5. odontogenic tumor (1)

Ne o : ne w; Plasia: fo rm atio n. A neoplasm is defined as an uncoordinated
proliferation of tissue, the growth of which persists in a potentially
unlimited fashion, even after cessation of the stimulus which evoked the
change.

Definition
• Benign tumors represent a new
uncoordinated growth.
• Benign tumors are slowly growing
• No metastases
• Histologically they tend to resemble the
tissue of origin.

Clinical Features
• Insidious onset
• Grow slowly
• Painless
• Do not metastasize
• Not life threatening (unless they interfere
with a vital organ by direct extension).

• Benign tumors are detected through:
– Enlargement of the jaws
– Accidentally during a radiographic examination
– While investigating the reason of missing tooth

• When a preliminary dignosis of tumor is
made:
– a full radiologic examination should be made to
fully document the extent and characteristics of
the lesion.

Radiographic features
Location:
• Important in establishing the differential
diagnosis
• Odontogenic lesions occur above the inferior
alveolar nerve canal.
• Vascular or neural lesions may originate inside
the mandibular canal
• Cartilagenous tumors occur in jaw locations
with residual cartilagenous cells(around
mandibular condyle)

Periphery and shape
• Smooth, well defined, and sometimes
corticated.
(Because benign tumors enalrge slowly by
formation of additional internal tissue)
• Sometimes tumor produce calcified
material.
(Mature=Center / Immature:periphery)

Internal structure
• Radiolucent
• Radiopaque
• Mixed:
– Residual bone
– Calcified material
Internal pattern is characteristic for specific types of tumors and may help
with the diagnosis.

Effects on surrounding structures
• Displacement of teeth or bony cortices
(Growth is slow enough to allow remodeling)
• Resorption of roots

CLASSIFICATION
BENIGN NEOPLASMS
Odontogenic tumors Non-odontogenic tumors
A. Epithelial origin
1. Ameloblastoma
2. Adenomatoid odontogenic tumor
3. Calcifying epithelial odontogenic tumor
4. Squamous odontogenic tumor
B Mixed origin
1. Ameloblastic fibroma
2. Odontomes
C Mesodermal origin
1. Myxoma & Myxofibroma
2. Odontogenic fibroma
3. Cementifying fibroma
4. Periapical cemental dysplasia
5. Benign cementoblastoma
6. Familial multiple cementoma
A. Hyperplastic lesions
1. Polyp
2. Epulis
3. Giant cell granuloma
B. Epithelial origin
1. Papilloma
2. Adenoma
3. Pigmented nevus
4. Keratoacanthoma
C. Mesenchymal
1. Connective tissue origin
a. Fibroma
b. Lipoma / Fibrolipoma
c. Haemangioma
d. Lymphangioma
e. Chondroma
f. Osteoma
C. Mesenchymal
2. Muscle tissue origin
a. Leiomyoma
b. Rhabdomyoma
c. Granular cell myoblastoma
3. Nerve tissue origin
a. Neurofibroma
b. Neurilemmoma
c. Melanotic progonoma

Common Clinical Features
Age of occurrence: Varies with each tumor
Sex predilection: Varies with each tumor
Symptoms: Most of the tumors present as a
painless, gradually / rapidly enlarging swelling.
If infected, pain may be present. Other
symptoms include facial deformity, mobility in
teeth, numbness.
ODONTOGENIC TUMORS

Common Clinical Features
ODONTOGENIC TUMORS
Signs: The swelling has the following features:
Inspe ctio n: usually single, round or oval, well-defined
boundaries, smooth or nodular surface, normal
overlying skin or mucosa, expansion of jaw bone,
obliteration of vestibule
Palpatio n: Normal temperature of the overlying skin or
mucosa, non-tender, consistency is bony hard (if
entirely within bone); ‘egg-shell crackling’ (if
overlying bone is thin); firm (if no bone coverage),
teeth mobility, paraesthesia
Additio nalfe ature s: missing tooth or normal dentition,
displacement of teeth, pathological jaw fracture,
signs of inflammation if tumor is infected

Common Radiographic Features
ODONTOGENIC TUMORS

Ameloblastoma
• Definition
• The ameloblastoma, a true neoplasm of
odontogenic epithelium, is a persistent and
locally invasive tumor; it has aggressive but
benign growth characteristics.
• Ameloblastomas may be divided into the
solid/multicystic type, and unicystic type.

• Clinical Features
• Occur more in men, more often in black
• Ameloblastomas grow slowly, and few, if any, symptoms
occur in the early stages.
• Usually the patient eventually notices gradually increasing
facial asymmetry
• Swelling of the cheek, gingiva, or hard palate has been
reported as the chief complaint in 95% of untreated
maxillary ameloblastomas.
• The mucosa over the mass is normal, but teeth in the
involved region may be displaced and become mobile.

Inspe ctio n: single, round or oval, well-defined boundaries, smooth or
lobulated, normal overlying skin or mucosa (ulcerated if large),
expansion of jaw bone in all the 3 planes, obliteration of vestibule
Palpatio n: normal temperature of the overlying skin or mucosa, non-tender,
consistency is bony hard (if entirely within bone); ‘egg-shell crackling’
(if overlying bone is thin); firm (if no bone coverage) or soft (if
unicystic), teeth mobility, paraesthesia
Additio nalfe ature s: missing tooth or normal dentition, displacement of teeth,
pathological jaw fracture, thin straw colored fluid on aspiration
(unicystic variety) signs of inflammation if tumor is infected
ODONTOGENIC TUMORS
Ameloblastoma
(‘locally malignant’)
Clinical Features

ODONTOGENIC TUMORS
Type of lesion: radiolucent
Site: usually mandibular 3rd
molar-ramus region
Size: large lesion
Shape: unilocular (round or oval), multilocular (‘soap bubble’,
‘honeycomb’) with locules separated by bony septae
Number: single
Outline: regular or scalloped
Border: well-defined hyperostotic (‘partially hyperostotic’)
Contents: homogenous radiolucency
Additional features: impaction of tooth with displacement deep in the
jaw, expansion of jaw bone bucco-lingually, antero-posteriorly
and vertically, displacement & resorption of roots, displacement
of inferior alveolar canal, obliteration of maxillary antrum,
thinning of cortical plates, thinning of inferior border of
mandible, ‘cyst-in-cyst’ appearance, pathological jaw fracture
Ameloblastoma
Radiographic Features

• An untreated tumor may grow to great size
and is more of a concern in the maxilla,
where it can extend into vital structures and
reach into the cranial base
• Tumors that develop in the maxilla may
extend into the paranasal sinuses, orbit,
nasopharynx, or vital structures at the base
of the skull.

• Location
• Most ameloblastomas (80%) develop in the
molar ramus region of the mandible, but
they may extend to the symphyseal area.
• Most lesions that occur in the maxilla are in
the third molar area and extend into the
maxillary sinus and nasal floor.

• Periphery
• well defined and frequently delineated by a cortical border.
• The periphery of lesions in the maxilla is usually more ill
defined.
• Internal Structure
• varies from totally radiolucent to mixed with the presence of
bony septa creating internal compartments.
• Septa can be straight but are more commonly coarse and curved
• Generally the loculations are larger in the posterior mandible
and smaller in the anterior mandible.
• Effects on Surrounding Structures.
• There is a pronounced tendency for ameloblastomas to cause
extensive root resorption
• Tooth displacement is common

Differential Diagnosis:
Dentigerous cyst, odontogenic keratocyst, giant cell
granuloma, odontogenic myxoma, and ossifying
fibroma
Ameloblastoma
ODONTOGENIC TUMORS

Treatment
• The surgical procedure should take into account the
tendency of the neoplasm to invade adjacent bone beyond
its apparent radiographic margins.
• CT and MRI are useful in determining the exact extent of
the tumor.
• The maxilla is usually treated more aggressively because
of the tendency of ameloblastoma to invade adjacent vital
structures.
• Radiation therapy may be used for inoperable tumors,
especially those in the posterior maxilla.

BENIGN NEOPLASMS
Odontogenic tumors
A. Epithelial origin
1. Ameloblastoma
2. Adenomatoid odontogenic tumor
3. Calcifying epithelial odontogenic tumor
4. Squamous odontogenic tumor
5. Ameloblastic fibroma
6. Odontomes
B. Mesodermal origin
1. Myxoma & Myxofibroma
2. Odontogenic fibroma
3. Cementifying fibroma
4. Periapical cemental dysplasia
5. Benign cementoblastoma
6. Familial multiple cementoma
Non-odontogenic tumors
CLASSIFICATION

• Adenomatoid odontogenic tumors are uncommon
nonaggressive tumors of odontogenic epithelium in variety
of patterns mixed with mature connective tissue stroma.
• Can be central or peripheral
• Central tumors can be follicular or extrafollicular
• 73% of central lesions are of the follicular type
Adenomatoid Odontogenic Tumor
(‘AOT’)

Age of occurrence: mostly in 2nd
& 3rd
decades of
life
Sex predilection: 2:1 females predilection
painless, gradually enlarging swelling.
Sometimes asymptomatic, being discovered
radiographically.
Site: almost 75% of cases involve maxillary anterior
teeth
ODONTOGENIC TUMORS
(‘AOT’)

ODONTOGENIC TUMORS
(‘AOT’)
Clinical
Features
Inspe ctio n: single, round or oval, well-defined
boundaries, smooth, normal overlying skin or
mucosa, little expansion of jaw bone, obliteration of
vestibule
Palpatio n: normal temperature of the overlying skin or
overlying bone is thin); firm (if no bone coverage)
Additio nalfe ature s: normal dentition, displacement of
teeth

Type of lesion: radiolucent
radiopacities develop in about two thirds of cases.
Site: maxillary anterior region
Often does not attach at the cementoenamel junction but surrounds a
greater area of the tooth
Size: about 3 cms in diameter
Shape: unilocular (round or oval)
Number: single
Outline: regular
Border: well-defined hyperostotic
Contents: homogenous radiolucency interspersed with radiopaque foci
(‘driven snow’ appearance)
Additional features: sometimes impaction of tooth, little expansion of jaw
bone, displacement & resorption of roots, thinning of cortical plates
ODONTOGENIC TUMORS
(‘AOT’)

ODONTOGENIC TUMORS
(‘AOT’)
No radiopaque foci – ameloblastoma, ameloblastic
fibroma, odontogenic fibroma, primordial cyst,
lateral periodontal cyst
Radiopaque foci – CEOC, CEOT
Management: surgical enucleation
Image: Atlas of Oral Diagnostic Imaging by Higashi

An adenomatoid odontogenic tumor in the region of
the right maxillary canine and lateral incisor. Calcifi
cation is present within the tumor mass, and the
canine and lateral incisor have been displaced
by the lesion.

Examples of adenomatoid odontogenic tumor with various amount of internal calcification.
A, A cropped panoramic film with a totally radiolucent lesion associated with a mandibular
cuspid. B, A lesion with sparse pebblelike calcifications associated with a maxillary cuspid.
C, A lesion related to a maxillary lateral incisor with abundant calcification.

• Calcifying epithelial odontogenic tumors
(CEOTs) are rare neoplasms.
• They account for about 1% of odontogenic
tumors
• These tumors usually are located within
bone and produce a mineralized substance
• Epithelium resembles the stratum
intermedium of the enamel organ
Calcifying Epithelial Odontogenic Tumor
(‘CEOT’, Pindborg tumor)

Age of occurrence: mostly in middle aged patients
Sex predilection: more common in men
painless, gradually enlarging swelling.
Sometimes non-eruption of tooth /
asymptomatic, being discovered
radiographically
A CEOT is less aggressive than the ameloblastoma
Site: majority in mandibular premolar-molar region
ODONTOGENIC TUMORS
Clinical
Features

Inspe ctio n: single, round or oval, well-defined
boundaries, smooth, normal overlying skin or
mucosa, little expansion of jaw bone, obliteration of
vestibule
Palpatio n: normal temperature of the overlying skin or
overlying bone is thin); firm (if no bone coverage)
Additio nalfe ature s: missing tooth, displacement of teeth

Type of lesion: unilocular or multilocular with numerous scattered,
radiopaque foci of varying size and density.
The most characteristic and diagnostic finding is the
appearance of radiopacities close to the crown of the embedded tooth
Site: mandibular premolar-molar region
Size: about 3 cms in diameter
Shape: somewhat irregular
Number: single
Outline: somewhat irregular
Border: well-defined, at times diffuse
Contents: homogenous radiolucency interspersed with diffuse
radiopacities
Additional features: impaction of tooth is common, little expansion of
jaw bone, displacement & resorption of roots, thinning of cortical
plates
ODONTOGENIC TUMORS

ODONTOGENIC TUMORS
Differential Diagnosis: CEOC, AOT, intermediate stages
of fibro-osseous lesions
Management: The treatment of the CEOT is more
conservative than the ameloblastoma,
with local resection
Image: Lucas’s Pathology of Tumors of the Oral Tissues, 5th
edition

The tumor appears as
a mixed radiolucent-radiopaque
lesion associated with an unerupted
tooth.
Calcifying odontogenic
tumor, or Pindborg tumor
(arrows).

• The term odontoma is used to identify a tumor that is radiographically
and histologically characterized by the production of mature enamel,
dentin, cementum, and pulp tissue.
• It may vary from nondescript masses of dental tissue referred to as a
complex odontoma to multiple well-formed teeth (denticles) of a
compound odontoma.
• Odontomas are the most common odontogenic tumor.
• They often interfere with the eruption of permanent teeth
Odontome
(‘complex/compound composite odontome’, Odontoma)

Age of occurrence: mostly in young adults
Sex predilection: (compound )no sex predilection.
(complex) 60% occur in women
Symptoms: mostly asymptomatic, being
discovered radiographically for non-eruption
of tooth, sometimes slowly enlarging
swelling
Site: complex more common in mandibular
premolar-molar region, compound more
common in maxillary anterior region
ODONTOGENIC TUMORS
Odontome
Clinical Features

Type of lesion: radiopaque mass surrounded by a radiolucent line
and further by a radiopaque line, ‘mixed’ in early stages
Site: mandibular premolar-molar region / maxillary anterior region
Size: complex can be large, compound usually small
Shape: round or oval
Number: single
Outline: regular
Border: well-defined hyperostotic
Contents: Irregular mass of calcifi ed tissue (‘complex’) or a number of
toothlike structures or denticles that look like deformed
teeth(‘compound’)
Additional features: associated with supernumerary tooth, impaction
of tooth, little expansion of jaw bone, displacement & resorption
of roots, thinning of cortical plates
ODONTOGENIC TUMORS
Odontome

ODONTOGENIC TUMORS
Odontome
Images: Atlas of Oral Diagnostic Imaging by Higashi

in the e arly stag e : CEOC, AOT,
intermediate stage of fibro-
osseous lesions
in the m ature stag e : mature stage of
fibro-osseous lesions, osteoma
in the e arly stag e : CEOC, AOT,
intermediate stage of fibro-
osseous lesions
in the m ature stag e : mature stage of
fibro-osseous lesions, osteoma
Management: surgical removal to
allow eruption of impacted tooth
and avoid cystic changes
Management: surgical removal to
allow eruption of impacted tooth
and avoid cystic changes
ODONTOGENIC TUMORS
Odontome

Odontogenic Myxoma
• Odontogenic myxomas are uncommon, accounting for only 3% to 6%
of odontogenic tumors.
• They are benign, intraosseous neoplasms that arise from odontogenic
ectomesenchyme
• These myxomas are not encapsulated and tend to infi ltrate the
surrounding cancellous bone but do not metastasize.
• If odontogenic myxomas have a sex predilection, they slightly favor
females.
• Second decade of life
• 25% recurrence rate

• Radiographic picture
• More commonly affect the mandible by a margin of 3 : 1. premolar/
molar area
• Residual bone trapped within the tumor will remodel into curved and
straight, coarse or fine septa.
• A characteristic septa identified with this tumor is a straight, thin-
etched septa (a tennis racket – like or stepladder-like pattern)(rare)
• The tumor displaces and loosens teeth but rarely causes resorption of
teeth
• Differential diagnosis:
• Ameloblastoma, central giant cell granuloma
Treatment:
• Resection with margin

5. odontogenic tumor (1)

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