ODONTOGENIC

TUMOR
AMELOBLASTOMA

PRESENTED BY:
ANKITA SINGH
BDS FINAL YEAR
ROLL NO 37
INTRODUCTION
 Odontogenic tumor are the lesions derived
from cellular elements that are forming the
tooth structure.
 Epithelial odontogenic tumor are composed
of odontogenic epithelium without
participation of odontogenic
ectomesenchyme.
 Several distinctly tumors are included in this
group; ameloblastoma is the most important
and common of them.
 CONTENT
 Odontogenic tumor < introduction>
 Classification of odontogenic tumor
 Ameloblastoma
 Pathogenesis
 Classification
 Conventional solid ameloblastoma
i. Clinical features
ii. Radiographic features
iii. Differential diagnosis
iv. Histopathology
Unicystic
 ameloblastoma
i. Clinical features
ii. Radiographic features
iii. Histopathology
Peripheral ameloblastoma
i. Clinical features
ii. Histopathology
Ameloblastic carcinoma
Rathke’s pouch tumor
Management
i. Curettage
ii. En-bloc resection
iii. Peripheral osteotomy
iv. Segmental resection
v. Cautery
 Conclusion
 References
0DONTOGENIC TUMOR
 Odontogenic tumor comprise a complex
group of lesion of diverse histopathological
type and clinical behaviour.
 They may be:
1) True neoplasm
2) Malignant <rare>
3) Hamartomas
 All arise from odontogenic residue i.e.
 odontogenic epithelium
 ectomesenchyme
 variable amount of dental hard tissue
CLASSIFICATION OF
ODONTOGENIC TUMOR
 TUMOR OF ODONTOGENIC EPITHELIUM
a) Ameloblastoma
i. Malignant Ameloblastoma
ii. Ameloblastic carcinoma
b) Clear cell odontogenic carcinoma
c) Adenomatoid odontogenic tumor
d) Calcifying epithelial odontogenic tumor
e) Squamous odontogenic tumor
 MIXED ODONTOGENIC TUMORS
a) Ameloblastic fibroma
b) Ameloblastic fibro-odontoma
c) Ameloblastic fibrosarcoma
d) Odontoameloblastoma
e) Compound odontoma
f) Complex odontoma
 TUMOR OF ODONTOGENIC
ECTOMESENCHYME
a) Odontogenic fibroma
b) Granular cell odontogenic tumor
c) Odontogenic myxoma
d) Cementoblastoma
 AMELOBLASTOMA
(adamantinoma, adamantoblastoma )
 AMELOBLASTOMA
 Most common clinically significant
odontogenic tumor.
 It is odontogenic epithelial in origin.

 HISTORY
I. First recognized by Cuzack in 1827.
II. Falksson in 1879 described it as follicular cystoid
tumor.
III. Malassez in 1885 used the term Adamantinoma.
IV. Icy & Churchill in 1934 coined the term
Ameloblastoma.
DEFINITION
 By Robinson
“Usually unicentric, non functional,
intermittent in growth, anatomically benign
and clinically persistent.”
 By WHO
“It is a true neoplasm of enamel organ
type tissue, which does not undergo
differentiation to a point of enamel
formation.”
 PATHOGENESIS
1. Late developmental sources
a. Cell rest of enamel organ
b. Remenants of dental lamina
c. Epithelial cell rests of malassez
d. Remenant of Hertwig’s sheath
e. Follicular sacs
2. Early embroynic sources- disturbance of developing

I. Enamel Organ
II. Dental Lamina
III. Tooth bud
3. Basal cell of the surface epithelium of oral mucosa.
4.Secondary developmental sources:
a. epithelium of odontogenic cyst .
b. primordial
c. lateral periodontal cyst
d. dentigerous cyst
e. odontomas
5. Heterotopic epithelium in other parts of body,
especially from the pituitary gland.
CLASSIFICATION
1. On pathological basis:
a. Conventional ameloblastoma
b. Unicystic ameloblastoma
c. Peripheral ameloblastoma
d. Pituitary ameloblastoma
e. Adamantinoma of long bones
2. On histological type
 Plexiform ameloblastoma
 Acanthomatous ameloblastoma
 Basal cell ameloblastoma
 Follicular ameloblastoma
 Granular ameloblastoma
 Desmoplastic ameloblastoma
 Unicystic ameloblastoma
 Peripheral ameloblastoma
 Malignant subtype
CONVENTIONAL
SOLID
<MULTICYSTIC
AMELOBLASTOMA>
Clinical features
 Incidence:
 1% of all oral tumor.
 11% of all odontogenic tumor.
 Age:
 20-50 year
 Mean age 40 year
 Sex predilection and race:
 Men= women
 Often seen in blacks.
 Site
 Occur in either jaw.
 Mandible to maxilla ratio of ameloblastoma 5:1.
 Posterior maxilla & posterior molar ramus of
mandible often involve.
 Followed by maxillary sinus & floor of nose.
 Right side of mandible is affected more than left
side.
 Preceding factor:
 Neoplasm is frequently preceded by:
I. Extraction of teeth
II. Cystectomy
III. Other traumatic episode
 Onset
 It begins as a central lesion of bone which is slowly
destructive but tends to expand bone rather than
perforating it.
 Symptom
 Slow growing painless swelling.
 Increase facial asymmetry.
 Teeth in involved region is displaced and mobile.
 Exfoliation of teeth.
 Nasal obstruction.
 Inability to occlude properly.
 Pain < secondarily infected >
 Paresthesia < nerve involvement >
 Ill-fitting denture FACIAL ASYMMETRY
 Sign
 Ovoid and fusiform enlargement.
 It is hard and nontender.
 Egg shell crackling
 Palpation elict hard sensation or crepitus.
 Surrounding bone become thin.
 Fluctuation and egg shell cracking is elected.
 In the absence of treatment
 It keep on enlarging in size.
 Cause thinning of surrounding bone lead to
fluctuation and egg shell crackling.
 Tumor is not encapsulated.
 It enlarge and invade neighbouring tissue by
replacing them.
 It causes invasion of medullary space.
 Then it escape into periosteum & mucosa &
muscle of the adjoining region.
 Root resorption seen.
 Compress vital structure.
 Obstruct airway
 Impair swallowing
 Erode major artery or invade middle cranial
fossa.
 Size
 Ranges from 1cm – 16cm
 In maxilla, it enlarge to involve
i. Maxillary sinus,
ii. Nasal cavity lead to nasal obstuction
iii. Proptosis of eye
 Spread
 Though it is benign, locally invasive lesion, in rare
instances it spread to distant site.

 Factor contributing to spread are:

i. duration
ii. extensive local spread
iii. multiple operation/ radiotherapy
iv. proximity to anatomical passage

 most common site for metastasis-- lungs <aspiration

of tumor cell>
 Other site
regional lymphnode, spleen, kidney, long bones,
skull, cranium, lumbar vertebrae, ilium
RADIOGRAPHIC
FEATURES

HONEYCOMB
APPEARANCE
or
SOAP BUBBLE
APPEARANCE
 Radiodensity
 In early stage- area of bone destruction
hyperostotic borders
 Margins
 Smooth & scalloped.
 Well defined & well corticated.
 Internal structure
 Usually multilocular but may be unilocular.
 Coarse/ fine trabeculae.
 May contain unerupted deciduous or permanent
teeth <resemble dentigerous cyst>.
 Appearance
 Septa present in lesion
 Honeycomb appearance < numerous small compartment>
 Soap bubble appearance <large compartments>
 Progress
 Early stage– large round distinct compartments present.
 Late stage– compartment coalesce & fuse.
 As lesion increase in size, cortex expanded & destroyed.
 Effect on surrounding structure
 Jaws are enlarged depending on size of tumor.
 Root resorption.
 Buccolingual cortical expansion.
 Maxillary lesion involve maxillary sinus.
 Eggshell of bone
 Expansion and thinning of cortical plate occur
leaving thin egg shell of bone.
 Bone perforation in late stage.
 CT feature
 Computed tomography explain exact dimension &
nature of lesion.
 Desmoplastic ameloblastoma
 Found in anterior maxilla or mandible.
 Appear radiopaque because of dense connective
tissue content.
Intraoral radiograph showing honeycomb pattern
between 11 and 12 and displacement of 12.
Differential diagnosis
1. Dentigerous cyst
2. Odontogenic keratocyst
3. Cherubism
4. Giant cell granuloma
5. Odontogenic myxoma
6. Aneurysmal bone cyst
Histopathological
features
 It is thePATTERN
 1. FOLLICULAR most commonly encountered variant.

 Islands of epithelium resemble enamel organ epithelium in a mature fibrous

connective tissue stroma.

 The epithelial nests consists of a core of loosely arranged angular cells

resembling the stellate reticulum of an enamel organ.

 A single layer of tall columnar ameloblast like cells surrounds this central
core.

 The nuclei of these cells are located at the opposite pole to the basement
membrane< reverse polarity >.

 In other areas, the peripheral cells may be more cuboidal and resemble
basal cells.

 Cyst formation commonly seen.

2. PLEXIFORM PATTERN
 The plexiform type of
ameloblastoma consists of long,
anastomosing cords of larger sheets
of odontogenic epithelium.

 The cords or sheets of epithelium

are bounded by columnar or
cuboidal ameloblast likes cells
surrounding more loosely arranged
epithelial cells.

 The supporting stroma tends to be

loosely arranged and vascular.

 Cyst formation is relatively

uncommon in this variety.
3. ACANTHOMATOUS PATTERN
 When extensive
squamous metaplasia,
often associated with
keratin formation.

 It occurs in the central

portion of the epithelial
islands of a follicular
ameloblastoma, the
term acanthomatous
ameloblastoma is
sometimes applied.
4. GRANULAR PATTERN
 Ameloblastoma may
sometimes show
transformation of groups
of lesional epithelial
cells to granular cells.

 These cells have

abundant cytoplasm
fillled with eosinophilic
granules that resembles
lysosomes
ultrastructually and
histochemically.
5.Basal Cell Pattern
 The basal cell variant of
ameloblastoma is the least common
type.
 These lesions are composed of nest
of uniform basaloid cells.
 They histoplathologically are the
similar to basal cells carcinoma of
the skin.
 No stellate reticulum is present in
the central portions of the nests.
 The peripheral cells about the nests
tends to be cuboidal rather than
columnar.
6.Desmoplastic pattern
This type of ameloblastoma contains smalls
islands and cords of odontogenic epithelium in
densely collagenized stroma.

Immunohistochemical studies have shown

increased production of the cytokine known as
transforming growth factor in association with
this lesion, suggesting that this may be
responsible for the desmoplasia.

Peripheral columnar ameloblast like cells are

inconspicuous about the epithelial islands.
UNICYSTIC
AMELOBLASTOMA
 UNICYSTIC AMELOBLASTOMA
 Unicystic ameloblastoma, less aggressive variant.
 Most common in younger population.
 Mostly located in posterior mandible and anterior
maxilla.
 It represent about 5% of all ameloblastoma.
 The conventional ameloblastoma and mural
ameloblastoma are similar in predilection for
gender(males & females equally affected).
 Site(mand. 3rd molar region).
 However the mural variety occur in younger age
group(2nd &3rd decades).
 In early stage asymptomatic, undetected until
pericoronal radiolucency is seen on routine
radiograph.
 Slowly enlarged, slight non tender swelling
appear clinically.
 If bone destruction occur, palpation discloses
softer areas.
Radiographically:
 Haziness & thinning of hyperostotic radiopaque
rim of pericoronal radiolucency.
 Tumor invade the capsule of the cyst & start to
infiltrate the bone trabeculae of often areas.
HISTOPATHOLOGY
 As cellular level, the unicystic ameloblatoma is seen
manifesting three types:-

I. Luminal unicystic ameloblatoma

II. Intraluminal unicystic ameloblastoma
III. Intramural unicystic ameloblastoma

 The lesion exhibits a cyst comprising of epithelial lining that

is composed of ameloblastic epithelium.

 The basal cell layer of the cyst is tall, columnar or cuboidal

cells with hyperchromatic nuclei.

 These cells further show palisading and polarization of

basal cell nuclei of epithelial lining away from basement
membrane and basilar vacuolization of cytoplasm.

 The overlying Epithelial lining is loose and resembles

stellate reticulum cells.
Peripheral
ameloblastoma
PERIPHERAL AMELOBLASTOMA
 Occur in middle age.
 Occurs in gingiva with no
bony involvement.
 Painless, sessile growth,
firm and exophytic.
 Most commonly found on
posterior gingival and
alveolar mucosa.
 More common in
mandible than maxilla.
 Complete excision solves
the problem.
histopathology
 Have island of ameloblastic
epithelium that occupy
underneath the surface
epithelium
 Connection of tumor with basal
layer of surface epithelium is
seen in 50% cases.
 Whether the origin of tumor
from basal layer of epithelium
or merging of tumor with
surface epithelium has not
been ascertained.
AMELOBLASTIC CARCINOMA

Amelo ca
Malignant ameloblastoma
 Those lesion that have metastasized yet
retain classic ameloblastoma like microscopic
appearance.
 Very aggressive with poor prognosis.
 AMELOBLASTIC CARCINOMA
 A metastasis of ameloblastoma that
undergoes malignant transformation of
epithelial component into a well
differentiated carcinoma is called
ameloblastic carcinoma.
 Swelling and pain present.
 Grows rapidly than conventional
ameloblastoma.
 Mandible more frequently involved.
 Root resorption
 Perforation of buccal and lingual cortical
plate.
 Radiographically
 Ill-defined area of radiolucency, with focal
radiopacities within the radiolucency.
Pituitary ameloblastoma
< craniopharyngioma, rathke’s pouch
tumor>
 Neoplasm of CNS that grows in a
pseudoencapsulated mass in the
suprasellar or intrasellar area
after destroying the pituitary
gland.
 Common tumor of childhood and
adolescents.
 It consist of 25% of all CNS tumor
regardless of age.
 Derived from cell rests of the
craniopharyngeal duct formed by
RATHKE’S POUCH ( oral
ectoderm).
 Histologically similar to oral ameloblastoma
but also contains irregular calcified masses
as well as occasional foci of metaplastic bone
or cartilage, ghosts cell, and sometime tooth
material.
 MANAGEMENT
 Treatment guided by:
 Behaviour & potential
 Growth characteristics
 Anatomic site
 Clinical extent & size
 Histologic assessment
 TREATMENT
 Treatment of ameloblastoma ranges from
conservative curettage to radicular resection.
 Treatment varies according to site, size &
characteristics of the ameloblastoma.
 It has high recurrence rate.
 Curettage of ameloblastoma, which was favoured
in past, is now not advocated because of high
recurrence rate. Since residual tumor cells is left
at the tumor bone margin following curettage.
 Curettage is successful in unicystic ameloblastoma
due to intraluminal location of tumor.
 Follicular ameloblastoma is treated best by
resection.
 Intraosseus solid & multicystic ameloblastoma
treated by mandibular excision, block
resection without continuity defect or block
resection with continuity defect.
 Inferior alveolar nerve is sacrificed if it lies
within the lesion.
 Peripheral ameloblastoma are treated by
excision ( no bone involvement)
 If bone is involved then block resection is
choice of treatment.
 Treatment of solid ameloblastoma is wide
excision including upto 1.5cm of clinically
normal bone around the margin.
(a) Ameloblastoma of right body of mandible causing expansion, (b)
OPG showing multilocular lesion at right body of mandible, (c)
Resected part of mandible involving 2 cm of normal bone, (d)
Postoperative X-ray
 (a) Preoperative frontal view, (b) Multilocular radiolucency
involving right body and angle of mandible, (c) Resected part of
mandible involving 2 cm of normal bone, (d) Reconstruction of
mandible with iliac crest graft, (e) Postoperative X-ray, (f)
Postoperative frontal view
curettage
 It is the removal of the tumor by scraping it
from the surrounding normal tissue.
 It is the least desirable form of therapy.
 Failure of curettage is due to extension of
tumor cell nests beyond the clinical &
radiographic margins of the lesion,
therefore it is impossible to eradicate by
scraping procedure.
 It can be used in small lesion of unicystic
ameloblastoma.
 Procedure
 Raising an adequate mucosal flap for wide
exposure and entrance into the lesion either
through the already existing opening or
creation of an opening and scraping out the
whole lesion.
En –bloc resection
 It is removal of the tumor with a rim of
uninvolved bone safe margin, but with
maintaining the continuity of the jaw.
 This technique require an osteotomy
approximately 1-2cm from the margin of
tumor.
 It is frequently used for ameloblastoma.
 It does not violate the tumor margins during
resection, which might provide the
possibility of tumor seeding in surgical site.
Peripheral osteotomy
 It involve complete excision of the tumor but
at the same time a span of bone is retained
which preserves the continuity of jaw.
 Curettage with peripheral osteotomy
preserves vital structures & jaw function.
 Procedure
 Curettage of all visible tumor
 Now rotary instrument are used to remove a
margin of bone from entire surgical defect.
  Advantage
 Preservation of all vital structures.
 Disadvantage
 Seeding of tumor into surrounding tissues.

 A.Clinical appearance; B:
Peripheral ostectomy after
surgical excision; C:
Removable acrylic
appliance on surgical site;
D: Follow-up period of 12
months
 Segmental resection
 Segmental resection including hemimaxillectomy &
hemimanibulectomy has been the most commonly
used treatment for ameloblastoma.
 Immediate reconstruction( carried out if there is
clinical or intraoperative frozen section confirmation
of complete excision of tumor).
 Delayed reconstuction (until tissue section are
studied).
 An autogenous free bone graft( illiac or rib graft) is
commonly used.
 In case of non-availability of the above option a simple
reconstruction plate can be used.
hemimaxillectomy

RECONSTRUCTIO
hemimanibulectomy
JACKSON & CALLON FORTE <1996>
 Given guideline depending upon anatomical extent.

 Tumor confined to maxilla without orbital floor involvement–

partial maxillectomy

 Tumor involving orbital floor, but not the periorbital area– total
maxillectomy

 Tumor involving orbital content—total maxillectomy with orbital

exenteration

 Tumor involving the skull bone– along withskull base resection—

neurourgical procedure.
 cautery
 Cautery is desiccation or
electrocoagulation of the lesion.

 It is not commonly used.

 Much more effective therapy than

curettage (recurrence rate 50%) as
compared to curettage whose
recurrence rate is 90%.

 The secondary ischaemia and

necrosis that occur during the use of
cautery for some distance from
margins of tumor may destroy
invading tumor cells not reached by
direct instrumentation.
 conclusion
 Ameloblastoma is most common of all odontogenic tumor.

 It is slow growing, locally invasive tumor and benign in

nature.

 Consist of 3 clinicoradiographic form i.e.Conventional solid

or multicystic, Unicystic, peripheral or extraosseous.

 Shows diverse histopathology.

 Radiographically “honeycomb/ soap bubble appearance” is

seen.

 Can be treated by curettage, en-block resection, peripheral

osteotomy, segmental resection, cautery.
references
 Textbook of oral and maxillofacial surgery by
Neelima Anil Malik.
 Textbook of oral and maxillofacial surgery by
S M Balaji.
 Oral and maxillofacial pathology by Nevill,
Damm, Allen, Bouquot.
 Textbook of oral pathology by Shafer’s, Hine,
Levy.
 Textbook of oral medicine by Anil Govindrao
Ghom.
Thank you