odntogenic tumors oral patho / orthodontic courses by indian dental academy

Odontogenic tumors

INDIAN DENTAL ACADEMY

Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.com

DEFINITION:

Odontogenic tumors are the lesions derived from cellular elements that are forming the tooth structure.


TOOTH FORMING APPARATUS

Neoplastic Intersection Hamartomatous

Benign Malignant Cystic changes Odontoma

Amelobl Ameloblastoma astic CalcifyingCementoma Cementoma odontogenic cyst

Ameloblastic fibro odontomawww.indiandentalacademy.com

CLASSIFICATIONNEOPLASMA). Benign 1). Odontogenic epithelium (i). Ameloblastoma (ii). Squamous odontogenic tumor (iii).Calcifying epithelial

odontogenic tumor (iv).Clear cell odontogenic tumor (Pindborg’s tumor)


2). Odontogenic epithelium with odontogenic ectomesenchyme

(i). Ameloblastic fibroma (ii). Ameloblastic fibro dentinoma

and ameloblastic fibro odontoma (iii). Odontoameloblastoma (iv). Adenomatoid

OdontogenicTumor (v). Calclifying odontogenic cyst (vi). Complex odontoma (vii). Compound odontoma


3). Odontogenic ectomesenchyme

(i). Odontogenic fibroma (ii). Myxoma / Odontogenic

myxofibroma (iii).Benign

cementoblastoma( True Cementoblastoma)


MALIGNANT1). Odontogenic carcinomas (i). Malignant Ameloblastoma (ii). Primary intraosseous

carcinoma (iii). Malignant variant of other

odontogenic epithelial tumor (iv). Malignant changes in

odontogenic epithelial tumors (v). Malignant changes in

odontogenic epithelial cyst


2). Odontogenic sarcomas (i). Ameloblastic fibrosarcoma

(Ameloblastic sarcoma) (ii). Ameloblastic fibrodentine

sarcoma & Amleoblastic fibro odontosarcoma

3). Odontogenic carcinosarcoma


AMELOBLASTOMADefinitionAn epithelial tumor arising

from the odontogenic apparatus or from cells with a potentiality for forming tissues of the enamel organ.

WHO Defined it asUnicentric, non functional,

intermittent in growth, anatomically benign and clinically persist


Origin of the ameloblastic cells 1). Odontogenic epithelium a). Remenants of Dental lamina b). Reduced enamel epithelium c). Rests cells of malassez 2). Basal cell layer o overlying

surface epithelium 3). Epithelial lining of odontogenic

cyst


Three clinical subtypes1). Common polycystic

Ameloblastoma (80% of all cases)2). Unicystic Ameloblastoma (13% of

all cases)3). Peripheral (Extraosseous)

Ameloblastoma (1% of all cases)


A). Common polycystic ameloblastomaAlso called conventional, Intraosseous ,

MulticysticClinical features Age - 20 to 40yrs Site - mandible > maxilla slow growing, painless, bony

expansion initially Tennis ball like consistency

“Egg shell” like cracking

Jaw bone enlargement & parasthesiawww.indiandentalacademy.com

Radiographic features Round cyst like radiolucency Honey comb (if small

loculations) or soap bubble like

consistency(if large loculations)

Histopathology: (Vicker’s and Gorlins criteria).1). Hyperchromatism2). Palisading cells3). Vacuolization4). Hyalinization


Histopathological variants1). Follicular ameloblastoma2). Plexiform ameloblastoma3). Plexiform unicystic ameloblastoma4). Acanthomatous ameloblastoma5). Papilliferous keratoameloblastoma6).Granular cell ameloblastoma7). Desmolytic ameloblastoma8). Basal cell ameloblastoma9). Clear cell Ameloblastoma


Follicular Ameloblastoma

Consists of different shapes & sizes of epithelial islands in the form of epithelial nests or follicles.

Plexiform ameloblastoma

Consists of interlacing strands of odontogenic epithelial trabeculae


Acanthomatous Ameloblastoma

central epithelial cells squamous cell metaplasia keratin deposition.

Desmoplastic Ameloblastoma

Small epithelial islands widely separated by dense, scar like fibrous tissue.www.indiandentalacademy.com

Granular cell Ameloblastoma

central cells appears swollen & densely packed with eiosinophillic granules.

Basal cell pattern Islands of uniform

basaloid cells.


Treatment options 1). Simple Curettage - high

recurrence rate. In mandible, wide marginal resection leaving compact bone of lower border intact provided the lower border is not involved radiographically

Large tumors invading lower border of mandible, segment resection using bone grafts. In maxilla, wide excision is treatment of choice


A 17-year-old girl with obvious facial expansion (A) related to a multilocular radiolucency of the left mandible associated with impacted tooth no. 17 (B). Note the aggressive nature of this tumor. The incisional biopsy showed solid/multicystic ameloblastoma. www.indiandentalacademy.com

Twenty years of undisturbed growth of a solid/multicystic ameloblastoma led to significant facial disfigurement (A), with an impressive radiographic appearance (B). A segmental resection of the right mandible was performed(C).


B). UNICYSTIC AMELOBALSTOMADefinition :Is defined as a single unicystic cavity

that shows ameloblastous differentiation in the lining.

origin - a). De-novo as a neoplasm b).result of neoplastic

transformation.Clinical features age - 16 to 20yrs (younger patients). Site - mandible > maxilla Large lesions painless swelling in the

jaw. www.indiandentalacademy.com

Radiographic features

Well-circumscribed, radiolucent area that surrounds the crown of an unerupted molar.

3 histopathological variants.

1). Luminal unicystic 2). Intaluminal

unicystic 3). Mural unicystic


Differential diagnosis (1). Dentigerous cyst (2). Residual cystTreatment and prognosis (1). Enucleation and curettage

(recurrence rate - 10% to 20%) less recurrence as surrounding fibrous connective tissue limits the lesion .

(2). If the lesion extends into fibrous cyst wall Prophylactic measure Local resection of the area


A, Treatment of the ameloblastoma of the patient in Figure 30-17 required a disarticulation resection of the left mandible. B, The effectiveness of the bony linear margin should always be evaluated by intraoperative specimen radiographs.


A, The luminal unicysticameloblastoma in Figure 30-21 is treated withan enucleation and curettage surgery. B, The

5-year postoperative radiograph shows anacceptable bony fill.www.indiandentalacademy.com

This 18-year-old presented with significant right facial expansion (A) associated with the destructive radiolucency of the right mandible noted on the panoramic radiograph (B). The incisional

biopsy documented the mural variant of unicystic ameloblastoma (hematoxylin and eosin; original magnification ×20) (C). A disarticulation resection was performed (D).


3).PERIPHERAL OR EXTRAOSSEOUSIncidence - 1%origin - a). Remnants of dental lamina

beneath the oral mucosa b). Basal epithelial cells of surface epithelium Clinical features Age - middle age site - posterior gingival & alveolar mucosa Mandible > maxilla Painless, nonulcerated, sessile or

pedunculated gingival or alveolar mucosal lesion.


Histopathology: bear islands of

ameloblastic epithelium occupying lamina propria underneath surface epithelium.

Treatment & prognosis Surgical excision

(Recurrence rate - 15 to 20%).

Earliest diagnosis


MALIGNANT AMELOBLASTOMA

Benign tumor that in the typical intraosseous form has a tendency to infiltrate cancellous bone

AMELOBLASTIC CARCINOMAAmeloblastoma that has acytologic evidence of malignancy.


Clinical features: swelling, pain and

inflammation Ulceration of

mucosa & loosening of teeth

Epitaxis & nasal obstruction.

Radiographic features

unilocular or multilocular radiolucency, soap bubble appearance.www.indiandentalacademy.com

TreatmentSimple curettage (high recurrence rate). In mandible, wide

marginal resection leaving compact bone of lower border is not involved radiographically.

Large tumors - segmental resection followed by reconstruction using bone graft.


A, The large destructive radiolucencyof the right mandible was present in a 22-year-oldman who complained of precipitous growth andpain. The incisional biopsy showed benign solid/multicystic ameloblastoma. B, A segmental resection was performed. D and E, Final histopathology of the resection specimen showed ameloblastic carcinoma


ADENOMATOID ODONTOGENIC TUMOROrigin - Tumor cell derived from a). Enamel organ epithelium b). Remnants of dental laminaClinical features Age - younger patient (10 to 19yrs). Site - anterior portion of the jaw maxilla > mandible Asymptomatic, painless, slow

growing. large lesions causes expansion of

bone.www.indiandentalacademy.com

Site of occurance o f AOT

A well circumscrbed solid mass enveloping the cown of this tooth


AOT variants

Central Peripheral (intraosseous) (extraosseous)1). Follicular type rare, small involves crown of sessile masses

onan unerupted tooth facial gingiva of maxilla 2). Extrafollicular type DD: Gingival

located b/w roots fibrous lesionof erupted toothDD: globulomaxillary cystwww.indiandentalacademy.com

Radiographic features Usually unilocular with well defined corticated border may or may not contain a tooth often contains fine calcifications. tubular or duct like structures

Follicular Extrafollicular


Histopathology: surrounded by fibrous capsule Spindle shaped epithelial cells

forming sheets, strands or whorled masses of cells

epithelial cells Calcification- small foci as well as larger areasTreatmentSurgical enucleation (recurrence is

rare).www.indiandentalacademy.com

CALCIFYING EPITHELIUM ODONTOGENIC TUMOR( Pindborg’s tumor )

Definition:It is a locally aggressive tumor consist of

sheets & strands of polyhedral cells in fibrous stroma with no inflammatory component & are often accompanied by spherical calcifications & amyloid staining hyaline deposits.

Origin -Rest of dental lamina -Reduced enamel epithelium1% of all odontogenic tumor


Clinical features CEOT

Central Peripheral(intraosseous) (extraosseous)age - 40yrs site - anterior gingivasite - 2/3rd of appears as superficiallesions in mandible soft tissue swelling slow growing. of gingiva in a tooth painless mass. bearing area or edentulous area of jaw


Radiographic features: Early lesions - unilocular, old

lesions - multilocular or honey comb appearance.

Scalloped margins entire radiolucency with calcified

structures of varying size & density “Snow driven” appearance.


Histopathology: sheets of polyhedral epithelial cells

on fibrous stroma cells show pleomorphism, prominent

nucleoli & hyperchromatism. Liesegang ring calcifications

• • amyloid stained by

• congo red www.indiandentalacademy.com

A 40-year-old woman with a 5-year history of an expansile mass of the left maxilla. The patient with the Pindborg tumor in Figure 30-38 is treated with hemimaxillectomy.


ODONTOMA Most common type of odontogenic

tumor HamartomaDefinition: A non-neoplastic developmental

anomaly or malformation that contains fully formed enamel and dentin.


Types:1). Invaginated odontome(Dens

invaginatus, Dens in dente)2). Evaginated odontome3). Enamel pearl4). Germinated odontome5). Complex odontome6). Compound odontomeClinical features: Age- 10 to 20yrs Site - Maxilla > mandible Slow growing , hard , painless mass


GARDNER’S Syndrome is associated with it

(a). Multiple odontomas (b). Multiple osteomas (c ). Intestinal polyps (d). Epidermoid cyst (e). Dermoid

tumor(fibrous) 2 Types (1). Complex (2). Compound


Compound odontomasite - anterior part of maxillaorigin - repeated divisions of

tooth germs. By overgrowths multiple budding of dental lamina with formation of multiple tooth germ.

Radiographically -Dense opacity with radioluscent rim

surrounding it.Collection of tooth like structures of

varying size & shape surrounded by narrow radiolescent zone.


HistolopathologyNumerous denticles having structures of normal

teeth embedded in fibrous connective tissue.


Complex odontomasite - posterior part of maxillaConsist of congomerated mass of enamel &

dentin which bears no anatomic resemblence to a tooth.Cauliflower like mass of hard tissues.

Radiographically:Calcified mass with the radiodensity of tooth

structures


Histolopathology:Mass consist of enamel, mature

tubular dentine, cementum together with pulp & PDL members in varying amount


CALCIFYING ODOTOGENIC CYST(Odontogenic ghost cell cyst)Definition:A rare well circumscribed solid or

cystic lesion derived from odontogenic epithelium that resembles follicular ameloblastoma but consists ghost cells & spherical calcifications.

Cutaneous counterpart- Benign calcifying epithelioma of MALHERBE/ Pilomatrixoma


Clinical featuresOrigin - remnants of dental lamina Site - areas anterior to molarAge - most common in 2nd decade painless asymptomatic slow

growing hard lesion expansion of buccal cortical plate.


TYPES

Extaosseous IntraosseousFocal localized generalized swelling expansion of buccal

cortical plates

DD. gingival fibroma Dentigerous cystperipheral giant AmeloblastomaGingival cyst Adenomatoid

odontogenic cystwww.indiandentalacademy.com

Radiographic featureWell circumscribed unilocular

radiolucency containing.Flecks of indistinct radiopacities.Histolopathology: Epithelium lining a cystic space. Epithelium consist of pallisaded

columnar cells with reverse polarity of nuclei. Inner layer of stellate reticulum.

GHOST cells present. Multiple spherical & diffuse

calcification. Deposites of hyaline material.


1). Curettage2). Recontouring 3). Resection with or without

loss of continuity.CurettageScrapping of the tumor tissue away

from bone. Tumor usually comes out in


A, The patient underwent a segmental resection of his odontogenic tumor B, As with the ameloblastoma,specimen radiographs should be obtained whenresecting to verify the bony linear margin. A better depiction of the “stepladder” pattern of the odontogenic myxoma is noted on this specimen radiograph.www.indiandentalacademy.com

Ameloblastic fibromapainless mixed tumor occurring in younger

patients in the premolar and molar region.Sharply demarcated radiographic borders.Microscopically epi. Cells lie in conn. Tissue

stroma. Enucleation and curettage


An enucleation and curettage surgery is performed in the patient of 15-years of age. The associated permanent teeth are removedwith the tumor.


Ameloblasticfibro - odontomaTumor with features of ameloblastic fibroma but

that also contains enamel and dentin.histologically epi. Islands in conn. Tissue stroma .Radiographically well circumscribed unilocular. Treated by enucleation.


Ameloblastic fibrosarcoma Malignant counterpart of ameloblastic

fibroma. Radiographically ill defined destructive radiolucency.


Cellular mesenchyme shows hyperchromatism and atypical cells with island of ameloblastic epithelium


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