Odontogenic Tumors

Odontogenic TumorsOdontogenic Tumors
Dr. Adel I. AbdelhadyDr. Adel I. Abdelhady
BDS, MSC, (Egypt) PhD. (Egypt,USA)BDS, MSC, (Egypt) PhD. (Egypt,USA)
Oral and Maxillofacial Surgery Dept.Oral and Maxillofacial Surgery Dept.
College of Dentistry, King Faisal University, KSA.College of Dentistry, King Faisal University, KSA.

Classification of Odontogenic TumorsClassification of Odontogenic Tumors
From Neville, et al.From Neville, et al.
I.I.Tumors of odontogenicTumors of odontogenic
epitheliumepithelium
AmeloblastomaAmeloblastoma
1. Malignant1. Malignant
ameloblastomaameloblastoma
2. Ameloblastic2. Ameloblastic
carcinomacarcinoma
B. Clear cell odontogenicB. Clear cell odontogenic
carcinomacarcinoma
C.AdenomatoidC.Adenomatoid
odontogenic tumorodontogenic tumor
D.Calcifying epithelialD.Calcifying epithelial
odontogenic tumorodontogenic tumor
E.Squamous odontogenicE.Squamous odontogenic
tumortumor
II.II. Mixed odontogenic tumorsMixed odontogenic tumors
A.Ameloblastic fibromaA.Ameloblastic fibroma
B.Ameloblastic fibro-odontomaB.Ameloblastic fibro-odontoma
C.Ameloblastic fibrosarcomaC.Ameloblastic fibrosarcoma
D.OdontoameloblastomaD.Odontoameloblastoma
E.E. Compound odontomaCompound odontoma
F.F. Complex odontomaComplex odontoma
III. Tumors of odontogenicIII. Tumors of odontogenic
ectomesenchymeectomesenchyme
A.Odontogenic fibromaA.Odontogenic fibroma
B.Granular cell odontogenicB.Granular cell odontogenic
tumortumor
C.Odontogenic myxomaC.Odontogenic myxoma
D.CementoblastomaD.Cementoblastoma

 BENIGN, NO RECURRENCEBENIGN, NO RECURRENCE
POTENTIALPOTENTIAL
 Adenomatoid odontogenicAdenomatoid odontogenic
tumortumor
 Squamous odontogenic tumorSquamous odontogenic tumor
 CementoblastomaCementoblastoma
 Periapical cementoosseousPeriapical cementoosseous
dysplasiadysplasia
 OdontomaOdontoma
 BENIGN, SOME RECURRENCEBENIGN, SOME RECURRENCE
POTENTIALPOTENTIAL
 Cystic ameloblastomaCystic ameloblastoma
(unicystic)(unicystic)
 Calcifying epithelial odontogenicCalcifying epithelial odontogenic
tumortumor
 Central odontogenic fibromaCentral odontogenic fibroma
 Florid cementoosseousFlorid cementoosseous
dysplasiadysplasia
 Ameloblastic fibroma andAmeloblastic fibroma and
fibroodontomafibroodontoma
 *From Regezi, et al.*From Regezi, et al.
 BENIGN AGGRESSIVEBENIGN AGGRESSIVE
 AmeloblastomaAmeloblastoma
 Clear cell odontogenic tumorClear cell odontogenic tumor
(some consider this a(some consider this a
carcinoma)carcinoma)
 Odontogenic ghost cell tumorOdontogenic ghost cell tumor
(COC, solid type)(COC, solid type)
 Odontogenic myxomaOdontogenic myxoma
 OdontoameloblastomaOdontoameloblastoma
 MALIGNANTMALIGNANT
 Malignant ameloblastomaMalignant ameloblastoma
 Ameloblastic carcinomaAmeloblastic carcinoma
 Primary intraosseousPrimary intraosseous
carcinomacarcinoma
 Odontogenic ghost cellOdontogenic ghost cell
carcinomacarcinoma
 Ameloblastic fibrosarcomaAmeloblastic fibrosarcoma
Biologic Classification of Odontogenic Tumors*Biologic Classification of Odontogenic Tumors*

Tumors of OdontogenicTumors of Odontogenic
EpitheliumEpithelium

 The ameloblastoma is the most common
odontogenic tumor. It is a benign but locally
invasive neoplasm derived from odontogenic
epithelium. It has three different
clinicopathologic subtypes: multicystic (86%),
unicystic (13%) and peripheral (extraosseus –
1%). It usually occurs in the 4th and 5th decades
without a gender predilection.

 It is typically slow-growing, locally invasive andIt is typically slow-growing, locally invasive and
runs a benign course.runs a benign course.
 WHO described it as being a benign tumor thatWHO described it as being a benign tumor that
is “usually unicentric, non-functional, intermittentis “usually unicentric, non-functional, intermittent
in growth, anatomically benign and clinicallyin growth, anatomically benign and clinically
persistent.”persistent.”
 It may develop from cell rests of the enamelIt may develop from cell rests of the enamel
organ; from the developing enamel organ; fromorgan; from the developing enamel organ; from
the lining of odontogenic cysts or from the basalthe lining of odontogenic cysts or from the basal
cells of the oral mucosa.cells of the oral mucosa.

 It may arise from the lining of a dentigerous cyst
but more often arises independently of impacted
teeth. It is characterized by a progressive growth
rate and , when untreated, may reach enormous
proportions. Early symptoms are often absent,
but late symptoms may include a painless
swelling, loose teeth, malocclusion, or nasal
obstruction

 Ameloblastomas occur in 3 differentAmeloblastomas occur in 3 different
clinico-radiographic situations requiringclinico-radiographic situations requiring
different therapeutic considerations anddifferent therapeutic considerations and
having different prognoses.having different prognoses.
 Conventional Solid/Multicystic (86 % of allConventional Solid/Multicystic (86 % of all
cases)cases)
 Unicystic (13 % of all cases)Unicystic (13 % of all cases)
 Peripheral or Extraosseous (1 % of all cases)Peripheral or Extraosseous (1 % of all cases)

 Maxillary tumors frequently perforate
into the antrum and may grow freely,
with extension into the nasal cavity,
ethmoid sinuses, and skull base.

Solid or Multicystic Ameloblastoma:Solid or Multicystic Ameloblastoma:
Clinical FeaturesClinical Features
 Patient Age: Approximately equal frequencyPatient Age: Approximately equal frequency
from the third through the seventh decades.from the third through the seventh decades.
 Sex Predilection: Approximately equal.Sex Predilection: Approximately equal.
 Location: 80 % in mandible; 70 % in posteriorLocation: 80 % in mandible; 70 % in posterior
regions.regions.
 Radiographic Appearance: Radiolucent lesionRadiographic Appearance: Radiolucent lesion
which is usually well-circumscribed; it may bewhich is usually well-circumscribed; it may be
unilocular or multilocular (soap-bubble,unilocular or multilocular (soap-bubble,
honeycomb); occasionally an ameloblastomahoneycomb); occasionally an ameloblastoma
will be ill-defined with a ragged border.will be ill-defined with a ragged border.

Histologic FeaturesHistologic Features
 There are several microscopic subtypesThere are several microscopic subtypes
but these generally have little bearing onbut these generally have little bearing on
the behavior of the tumor.the behavior of the tumor.
 The follicular and plexiform types are theThe follicular and plexiform types are the
most common.most common.
 TheThe follicularfollicular type is composed of islandstype is composed of islands
of epithelium which resemble the enamelof epithelium which resemble the enamel
organ in a mature fibrous connectiveorgan in a mature fibrous connective
tissue stoma.tissue stoma.

 TheThe plexiformplexiform type is composed of long,type is composed of long,
anastomosing cords or larger sheets ofanastomosing cords or larger sheets of
odontogenic epithelium. Its stroma tends to beodontogenic epithelium. Its stroma tends to be
loose and more vascular.loose and more vascular.
 TheThe acanthomatousacanthomatous type shows evidence oftype shows evidence of
extensive squamous metaplasia with keratinextensive squamous metaplasia with keratin
formation in the island of odontogenicformation in the island of odontogenic
epithelium.epithelium.

 In theIn the granular cellgranular cell type there istype there is
transformation of groups of epithelialtransformation of groups of epithelial
cells to granular cells; the nature ofcells to granular cells; the nature of
the granular change is unknown.the granular change is unknown.
This type is more common inThis type is more common in youngyoung
patientspatients and has been shown to beand has been shown to be
clinically aggressive.clinically aggressive.

 TheThe desmoplasticdesmoplastic form is composed ofform is composed of
islands/cords of odontogenic epithelium in aislands/cords of odontogenic epithelium in a
very dense collagenous stroma. It has avery dense collagenous stroma. It has a
predilection for thepredilection for the anterior maxillaanterior maxilla and becauseand because
of the dense connective tissue may appear as aof the dense connective tissue may appear as a
radiolucent-radiopaque lesion.radiolucent-radiopaque lesion.
 TheThe basaloidbasaloid type is the least common and istype is the least common and is
composed of uniform basaloid cells with nocomposed of uniform basaloid cells with no
stellate reticulum.stellate reticulum.

Additional FeaturesAdditional Features
 In some studies solid/multicysticIn some studies solid/multicystic
ameloblastomas are reported to be moreameloblastomas are reported to be more
common in Blacks.common in Blacks.
 While lesions are generallyWhile lesions are generally
asymptomaticasymptomatic, ameloblastomas may, ameloblastomas may
causecause paresthesiaparesthesia,, painpain particularly ifparticularly if
infected and they caninfected and they can erode theerode the
cortical palatescortical palates..

Radiographic findingsRadiographic findings
 Radiographs classically show a well-
circumscribed, expansile soap-bubble
radiolucency with clearly demarcated borders.
 However, the unilocular lesion is
indistinguishable from an odontogenic cyst.
The extent of root resorption may indicate a
neoplastic process.
 Well-circumscribed, soap-bubbleWell-circumscribed, soap-bubble
 Unilocular – often confused with odontogenicUnilocular – often confused with odontogenic
cystscysts
 Root resorption – associated with malignancyRoot resorption – associated with malignancy

Ameloblastoma VIPAmeloblastoma VIP
 What are the main points about this tumor? It is
 unencapsulated and infiltrates surrounding bone
marrow.
 Even though they are locally infiltrative, they do
 not metastasize. They may occur in any part of
both jaws but most are in the middle and
posterior regions of the mandible.
 Ameloblastomas are always purely radiolucent
and may be unilocular but frequently become
multilocular as they increase in size.

TreatmentTreatment
 Treatments have ranged from simpleTreatments have ranged from simple
enucleation and curettage to en bloc resection.enucleation and curettage to en bloc resection.
 Marginal resection is the most widely usedMarginal resection is the most widely used
method of treatment with the least recurrencesmethod of treatment with the least recurrences
reported (up to 15 %).reported (up to 15 %).
 Most surgeons advocate a margin of at least 1.0Most surgeons advocate a margin of at least 1.0
cm beyond the radiographic limits of the tumorcm beyond the radiographic limits of the tumor
as the tumor often extends beyond the apparentas the tumor often extends beyond the apparent
radiologic/clinical margins.radiologic/clinical margins.

PrognosisPrognosis
 Treatment with curettage has resulted inTreatment with curettage has resulted in
recurrence rates ranging from 55-90 %.recurrence rates ranging from 55-90 %.
 Treatment with marginal resection has resultedTreatment with marginal resection has resulted
in approximately a 15 % recurrence rate.in approximately a 15 % recurrence rate.
 Ameloblastomas of this type arising in theAmeloblastomas of this type arising in the
maxilla are particularly dangerous as it is oftenmaxilla are particularly dangerous as it is often
difficult in getting adequate margins.difficult in getting adequate margins.
 Rarely is an ameloblastoma life threatening.Rarely is an ameloblastoma life threatening.

tttttt
 According to growth characteristics and typeAccording to growth characteristics and type
 UnicysticUnicystic
 Complete removalComplete removal
 Peripheral ostectomies if extension through cyst wallPeripheral ostectomies if extension through cyst wall
 Classic infiltrative (aggressive)Classic infiltrative (aggressive)
 Mandibular – adequate normal bone around marginsMandibular – adequate normal bone around margins
of resectionof resection
 Maxillary – more aggressive surgery, 1.5 cm marginsMaxillary – more aggressive surgery, 1.5 cm margins
 Ameloblastic carcinomaAmeloblastic carcinoma
 Radical surgical resection (like SCCa)Radical surgical resection (like SCCa)
 Neck dissection for LANNeck dissection for LAN

 The treatment of the classic infiltrative, more
aggressive ameloblastoma should not be taken lightly.
Mandibular resection must include an adequate zone of
normal-appearing bone around the main tumor mass.
Extension of tumor into surrounding soft tissues is an
ominous sign and demands surgery in these areas as
vigorous as within the confines of the bone.
 Maxillary ameloblastomas require more aggressive
initial management with at least a 1.5 cm margin of
radiographically normal bone. Postoperative follow-up
is critical for a minimum of 5, and preferably 10, years.
Ameloblastic carcinoma should be treated with radical
surgical resection as for squamous cell carcinoma, with
neck dissection reserved for apparent
lymphadenopathy.

Types of Surgical Operations Used
for the Removal of Jaw Tumors

Common types of mandibular resection A.Marginal or segmental resection,
which does not disrupt mandibular continuity. B and C, Partiacontinuity.
Attempts to leave mandibular condyle tthe apices of adjacent tooth roots
are completely uncov-ered during a surgical
rginal or segmental resection, which does not ibular resections, which
disrupt mandibular te reconstruction are demonstrated.

Types of Jaw Tumors and Primary Treatment
Modalities

Unicystic Ameloblastoma: ClinicalUnicystic Ameloblastoma: Clinical
FeaturesFeatures
 Patient Age: The patients are younger thanPatient Age: The patients are younger than
those with the solid/multicystic form. 50% arethose with the solid/multicystic form. 50% are
diagnosed during thediagnosed during the second decade of lifesecond decade of life..
 Sex Predilection: ? Same as for the solid??Sex Predilection: ? Same as for the solid??
 Location: 90 % occur in the mandible usually inLocation: 90 % occur in the mandible usually in
the posterior region.the posterior region.
 Radiographic Appearance: Typically appears asRadiographic Appearance: Typically appears as
a RL around the crown of an unerupted tootha RL around the crown of an unerupted tooth
(most commonly a mandibular third molar).(most commonly a mandibular third molar).

Unicystic Ameloblastoma:Unicystic Ameloblastoma:
 Three histopathologic variants areThree histopathologic variants are
recognized:recognized:
 Luminal:Luminal: the tumor is confined to the luminalthe tumor is confined to the luminal
surface of the cyst.surface of the cyst.
 Intraluminal/plexiform:Intraluminal/plexiform: the tumor projectsthe tumor projects
from the cystic lining; sometimes resemblesfrom the cystic lining; sometimes resembles
the plexiform type of solid/multicysticthe plexiform type of solid/multicystic
ameloblastoma.ameloblastoma.
 Mural:Mural: the tumor infiltrates the fibrous cysticthe tumor infiltrates the fibrous cystic
wall.wall.

Unicystic Ameloblastoma:Unicystic Ameloblastoma:
Treatment and PrognosisTreatment and Prognosis
 Enucleation of the cyst is probably adequate forEnucleation of the cyst is probably adequate for
the luminal and intraluminal/plexiform types.the luminal and intraluminal/plexiform types.
 Treatment of the mural type is controversialTreatment of the mural type is controversial
with some surgeons believing that local resectionwith some surgeons believing that local resection
is best.is best.
 10-20 % recurrence after enucleation and10-20 % recurrence after enucleation and
curettage with all unicystic ameloblastomas.curettage with all unicystic ameloblastomas.

Unicystic AmeloblastomaUnicystic Ameloblastoma

Peripheral AmeloblastomaPeripheral Ameloblastoma
 These tumors are extraosseous and thereforeThese tumors are extraosseous and therefore
occupy the lamina propria underneath theoccupy the lamina propria underneath the
surface epithelium but outside of the bone.surface epithelium but outside of the bone.
 Histologically, these lesions have the sameHistologically, these lesions have the same
features as the intraosseous forms of the tumor.features as the intraosseous forms of the tumor.

Peripheral Ameloblastoma: ClinicalPeripheral Ameloblastoma: Clinical
FeaturesFeatures
 Patient Age: Wide age range butPatient Age: Wide age range but
most occur during middle-age.most occur during middle-age.
 Gender Predilection: This is notGender Predilection: This is not
known.known.
 Location: Posterior gingival/alveolarLocation: Posterior gingival/alveolar
mucosa is involved most frequently.mucosa is involved most frequently.
There is a slight predilection for theThere is a slight predilection for the
mandible. The buccal mucosa hasmandible. The buccal mucosa has
been the site in a few reported cases.been the site in a few reported cases.

Peripheral Ameloblastoma:Peripheral Ameloblastoma:
Radiographic & Histologic FeaturesRadiographic & Histologic Features
 Radiographic Appearance: Although not inRadiographic Appearance: Although not in
bone, a few cases have shown superficial erosionbone, a few cases have shown superficial erosion
of the alvelolar bone.of the alvelolar bone.
 Histologic Appearance: Islands of ameloblasticHistologic Appearance: Islands of ameloblastic
epithelium are observed in the lamina propria;epithelium are observed in the lamina propria;
plexiform and follicular patterns are the mostplexiform and follicular patterns are the most
common; in 50 % of the cases the tumorcommon; in 50 % of the cases the tumor
connects with the basal cell layer of the surfaceconnects with the basal cell layer of the surface
epithelium.epithelium.

Peripheral Ameloblastoma: TreatmentPeripheral Ameloblastoma: Treatment
and Prognosisand Prognosis
 Unlike its intraosseous counterpart, this tumorUnlike its intraosseous counterpart, this tumor
has an innocuous clinical behavior.has an innocuous clinical behavior.
 Patients respond well to local surgical excision.Patients respond well to local surgical excision.
 Some reports indicate a 25 % recurrence rate butSome reports indicate a 25 % recurrence rate but
in these cases as second surgical procedurein these cases as second surgical procedure
results in cure.results in cure.
 There has been a rare malignant changeThere has been a rare malignant change
reported.reported.

Malignant Ameloblastoma andMalignant Ameloblastoma and
Ameloblastic CarcinomaAmeloblastic Carcinoma
 Less than 1 % of the ameloblastomas show malignantLess than 1 % of the ameloblastomas show malignant
behavior with the development of metastases.behavior with the development of metastases.
 Malignant ameloblastomaMalignant ameloblastoma is a tumor that showsis a tumor that shows
histologic features of the typical (benign)histologic features of the typical (benign)
ameloblastoma in both the primary and secondaryameloblastoma in both the primary and secondary
deposits.deposits.
 Ameloblastic carcinomaAmeloblastic carcinoma is a tumor that showsis a tumor that shows
cytologic features of malignancy in the primary tumor,cytologic features of malignancy in the primary tumor,
in recurrence and any metastases.in recurrence and any metastases.

Malignant Ameloblastoma &Malignant Ameloblastoma &
Ameloblastic Carcinoma: ClinicalAmeloblastic Carcinoma: Clinical
 Patients range in age from 4-75 with a mean ofPatients range in age from 4-75 with a mean of
30 years.30 years.
 Metastasis has occurred from 1-30 years afterMetastasis has occurred from 1-30 years after
the initial treatment.the initial treatment.
 Metastases most often occur in the lungs and inMetastases most often occur in the lungs and in
the case of malignant ameloblastoma raises thethe case of malignant ameloblastoma raises the
question of aspiration during surgery. Spreadquestion of aspiration during surgery. Spread
has also occurred to the cervical lymph nodeshas also occurred to the cervical lymph nodes
and to vertebrae and viscera.and to vertebrae and viscera.

Ameloblastic Carcinoma: X-RayAmeloblastic Carcinoma: X-Ray
 With the malignant ameloblastoma, theWith the malignant ameloblastoma, the
appearance is similar to the typicalappearance is similar to the typical
solid/multicystic ameloblastoma.solid/multicystic ameloblastoma.
 The ameloblastic carcinoma is often moreThe ameloblastic carcinoma is often more
aggressive with the lesion appearing as anaggressive with the lesion appearing as an
ill-defined radiolucency with corticalill-defined radiolucency with cortical
destruction.destruction.

Ameloblastic Carcinoma: HistologyAmeloblastic Carcinoma: Histology
 With the malignant ameloblastoma, both theWith the malignant ameloblastoma, both the
primary and metastases show no microscopicprimary and metastases show no microscopic
features that differ from those of the typicalfeatures that differ from those of the typical
solid/multicystic ameloblastoma.solid/multicystic ameloblastoma.
 The ameloblastic carcinoma shows cytologicalThe ameloblastic carcinoma shows cytological
features of malignancy in addition to a pattern offeatures of malignancy in addition to a pattern of
an ameloblastoma.an ameloblastoma.

Ameloblastic Carcinoma: Treatment &Ameloblastic Carcinoma: Treatment &
PrognosisPrognosis
 Long-term follow-up does not permit accurateLong-term follow-up does not permit accurate
assumptions to be made but prognosis appearsassumptions to be made but prognosis appears
to be poor.to be poor.
 Approximately 50 % of the patients withApproximately 50 % of the patients with
documented metastases and long-term follow-updocumented metastases and long-term follow-up
have died as the result of their disease.have died as the result of their disease.

Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor
(AOT)(AOT)
 Formerly called anFormerly called an
adenoameloblastoma, a somewhatadenoameloblastoma, a somewhat
deceptive term that should bedeceptive term that should be
discarded, the AOT represents aboutdiscarded, the AOT represents about
3-7 % of all odontogenic tumors.3-7 % of all odontogenic tumors.
 This epithelial tumor has an inductiveThis epithelial tumor has an inductive
effect on the odontogeniceffect on the odontogenic
ectomesenchyme with dentinoidectomesenchyme with dentinoid
frequently being produced.frequently being produced.

Adenomatoid Odontogenic TumorAdenomatoid Odontogenic Tumor
(AOT)(AOT)
 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 and it is more common
in females. This tumor is encapsulated and 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 cyst

AOT: Clinical FeaturesAOT: Clinical Features
 Patient Age: The peak age is in the secondPatient Age: The peak age is in the second
decade with a mean around 17 years.decade with a mean around 17 years.
 Gender Predilection: Females, 2:1.Gender Predilection: Females, 2:1.
 Location: Sixty-five percent of the AOTs occurLocation: Sixty-five percent of the AOTs occur
in the maxilla with 65 % occurring in the caninein the maxilla with 65 % occurring in the canine
region. Seventy-five percent of the cases areregion. Seventy-five percent of the cases are
associated with the crown of an uneruptedassociated with the crown of an unerupted
tooth. On rare occasion the lesion istooth. On rare occasion the lesion is
extraosseous.extraosseous.

AOT: Radiographic and AdditionalAOT: Radiographic and Additional
FeaturesFeatures
 AOTs typically appear as pericoronalAOTs typically appear as pericoronal
radiolucencies, which may have radiopaqueradiolucencies, which may have radiopaque
material (“snowflake” calcifications) within thematerial (“snowflake” calcifications) within the
lucency.lucency.
 These lesions are frequently asymptomatic andThese lesions are frequently asymptomatic and
therefore are discovered upon routinetherefore are discovered upon routine
radiographic examination. AOTs may also blockradiographic examination. AOTs may also block
the eruption of a permanent tooth and bethe eruption of a permanent tooth and be
discovered when radiographs are taken todiscovered when radiographs are taken to
“search for” the unerupted tooth.“search for” the unerupted tooth.

AOT: Histologic FeaturesAOT: Histologic Features
 The lesion is usually surrounded by a thick, fibrousThe lesion is usually surrounded by a thick, fibrous
capsule.capsule.
 The tumor is composed of spindle-shaped epithelialThe tumor is composed of spindle-shaped epithelial
cells that form sheets, strands or whorled masses withcells that form sheets, strands or whorled masses with
little connective tissue.little connective tissue.
 The epithelial cells may form rosette-like structures,The epithelial cells may form rosette-like structures,
tubular or duct-like structures may be prominent ortubular or duct-like structures may be prominent or
absent.absent.
 Calcifications may be observed in the tumor mass.Calcifications may be observed in the tumor mass.

AOT: Treatment and PrognosisAOT: Treatment and Prognosis
 Enucleation is the treatment ofEnucleation is the treatment of
choice as the tumor is easilychoice as the tumor is easily
removed from the bone.removed from the bone.
 AOTs seldom recur.AOTs seldom recur.

Calcifying Epithelial OdontogenicCalcifying Epithelial Odontogenic
Tumor (CEOT; Pindborg Tumor)Tumor (CEOT; Pindborg Tumor)
 Pindborg tumor accounts for < 1 % of allPindborg tumor accounts for < 1 % of all
odontogenic tumors.odontogenic tumors.
 It is clearly of odontogenic origin but itsIt is clearly of odontogenic origin but its
histogenesis is uncertain.histogenesis is uncertain.
 The tumor cells are said to resemble cells of theThe tumor cells are said to resemble cells of the
stratum intermedium.stratum intermedium.

CEOTCEOT
 This tumor forms an
amorphous material
 that is said to be amyloid or
amyloid-like
 Whatever it is, it calcifies in a
concentrically lamellated
 “tree-ring” pattern
calcifications.
 This explains the name of
calcifying epithelial
odontogenic tumor.
Calcifying epithelial odontogenic tumor in
the body of the mandible. It appears as
a radiolucent lesion with smokey dense
areas.

CEOT: Clinical FeaturesCEOT: Clinical Features
 Patient Age:Patient Age: Patients ages range from thePatients ages range from the
second to the tenth decades with a mean aroundsecond to the tenth decades with a mean around
40 years.40 years.
 Gender Predilection:Gender Predilection: There is no reported sexThere is no reported sex
predilection.predilection.
 Location:Location: 75 % of the CEOTs occur in the75 % of the CEOTs occur in the
mandible with most occurring in the posteriormandible with most occurring in the posterior
region. A rare peripheral CEOT does occur.region. A rare peripheral CEOT does occur.

CEOT: Radiographic FeaturesCEOT: Radiographic Features
 CEOTs occur as radiolucent lesionsCEOTs occur as radiolucent lesions
with/without opaque foci.with/without opaque foci.
 They are usually well-circumscribed and may beThey are usually well-circumscribed and may be
unilocular or multilocular.unilocular or multilocular.
 Slightly over 50 % of the CEOTs are associatedSlightly over 50 % of the CEOTs are associated
with an unerupted tooth.with an unerupted tooth.

CEOT: Histologic FeaturesCEOT: Histologic Features
 This lesion is typically composed of islands, sheets orThis lesion is typically composed of islands, sheets or
strands of polyhedral epithelial cells in a fibrous stroma.strands of polyhedral epithelial cells in a fibrous stroma.
 Areas of amorphous, eosinophilic, hyalinizedAreas of amorphous, eosinophilic, hyalinized
extracellular material may be scattered throughout.extracellular material may be scattered throughout.
 Cells outlines are distinct and intercellular bridges mayCells outlines are distinct and intercellular bridges may
be seen.be seen.
 Nuclei show considerable variation with giant nucleiNuclei show considerable variation with giant nuclei
and pleomorphism observed.and pleomorphism observed.
 Calcifications may be noted as well as amyloid-likeCalcifications may be noted as well as amyloid-like
material. Liesegang rings also may be present.material. Liesegang rings also may be present.

CEOT: Additional Features,CEOT: Additional Features,
 Bony lesions most commonly present as painless, slow-Bony lesions most commonly present as painless, slow-
growing swellings.growing swellings.
 Peripheral lesions typically appear as non-specific sessilePeripheral lesions typically appear as non-specific sessile
gingival masses.gingival masses.
 Conservative local resection is the treatment of choiceConservative local resection is the treatment of choice
as these lesions are typically less aggressive than theas these lesions are typically less aggressive than the
ameloblastoma.ameloblastoma.
 With this treatment the recurrence rate is approximatelyWith this treatment the recurrence rate is approximately
15 % and the overall prognosis is good.15 % and the overall prognosis is good.

Calcifying Epithelial Odontogenic Tumor (CEOT; Pindborg Tumor)Calcifying Epithelial Odontogenic Tumor (CEOT; Pindborg Tumor)

Mixed OdontogenicMixed Odontogenic
TumorsTumors
This group of tumors is composed ofThis group of tumors is composed of
proliferating odontogenic epithelium inproliferating odontogenic epithelium in
a cellular ectomesenchyme resemblinga cellular ectomesenchyme resembling
the dental papilla.the dental papilla.

Ameloblastic FibromaAmeloblastic Fibroma
 This true mixed odontogenic tumor is more commonThis true mixed odontogenic tumor is more common
in patients in the first and second decades of life with ain patients in the first and second decades of life with a
mean of 14 yearsmean of 14 years seldom is it seen beyond age 20.
 It is slightly more common in males than females.It is slightly more common in males than females.
 Approximately 70 % of the ameloblastic fibromasApproximately 70 % of the ameloblastic fibromas
occur in the posterior mandible.occur in the posterior mandible.
 Local swelling or failure of teeth to erupt on time or in
proper alignment may call attention to the tumor.

Ameloblastic Fibroma:Ameloblastic Fibroma:
Radiographic FeaturesRadiographic Features
 Generally, these lesions appear as either aGenerally, these lesions appear as either a
unilocular or multilocular radiolucency.unilocular or multilocular radiolucency.
 They tend to be well-defined and may have aThey tend to be well-defined and may have a
sclerotic border.sclerotic border.
 Approximately, 50 % are associated with anApproximately, 50 % are associated with an
unerupted tooth.unerupted tooth.

Ameloblastic Fibroma: AdditionalAmeloblastic Fibroma: Additional
Features, Treatment and PrognosisFeatures, Treatment and Prognosis
 The tumor is often encapsulated with smallThe tumor is often encapsulated with small
tumors usually being asymptomatic. Largertumors usually being asymptomatic. Larger
tumors produce swelling, which can expand thetumors produce swelling, which can expand the
cortex and be quite pronounced.cortex and be quite pronounced.
 Most ameloblastic fibromas are treated byMost ameloblastic fibromas are treated by
conservative surgical excision; however, a 20 %conservative surgical excision; however, a 20 %
recurrence rate has led some surgeons torecurrence rate has led some surgeons to
recommend a more aggressive approach.recommend a more aggressive approach.

Ameloblastic Fibro-odontomaAmeloblastic Fibro-odontoma
 This lesion is defined as a tumor with generalThis lesion is defined as a tumor with general
features of an ameloblastic fibroma butfeatures of an ameloblastic fibroma but
containing enamel and dentin.containing enamel and dentin.
 Some investigators believe that this entity is butSome investigators believe that this entity is but
a stage in the development of an odontoma;a stage in the development of an odontoma;
however, most agree that progressive destructivehowever, most agree that progressive destructive
tumors are true neoplasms.tumors are true neoplasms.

Ameloblastic Fibro-odontoma:Ameloblastic Fibro-odontoma:
Clinical and Radiographic FeaturesClinical and Radiographic Features
 Patient Age:Patient Age: Most common in the 5-12 year age rangeMost common in the 5-12 year age range
with a mean of 10 years.with a mean of 10 years.
 Gender Predilection:Gender Predilection: None.None.
 Location:Location: It is more common in the premolar/molarIt is more common in the premolar/molar
regions of both jaws.regions of both jaws.
 Radiographic Features:Radiographic Features: Usually appears as a well-Usually appears as a well-
defined unilocular or rarely multilocular radiolucencydefined unilocular or rarely multilocular radiolucency
with variable amounts of calcified material which iswith variable amounts of calcified material which is
radiopaque. Therefore, it may appear as a mixed,radiopaque. Therefore, it may appear as a mixed,
radiolucent-radiopaque lesion.radiolucent-radiopaque lesion.

 The soft tissue component is identical to theThe soft tissue component is identical to the
ameloblastic fibroma. The calcified portionameloblastic fibroma. The calcified portion
consists of foci of enamel and dentin matrixconsists of foci of enamel and dentin matrix
formation in close relationship to the epithelialformation in close relationship to the epithelial
structures.structures.

 The ameloblastic fibro-odontoma is usuallyThe ameloblastic fibro-odontoma is usually
treated by conservative curettage with the lesiontreated by conservative curettage with the lesion
separating easily from the surrounding bone.separating easily from the surrounding bone.
 Prognosis is excellent and recurrence is unusual.Prognosis is excellent and recurrence is unusual.

OdontomaOdontoma
 The tumors in which
odontogenic differentiation is
fully expressed are the
odontomas. In these tumors,
the epithelium an
ectomesenchyme realize their
potentialand make enamel and
dentin respectively.
 As a result, these tumors are
mostly radiodense.
 In the compound odontoma,
multiple small and malformed
tooth-like structures are
formed creating a “bag of
marbles” radiographic
appearance
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).
E
D
P

OdontomaOdontoma
 The odontoma is the most common odontogenicThe odontoma is the most common odontogenic
tumor.tumor.
 It is not a true neoplasm but rather is considered to beIt is not a true neoplasm but rather is considered to be
a developmental anomaly (hamartoma).a developmental anomaly (hamartoma).
 Two types of odontomas are recognized:Two types of odontomas are recognized:
 Compound: this type of odontoma is composed of multipleCompound: this type of odontoma is composed of multiple
small tooth-like structures.small tooth-like structures.
 Complex: this lesion is composed of a conglomerate mass ofComplex: this lesion is composed of a conglomerate mass of
enamel and dentin, which bears no anatomic resemblance toenamel and dentin, which bears no anatomic resemblance to
a tooth.a tooth.

Odontoma: Clinical FeaturesOdontoma: Clinical Features
 Patient Age:Patient Age: Most cases are recognized duringMost cases are recognized during
the second decade of life with a mean of 14the second decade of life with a mean of 14
years.years.
 Gender Predilection:Gender Predilection: Approximately equal.Approximately equal.
 Location:Location: Somewhat more common in theSomewhat more common in the
maxilla. Themaxilla. The compound typecompound type is more often inis more often in
thethe anterior maxillaanterior maxilla while the complex typewhile the complex type
occurs more often in the posterior regions ofoccurs more often in the posterior regions of
either jaw.either jaw.

Odontoma: Clinical FeaturesOdontoma: Clinical Features
 Both types of odontoma are found in the early years,
usually in the teens or early twenties. Compound
odontoma is more common in the anterior jaw segment
whereas the complex type is found more commonly in
the posterior jaws.
 Many are associated with an unerupted tooth.
Odontomas behave more like developmental
abnormalities (hamartomas) than true neoplasms.
 Although they may reach a large size, they do eventually
cease growing in contrast to true neoplasms which
show continuous growth.

Odontoma: Radiographic FeaturesOdontoma: Radiographic Features
 Early lesions are radiolucent with smooth, well-Early lesions are radiolucent with smooth, well-
defined contours.defined contours.
 Later a well-defined radiopaque appearanceLater a well-defined radiopaque appearance
develops.develops.
 The compound type shows apparent toothThe compound type shows apparent tooth
shapes while the complex type appears as ashapes while the complex type appears as a
uniform opaque mass with no apparent toothuniform opaque mass with no apparent tooth
shapes present.shapes present.

Odontoma: Additional FeaturesOdontoma: Additional Features
 Most odontomas are small and do not exceed the sizeMost odontomas are small and do not exceed the size
of a normal tooth in the region.of a normal tooth in the region.
 However, large ones do occur and these may causeHowever, large ones do occur and these may cause
expansion of the jaw.expansion of the jaw.
 Most odontomas are asymptomatic and as a result areMost odontomas are asymptomatic and as a result are
discovered upon routine radiographic examination.discovered upon routine radiographic examination.
 Odontomas may block the eruption of a permanentOdontomas may block the eruption of a permanent
tooth and in these cases are often discovered whentooth and in these cases are often discovered when
“searching for” the “missing” tooth radiographically.“searching for” the “missing” tooth radiographically.

Odontoma: Histologic FeaturesOdontoma: Histologic Features
 The compound odontoma is composed ofThe compound odontoma is composed of
enamel, dentin and cementum arrange inenamel, dentin and cementum arrange in
recognizable tooth forms; some enamel matrixrecognizable tooth forms; some enamel matrix
may be retained in immature andmay be retained in immature and
hypomineralized specimens.hypomineralized specimens.
 The complex odontoma is composed of enamel,The complex odontoma is composed of enamel,
dentin and cementum but these tissues aredentin and cementum but these tissues are
arranged in a random manner that bears noarranged in a random manner that bears no
morphological resemblance to a tooth.morphological resemblance to a tooth.

Odontoma: Treatment andOdontoma: Treatment and
PrognosisPrognosis
 Odontomas are treated by simpleOdontomas are treated by simple
local excision and the prognosis islocal excision and the prognosis is
excellent.excellent.

Odontogenic MyxomaOdontogenic Myxoma
 Tissue that is cell-poor and rich in mucopolysaccharide
 ground substance such as hyaluronic acid and
chondroitin sulfate is said to be myxoid tissue.
 Tumors that have the same histologic quality are called
myxoma (mix-oma). They are uncommon.
 Within the skeleton, they occur almost exclusively in
 the jaws. Extragnathic skeletal lesions are a rarity.
 Those that occur in the jaws are said to be of
odontogenic origin but there is no hard evidence that it
is so.

 Myxoma is a tumor that occurs over a wide age range
but most occur in the second and third decades.
 It is an unencapsulated, locally infiltrating tumor. If
allowed to reach a large size, it takes a big operation to
remove it.
 Like many odontogenic tumors, when small it is
ordinarily unilocular but becomes multilocular as it
enlarges. Since it does not produce a calcified matrix
material, it is purely radiolucent.

Odontogenic Myxoma: Clinical andOdontogenic Myxoma: Clinical and
Radiographic FeaturesRadiographic Features
 Patient Age: 10-50 years with a mean around 30Patient Age: 10-50 years with a mean around 30
years.years.
 Gender Predilection: Reported to be aboutGender Predilection: Reported to be about
equal.equal.
 Location: May occur in any area of the jaws butLocation: May occur in any area of the jaws but
more common in the mandible.more common in the mandible.
 Radiographic Appearance: Radiolucent lesionRadiographic Appearance: Radiolucent lesion
often with a multilocular appearance. Theoften with a multilocular appearance. The
borders may be indistinct.borders may be indistinct.

Odontogenic Myxoma: HistologicOdontogenic Myxoma: Histologic
FeaturesFeatures
 The tumor is composed of loosely arrangedThe tumor is composed of loosely arranged
stellate, spindle-shaped and round cells in anstellate, spindle-shaped and round cells in an
abundant, loose myxoid stroma with fewabundant, loose myxoid stroma with few
collagen bundles.collagen bundles.
 Epithelial cells are not required for diagnosis.Epithelial cells are not required for diagnosis.
 The odontogenic myxoma may be confusedThe odontogenic myxoma may be confused
with a chrondromyxoid fibroma or with myxoidwith a chrondromyxoid fibroma or with myxoid
change in an enlarged dental follicle or papilla.change in an enlarged dental follicle or papilla.

Odontogenic Myxoma: TreatmentOdontogenic Myxoma: Treatment
 Small odontogenic myxomas are treated bySmall odontogenic myxomas are treated by
curettage, while larger lesions may requirecurettage, while larger lesions may require
surgical resection.surgical resection.
 Odontogenic myxomas are not encapsulated andOdontogenic myxomas are not encapsulated and
tend to infiltrate adjacent tissues.tend to infiltrate adjacent tissues.
 Recurrence rates of up to 25 % are reported.Recurrence rates of up to 25 % are reported.
 Overall, the prognosis is good for mostOverall, the prognosis is good for most
odontogenic myxomas.odontogenic myxomas.

 This tumor typically occurs
around the roots of the lower
posterior teeth. Like virtually all
odontogenic tumors, it is benign
but it expands the jaw, causes
pain and requires surgical
removal. Radiographically it
appears as a ball of dense material
attached to the end of the root
CementoblastomaCementoblastoma

Tumors of OdontogenicTumors of Odontogenic
EctomesenchymeEctomesenchyme

(Central) Odontogenic Fibroma:(Central) Odontogenic Fibroma:
 Fewer than 50 cases have been reported in the EnglishFewer than 50 cases have been reported in the English
literature.literature.
 Patient Age: Patients have ranged in age from 9-80Patient Age: Patients have ranged in age from 9-80
years old with a mean of 40 years.years old with a mean of 40 years.
 Gender Predilection: Females, 7.4:1 in one study.Gender Predilection: Females, 7.4:1 in one study.
 Location: Sixty percent occur in the maxilla whereLocation: Sixty percent occur in the maxilla where
most are located anterior to the first molar. When inmost are located anterior to the first molar. When in
the mandible, approximately 50 % occur in thethe mandible, approximately 50 % occur in the
posterior jaw.posterior jaw.

Odontogenic Fibroma:Odontogenic Fibroma:
Radiographic AppearanceRadiographic Appearance
 The odontogenic fibroma usually appears as aThe odontogenic fibroma usually appears as a
well-defined, unilocular radiolucency. It is oftenwell-defined, unilocular radiolucency. It is often
associated with the apical area of an eruptedassociated with the apical area of an erupted
tooth.tooth.
 Larger lesions are often multilocular.Larger lesions are often multilocular.
 Many odontogenic fibromas have scleroticMany odontogenic fibromas have sclerotic
borders. Root resorption is common.borders. Root resorption is common.

Odontogenic Fibroma: AdditionalOdontogenic Fibroma: Additional
FeaturesFeatures
 Small odontogenic fibromas are usuallySmall odontogenic fibromas are usually
asymptomatic.asymptomatic.
 The larger lesions may be associated withThe larger lesions may be associated with
localized bony expansion of the jaw or with thelocalized bony expansion of the jaw or with the
loosening of adjacent teeth.loosening of adjacent teeth.

Odontogenic Fibroma: HistologicOdontogenic Fibroma: Histologic
FeaturesFeatures
 Some authors have described two separate types ofSome authors have described two separate types of
odontogenic fibromas.odontogenic fibromas.
 TheThe simple odontogenic fibromasimple odontogenic fibroma is composed ofis composed of
stellate fibroblasts arranged in a whorled pattern withstellate fibroblasts arranged in a whorled pattern with
fine collagen fibrils and a lot of ground substance.fine collagen fibrils and a lot of ground substance.
 Foci of odontogenic epithelium may or may not beFoci of odontogenic epithelium may or may not be
present.present.
 Occasionally, foci of dystrophic calcification may beOccasionally, foci of dystrophic calcification may be
present.present.

Odontogenic Fibroma: HistologicOdontogenic Fibroma: Histologic
FeaturesFeatures
 TheThe WHO type odontogenic fibromaWHO type odontogenic fibroma appearsappears
as a fairly cellular fibrous connective tissue withas a fairly cellular fibrous connective tissue with
collagen fibers arranged in interlacing bundles.collagen fibers arranged in interlacing bundles.
 Odontogenic epithelium in the form of longOdontogenic epithelium in the form of long
strands or isolated nests is present throughoutstrands or isolated nests is present throughout
the lesion.the lesion.
 Calcifications composed of cementoid and/orCalcifications composed of cementoid and/or
dentinoid may be present.dentinoid may be present.

Odontogenic Fibroma: TreatmentOdontogenic Fibroma: Treatment
 The odontogenic fibroma is usually treated byThe odontogenic fibroma is usually treated by
enucleation and curettage.enucleation and curettage.
 There have been few recurrences, this theThere have been few recurrences, this the
prognosis is good.prognosis is good.

Mixed Odontogenic TumorsMixed Odontogenic Tumors
 Ameloblastic fibromaAmeloblastic fibroma,, ameloblasticameloblastic
fibrodentinomafibrodentinoma,, ameloblastic fibro-odontoma,ameloblastic fibro-odontoma,
odontomaodontoma
 Both epithelial and mesenchymal cellsBoth epithelial and mesenchymal cells
 Mimic differentiation of developing toothMimic differentiation of developing tooth
 Treatment – enucleation, thorough curettageTreatment – enucleation, thorough curettage
with extraction of impacted toothwith extraction of impacted tooth
 Ameloblastic fibrosarcomas – malignant, treatAmeloblastic fibrosarcomas – malignant, treat
with aggressive en bloc resectionwith aggressive en bloc resection

Related Jaw LesionsRelated Jaw Lesions
 Giant Cell LesionsGiant Cell Lesions
 Central giant cellCentral giant cell
granulomagranuloma
 Brown tumorBrown tumor
 Aneurysmal bone cystAneurysmal bone cyst
 Fibroosseous lesionsFibroosseous lesions
 Fibrous dysplasiaFibrous dysplasia
 Ossifying fibromaOssifying fibroma
 Condensing OsteitisCondensing Osteitis

Central Giant Cell GranulomaCentral Giant Cell Granuloma
 This is a neoplastic-like reactive
proliferation of the jaws that accounts for
less than 7% of all benign lesions of the
jaws in tooth-bearing areas.
 It commonly occurs in children and young
adults with a slight female predilection.
 The lesion is more common in the
mandible than maxilla underlying anterior
or premolar teeth. Expansile lesions can
cause root divergence or resorption.

 The clinical features vary according to the type
of development the lesion assumes. Lesions may
be slow-growing and asymptomatic or rapidly
expanding with pain, facial swelling and root
resorption.
 The fast growing variants have a high rate of
recurrence.
 Because of the higher incidence of these lesions
among girls and women of child-bearing years,
hormonal influences have been suggested as
influential in their development.

 Neoplastic-like reactive proliferationNeoplastic-like reactive proliferation
 Common in children and young adultsCommon in children and young adults
 Females > males (hormonal?)Females > males (hormonal?)
 Mandible > maxillaMandible > maxilla
 Expansile lesions – root resorptionExpansile lesions – root resorption
 Slow-growing – asymptomatic swellingSlow-growing – asymptomatic swelling
 Rapid-growing – pain, loose dentition (highRapid-growing – pain, loose dentition (high
rate of recurrence)rate of recurrence)

 Radiographic findingsRadiographic findings
 Unilocular, multilocular radiolucenciesUnilocular, multilocular radiolucencies
 Well-defined or irregular bordersWell-defined or irregular borders
 HistologyHistology
 Multinucleated giant cells, dispersed throughout aMultinucleated giant cells, dispersed throughout a
fibrovascular stromafibrovascular stroma

 TreatmentTreatment
 Curettage, segmental resectionCurettage, segmental resection
 Radiation – out of favor (risk of sarcoma)Radiation – out of favor (risk of sarcoma)
 Intralesional steroids – younger patients, very largeIntralesional steroids – younger patients, very large
lesionslesions
 Individualized treatment depending onIndividualized treatment depending on
characteristics and location of tumorcharacteristics and location of tumor

Brown TumorBrown Tumor
 Local manifestation of hyperparathyroidLocal manifestation of hyperparathyroid
 Histologically identical to CGCGHistologically identical to CGCG
 Serum calcium and phosphorusSerum calcium and phosphorus
 More likely in older patientsMore likely in older patients

Fibrous DysplasiaFibrous Dysplasia
 Monostotic vs. polystoticMonostotic vs. polystotic
 MonostoticMonostotic
 More common in jaws and craniumMore common in jaws and cranium
 PolystoticPolystotic
 McCune-Albright’s syndromeMcCune-Albright’s syndrome
 Cutaneous pigmentation, hyper-functioningCutaneous pigmentation, hyper-functioning
endocrine glands, precocious pubertyendocrine glands, precocious puberty

 Painless expansile dysplastic process ofPainless expansile dysplastic process of
osteoprogenitor connective tissueosteoprogenitor connective tissue
 Maxilla most commonMaxilla most common
 Does not typically cross midline (one bone)Does not typically cross midline (one bone)
 Antrum obliterated, orbital floor involvementAntrum obliterated, orbital floor involvement
(globe displacement)(globe displacement)
 Radiology – ground-glass appearanceRadiology – ground-glass appearance

 Histology – irregular osseous trabeculae inHistology – irregular osseous trabeculae in
hypercellular fibrous stromahypercellular fibrous stroma
 Deferred, if possible until skeletal maturityDeferred, if possible until skeletal maturity
 Quarterly clinical and radiographic f/uQuarterly clinical and radiographic f/u
 If quiescent – contour excision (cosmesis orIf quiescent – contour excision (cosmesis or
function)function)
 Accelerated growth or disabling functionalAccelerated growth or disabling functional
impairment - surgical intervention (en bloc resection,impairment - surgical intervention (en bloc resection,
reconstruction)reconstruction)

Ossifying FibromaOssifying Fibroma
 True neoplasm of medullary jawsTrue neoplasm of medullary jaws
 Elements of periodontal ligamentElements of periodontal ligament
 Younger patients, premolar – mandibleYounger patients, premolar – mandible
 Frequently grow to expand jaw boneFrequently grow to expand jaw bone
 RadiologyRadiology
 radiolucent lesion early, well-demarcatedradiolucent lesion early, well-demarcated
 Progressive calcification (radiopaque – 6 yrs)Progressive calcification (radiopaque – 6 yrs)

 Histologically similar to fibrous dysplasiaHistologically similar to fibrous dysplasia
 Surgical excision – shells outSurgical excision – shells out
 Recurrence is uncommonRecurrence is uncommon

Aspiration
Value:
To investigate the fluid content of soft, cheesy, or rubbery
masses, whose characterisitcs suggest that they may
contain fluid.
Aspirate:
 Straw-colored fluid (may has cholesterol crystals)…. Odontogenic &
some Fisural Cysts & ooccasionally Cystic Ameloblastoma.
 Thick, yellowish-white, granular fluid (containing Keratin)….
Epidermoid & Keratocyst.
 Thick, homogenous, yellowish to gray (Sebum)…. Sebaceous Cyst.
 Thickest, yellowish, cheesy substance “with Difficulty” (contains
Keratin, sebum, sweat, and exfoliated squamous cells…. Dermoid Cyst.

 Dark, amber-colored fluid…. Thyroglossal duct Cyst.
 Colorless, cloudy, somewhat frothy “has a high lipid
content” (Lymph fluid)…. Cystic Hygroma and
Lymphangioma.
 Bright-red Blood (oxygenated hemoglobin)….
Ateriovenous Malformation.
 Dark venous blood (Bluish Blood)…. Early Hematoma,
Aneurysmal bone cyst & Hemangioma.
 Small amounts of blood that require negative pressure for
withdrawal (is not uncommon with many central lesions of
bone)…. Idiopathic bone cavity, Central giant cell
granuloma, Inflammatory lesions & Metastatic lesions.

 Pus (yellow, or yellowish-white)…. Abscess (painful, warm,
fluctuant swelling)
 Pus with sulfur Granules (firm yellow granules)….
Actinomycosis.
 Sticky, clear, viscous fluid (concentrated Mucous)….
Mucocele, Ranula& some minor salivary gland Tumors.
 Air…. Air filled space (max sinus), Subcutanous
Emphysema.
 -Ve …. Cellular Mass (Tumor).

Features obtained by Palpation
o Surface Temperature.
o Anatomic regions and
Planes involved.
o Mobility.
o Extent.
o Borders of the mass.
o Consistency of surrounding
tissue.
o Thickness of overlying
tissue.
o Size ad Shape.

o Consistency.
o Fluctuance and
Emptiability.
o Painless, Tender, or
Painful.
o Unilateral or Bilateral.
o Solitary or Multiple.
Percussion:
Auscultation:

Bone Lesions
The differential diagnosis of
bone lesions can be more
challenging than that of soft
tissue for a number of reasons:
Less common than soft tissue
lesions (except reactive lesions
secondary to degenerative pulpal
disease).
Most osseous lesions are
centrally located and not
accessible to visual examination
or palpation.

Bone lesions are frequently
asymptomatic and found on
routine radiographic
examination, so the history is
often less informative.
In addition, the jaws have a
number of unique pathologic
entities as compared with other
bones.

Classification of Osseous lesions of the Jaws
5 categories:
1. Cysts.
2. Odontogenic tumors.
3. Benign nonodontogenic tumors.
4. Malignant tumors.
5. Diseases of bone:
 inflammatory (specific, nonspecific).
 primary diseases.

Terminology for Surgical Procedures
Enucleation.
Curettage.
Marsupialization.
Resection without
Continuity Defect
(RsCD).
Resection with
Continuity Defect
(RcCD).
Disarticulation.
Recontouring.

Cysts
 Lateral periodontal cyst
 Radicular cyst and periapical dental granuloma
 Hyperplastic dental follicle
 Follicular cysts (dentigerous, primordial)
 Odontogenic keratocyst
 Calcifying and keratinizing odontogenic cyst
 Fissural cysts
 Traumatic cysts
 Lingual bone defect

G M Kerato
.
Stati
c
Lat Period.Gorli
n
Dentig.

Odontogenic Tumors
 Ameloblastoma
 odontogenic adenomatoid tumor
 Squamous odontogenic tumor
 Calcifying epithelial odontogenic tumor
 Odontogenic fibroma
 Odontogenic myxoma
 Ameloblastic fibroma
 Odontoma (ameloblastic, cystic(
 Ameloblastic fibro-odontoma
 Periapical cemental dysplasia
 Cementoblastoma

Ameloblastom
a
Pindborg T.
Ameloblastom
a

Ameloblastic Fibroma
Odontog. Fibroma
Comp.
Odontom
Odontog. Myxoma Complex
Odontom

Benign Nonodontogenic Tumors
 Central giant cell granuloma
 Aneurysmal bone cyst
 Myxoma
 Chondroma
 Osteoma
 Fibroma
 Congenital arteriovenous malformation
 Hemangioma
 Melanotic neuroectodermal tumor
 Fibro-osseous lesion
 Ossifying fibroma
 Cementifying fibroma
 Monostotic fibrous dysplasia
 Polyostotic fibrous dysplasia

Cent.
Hemangioma
Osteoma
Aneurysmal B. Cent. G. C. G.

Ossifying
Fibroma
Fibro-oss.
Dysplasia
Fibrous
Dyspalsia
Fibrous
Dyspalsia

Malignant Tumors
 Metastatic carcinoma
 Osteosarcoma
 Chondrosarcoma
 Ewing's sarcoma
 Burkitt's lymphoma
 Multiple myeloma
 Langerhans cell disease (acute disseminated(

Diseases of Bone
Inflammatory:
 Osteomyelitis
 Condensing osteitis
 Osteitis
 Langerhans cell disease
 Infantile cortical hyperostosis
: Primary
 Paget's
 Cherubism
 Hyperparathyroidism
 Osteogenesis imperfecta
 Osteopetrosis
 Achondroplasia
 Multiple diaphyseal sclerosis


Bone
Infection
Langerhans C.
H.
Osteoradionecros
is
Ch. Supp.
Osteomy.
Inflammator
y

Florid Oss.
Dysplasia
Osteopetrosi
s

Importance of History Informations
For Asymptomatic Lesions (discovered on routine
radiographic examination)…
Some initial assumptions may be based on…
Pt. Age……..(as new lesions) Ex;
 < 50 y: Odontogenic tumors.
 < 40 y: Paget's disease, metastatic carcinoma (excluding
breast carcinoma), and multiple myeloma.

Definition:Definition:
 Removal of tissue from living beings forRemoval of tissue from living beings for
macroscopic examination ,microscopicmacroscopic examination ,microscopic
 analysis, bacterial analysis & combination ofanalysis, bacterial analysis & combination of
above is called “BIOPSYabove is called “BIOPSY

INDICATIONSINDICATIONS
1.To determine the nature of lesion which does not1.To determine the nature of lesion which does not
readily respond to conservative & simple therapy.readily respond to conservative & simple therapy.
2.To determine the nature of the lesion which is2.To determine the nature of the lesion which is
unknown.unknown.
3.To establish the diagnosis where there is3.To establish the diagnosis where there is
suspecious of neoplasm.suspecious of neoplasm.
4.To determine nature of any intraosseous lesion4.To determine nature of any intraosseous lesion
which can’t be identified radiographically.which can’t be identified radiographically.
5.To determine the nature of all abnormal tissue5.To determine the nature of all abnormal tissue
removed from the oral cavity including cysts &removed from the oral cavity including cysts &
granulomas.granulomas.

Contraindications:Contraindications:
A.A. Relative contraindicationsRelative contraindications::
1.In cases of inflammatory lesions may be due to1.In cases of inflammatory lesions may be due to
allergy ,viral ,fungal, or bacterial lesion. e.g.allergy ,viral ,fungal, or bacterial lesion. e.g.
candidiasis.candidiasis.
2.Compromised generalised health of patient. e.g.2.Compromised generalised health of patient. e.g.
patient on anticoagulant therapy.patient on anticoagulant therapy.
3.Proximity of lesions to vital , anatomic,3.Proximity of lesions to vital , anatomic,
physiologic, neural, vascular, or glandularphysiologic, neural, vascular, or glandular
structures.structures.

 B)B) Absolute contraindications:Absolute contraindications:
1.Pulsatile vascular lesions. e.g. angiosarcoma.1.Pulsatile vascular lesions. e.g. angiosarcoma.
2.Pigmented lesion should not be biopsied. e.g.2.Pigmented lesion should not be biopsied. e.g.
Melanoma.Melanoma.
3.Intrabony radiolucent lesions should not be3.Intrabony radiolucent lesions should not be
biopsied or removed without priorbiopsied or removed without prior
investigational aspirationinvestigational aspiration

ARMAMENTERIUM:ARMAMENTERIUM:
1.Mouth mirror & probe,1.Mouth mirror & probe,
colourless antisepticcolourless antiseptic
agent.agent.
2.LA & syringe.2.LA & syringe.
3.Surgical scalpel.3.Surgical scalpel.
4.Long pointed surgical4.Long pointed surgical
scissors.scissors.
5.Tissue forceps5.Tissue forceps
6.Biopsy punch6.Biopsy punch
7.Bone burs7.Bone burs
8.Periosteal elevator8.Periosteal elevator
9.Chiesel9.Chiesel
10.Bow curette10.Bow curette
11.Suture material11.Suture material
12.Needle holder12.Needle holder
13.Sponges13.Sponges
14.Wide mouthed bottle14.Wide mouthed bottle
with10% neutralwith10% neutral
buffered formalinbuffered formalin

Points must be considered to ensurePoints must be considered to ensure
obtaining proper specimenobtaining proper specimen
1.Do not paint the surface of the area to be biopsied with1.Do not paint the surface of the area to be biopsied with
iodine or other highly coloured antiseptic.iodine or other highly coloured antiseptic.
2.Don’t inject LA into the lesion.2.Don’t inject LA into the lesion.
3.Use sharp scalpel to avoid tearing of tissue.3.Use sharp scalpel to avoid tearing of tissue.
4.Use care not to mutilate the specimen when grasping it4.Use care not to mutilate the specimen when grasping it
with forceps.with forceps.
5.Fix the tissue immediately upon removal in 10%5.Fix the tissue immediately upon removal in 10%
formalin or 70% alcohol.formalin or 70% alcohol.
6.If the specimen is thin, place it upon a piece of glazed6.If the specimen is thin, place it upon a piece of glazed
paper & drop into fixative which prevents curling ofpaper & drop into fixative which prevents curling of
tissue.tissue.

TYPES OF BIOPSYTYPES OF BIOPSY
1.Excisional biopsy1.Excisional biopsy
2.Incisional biopsy2.Incisional biopsy
3.Punch biopsy3.Punch biopsy
4.Needle/trephine/drill4.Needle/trephine/drill
5.Aspiration biopsy5.Aspiration biopsy
6.Exfoliative cytology6.Exfoliative cytology

 Illustration of excisional biopsy of soft tissue lesion. A, Surface
view. Elliptic incision is made around lesion . A, Surface view.
Elliptic incision. B, Side view, Incision is made deep enough to
remove lesion completely. C, End view. Incision are made
convergent to depth of wound. If excision is made in this way,
closure will be facilitated.

 A, Illustration showing desirability of obtaining deep specimen
rather than broad and shallow specimen when incisional biopsy is
performed. If malignant cells are present only at base of lesion,
broad and shallow biopsy might not obtain these diagnostic cells. B,
Illustration showing desirability of obtaining incisional biopsy at
margin of soft tissue lesion. Junction of lesion with normal tissue
frequently provides pathologist with more diagnostic information
than if biopsy were taken only from center of lesion.

Illustration demonstrating
desirability of obtaining more
than one incisional biopsy if
characteristics of lesion differ
from one area to another.
Frequently one area of lesion
appears histologically
different from another (A).
When obtaining biopsy on
buccal or labial mucosa,
incision is usually carried to
depth of musculature (B).

 Illustration showing use of
traction suture piaced
through specimen. While
lesion is incised, traction
suture is use to lift
specimen from wound bed.
Suture can then be tied and
left attached to lesion to
identify margin of
specimen.

 Illustration showing
principles used in closing
an elliptic biopsy wound.
Mucosa should be
undermined bluntly with
scissors to width of
original ellipse in each
direction. This allows
approximation of wound
margins without tension.

EXCISIONAL BIOPSYEXCISIONAL BIOPSY
*Definition*Definition: Total excision of a small lesion: Total excision of a small lesion
for microscopic study is calledfor microscopic study is called
““excisional biopsy”.excisional biopsy”.
*Use*Use : Lesions smaller than 1cm in: Lesions smaller than 1cm in
diameter.diameter.

MethodMethod
 Give LA which should not be closer than 2cmGive LA which should not be closer than 2cm
from the site.from the site.
 Stabilize the lesion via the suture.Stabilize the lesion via the suture.
 Incise mucosa around the base of the lesion inIncise mucosa around the base of the lesion in
an elliptical shape.an elliptical shape.
 Place specimen immediately in a fixative.Place specimen immediately in a fixative.
 Close the wound using suture.Close the wound using suture.

INCISIONAL BIOPSYINCISIONAL BIOPSY
Definition:Definition:
Some lesions are too large to excise initiallySome lesions are too large to excise initially
without having established diagnosis or are ofwithout having established diagnosis or are of
such a nature that excision would be inadvisablesuch a nature that excision would be inadvisable
in such instances a small section is removed forin such instances a small section is removed for
examination called incisional or diagnosticexamination called incisional or diagnostic
biopsy.biopsy.
UseUse : For large lesions: For large lesions

MethodMethod
 Administer LA.Administer LA.
 Identify the apparent junction between normal tissue &Identify the apparent junction between normal tissue &
the lesion select the specimen across region.the lesion select the specimen across region.
 Stabilize the specimen with a suture.Stabilize the specimen with a suture.
 Dissect the specimen from the edge of the lesion &Dissect the specimen from the edge of the lesion &
include a margin of apparently normal tissue.include a margin of apparently normal tissue.
 The specimen should include representative area of theThe specimen should include representative area of the
lesion.lesion.
 Place the specimen immediately in a prescribedPlace the specimen immediately in a prescribed
specimen bottle containing 10% formalin.specimen bottle containing 10% formalin.
 Close surgical site by sutures.Close surgical site by sutures.

PUNCH BIOPSY:PUNCH BIOPSY:
 A surgical instrument is used to punch out aA surgical instrument is used to punch out a
representative portion of tissue.representative portion of tissue.
 Since resulting specimen is often damagedSince resulting specimen is often damaged
by the procedure so biopsy by scalpel isby the procedure so biopsy by scalpel is
preffered.preffered.

Needle/trephine/drill biopsy:Needle/trephine/drill biopsy:
 Use : to biopsied deep-seated fibro-osseousUse : to biopsied deep-seated fibro-osseous
lesions.lesions.
 The resulting specimen is smaller may be non-The resulting specimen is smaller may be non-
representative & again often damaged by therepresentative & again often damaged by the
procedures so they are not often used.procedures so they are not often used.

Aspiration biopsyAspiration biopsy
 UseUse – Applicable to many cystic & fluctuant lesions– Applicable to many cystic & fluctuant lesions
Method-Method-
Clean the tissue over the proposed aspiration site.Clean the tissue over the proposed aspiration site.
-Inject LA solution over the lesion.-Inject LA solution over the lesion.
-Select a wide bore needle & 10 ml syringe.-Select a wide bore needle & 10 ml syringe.
-Penetrate tissue & aspirate fluid.-Penetrate tissue & aspirate fluid.
-Transfer the aspirate into a screw top specimen bottle.-Transfer the aspirate into a screw top specimen bottle.

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