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Odontogenic tumors Presentation Transcript

  • 1. ODONTOGENIC TUMORS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  • 2. • 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 modalities- cons to very aggressive (radical). INTRODUCTION www.indiandentalacademy.com
  • 3. –The permutation of different cells of different origin makes odontogenic tumors a highly complicated group of lesions www.indiandentalacademy.com
  • 4. Odontogenic tumors Normal odontogenesis Epithelium undifferentiated mesenchymal cells of dental papillae odontoblasts dentin enamel matrix formation by the ameloblasts www.indiandentalacademy.com
  • 5. Classification 1.WHO 2.KRAMER, PINDBORG AND SHEAR 1992 www.indiandentalacademy.com
  • 6. 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) www.indiandentalacademy.com
  • 7. 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 c Benign cementoblastoma 4. Dentinoma www.indiandentalacademy.com
  • 8. 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 www.indiandentalacademy.com
  • 9. • 2.KRAMER, PINDBORG AND SHEAR 1992 Classification www.indiandentalacademy.com
  • 10. ODONTOGENIC EPITHELIUM WITHOUT ODONTOGENIC ECTOMESENCHYME –AMELOBLASTOMA. –CEOT (PINDBORG’S) –CLEAR CELL –SQUAMOUS ODONTOGENIC www.indiandentalacademy.com
  • 11. ODONTOGENIC EPITHELIUM WITH ECTOMESENCHYME WITH OR WITHOUT DENTAL HARD TISSUE • Ameloblastic fibroma • Ameloblastic fibro-odontoma • Odontoameloblastoma • AOT • Complex odontoma. • Compound odontoma www.indiandentalacademy.com
  • 12. Odontogenic Ectomesenchyme with or without O.Epithelium : –O.Fibroma –O.Myxoma –Benign Cementoblastoma www.indiandentalacademy.com
  • 13. MALIGNANT • Odontogenic carcinoma • Malignant ameloblastoma • Primary intra osseous carcinoma • Malignant changes in cyst • Odontogenic sarcomas • Carcinosarcomas www.indiandentalacademy.com
  • 14. AMELOBLASTOMA www.indiandentalacademy.com
  • 15. •WHO (1992) “Is a true neoplasm of enamel organ like tissue which does not undergo differentiation to the point of enamel formation” www.indiandentalacademy.com
  • 16. Robinson described it as • A TUMOUR THAT IS USUALLY UNICENTRIC, NONFUNCTIONAL INTERMITTENT IN GROWTH ANATOMICALLY BENIGN CLINICALLY PERSISTENT www.indiandentalacademy.com
  • 17. Synonyms : –Adamantinoma –Multilocular cyst –Adamantoblastoma –Eve’s Diesease www.indiandentalacademy.com
  • 18. History : • CUZACK (1827)- FIRST RECOGNIZED • FALKSON (1879) – DESCRIPTION • MALASSEZ (1885) – ADAMANTINOMA • IVY &CHURCHILL (1934) – AMELOBLASTOMA • Unicystic ameloblastoma- Robinson and Martinez in 1977www.indiandentalacademy.com
  • 19. 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) www.indiandentalacademy.com
  • 20. extra osseous • Dental lamina ameloblast • Oral epithelium www.indiandentalacademy.com
  • 21. Incidence –1% of oral tumors –18-20% of odontogenic tumors www.indiandentalacademy.com
  • 22. Clinical features –20-50 years –Number of cases reported in children –Youngest reported one month old –Oldest 98 yrs www.indiandentalacademy.com
  • 23. –Frequent in mandible than maxilla(80% in mand.20% in max. –3:1 –In mandible- 75% in molar & ramus –In maxilla- common in tuberosity areawww.indiandentalacademy.com
  • 24. • 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. www.indiandentalacademy.com
  • 25. Signs & symptoms –Asymptomatic –Asymmetry –Slow growing – non tender –Later stages pain www.indiandentalacademy.com
  • 26. –Secondary infection –Ulceration –Egg shell crackling –Extra osseous Small nodule –Draining sinuses www.indiandentalacademy.com
  • 27. Clinical classification Anatomic site –Central /intraosseous • Conventional/Multicystic • Unicystic • solid –Peripheral/ extra osseous – Malignant – Pituitary ameloblastoma (craniopharyngioma,or Rathke’s pouch tumour) www.indiandentalacademy.com
  • 28. Radiographic appearance Lagundoye et al (1975) classified ameloblastoma in 4 types 1.Multiloculated, multicystic 2. Unilocular 3. Septate-trabeculated 4. Solid type www.indiandentalacademy.com
  • 29. 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 www.indiandentalacademy.com
  • 30. www.indiandentalacademy.com
  • 31. AmeloblastomaAmeloblastoma With in medullary cavityWith in medullary cavity Scalloping of inner cortexScalloping of inner cortex Pressure erosion.Pressure erosion. Shell of the original cortex remains.Shell of the original cortex remains. www.indiandentalacademy.com
  • 32. C T SCAN • Show edge definition. • Extensions • Involvement of the vital structures MRI Show soft tissue involvement & extensions www.indiandentalacademy.com
  • 33. www.indiandentalacademy.com
  • 34. –When maxillary sinus involved –Cloudiness of sinus –Destruction of wall –Nasal obstruction –Bleeding & trismus –Unicystic in maxilla www.indiandentalacademy.com
  • 35. Histopathology –Follicular –Plexiform –Acanthomatous –Granular cell –Desmoplastic –Basal cell type www.indiandentalacademy.com
  • 36. 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 www.indiandentalacademy.com
  • 37. plexiform www.indiandentalacademy.com
  • 38. acanthomatous www.indiandentalacademy.com
  • 39. Granular cell www.indiandentalacademy.com
  • 40. desmoplastic www.indiandentalacademy.com
  • 41. Basal cell www.indiandentalacademy.com
  • 42. Unicystic ameloblastoma Ackerman in 1988 –Type-I Intra Luminal –Type-II Mural ameloblastoma –Type-III Invasive ameloblastoma www.indiandentalacademy.com
  • 43. www.indiandentalacademy.com
  • 44. DIFFERENTIAL DIAGNOSIS –Multilocular cyst Dentigerous cyst odontogenic kerato cyst –Giant cell granuloma, cherubism –Brown’s tumor –Central hemangioma –odontogenic myxoma www.indiandentalacademy.com
  • 45. ManagementManagement ofof AmeloblastomaAmeloblastoma www.indiandentalacademy.com
  • 46. • ConservativeConservative treatmenttreatment –Curettage –Cryotherapy • Radical treatmentRadical 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. www.indiandentalacademy.com
  • 47. • 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. www.indiandentalacademy.com
  • 48. • 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. www.indiandentalacademy.com
  • 49. CONSERVATIVE TREATMENTCONSERVATIVE TREATMENT www.indiandentalacademy.com
  • 50. CONSERVATIVE TREATMENTCONSERVATIVE TREATMENT www.indiandentalacademy.com
  • 51. Complications • Extension into vital structures • Seeding into lungs • Direct extension into brain • Malignant transformation CONSERVATIVE TREATMENTCONSERVATIVE TREATMENT www.indiandentalacademy.com
  • 52. En-Bloc Resection www.indiandentalacademy.com
  • 53. Segmental Resection www.indiandentalacademy.com
  • 54. Partial Maxillectomy www.indiandentalacademy.com
  • 55. 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 www.indiandentalacademy.com
  • 56. 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 yrswww.indiandentalacademy.com
  • 57. www.indiandentalacademy.com
  • 58. – IMMEDIATE RECONSTRUCTION –DELAYED RECONSTRUCTION www.indiandentalacademy.com
  • 59. 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 www.indiandentalacademy.com
  • 60. 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 www.indiandentalacademy.com
  • 61. 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. www.indiandentalacademy.com
  • 62. Cautery • Chemical agents • Electro cautery • Cryotherapy www.indiandentalacademy.com
  • 63. 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 www.indiandentalacademy.com
  • 64. Unicystic ameloblastoma – use of Carnoy’s solution after enucleation –P K Lee N Samman –Int J Oral Maxillofac Surg 2004; 33 ; 263-7 www.indiandentalacademy.com
  • 65. EXTRAORAL EXAMINATION www.indiandentalacademy.com
  • 66. INTRAORAL EXAMINATION • PERICORNITIS WITH 48 www.indiandentalacademy.com
  • 67. RADIOGRAPHIC EXAMINATION www.indiandentalacademy.com
  • 68. www.indiandentalacademy.com
  • 69. HISTOPATHOLOGY www.indiandentalacademy.com
  • 70. FOLLICULAR( CYSTIC) AMELOBLASTOMA www.indiandentalacademy.com
  • 71. www.indiandentalacademy.com
  • 72. www.indiandentalacademy.com
  • 73. www.indiandentalacademy.com
  • 74. www.indiandentalacademy.com
  • 75. RESECTED HEMIMANDIBLE WITH TUMOR MASS www.indiandentalacademy.com
  • 76. POSTEROMEDIAL VIEW SUPEROLATERAL VIEW www.indiandentalacademy.com
  • 77. www.indiandentalacademy.com
  • 78. RECONSTRUCTION www.indiandentalacademy.com
  • 79. RECONSTRUCTION PLATE WITH CONDYLE www.indiandentalacademy.com
  • 80. www.indiandentalacademy.com
  • 81. www.indiandentalacademy.com
  • 82. www.indiandentalacademy.com
  • 83. www.indiandentalacademy.com
  • 84. www.indiandentalacademy.com
  • 85. www.indiandentalacademy.com
  • 86. RADIOTHERAPY –Inoperable cases –Invasion into cranium –Primarily intraosseous- resistant –Extra osseous ameloblastoma - reduced –Possible osteoradionecrosis –Cause of metastasis www.indiandentalacademy.com
  • 87. conclusion • Careful examination • Appropriate treatment • Complete cure • Reconstruction • Follow up www.indiandentalacademy.com
  • 88. 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 cystwww.indiandentalacademy.com
  • 89. 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. www.indiandentalacademy.com
  • 90. 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 www.indiandentalacademy.com
  • 91. 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 www.indiandentalacademy.com
  • 92. 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 www.indiandentalacademy.com
  • 93. • 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. www.indiandentalacademy.com
  • 94. 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. www.indiandentalacademy.com
  • 95. 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). www.indiandentalacademy.com
  • 96. 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 smokey dense areas.www.indiandentalacademy.com
  • 97. Treatment Intraosseous lesions: Marginal or segmental resection Extraosseous lesion : Simple local excision 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. www.indiandentalacademy.com
  • 98. 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. www.indiandentalacademy.com
  • 99. 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.www.indiandentalacademy.com
  • 100. • 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 and cords Ameloblastic 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. www.indiandentalacademy.com
  • 101. Ameloblastic fibroma, high power. Cords of epithelium lie in an ectomesenchyme stroma. www.indiandentalacademy.com
  • 102. 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. www.indiandentalacademy.com
  • 103. 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. www.indiandentalacademy.com
  • 104. RADIOGRAPHIC FEATURES In the compound odontoma, multiple small and malformed tooth-like structures are formed creating a “bag of marbles” radiographic appearance . www.indiandentalacademy.com
  • 105. 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 www.indiandentalacademy.com
  • 106. 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. www.indiandentalacademy.com
  • 107. Compound odontoma of tumor . the small,closely spaced white bodies are individual malformed tooth-like structures. 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. P D E www.indiandentalacademy.com
  • 108. 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. www.indiandentalacademy.com
  • 109. 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. www.indiandentalacademy.com
  • 110. 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 folliclewww.indiandentalacademy.com
  • 111. Complex odontoma in anterior maxilla. Deciduous tooth is retained. www.indiandentalacademy.com
  • 112. • Site – posterior part of mand. • Age -2 ,3 decade of life • Potency to grow to a large size. Treatment • Enucleation & curettage www.indiandentalacademy.com
  • 113. 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. www.indiandentalacademy.com
  • 114. Periapical cemental dysplasia • 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. www.indiandentalacademy.com
  • 115. Periapical cemental dysplasia • 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. www.indiandentalacademy.com
  • 116. Periapical cemental dysplasia • Differential diagnosis  Periapical cyst or Granuloma • Treatment : Observation ( Limited growth potential ) • Surgical removal  Often renders adjacent teeth Non- vital. www.indiandentalacademy.com
  • 117. 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, causes pain and requires surgical removal. www.indiandentalacademy.com
  • 118. 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. www.indiandentalacademy.com
  • 119. Cementoblastoma, gross specimen. This dense material is presumed to be cementum and the tumor cell line that secretes it is cementoblasts, hence the name.www.indiandentalacademy.com
  • 120. So why the other name “true cementoma”? Recall that the lesion we know as cementoma is a self- limiting 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. www.indiandentalacademy.com
  • 121. Histologically • the mass of cementum is attached to the tooth root. • As it expands, the cementoblasts at the periphery add new cementum. C Cementoblastoma, medium power histopathology of the decalcified specimen. The field is dominated by sheets of cementum with a rim of cementoblasts (C) with an outer rim of normal bonewww.indiandentalacademy.com
  • 122. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com