Management of Odontogenic Tumors / orthodontic courses by Indian dental academy
Odntogenic Tumors Oral Patho / orthodontic courses by Indian dental academy
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Odontogenic tumors
INDIAN DENTAL ACADEMY
Leader in continuing dental education www.indiandentalacademy.com
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DEFINITION:
Odontogenic tumors are the lesions derived from cellular elements that are forming the tooth structure.
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TOOTH FORMING APPARATUS
Neoplastic Intersection Hamartomatous
Benign Malignant Cystic changes Odontoma
Amelobl Ameloblastoma astic CalcifyingCementoma Cementoma odontogenic cyst
Ameloblastic fibro odontomawww.indiandentalacademy.com
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CLASSIFICATIONNEOPLASMA). Benign 1). Odontogenic epithelium (i). Ameloblastoma (ii). Squamous odontogenic tumor (iii).Calcifying epithelial
odontogenic tumor (iv).Clear cell odontogenic tumor (Pindborg’s tumor)
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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
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3). Odontogenic ectomesenchyme
(i). Odontogenic fibroma (ii). Myxoma / Odontogenic
myxofibroma (iii).Benign
cementoblastoma( True Cementoblastoma)
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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
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2). Odontogenic sarcomas (i). Ameloblastic fibrosarcoma
(Ameloblastic sarcoma) (ii). Ameloblastic fibrodentine
sarcoma & Amleoblastic fibro odontosarcoma
3). Odontogenic carcinosarcoma
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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
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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
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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)
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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
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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
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Histopathological variants1). Follicular ameloblastoma2). Plexiform ameloblastoma3). Plexiform unicystic ameloblastoma4). Acanthomatous ameloblastoma5). Papilliferous keratoameloblastoma6).Granular cell ameloblastoma7). Desmolytic ameloblastoma8). Basal cell ameloblastoma9). Clear cell Ameloblastoma
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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
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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
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Granular cell Ameloblastoma
central cells appears swollen & densely packed with eiosinophillic granules.
Basal cell pattern Islands of uniform
basaloid cells.
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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
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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
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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).
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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
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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
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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
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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.
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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
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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).
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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.
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Histopathology: bear islands of
ameloblastic epithelium occupying lamina propria underneath surface epithelium.
Treatment & prognosis Surgical excision
(Recurrence rate - 15 to 20%).
Earliest diagnosis
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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.
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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
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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.
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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
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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
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Site of occurance o f AOT
A well circumscrbed solid mass enveloping the cown of this tooth
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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
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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
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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
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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
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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
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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.
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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
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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.
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ODONTOMA Most common type of odontogenic
tumor HamartomaDefinition: A non-neoplastic developmental
anomaly or malformation that contains fully formed enamel and dentin.
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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
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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
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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.
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HistolopathologyNumerous denticles having structures of normal
teeth embedded in fibrous connective tissue.
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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
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Histolopathology:Mass consist of enamel, mature
tubular dentine, cementum together with pulp & PDL members in varying amount
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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
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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.
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TYPES
Extaosseous IntraosseousFocal localized generalized swelling expansion of buccal
cortical plates
DD. gingival fibroma Dentigerous cystperipheral giant AmeloblastomaGingival cyst Adenomatoid
odontogenic cystwww.indiandentalacademy.com
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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.
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1). Curettage2). Recontouring 3). Resection with or without
loss of continuity.CurettageScrapping of the tumor tissue away
from bone. Tumor usually comes out in
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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
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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
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An enucleation and curettage surgery is performed in the patient of 15-years of age. The associated permanent teeth are removedwith the tumor.
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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.
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Ameloblastic fibrosarcoma Malignant counterpart of ameloblastic
fibroma. Radiographically ill defined destructive radiolucency.
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Cellular mesenchyme shows hyperchromatism and atypical cells with island of ameloblastic epithelium
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