfed teeth with
malformed crown and roots. The No. vary
from 2 to 2000.
• Different components such as enamel,
dentin, cementum, pulpal tissue is
present in disoriented fashion.
• There is generally a surrounding capsule
representing the dental follicle.
• There may be inductive hyalinization of
the surrounding connective tissue.

Compound
odontoma of tumor .
the small,closely
spaced white
bodies are individual
malformed tooth-like
structures.

E
D
P

Compound odontoma,
photomicrograph
of decalcifed specimen. Note
the structure that resembles a
tooth with a pulp (P), a
surrounding
mantle of dentin (D) capped
by enamel (E), center and left
of center.


SURGICAL CONSIDERATIONS
• They are removed surgically to prevent
cystic change, bone destruction and to
their interference with normal eruption
of the permanent teeth.
• Recurrences are rare and can be
prevented by removing the entire soft
tissue portion.

COMPLEX COMPOSITE
ODONTOMAS

• It represents an abortive attempt at
tooth formation.
• Structural differentiation is poor.
• The end result being a calcified mass
displaying a disorderly pattern of hard
tissues.
• There is little resemblance to tooth
form. The dentin and enamel are
entwined in a mass that bears no
resemblance to teeth. The result is a
solid, dense mass of hard tissue.

Radiological Features
Complex odontoma,
posterior maxilla of a
child.

Nodular radiopacity with a density approximating
that of tooth structure
Surrounding opacity is radioluscent area
representig the follicle

Complex odontoma in
anterior maxilla.
Deciduous tooth
is retained.


• Site – posterior part of mand.
• Age -2 ,3 decade of life
• Potency to grow to a large size.

Treatment
• Enucleation & curettage


Periapical lesions
•
•
•
•
•
•

Periapical cemental dysplasia
( Cementoma, periapical osteofibrosis,
periapical dysplasia)
Common cementum producing lesion.
Incidence  2-3 per thousand pts. Gorlin
(1958)
83% in black people
Primarily affects women  91% (Zegarelli
1964)
Average age  39 yrs. Rarely before 20
yrs.
Lesions are multiple & 77% occur in
ant. Mand. Regn.

• Radiographically  3 distinct stages /
considered
progressive.
• First osteolytic stage ( radiolucent like
lesion surrounding apex )
• Second stage – intermediate referred to as
cementoblastic ( partially calcified & show
central area of opacity )
• Third or mature stage ( completely radio
opaque surrounded by a thin radiolucent
line )
• Limited growth potential / rarely grows
larger than 5 mm.

• Microscopically  Variation in presention
depending on stage of development.
• Early lesion  composed of collagen producing
fibroblasts & nutrient vessels. As it matures
fibroblasts differentiate into cementoblasts or
osteoblasts. Followed by formation of
cementicles which coalesce to form solid masses
of cementum. Occasionally incremental lines may
give pagotoid appearance.
• Diagnosis  By Radiographic & Clinical evalun.

• Differential diagnosis  Periapical
cyst or
Granuloma
• Treatment : Observation ( Limited
growth potential )
• Surgical removal  Often renders
adjacent teeth Nonvital.

CEMENTOBLASTOMA
(TRUE CEMENTOMA )
As a group, odontogenic tumors are not
common.
Cementoblastoma is among the rarest of the
rare.
This tumor typically occurs around the roots of
the lower
posterior teeth.
Like virtually all odontogenic tumors,it is
benign but
expands the jaw,www.indiandentalacademy.com requires
causes pain and
surgical removal.

Radiographically
it appears as a ball of dense material
attached to the end of the root

Cementoblastoma,
typical radiographic
appearance of a ball of
cementum clinging to the
root.

Cementoblastoma,
gross specimen.

This dense material is presumed to be
cementum and the tumor cell line that
secretes it is cementoblasts,
w
hence the name. ww.indiandentalacademy.com

So why the other name
“true cementoma”?
Recall that the lesion we know as cementoma is a selflimiting lesion ordinarily found in and around the
apices of the lower incisor teeth.
But the cementoblastoma is not self-limiting, it
continues
to grow until it is removed, hence it is a “true” tumor,
a true cementoma.
Maybe we should call the self-limiting
cementoma by its other name, periapical cemental
dysplasia.

Histologically
• the mass of cementum is attached to the
tooth root.
• As it expands, the cementoblasts at the
periphery add new cementum.
Cementoblastoma, medium
power histopathology of the
decalcified specimen.
The field is dominated by
sheets of cementum with a
C rim of cementoblasts (C) with
an outer
www.indiandentalacademy.com rim of normal bone

Thank you
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Odontogenic tumors /certified fixed orthodontic courses by Indian dental academy

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