Odontogenic tumors

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Many radiolucent or mixed radiolucent/radiopaque lesions of the mandible & maxilla may present as incidental findings on radiographs or as the main symptom of a patient. Complete history & physical examination with appropriate radiographic examination & pathologic confirmation completes the management of these diseases.

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  • The clinical differential diagnosis of a peripheral odontogenic fibroma includes inflammatory gingival hyperplasia, peripheral cemento-ossifying fibroma, and peripheral giant cell granuloma
    Microscopically, the tumor consists of an unencapsulated mass of interwoven cellular fibrous connective tissue that contains scattered nests or strands of odontogenic epithelium. Myxoid foci, osteoid, cementoid, or dystrophic calcifications are sometimes seen. The surface generally is not ulcerated.
    Treatment consists of conservative excision performed with care to maintain or reestablish the gingival architecture and periodontal integrity. Recurrence is rare
  • Odontogenic tumors

    1. 1. Frederick Mars Untalan, MD
    2. 2. Introduction  Variety of cysts and tumors  Uniquely derived from tissues of developing teeth  May present to otolaryngologist
    3. 3. Odontogenesis Projections of dental lamina into ectomesenchyme Layered cap (inner/outer enamel epithelium, stratum intermedium, stellate reticulum) Odontoblasts secrete dentin  ameloblasts (from IEE)  enamel Cementoblasts  cementum Fibroblasts  periodontal membrane
    4. 4. Diagnosis  Complete history  Pain, loose teeth, occlusion, swellings, dysthesias, delayed tooth eruption  Thorough physical examination  Inspection, palpation, percussion, auscultation  Plain radiographs  Panorex, dental radiographs  CT for larger, aggressive lesions
    5. 5. Diagnosis  Differential diagnosis  Obtain tissue  FNA – r/o vascular lesions, inflammatory  Excisional biopsy – smaller cysts, unilocular tumors  Incisional biopsy – larger lesions prior to definitive therapy
    6. 6. Odontogenic Cysts  Inflammatory  Radicular  Paradental  Developmental  Dentigerous  Developmental lateral periodontal  Odontogenic keratocyst  Glandular odontogenic
    7. 7. Radicular (Periapical) Cyst  Most common (65%)  Epithelial cell rests of Malassez  Response to inflammation  Radiographic findings  Pulpless, nonvital tooth  Small well-defined periapical radiolucency  Histology  Treatment – extraction, root canal
    8. 8. Radicular Cyst
    9. 9. Residual Cyst
    10. 10. Paradental Cyst  Associated with partially impacted 3rd molars  Result of inflammation of the gingiva over an erupting molar  0.5 to 4% of cysts  Radiology – radiolucency in apical portion of the root  Treatment – enucleation
    11. 11. Paradental Cyst
    12. 12. Dentigerous (follicular) Cyst  Most common developmental cyst (24%)  Fluid between reduced enamel epithelium and tooth crown  Radiographic findings  Unilocular radiolucency with well-defined sclerotic margins  Histology  Nonkeratinizing squamous epithelium  Treatment – enucleation, decompression
    13. 13. Dentigerous Cyst
    14. 14. Developmental Lateral Periodontal Cyst  From epithelial rests in periodontal ligament vs. primordial cyst – tooth bud  Mandibular premolar region  Middle-aged men  Radiographic findings  Interradicular radiolucency, well-defined margins  Histology  Nonkeratinizing stratified squamous or cuboidal epithelium  Treatment – enucleation, curettage with preservation of adjacent teeth
    15. 15. Developmental Lateral Periodontal Cyst
    16. 16. Odontogenic Keratocyst 11% of jaw cysts  May mimic any of the other cysts  Most often in mandibular ramus and angle  Radiographically  Well-marginated, radiolucency  Pericoronal, inter-radicular, or pericoronal  Multilocular
    17. 17. Odontogenic Keratocyst
    18. 18. Odontogenic Keratocyst
    19. 19. Odontogenic Keratocyst  Histology  Thin epithelial lining with underlying connective tissue (collagen and epithelial nests)  Secondary inflammation may mask features  High frequency of recurrence (up to 62%)  Complete removal difficult and satellite cysts can be left behind
    20. 20. Treatment of OKC  Depends on extent of lesion  Small – simple enucleation, complete removal of cyst wall  Larger – enucleation with/without peripheral ostectomy  Bataineh,et al, promote complete resection with 1 cm bony margins (if extension through cortex, overlying soft tissues excised)  Long term follow-up required (5-10 years)
    21. 21. Glandular Odontogenic Cyst  More recently described (45 cases)  Gardner, 1988  Mandible (87%), usually anterior  Very slow progressive growth (CC: swelling, pain [40%])  Radiographic findings  Unilocular or multilocular radiolucency
    22. 22. Glandular Odontogenic Cyst
    23. 23. Glandular Odontogenic Cyst  Histology  Stratified epithelium  Cuboidal, ciliated surface lining cells  Polycystic with secretory and epithelial elements
    24. 24. Treatment of GOC  Considerable recurrence potential  25% after enucleation or curettage  Marginal resection suggested for larger lesions or involvement of posterior maxilla  Warrants close follow-up
    25. 25. Nonodontogenic Cysts  Incisive Canal Cyst  Stafne Bone Cyst  Traumatic Bone Cyst  Surgical Ciliated Cyst (of Maxilla)
    26. 26. Incisive Canal Cyst Derived from epithelial remnants of the nasopalatine duct (incisive canal)  4th to 6th decades  Palatal swelling common, asymptomatic  Radiographic findings  Well-delineated oval radiolucency between maxillary incisors, root resorption occasional  Histology  Cyst lined by stratified squamous or respiratory epithelium or both
    27. 27. Incisive Canal Cyst
    28. 28. Incisive Canal Cyst  Treatment consists of surgical enucleation or periodic radiographs  Progressive enlargement requires surgical intervention
    29. 29. Stafne Bone Cyst  Submandibular salivary gland depression  Incidental finding, not a true cyst  Radiographs – small, circular, corticated radiolucency below mandibular canal  Histology – normal salivary tissue  Treatment – routine follow up
    30. 30. Stafne Bone Cyst
    31. 31. Traumatic Bone Cyst Empty or fluid filled cavity associated with jaw trauma (50%)  Radiographic findings  Radiolucency, most commonly in body or anterior portion of mandible  Histology – thin membrane of fibrous granulation  Treatment – exploratory surgery may expedite healing
    32. 32. Traumatic Bone Cyst
    33. 33. Surgical Ciliated Cyst  May occur following Caldwell-Luc  Trapped fragments of sinus epithelium that undergo benign proliferation  Radiographic findings  Unilocular radiolucency in maxilla  Histology  Lining of pseudostratified columnar ciliated  Treatment - enucleation
    34. 34. Odontogenic Tumors  Ameloblastoma  Calcifying Epithelial Odontogenic Tumor  Adenomatoid Odontogenic Tumor  Squamous Odontogenic Tumor  Calcifying Odontogenic Cyst
    35. 35. Ameloblastoma  Most common odontogenic tumor  Benign, but locally invasive  Clinically and histologically similar to BCCa  4th and 5th decades  Occasionally arise from dentigerous cysts  Subtypes – multicystic (86%), unicystic (13%), and peripheral (extraosseous – 1%)
    36. 36. Ameloblastoma  Radiographic findings  Classic – multilocular radiolucency of posterior mandible  Well-circumscribed, soap-bubble  Unilocular – often confused with odontogenic cysts  Root resorption – associated with malignancy
    37. 37. Ameloblastoma
    38. 38. Ameloblastoma Histology  Two patterns – plexiform and follicular (no bearing on prognosis)  Classic – sheets and islands of tumor cells, outer rim of ameloblasts is polarized away from basement membrane  Center looks like stellate reticulum  Squamous differentiation (1%) – Diagnosed as ameloblastic carcinoma
    39. 39. Treatment of Ameloblastoma  According to growth characteristics and type  Unicystic  Complete removal  Peripheral ostectomies if extension through cyst wall  Classic infiltrative (aggressive)  Mandibular – adequate normal bone around margins of resection  Maxillary – more aggressive surgery, 1.5 cm margins  Ameloblastic carcinoma  Radical surgical resection (like SCCa)  Neck dissection for LAN
    40. 40. Calcifying Epithelial Odontogenic Tumor  a.k.a. Pindborg tumor  Aggressive tumor of epithelial derivation  Impacted tooth, mandible body/ramus  Chief sign – cortical expansion  Pain not normally a complaint
    41. 41. Calcifying Epithelial Odontogenic Tumor  Radiographic findings  Expanded cortices in all dimensions  Radiolucent; poorly defined, noncorticated borders  Unilocular, multilocular, or “moth-eaten”  “Driven-snow” appearance from multiple radiopaque foci  Root divergence/resorption; impacted tooth
    42. 42. Calcifying Epithelial Odontogenic Tumor
    43. 43. Calcifying Epithelial Odontogenic Tumor  Histology  Islands of eosinophilic epithelial cells  Cells infiltrate bony trabeculae  Nuclear hyperchromatism and pleomorphism  Psammoma-like calcifications (Liesegang rings)
    44. 44. Treatment of CEOT  Behaves like ameloblastoma  Smaller recurrence rates  En bloc resection, hemimandibulectomy partial maxillectomy suggested
    45. 45. Adenomatoid Odontogenic Tumor  Associated with the crown of an impacted anterior tooth  Painless expansion  Radiographic findings  Well-defined expansile radiolucency  Root divergence, calcified flecks (“target”)  Histology  Thick fibrous capsule, clusters of spindle cells, columnar cells (rosettes, ductal) throughout  Treatment – enucleation, recurrence is rare
    46. 46. Adenomatoid Odontogenic Tumor
    47. 47. Squamous Odontogenic Tumor  Hamartomatous proliferation  Maxillary incisor-canine and mandibular molar  Tooth mobility common complaint  Radiology – triangular, localized radiolucency between contiguous teeth  Histology – oval nest of squamous epithelium in mature collagen stroma  Treatment – extraction of involved tooth and thorough curettage; maxillary – more extensive resection; recurrences – treat with aggressive resection
    48. 48. Squamous Odontogenic Tumor
    49. 49. Calcifying Odontogenic Cyst Tumor-like cyst of mandibular premolar region  ¼ are peripheral – gingival swelling  Osseous lesions – expansion, vital teeth  Radiographic findings  Radiolucency with progressive calcification  Target lesion (lucent halo); root divergence  Histology  Stratified squamous epithelial lining  Polarized basal layer, lumen contains ghost cells  Treatment – enucleation with curettage; rarely recur
    50. 50. Mesenchymal Odontogenic Tumors  Odontogenic Myxoma  Cementoblastoma
    51. 51. Odontogenic Myxoma Originates from dental papilla or follicular mesenchyme  Slow growing, aggressively invasive  Multilocular, expansile; impacted teeth?  Radiology – radiolucency with septae  Histology – spindle/stellate fibroblasts with basophilic ground substance  Treatment – en bloc resection, curettage may be attempted if fibrotic
    52. 52. Cementoblastoma True neoplasm of cementoblasts  First mandibular molars  Cortex expanded without pain  Involved tooth ankylosed, percussion  Radiology – apical mass; lucent or solid, radiolucent halo with dense lesions  Histology – radially oriented trabeculae from cementum, rim of osteoblasts  Treatment – complete excision and tooth sacrifice
    53. 53. Cementoblastoma
    54. 54. Mixed Odontogenic Tumors Ameloblastic fibroma, ameloblastic fibrodentinoma, ameloblastic fibro-odontoma, odontoma  Both epithelial and mesenchymal cells  Mimic differentiation of developing tooth  Treatment – enucleation, thorough curettage with extraction of impacted tooth  Ameloblastic fibrosarcomas – malignant, treat with aggressive en bloc resection
    55. 55. Other Jaw Lesions  Giant Cell Lesions  Central giant cell granuloma  Brown tumor  Aneurysmal bone cyst  Fibroosseous lesions  Fibrous dysplasia  Ossifying fibroma  Condensing Osteitis
    56. 56. Central Giant Cell Granuloma  Neoplastic-like reactive proliferation  Common in children and young adults  Females > males (hormonal?)  Mandible > maxilla  Expansile lesions – root resorption  Slow-growing – asymptomatic swelling  Rapid-growing – pain, loose dentition (high rate of recurrence)
    57. 57. Central Giant Cell Granuloma  Radiographic findings  Unilocular, multilocular radiolucencies  Well-defined or irregular borders  Histology  Multinucleated giant cells, dispersed throughout a fibrovascular stroma
    58. 58. Central Giant Cell Granuloma
    59. 59. Central Giant Cell Granuloma  Treatment  Curettage, segmental resection  Radiation – out of favor (risk of sarcoma)  Intralesional steroids – younger patients, very large lesions  Individualized treatment depending on characteristics and location of tumor
    60. 60. Aneurysmal Bone Cyst  Large vascular sinusoids (no bruit)  Not a true cyst; aggressive, reactive  Great potential for growth, deformity  Multilocular radiolucency with cortical expansion  Mandible body  Simple enucleation, rare recurrence
    61. 61. Fibrous Dysplasia  Monostotic vs. polystotic  Monostotic  More common in jaws and cranium  Polystotic  McCune-Albright’s syndrome  Cutaneous pigmentation, hyper-functioning endocrine glands, precocious puberty
    62. 62. Fibrous Dysplasia  Painless expansile dysplastic process of osteoprogenitor connective tissue  Maxilla most common  Does not typically cross midline (one bone)  Antrum obliterated, orbital floor involvement (globe displacement)  Radiology – ground-glass appearance
    63. 63. Fibrous Dysplasia
    64. 64. Fibrous Dysplasia Histology – irregular osseous trabeculae in hypercellular fibrous stroma  Treatment  Deferred, if possible until skeletal maturity  Quarterly clinical and radiographic f/u  If quiescent – contour excision (cosmesis or function)  Accelerated growth or disabling functional impairment - surgical intervention (en bloc resection, reconstruction)
    65. 65. odontogenic fibrosarcoma  a malignant neoplasm of the jaw that develops in a mesenchymal component of a tooth or tooth germ.
    66. 66. Ossifying Fibroma  True neoplasm of medullary jaws  Elements of periodontal ligament  Younger patients, premolar – mandible  Frequently grow to expand jaw bone  Radiology  radiolucent lesion early, well-demarcated  Progressive calcification (radiopaque – 6 yrs)
    67. 67. Ossifying Fibroma
    68. 68. Ossifying Fibroma  Histologically similar to fibrous dysplasia  Treatment  Surgical excision – shells out  Recurrence is uncommon
    69. 69. Peripheral Odontogenic Fibroma  to arise from odontogenic epithelial rests in the periodontal ligament or the attached gingiva itself.  The entity, formerly confused with peripheral cemento-ossifying fibroma, is considered to be the extraosseous counterpart of the central odontogenic fibroma of the World Health Organization type.  A peripheral odontogenic fibroma manifests as a firm, slowly growing, sessile, and nodular growth of the gingiva, most often on the mandibular buccal or labial aspect as depicted below.  wide age range and affects both sexes equally.
    70. 70. Peripheral Odontogenic Fibroma  DDX of a peripheral odontogenic fibroma  inflammatory gingival hyperplasia  peripheral cemento-ossifying fibroma  peripheral giant cell granuloma  Microscopically: unencapsulated mass of interwoven cellular fibrous connective tissue that contains scattered nests or strands of odontogenic epithelium. Myxoid foci, osteoid, cementoid, or dystrophic calcifications are sometimes seen.  Treatment : conservative excision & reestablish the gingival architecture and periodontal integrity.
    71. 71. Condensing Osteitis  4% to 8% of population  Focal areas of radiodense sclerotic bone  Mandible, apices of first molar  Reactive bony sclerosis to pulp inflammation  Irregular, radiopaque  Stable, no treatment required
    72. 72. Condensing Osteitis
    73. 73. Maxillary Tumors  Squamous cell carcinoma
    74. 74. Physical Examination
    75. 75. Radiographs  Plain films – facial series  Computerized Tomography of facial series
    76. 76. Treatment
    77. 77. Treatment
    78. 78. Case  18 year-old female with several month history of lesion in right maxilla, treated initially by oral surgeon with multiple curettage.  Has experienced recent onset of rapid expansion, with complaints of loose dentition and pain.
    79. 79. summary  Variety of cysts and tumors  Uniquely derived from tissues of developing teeth  May present to otolaryngologist
    80. 80. Frederick Mars Untalan, MD

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