Odontogenic Tumours

Important causes of swelling of the jaws:

1) Cysts especially odontogenic ones.
2) Odontogenic tumours ( most common
neoplasms).
3) Giant cell lesions.
4) Fibro-osseous lesions.
5) Primary ( non-odontogenic ) neoplasms of bone.
6) Metastatic neoplasms.
7) Chronic osteomyelitis.

Classification of odontogenic tumours according to the behaviour of the lesions

(I) Benign
2

Epithelial

Mesenchymal

1- Ameloblastoma
Fibroma

1- Od. Fibroma

2- Adenomatoid

2- Od. Myxoma

odontogenic
tumour
3- Calcifying epithelium
Od. Tumour
4- Squamous odontogenic
tumour

3- Cementoblastoma

Mixed
1- Ameloblastoma
2- Odontomas

(II) Malignant
3

Epithelium
Mixed

Mesenchymal

1- Malignant Ab
-Amelofibrosarcoma

- Odontogenic

2- Ab. Carcinoma

Fibrosarcoma

3- Odontogenic
Carcinoma

I - Benign
4

Epithelial Odontogenic tumours

1)Ameloblastoma :
- It is the most common neoplasm of the jaws.
Clinical features : Age : Between 3rd to 5th decades.
Sex: No sex predilection
Site : Mandible more than maxilla 80% of cases were in mandible .
In the mandible 70% of cases were in molar ramous region.
Characters :
- Asymptomatic
- Slowly growing
- Discovered by X ray
Radiographic Appearances :
1) Multilocular radiolucent area.( Honey comb pattern) & expanded
lingually
2) Unilocular radiolucent area usually associated with impacted tooth
( as in dentigerous cyst).

Ameloblastoma. Typical
presentation. There is a
rounded, bony
swelling of the posterior
alveolar bone, body and
angle of the mandible.
There is no ulceration, a
feature only seen in very
large tumours which
have perforated the cortex.

Ameloblastoma. The typical

radiological appearance of
ameloblastoma is a multilocular
cyst or multiple cyst cavities of
different
sizes, as shown here.
121
Odontogenic tumours and
tumour-like lesions of the
5jaws

Macroscopic appearances :
- Solid or cystic or both together.
- Traversed by bony ridges.
6

Microscopic appearances:
-Different histological patterns are seen under microscope.
-The epithelium forming this neoplasm resembles that epithelium
which forms the enamel organ.
- The fibrous stroma surrounding this epithelium vary in both
quantity & cellularity ( not neoplastic one).
- In most cases the stroma is collagenous with few cells while in
other cases , the stroma may be abundantly cellular .
Two main histological patterns are commonly seen in
ameloblastoma.
1- Follicular
2- Plexiform.
Follicular Ameloblastoma: In this patterns , the odontogenic
epithelium takes the form of discrete islands separated from each
other by variable C.T. stoma ( non - neoplastic C.T.).

Ameloblastoma. This
ameloblastoma forms a
monolocular radiolucency
enveloping the crown of an
unerupted tooth. The radiological
appearance mimics a
dendgerous cyst, reinforcing the
maxim that ameloblastoma
should be considered in the
differential diagnosis of every
radiolucency at the angle of the
mandible.

Ameloblastoma. At high power in this

follicular ameloblastoma
the palisaded, elongated peripheral cells
with reversed polarity are seen to
be very similar in appearance to
ameloblasts.

Variants :
1-Solid form : Typical follicle consists of :
9

i Peripheral layer of cuboidal or columnar cells resembling the

pre-ameloblasts . This layer is called ( ameloblastic like cells). The
nucleus of that cell is deeply stained & at the opposite pole to the
basement membrane.
ii- Central mass of polyhedral cells which are loosely anastomosing
& resembling the stellate reticulum cells. These cells are called
( stellate reticulum like cells).
2- Cystic formation: Common : cystic breakdown & epithelium is
usual this degeneration occurs in stellate reticulum like cells.
i) Microcystic : This represent the starting of the process of
degeneration .Small microcysts appear in central mass of the follicle.
The peripheral layer of ameloblast like cells become low cuboidal
due to slight pressure of minute cystic fluid.
ii) Macrocystic : Microcysts will fuse to form a larger cyst filling the
whole center of the follicle . The peripheral cells will become flattened
& the lesion may be mistaken for a simple cyst. However many other
areas will show the typical follicular form beside the cystic form.

3) Acanthomatous form :
- Areas of squamous metaplasia may be found ( so high recurrency &
may turn malignant).
10

- The central cells become squamous , compact to each other.

- The tendency of squamous metaplasia appear to be increased by :
* Previous operation
* Radiation therapy
- In many areas of acanthomatous ameloblastoma , keratin may be
formed & may be so prominent that the neoplasm is referred to as
( kerato ameloblastoma).
4) Granular ameloblastoma :
- In rare cases , the follicles show their central cells undergo a
granular change. Part or all the tumour may show this variation.
- The central cells are larger than normal , cuboidal , rounded or
columnar in shape with their nuclei pushed against the cell wall &
their cytoplasm is filled by coarse eosinophilic granules.
- These granules are best demonstrated by E/M or histochemically
& are said to be lysosome like particles called phago - lysosomes.

Ameloblastoma. Islands of ameloblastoma

penetrating surrounding bone at the
periphery of the lesion. Such bony
infiltration demands that ameloblastoma is
excised with a margin rather than curetted.

11

5) Basal cell ameloblastoma :

12

The peripheral cells become cuboidal rather than columnar & central
cells become more compact. It cab be mistaken from basal cell
carcinoma .
6) Hyalinized C.T. stroma :
The stroma around epithelial masses undergo hyalinization to involve a
zone of about ( 30 microns) immediately adjacent to epithelial follicle.
This zone is due hyaline degeneration of collagen fibers. This zone does
not calcify ( i.e. remain eosinophilic. This zone is not diagnostic for
ameloblastoma.
7) Desmoplastic ameloblastoma : ( low recurrency)
The C.T. stroma is usually consisted of a cellular loose C.T. but in some
cases it becomes more collagenous with small follicles of epithelium.

Plexiform Ameloblastoma :
- In this variant , the tumour epithelium is arranged in the form
of irregular intercommunicating anastomosing strands but not in
the form of discrete islands as in follicular variant.
I) The arrangement of cells of these strands is the same as that
of follicular AB i.e. they are bounded by a layer of columnar or

Ameloblastoma. Granular cell change in an

ameloblastoma.
Ameloblast and stellate reticulum-like cells
have undergone degenerative change to
form large pink granular cells. In some
tumours this change is extensive and the
term 'granular cell ameloblastoma' is
applied.

13

14

Or cuboidal cells ( ameloblastic like cells) Surrounding another

layer of loosely intercommunicating cells ( stellate reticulum like
cells) but less abundant ( this form called solid plexiform
ameloblastoma).
II) Cystic plexiform AB :
- In some cases , cystic degeneration of C.T. stroma occurs
leading to stromal cysts.
- In some cases , following stroma degeneration many spaces are
found filled with blood & lined by epithelial strands. These cases
have been called Hemangio - AB.
- However , this term is not correct since no neoplastic change
could be seen in vascular endothelium , but however it represents
vasodilataion of stromal B.Vs that have lost their support by
stromal degeneration.
- These various histological patterns seen in ameloblastoma have
given rise to the different nomenclatures. However , these variants
are not accompanied by variation in clinical picture or behaviors as
well as treatment , because in one patient many histological
variants could be seen under microscope.

Plexiform unicystic ameloblastoma : It is a recent distinct entity of

AB
Histologically :
15

- Cystic cavity lined by tumour cells which are flattened ( non descript
epithelial cells & no ameloblast like cells).
- Unicystic plexiform ameloblastoma differs from the solid types in the
following : Low recurrence rate , so , treated without safety margin ( just
enucleation).
Histogenesis of ameloblastoma :
Several origins have been proposed as the origin of ameloblastoma .
1) Basal layer of oral epithelium : Due to :
A- Since few cases arises in soft tissue basal layer is suggested to be
the origin.
B- Basal cell ameloblastoma resemble basal cell carcinoma.
2) Dental lamina or it is remnants : because
A- few cases a rise in soft tissue ( rests of Serres are present in gingiva).
B- Different in histological patterns suggest the different pontencially of
dental lamina . Arise at any age.

3) Enamel organ or it is remnants : because

A- Some cases arise with impacted tooth.
16

B- Follicular Ab resemble enamel organ.

4) Epithelial lining of a follicular cyst : due to
A- Ab are common arised in the areas of dentigerous cyst.
B- May be mistaken radiographically as a dentigerous cyst.
C- Ab may arise with impacted tooth.
Behaviour & local spread of AB:
1) Ab tend to spread into cancellous ( spongy) space without
resorption of the compact bone.
2) Therefore the tumour tissue extend into areas of bone that
appear in X-ray normal .
3) This invasive character of AB & absence of capsule around the
tumour would suggest the local invasive nature of this neoplasm.
4) Since Ab does not tend to invade compact bone , the inferior
border of the mandible represents the actual limit of that
neoplasm.

Ameloblastoma, plexiform
type. There are thin, interlacing
strands of epithelium but
typical ameloblasts are not
seen.

17

Squamous metaplasia in an
ameloblastoma. Stellate
reticulum- like cells have
undergone squamous
metaplasia to form keratin.

Ameloblastoma. Islands of
follicular ameloblastoma
comprising
stellate reticulum and a
peripheral layer of elongated
ameloblast-like cells.

Ameloblastic carcinoma. Very rarely

a malignant variant of the
ameloblastoma is encountered.
Histologically they may be
indistinguishable from other
carcinomas, but in some cases, as
here, a peripheral layer of palisaded
ameloblast-like cells remains,
indicating the
tumour's nature.

Ameloblastoma. Plexiform
ameloblastoma composed of
interconnecting strands of
epithelium surrounding islands
of connective tissue. Several of
the stromal islands have
degenerated to form small
cystic cavities.

Ameloblastoma. Soft tissue

spread after repeated
inadequate excisions.

Diagnosis of Ab :
1- biopsy for histological examination.
2- X- Ray .
18

3- Magnetic resonance ( solid or cystic types).

Treatment :
1- Surgical removal with safety margins.
2- Large tumours may require bony resection or even the whole
jaw.
3- Ab id radioresistent tumour so it is not treated by
radiotherapy.
Prognosis :
1- Solid & multicystic have a higher tendency to recur when
treated conservatively ( i.e. without safety margin )
2- Maxillary Ab when allowed to reach a large size may give rise to
serious complication .
3- Adequate treatment gives good prognosis.

Malignant epithelial odontogenic tumours :

1) Malignant Ab
19

2) Ameloblastic Ca. 3) primary intra-osseous Ca.

Malignant Ab

Ameloblastic Ca

1ry intra.osseous Ca

Rare jaw Tu. That gives

rise to distant M. with
histological picture of AB
. It gives metastasis to
the pulmonary area ,
may be due to aspiration
implantation.

A variant of malig.
AB but with
metastatic Tus.
Showing sq. C.Ca AB
turn into Ca by Sq.
metaplasia , it
spreads to L.N.

It is a Sq.C.Ca.
arising within the
jaw having no initial
connection with oral
epithelium & arises
from odontogenic
epithelium
undergiong
squamous
metaplasia

Histologica Both 1ry & 2ry Tus. show 1ry Tu. Show typical
picture of AB with
AB as well as picture
l picture

Both 1ry & 2ry Tus.

Show typical
Sq.C.CA. the 1ry Tu.
May show
odontogenic patter
of distribution i.e.
plexiform pattern
for example with
palisaded
peripheral cells.

Defintion

definite histologic &

cytologic criteria of
malignancy

of Sq.C.Ca. 2ry Tus.

Show typical
Sq.C.Ca. ( due to Sq.
metaplasia of
odontogenic
epithelium)

2- Adenomatoid Odontogenic Tumour

20

It is benign epithelial odontogenic Tu. Characterized by duct like

structure & variable degrees of inductive change . It is probably a
hamartoma.
Clinically : Age 2nd decade of life ( young adult).
Sex : Female more than male .
Site : Maxilla > mandible 2: 1 , most common in canine
region.
Characters :
1- Slowly growing .
2- painless discovered by chance on X-ray.
3- cause jaw expansion especially of upper canine region .
4- Usually related to unerupted tooth ( may resemble dentigerous cyst
both clinically & radiographically ).
Radiographic picture :
- Well defined radiolucent area related to unerupted tooth.
- Inside this radiolucency , scattered radiopaque areas may be
seen.

Macroscopic picture :
-Size : few centimeters, capsulated.
- Cur surface : is greyish white in colour with dark areas of hemorrhage.
21

- It may show one or more cystic spaces .

- A tooth may be embedded in it .
Histopathology ( microscopic picture) : This tumour is capsulated.
1- The Tu. Is composed of sheets of small or spindle shaped epithelial
cells with clear cytoplasm & oval nuclei.
2- These sheets or masses are arranged in whorly patterns.
3- Some of these cells will differentiate into tall columnar cells
resembling ameloblasts & arranged in different patterns as follows :
I) Tubular structure : Two rows of cells with eosinophilic homogenous
material in between the two rows.
II) Convoluted bands : Two rows of cells with eosinophilic material in
between the two rows & with a shape of convoluted tubules.
III) Duct like structures : Some of tubular structures may expand
( open) to include a central space surrounded by single layer of flat
columnar cells.
-The nuclei of these radially arranged tall columnar cells are situated at

-The nuclei of these radially arranged tall columnar cells are

situated at The basal of the cell.
22

- The central space contains a homogenous eosinophilic material

forming a thin layer in contact with the free end of the cells.
N.B. : This eosinophilic material is thought to be a basement
membrane like material since it is PAS positive.
The tumour contains very small amount of C.T. stroma which may
undergo degeneration to give a cribriform pattern under
microscope.
- Small foci of calcification or hyaline material may be present
which was described as dysplastic abnormally formed dentin.
Histogenesis of adenomatoid odontogenic tumour:
Enamel organ or it is remnants.
Treatment : This tumor is capsulated , so it is treated with simple
enucleation.
Prognosis : Good prognosis since the tumour is benign with no rate
of recurrence as it is capsulated.

Adenomatoid odontogenic tumour. Low

magnification shows duct-like microcysts
and convoluted structures. The stroma is
scanty.

23

Adenomatoid odontogenic tumour. At

higher power the duct- like spaces
which give the tumour its name are
seen.

Calcifying Epithelial Odontogenic Tumour

Pindborg Tumour
24

It is a benign but locally invasive epithelial neoplasm characterized

by development of intra-epithelial amyloid like material which may
become calcified & liberated into surrounding stroma. Relatively rare
neoplasm as compared to AB , but it could be mistaken for a poorly
differentiated carcinoma.
Clinical picture : Age : Average age is 40 years.
Sex : pindborg discovered that male & female
occurance in equal incidence.
Site : Mandible > Maxilla 2: 1, In mandible , the most
common site is molar premolar region. Molar 3 : 1 Premolar
Half the cases are associated with the crown of unerupted tooth.
Characters :

1- Slowly growing . 2- Symptomless.

3- Hard ( due to calcification).
4- Diffuse or well defined swelling.
5- Usually a missing tooth is observed at site of the

tumour.

Radiographic picture :
- Irregular radiolucent area with radiopaque areas of variable size
usually related to the crown of unerupted tooth.
25

- The peripheral zone of this lesion is radiolucent which may or may

not be well demarcated from the normal bone.
- Usually radioopacities increase within the tumour as it matures.
Histopathology :
1- Tu. is made up of sheets of polyhedral epithelial cells with well
defined borders & prominent inter cellular bridge & may show cellular
pleomorphism.
2- Rounded eosinophilic homogenous masses are often present in the
epithelial masses.
3- These masses are commonly calcify in concenteric way to form
what is called ( Leisgang rings) .
4- Epithelial cells may degenerate to liberate the calcific basophilic
rings into the surrounding stroma.
5- Fusion between calcific rings occur to form large irregular masses.
6- The eosinophilic pink material give the similar staining reaction of
amyloid.

Origin of this amyloid material may be due to :

I) Active secretion of these cells.
II) A product of polyhedral cells degeneration.
26

Histogenesis : Most probably from reduced enamel epithelium of

impacted unerupted tooth.
Treatment As in AB. , curettage will result in recurrence ( not
capsulated).
Prognosis : Complete resection of the Tu. bearing area of the jaw
will result in complete & permanent cure with good prognosis.
Causes of aggressiveness of this neoplasm:
1- Irregular growth of neoplasm towards the surrounding bone.
2- Lack of encapsulation ( the tumour is not capsulated).

Calcifying epithelial odontogenic tumour.

At higher power the epithelial cells are
seen to have sharply defined cell
membranes resembling squamous
epithelium and pleomorphic
hyperchromatic nuclei. The pale pink
material is amyloid-like.
27

Calcifying epithelial odontogenic tumour (Pindborg

tumour .The tumour is composed of strands and
sheets of polyhedral epithelial cells lying in pale
pink staining amyloid-like material. Some of this
material has mineralised, stains a darker blue
colour and gives rise to radiopacities within the
lesion.

Clear cell odontogenic carcinoma.

This rare epithelial
odontogenic tumour is composed of
pale-staining clear cells.

28

Clear cell odontogenic carcinomas.

This neglected tumour has
fungated through the cheek.

4- Squamous odontogenic tumour

29

It is an intrabony ( central) benign but locally invasive neoplasm arising

from islands of well differentiated squamous epithelium present in fibrous
stroma. This neoplasm was considered as a variant of simple AB.
Clinical picture: Few cases were discovered.
Age : common age 3rd decade. Sex : equal Site : Mandible = Maxilla
The tumour is multicenteric ( i.e. in many bones).
Characters :
1- Most cases follow a benign course i.e. slowly growing painless .
2- In other cases , the tumour may be :
- Rapidly growing .
- Cause bone destruction.
- cause surface ulceration.
Radiographic picture : Unilocular radiolucent area.
Histological picture :
1) Islands of well differentiated squamous epithelium pained in
collagenous C.T. stroma ( resemble follicular AB)

2) Epithelial islands , in contrast to simple AB , are surrounded by

a layer of flat low cuboidal cells.
3) Epithelial islands may undergo calcification.
30

Squamous odontogenic tumour. The lesion is

composed of islands of squamous epithelium without
peripheral palisaded cells.

Melanotic Neuroectodermal Tumour in

infancy
31

It is a rare neoplasm or hamartoma of unknown nature & is confined to

infants less than one year old.
Clinical features : Age : Infants less than on year ( 6months).
Sex: Female more than male.
Site : Maxilla > Mandible ( maxilla anterior region mostly).
Characters:
1) Pigmented or non-pigmented swelling of the gums.
2) May be central ( i.e. intrabony)
3) Initial rate of growth is rapid ( resemble malignancy) then , the rate
becomes slow after sometimes & then it may stop , when the tumour
reaches a certain site.
Radiographic picture :
- Peripheral lesion ( outside bone) is negative in X ray except when
causing bone erosion.
- Central lesion is radiolucent area usually multilocular with displacement
of neighbouring teeth.

Histopathology : The lesion is not capsulated , two types of cells are found :
I) Epithelium like cells : Arranged in strands or sheets or duct like structure.
II) Lymphocyte like cells :
32

- darkly stained.
- May be small cells with dense rounded nucleus or may be larger
with larger nucleus showing fine chromatin.
- Lymphocyte like cells may be found inside duct like structure of
epithelial like cell.
* Sometimes , other type of cells is also present we can find small collection
of polyhedral or stellate cells filled with fine melanin granules.
* The lesion is not capsulated & the margins of the tumour is irregular giving
invasive appearance of that lesion.
* These types of cells are found in well formed C.T. stroma which is
sometimes fibrillated.
Histogenesis : 1) Pigmented lesions are derived from dentritic melanocytes of
neural crest origin . These cells ( melanocytes) are included in dental lamina
& enamel organs.
2) Epithelial like cells may be originate from paradental epith.

33

Benign Epithelial Hard odontogenic

tumours :
Enameloma ( enamel pearl) :
This is a developmental malformation in which small
nodule of enamel develop on the radicular portion of a
tooth usually upper molars at or near the root
bifurcation.
Macroscopically : It is a small circumscribed nodule of
normal enamel.
Histologically : it may be
1- Normal prismatic structure
2- Normal enamel with a core of dentin & pulp tissue
Histogenesis : It develops as a result of disturbed development
of an area of epithelial root sheath of Hertwig differentiated into
enamel organ lying down enamel

Enamel pear -A small, spherically shaped enamel projection on a root surface

is called an enamel pearl. It is usually seen on maxillary molars in the
furcation area. This photograph shows the mesial view of a maxillary third
molar.
34

35

Benign Mesenchymal
odontogenic tumours
1- Odontogenic fibroma
2- Odontogenic myxoma

Odontogenic fibroma
Definition

Odontogenic myxoma

Benign fibroblastic neoplasm with

presence of epithelial rests
( odontogenic origin) .
It is rare endosteal tumour

Benign , but locally

invasive neoplasm
consisted of stellate cells
in mucoid stroma
( resemble developing
dental papilla

Clinical picture

Age : 1st two decades of life may be

discovered later.
Sex : equal
Site : mandibular molars - premolar

Age : young adults

Sex : equal
Site : mandibular >
Maxilla 60
:
40%

Clinical features

1)
2)
3)
4)
5)

Usually painless
Rapidly growing due to
accumulation of
mucoid material
Fusiform swelling
Cause jaw expansion
Usually covered by
only thin layer of bone
6) Usually related to
place of missing tooth

X ray

Sharp defined radiolucent area in a

tooth bearing region

36

Painless
1)
Slowly growing
2)
Well circumscribed
Cause slight jaw expansion
Usually arise near root of tooth or 3)
in place of missing tooth
4)
5)

Multilocular radiolucent
area , soap bubble
radiolucency wit a crown
of impacted tooth

Histopatholog
y

37

Histogenesi
s

1) Primitive cellular
C.T.
2) Between
fibroblasts are
found inactive
islands of
odontogenic
epithelium
3) Collagen fibers are
variable in amount
but usually the
lesion is cellular
4) Sometimes ,
islands of osteoid
or cementoid
tissues could be
found

1) Primitive myxomatous tissue

2) Stellate or spindle shaped cells with long
anastomosing processes with basophilic
cytoplasm
3) These cells are found in mucoid matrix is
faintly basophilic
4) In this matrix , two types of fibers are present
: A- collagen B- Reticulin
5) Sometimes , the nuclei of stellate cells show:
a- Atypical shape b- Hyperchromatism
6) In active islands of epithelial cells are usually
present
7) The tumour may contain moderate amount of
collagen fibers & the lesion is called
fibromyxoma

This lesion originates

from : Fibroblastic
tissue of tooth follicle
or it is remnants in
periodontal tissue .
( pressure of
cementum like tissue
support this origin)

This lesion derived from odontogenic

mesenchyme of dental papilla because of it is
resemblance to that site , this theory is
supported by : 1) Presence of impacted or
missing tooth 2) Absence of that tumour in other
bones

Odontogenic myxoma of the mandible. An occlusal view showing

the finely trabeculated, soap-bubble appearance and gross
expansion of the mandible . Evidence of residual tumour was still
present after 35 years in spite of vigorous treatment, both
surgery and radiotherapy, in its earlier stages. 129

Odontogenic myxoma. High power view

showing the typical appearance of sparse
fibroblasts lying in a myxoid or ground
substance rich matrix.
38

Odontogenic fibroma. This rare mesenchymal odontogenic tumour consists

of fibrous tissue containing rests and strands of odontogenic epithelium
resembling those found in the periodontal ligament.
39

3) Cementoblastoma
It is the only neoplasm of cementum . Ii is a benign one
40

Clinical features : Age : young adults Sex: Male more than female
Site : Mandibular first molar region
Characters : slowly growing , painless , vital tooth
X-ray :
- radiopaque mass with a radiolucent rim attached to the root
apex
-resorption of the related roots is common - Vital tooth
Histopathology :
1- mass of cementum with many reversal lines
2- Cellular C.T. with cells resemble osteoblast & osteoclast
3- may be mistaken as osteosarcoma ( when it is very cellular )
4- Peripherally : a band zone of unmineralized tissue a
surrounding C.T. capsule
Treatment : excision with tooth extraction with good prognosis

Periapical radiograph showing the typical appearances of a

cementoblastoma, a radiopaque mass with a radiolucent rim
attached to the root apex.

A dense mass of
interconnected trabeculae
of osteoid is fused to the
resorbed roots of the first
permanent molar.

41

At high power at the periphery of the lesion there are

radiating seams of osteoid with a thick layer of atypical
cementoblasts on their surface.

Malignant Mesenchymal Odontogenic

tumours
42

Odontogenic Fibrosarcoma :
1-This is a rare neoplasm which result from
malignant transformation of odontogenic fibroma.
2- Histologically : it resemble odontogenic immature
C.T. fibroma but the cells show histological &
cytological criteria of malignancy .
3- Rate of growth is variable
4- Treatment is by complete excision with safety
margin

Mixed odontogenic tumours

43

Benign
1) Ameloblastic fibroma
It is a mixed odontogenic tumour composed of
actively proliferating neoplastic odontogenic
epithelium found in cellular actively proliferating
neoplastic fibrous tissue similar to tooth follicle or
dental papilla of the developing tooth.
Clinical features : Age : below 21 years Sex : M >
F
Site : Mandibular premolar molar
area
Characters : Rare , Painless , slowly growing ,
produce jaw expansion & does not invade the
surrounding the surrounding bone

44

X-ray : Well defined unilocular or multilocular

radiolucent area sometimes with impacted tooth
Histopathology :
1) The epithelial element forms follicles similar to
ameloblastoma i.e. peripheral layer of cuboidal or
columnar cells & central mass of stellate cells.
2) The follicles of epithelium form several shapes :
Compressed follicle , small nest & rossetts
3) The C.T. is much more cellular than C.T.
ameloblastoma & the cells are fusiform or angular
with primitive fibrous tissue resembles immature
dentine papilla
4) Sometimes , a layer of juxta epithelial
hyalinization is found around the epithelial islands
Treatment : excision with safety margin

Ameloblastic fibroma. The appearance is

somewhat similar to that of ameloblastoma
but the pattern of budding strands is
distinctive and the connective tissue
resembles the undifferentiated
mesenchyme of the dental papilla.

Ameloblastic fibroma. At higher power the

resemblance to dental papilla, ameloblasts
and stellate reticulum is seen more clearly.

45

46

2- Ameloblastic fibro-odontome
- It is that tumour resemble ameloblastic fibroma
but with inductive changes leading to formation of
enamel & dentin
- It is difficult to differentiate that lesion from the
early stage of composite odontome
X ray : Multilocular well defined radiolucent area
with radiopaque masses
Histology :
1- Similar to odontogenic myxoma but with
odontogenic epithelium showing active
ectomesenchymal border ( the layer just around the
epithelium is called cell rich zone)
2-Formation of enamel & dentine ( i.e. induction
changes are found)

Odontomes- 3
Compound odontome

Complex odontome

Definition

Developmental malformation
( hamartoma) consisted of large number
of denticles in which enamel , dentin ,
cementum are arranged in normal fashion

Developmental
malformation
( hamartoma ) in which
the enamel , dentine &
cementum are arranged
in habhazard fashion

Clinically

Age : children & young adults

Sex : F > M
Site : mandibular molar area

Age : children & young

adults
Sex : F>M
Site : Mandibular molar
area

Character
s

The lesion is usually small

Asymptomatic
Causing expansion
Diagnosed by routine X ray
It is associated with permanent dentition
but may be associated with deciduous
teeth.
Multiple odontomes could be present

It is usually small
Asymptomatic
Causing jaw ion
Small lesion are
diagnosed by X ray
Some cases develop in
association with a place of
missing tooth

Xray

Radiopaque
Numerous tooth like structures arranged
in various fashions

Radiopaque area

47

48

Histopatholog
y

Early stage :
Denticles are embedded in
fibrous C.T.
Hard tissue start to form
with development of tooth
like structures consisted of :
Central core of pulp
Surrounded by a layer of
dentin
Coronal part consisted of
enamel ( empty space in
decalcified section )
Radicular part covered by
layer of cementum

Enamel , dentin &

cementum forming
irregular mass

Treatment

Enucleation

Removal with
conservative surgery

Compound odontoma. A denticle of dentine

surrounded by enamel matrix is lying within
more irregular calcified tissues.

Complex odontoma. In this radiograph the

odontoma overlies the crown of a buried
molar and shows the typical dense
amorphous area of radiopacity.

49

Compound odontoma. Sections from various areas of the odontoma,

show denticles of dentine and enamel cut in various planes, and more
irregular calcified tissues, within a connective tissue capsule. 135

50

Complex odontoma. A disorganised mass of dentine, enamel

and cementum penetrated by fine divisions of pulp.

51

Malignant mixed odontogenic tumours

52

- It is a malignant variant of ameloblastic fibroma

( The ectomesenchymal part show malignant
criteria)
- It is more aggressive than it is benign
- More invasive with distant metastasis