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Drg.Astri Hapsari
Rare, BENIGNLOCALLY AGGRESIVE odontogenic tumor
The most common neoplasm of odontogenic origin. UNKNOWN
CAUSED and typically seen in the third decade

occur in the
mandible with
1% of all tumors 80% of the molar–
of the maxilla
cases ramus region
and mandible
most commonly

Clinical sign Loosening of

increasing Asymptomatic  intraoral
facial routine dental submucosal
mass may be
deformity examination present initially

ulceration occurs
as the mass
increases in size.
Clinical variants

Multicystic /

Ameloblastoma Unicystic

Unicystic Ameloblastoma
• Less common than solid variant. (15%) Most are found in the
posterior mandible, often occur in the second and third
decades, younger population than that reported for the solid
ameloblastoma. Frequently associated with impacted third
molars and can be mistaken for a cystic lesion (i.e., a
dentigerous cyst or odontogenic keratocyst).
• Clinically, they may be asymptomatic or demonstrate a
painless jaw swelling. unless secondarily inflamed. Pain and
neurosensory disturbance are not typical.
• Radiographic Features: unilocular radiolucensy lesions with
well-demarcated with or without expansion, corticated
borders indistinguishable from most odontogenic cysts or
• 22-year-old male with painless perimandibular swelling.
• A Panoramic view shows radiolucency and root resorption (arrow).
• B Axial CT image shows destroyed bone with expansion of buccal
cortical bone, which is very thin and partially absent (arrow)
Panoramic view shows unilocular
radiolucency with sclerotic
border (arrow).

Axial CT image shows expansive

process with intact, sclerotic
cortical outline.

Coronal CT image shows

expansion of thin intact, cortical
outline (arrow), and some air.
Histological Types

Have ameloblastoma tumor

Luminal confined within the cystic
lining itself Complete
enucleation of
the cyst.
Projections of ameloblastoma
Intraluminal into the cystic lumen

Within the cystic lining and

invades the surrounding Marginal or
Mural noncystic regions of the segmental
surrounding tissue resections
Multicystic ameloblastoma
• Locally invasive and destructive. Asymptomatic and typically slow
growing and show little tendency to become aggressive.
• Occur in the mandible and maxilla, and those in the mandible account
for about 80% of all cases especially posterior .
• The standard treatment is resection with 1 to 1.5 cm bony margins.
For lesions that have perforated through the cortical plate and/or
extended into adjacent areas, an intact anatomical boundary (i.e.,
periosteum) is included with the specimen.
• Radiographically: multilocular and expansile. radiolucent area with the
expansion of cortical plate, scalloped margins, and/or resorption of the roots of
adjacent teeth/ displace of surrounding teeth.

• The classic description of large lesion is a “soap bubble” or

“honeycomb” appearance.
Ameloblastoma, solid/multicystic,
mandible; 21-year-old female with
painless swelling of right ramus.
Panoramic view shows expansive
radiolucency and impacted third
molar (arrow).

Axial CT image shows expanded

cortical bone and partially scalloped
border (arrow).

Coronal CT image shows expanded

and thinned, intact cortical bone and
root resorption (arrow)
• Multiple microscopic subtypes of ameloblastoma exist, and whereas
these are of importance to the pathologist, these histologic subtypes
are not of therapeutic or prognostic importance.
• follicular,
• plexiform
• acanthomatous basaloid,
• granular cell and
• Desmoplastic --> anterior maxilla
• Two or more types may coexist within the same tumor, and there is
little evidence to suggest that one subtype is more aggressive than
90% local
100% of
recurrence of
Curretage mandibular

Subsequent 20% local
reccurence of
40% of maxillary
resection mandibular

HIGH LOCAL Segmental Recurrence Subsequent

RECURRENCE resection rate 12% resection

Partial Partial
Successful maxillectomy
maxilectom Successful
as treatment
y as initial rate 100% for rate 40%
treatment reccurence
19-year-old female patient. A (April 1971),
atypical radiolucency can be discerned below
tooth. Tooth was surgically removed. No
surgical specimen was
obtained. B (September 1974), Routine dental
roentgenogram revealed residual or recurrent
cystic lesion. Surgical curettage was performed
and “early” ameloblastoma demonstrated. No
further treatment was given. C (February
1978), Multilocular radiolucency of more typical
character. Tumor was resected. D (December
1978), There is no evidence of residual tumor.
(Courtesy of Dr. William Randall and Dr. Clark
Borstad, Minneapolis.)
Management of Mandibular Ameloblastomas
• 1 cm medullary bone margins in proximal and distal directions.
• Lingual and buccal cortical bone is sacrificed. 1-cm margins do not imply
inclusion of soft tissue outside the periosteum.
• Corpus mandible and anterior ramus: the teeth, gingiva, and mucosa are
submitted with the resected specimen.
• Basically, portions of the bone resection specimen without muscle
attachments will have overlying mucosal soft tissue included in the specimen.
• In where muscle attachments begin—the periosteum will remain with the
resection specimen. These periosteal surfaces will represent the surgical
margins of the specimen.
• If extension is suspected past any periosteal surface, frozen-tissue margin
protocols should be applied.
Management of Maxillary Ameloblastomas
• Some authors recommend 1- to 2-cm margins in the maxillae --> the
range is probably not necessary in the anterior region and is difficult to
obtain when lesions approach the orbit and/or the pterygoids.

• Soft tissue margins must be assessed by frozen section.

Peripheral Ameloblastoma
• Histologically identical to the intraosseous ameloblastomas; however,
typically small (<2.0 cm), non‐ulcerated, non painful, and located
within the posterior mandibular alveolar mucosa.

• Treatment consists of local excision with long‐term follow‐up as the

recurrence rate is approximately 15%.
Pattern of spread

• Ameloblastoma expands and destroys the bone and extends to

adjacent areas by contiguous growth.

• Ameloblastic carcinoma, a rare malignant variant

of ameloblastoma, may metastasize to regional
nodes and distant sites.
Ameloblastic Carcinoma
• Tumor having the overall MICROSCOPIC
ameloblastoma but also manifesting MALIGNANT
MORPHOLOGIC FEATURES, such as lack of differentiation,
hypercellularity, increased mitotic activity, increased nuclear and
cytoplasmic ratio, vascular invasion, and neural invasion.

• These are aggressive tumors with approximately one-third resulting

in distant metastasis and death.
Malignant Ameloblastoma
• Lesions that have any of the classic benign
features of ameloblastoma but metastasize to a distant
• In many cases the metastases are long delayed and may
occur many years after the initial tumor was treated.
• The lung and cervical lymph node are the most common site
for metastases, but cervical lymph node involvement has also been
• Treatment : Excision and radiotherapy
Differential Diagnosis
• The odontogenic keratocyst (OKC)  WHO  keratinizing odontogenic
tumor  due to its aggressive behaviors, which more resemble those of
an invasive tumor, and its high recurrence rates compared to a “benign”
• Occur over a wide age range, peaking within the second and third decades
of life
• The mandible is more often involved than the maxilla especially in
mandibular third molar area, but any area of the jaw may be involved.
• Patients are often symptomatic with swelling, pain, trismus, sensory
deficits, and infection being the most common complaints. However, the
lesion may also present as an incidental radiographic finding.
• Multiple OKCs may be seen in patients with nevoid basal cell syndrome
(Gorlin’s syndrome).
• Biologic behavior:
• enucleation alone  Recurrence rates of up to 62.5%.
• enucleation with careful curettage  less than 10%.
• incomplete removal of the epithelial lining  leaving satellite cysts left
behind  collagenase activity of the cyst  dental lamina rests left in the
cyst wall or overlying mucosa prostaglandin-induced bone resorption -->
increased mitotic activity.
Radiographically, OKCs can present as
unilocular or multilocular radiolucencies
and can present as non‐expansile lesions
or very large, expansile lesions
Keratocystic odontogenic tumor, mandible; 52-year-old female with incidental finding at
routine dental radiography.

Panoramic view shows scalloped radiolucency with bone septa and sclerotic border
3D CT image shows cortical defects on lingual side of mandible (arrowheads)
Keratocystic odontogenic tumor, mandible; 61-year-old
female with incidental finding at routine dental

Panoramic view shows unilocular radiolucency with

sclerotic border (arrow).
Axial CT image shows oval expansive process with
intact cortical outline (arrow)
• Treatment for these lesions includes:
• long‐term decompression or marsupialization (with or without future
enucleation and curettage)
• enucleation and curettage with adjunctive liquid nitrogen application
• aggressive removal of adjacent cyst cavity bone (peripheral ostectomy)
• application of Carnoy’s solution to the cystic cavity,
• Resection  for large lesions that perforate the cortex and for recurrent
• Long‐term follow‐up is recommended due to the high percentage of recurrence,
especially with enucleation and curettage.
Dentigerous cyst
• Dentigerous cysts are believed to arise from an accumulation of fluid between
the crown of an unerupted tooth. The epithelial origin is believed to be the
reduced enamel epithelium of the dental follicle. Dentigerous cysts typically
occur within the second and third decades of life. Radiographically, these lesions
are associated with the crown of an unerupted tooth and are radiolucent.
• Dentigerous cysts vary in size and produce no calcified structures.
• Treatment:
• enucleation.
• Marsupialization –> Large dentigerous cysts especially if wide surgical access is difficult to
• Recurrence is rare.
• Histologic studies of the entire lining are required due to the potential presence
of a mural meloblastoma.
Panoramic view shows radiolucency with sclerotic border around crown
of impacted third molar, and root resorption of molars
• FD is a benign, non‐encapsulated neoplasm characterized by cellular
fibrous connective tissue and irregular islands of metaplastic bone
replacing normal bone.
• FD commonly is discovered within the second decade of life. Sex
predilection is equal. The lesions are typically nonpainful and
• Displacement of adjacent structures is common.
• Maxillary involvement is more prevalent than mandibular
involvement. With maxillary involvement, other adjacent facial bones
may beinvolved. This is described as craniofacial fibrous dysplasia.
• Growth generally ceases with skeletal maturation.
• Radiographs demonstrate an expansile “ground‐glass” lesion with poorly defined
• Histologically, the lesion is characterized by a cellular fibrous tissue with woven
bone trabeculae that do not connect interspersed throughout this background. The
bone trabeculae have been classically described as resembling “Chinese
• The edges of the lesion fuse with the normal bone without a capsule.
• Treatment involves resection of small lesions.
• Surgical reduction and contouring are performed with larger lesions that cause
functional or aesthetic concerns.
• In up to 50% of cases, repeated debulking procedures are necessary until growth
ceases. Long‐term surveillance is needed due