Friday, July 8, 2011

Odontogenic Tumours

OVERVIEW
n General consideration
n Classification
n Description of some common and important odontogenic tumors.
n Odontogenic tumors comprise a complex group of lesions with varied histopathological and clinical features.
n Some tumors are true neoplasms, while some are hamartomas (developmental malformations).
n Some are composed only of odontogenic epithelium, while many are mixed i.e. both epithelium and mesenchyme, while some are composed only of mesenchyme
n CLASSIFICATION
A. TUMORS OF ODONTOGENIC EPITHELIUM: -
1. Ameloblastoma
2. Calcifying epithelial odontogenic tumor
3. Adenomatoid odontogenic tumor
4. Squamous odontogenic tumor
5. Clear cell odontogenic tumor
B. TUMORS OF ODONTOGENIC EPITHELIUM & MESENCHYME WITH / WITHOUT DENTAL HARD TISSUE FORMATION: -
1. Ameloblastic fibroma & Ameloblastic fibrosarcoma.
2. Ameloblastic fibro odontoma
3. Odontoameloblastoma
4. Odontoma – Compound & Complex
C. TUMORS OF ODONTOGENIC MESENCHYME WITH / WITHOUT DENTAL HARD TISSUE FORMATION: -
1. Odontogenic fibroma
2. Odontogenic myxoma
3. Cementoblastoma
4. Granular cell odontogenic tumor
AMELOBLASTOMA
n Most common odontogenic neoplasm, derived from odontogenic epithelium.
n Slowly growing, locally aggressive, benign neoplasm.
n Occurs in 3 different types with differing clinical, radiological and histological features.
1. CONVENTIONAL / MULTICYSTIC
2. UNICYSTIC
3. PERIPHERAL
AMELOBLASTOMA - CONVENTIONAL
CLINICAL FEATURES: -
Age incidence: 3rd & 4th decades.
Sex incidence: Slightly more in males.
Site predilection: 80% ameloblastomas occur in posterior mandible, followed by maxillary molar region.
Signs & symptoms: -
n Slowly growing, painless, hard bony swelling or expansion of jaw.
n Thinning of cortical plates produces “Egg shell crackling”.
n Other symptoms – Tooth mobility root resorption and paresthesia if inferior alveolar nerve is affected.
RADIOLOGICAL FEATURES: -
n Typically rounded, well defined multilocular radiolucency with scalloped margins.
n When loculations are large, the appearance is called as “SOAP BUBBLE” appearance.
n When loculations are smaller, the appearance is called “HONEY COMBED” appearance.
n Buccal & lingual cortical plates are expanded.
n Roots of adjacent teeth displaced / resorbed.
n As it spreads through medullary spaces, radiographic margins are not accurate indication of bone involvement.
DIFFERENTIAL DIAGNOSIS: -
  1. ODONTOGENIC KERATOCYST
  2. FIBROUS DYSPLASIA
  3. OSSIFYING FIBROMA
  4. CENTRAL GIANT CELL GRANULOMA.
HISTOPATHOLOGICAL FEATURES: -
Many subtypes are seen.
    1. FOLLICULAR
    2. PLEXIFORM
    3. ACANTHOMATOUS
    4. GRANULAR CELL
    5. DESMOPLASTIC
    6. BASAL CELL TYPE
    7. CLEAR CELL TYPE
AMELOBLASTOMA (FOLLICULAR)
n Islands of epithelium resemble dental organ surrounded by mature connective stroma.
n Individual follicles show central mass of stellate reticulum like cells surrounded by a single peripheral layer of ameloblast like cells.
n Nuclei of peripheral cells are reversely polarized.
n Within the islands, cyst formation is common.
AMELOBLASTOMA (PLEXIFORM)
n Instead of islands, long, anastomosing cords and occasional sheets of epithelial cells bounded by columnar / cuboidal cells.
n Cells within cords are more loosely arranged than peripheral cells.
n Supporting stroma is loose and vascular.
n Cyst formation occurs, not inside follicles, but in surrounding stroma.
AMELOBLASTOMA (ACANTHOMATOUS)
n Central area of follicles show extensive squamous metaplasia, often associated with keratin formation.
n DOEAS NOT INDICATE A MORE AGGRESSIVE COURSE OF TUMOR.
n Can be confused with squamous cell carcinoma.
AMELOBLASTOMA (GRANULAR CELL)
  • Follicles / sheets of cells show granular cell change.
n These cells have abundant cytoplasm filled with eosinophilic granules.
n Seen in younger persons and appears to be more aggressive clinically.
AMELOBLASTOMA (DESMOPLASTIC)
n This variant is composed of small islands / cords of odontogenic epithelial cells surrounded by a dense, collagenized stroma.
n Peripheral ameloblast like cells are missing / inconspicuous around the islands / cords.
n Occurs in anterior jaw and radiologically looks like a fibro-osseous lesion due to mixed opacity & lucency.
AMELOBLASTOMA (BASAL CELL)
n Least common type.
n Composed of nests / sheets of hyperchromatic basaloid cells.
n No stellate reticulum present centrally and peripheral cells tend to be cuboidal rather than tall columnar.
TREATMENT: -
n Can vary from simple enucleation to curettage to en bloc resection.
n As lesion spreads through medullary spaces, simple enucleation can leave islands of tumor within the jaws, leading to recurrence.
n Marginal resection is the optimal method.
n Rarely can undergo malignant transformation.
UNICYSTIC AMELOBLASTOMA
n Controversy, whether it arises de novo or as neoplastic transformation of odontogenic cyst lining.
CLINICAL FEATURES: -
Age incidence: Young individuals.
Sex incidence: males.
Site predilection: 90% cases occur in post mandible.
Signs & Symptoms: Asymptomatic swelling of jaws. Many lesions contain a tooth inside.
RADIOLOGICAL FEATURES: -
n Typically seen as well defined, unilocular ‘lucency, many times surrounding the neck of impacted 38 or 48 – impossible to distinguish from dentigerous cyst.
n Occasionally, may be seen unassociated with teeth – then they nay be diagnosed as OKC or a radicular cyst.
DIFFERENTIAL DIAGNOSIS: -
  1. Odontogenic cysts like – Dentigerous, OKC, radicular etc.
  2. Odontogenic tumors like – Ameloblastoma, AOT, CEOT etc.
HISTOPATHOLOGICAL FEATURES: -
n Three variants are recognized.
1. LUMINAL UNICYSTIC
2. INTRALUMINAL UNICYSTIC
3. MURAL UNICYSTIC
UNICYSTIC - LUMINAL
n Tumor is confined to luminal surface of cyst.
n Seen as fibrous cyst wall with lining comprised totally / partially of ameloblastic epithelium, showing a basal layer of columnar / cuboidal reversely polarized cells.
n Overlying epithelial cells are loosely adhesive, resembling the stellate reticulum of dental organ.
UNICYSTIC - INTRALUMINAL
n This variant shows the tumor from cyst lining protruding into the lumen of cyst.
n Intraluminal projections resemble plexiform ameloblastoma in most cases, though not always.
UNICYSTIC - MURAL
n In this type, the fibrous wall of the cyst is infiltrated with typical follicular / plexiform ameloblastoma.
n Believed to be more aggressive than other two variants.
AMELOBLASTOMA (PERIPHERAL)
n Typically presents as non ulcerated, sessile / pedunculated gingival mass.
n Must be differentiated from other more common gingival swellings.
ADENOMATOID ODONTOGENIC TUMOUR
n Earlier, believed to be a variant of Ameloblastoma with glandular elements and was referred to as ADENOAMELOBLASTOMA.
n Now believed to be a separate entity and thought to arise from odontogenic epithelial cells.
CLINICAL FEATURES: -
Age incidence: Young individuals, 1st & 2nd decades.
Sex incidence: More in females, twice more.
Site predilection: Anterior aspect of maxilla.
Signs & symptoms:
n Small, asymptomatic lesion.
n Discovered accidentally during routine dental X-ray examination to ascertain cause for unerupted tooth.
n Larger lesions cause jaw expansion
RADIOLOGICAL FEATURES:
n Typical well defined unilocular ‘lucency attached to an impacted / unerupted tooth, usually canine (FOLLICULAR VARIETY).
n ‘Lucency extends past cervical region & must be distinguished from dentigerous cyst.
Extrafollicular – well defined ‘lucency not related to unerupted tooth.
n In both cases, ‘lucency may contain snowflake like radio opacities.
DIFFERENTIAL DIAGNOSIS: -
n Radiographic appearance can suggest following lesions for provisional diagnosis -
1. Unicystic ameloblastoma
2. CEOT
3. COC
HISTOLOGICAL FEATURES: -
n Lesion is composed of spindle shaped epithelial cells that form sheets, strands or whorls in a scanty stroma.
n Rosette like structures may show a central space which may be empty or contain some eosinophilic amyloid like material.
n Tubular duct like spaces are also seen which show a central space surrounded by reversely polarized cells.
CALCIFYING EPITHELIAL ODONTOGENIC TUMOUR
n Rare tumor, accounts for > 1% of all odontogenic tumors.
n Although odontogenic in origin, its histogenesis is uncertain.
n Tumor cells strongly resemble stratum intermedium of dental organ.
CLINICAL FEATURES: -
Age incidence: 3rd to 5th decades.
Sex incidence: Equal.
Site predilection: 75% cases occur in posterior mandible.
Signs & symptoms: Asymptomatic, slow growing swelling.
RADIOLOGICAL FEATURES:
n Commonly appears as a well defined, scalloped, uni/multilocular ‘lucency, usually associated with an impacted tooth.
n Lesion may also show presence of scattered radiopaque material within the ‘lucency.
DIFFERENTIAL DIAGNOSIS: -
  1. Odontogenic cysts like dentigerous, OKC, etc.
  2. Odontogenic tumors like Ameloblastoma, etc.
  3. Other bony lesion like Central giant cell granuloma, Aneurismal bone cyst etc.
HISTOLOGICAL FEATURES: -
n Tumor shows discrete islands / sheets of polyhedral epithelial cells in a fibrous stroma.
n Nuclei show lot of size variation, even giant nuclei can be seen.
n Tumor islands also enclose large areas of eosinophilic, amorphous, amyloid like material
n The cell outlines of tumor epithelial cells are distinct and intercellular bridges may be noted.
n The amyloid like material usually calcifies to form concentric rings (LEISEGANG RINGS).
ODONTOMA
n Most common odontogenic tumor.
n Considered hamartomas, rather than neoplasm.
n In a fully developed odontoma, mainly enamel and dentin along with variable amounts of pulp and cementum are seen.
CLASSIFICATION: -
n Odontomas are further sub classified into
- COMPOUND ODONTOMA
- COMPLEX ODONTOMA
n Both occur with equal frequency.
Compound – composed of multiple, small, tooth like structures.
Complex – composed of conglomerate mass of enamel and dentin with no anatomic relationship to tooth.
CLINICAL FEATURES : -
Age incidence: First 2 decades.
Sex incidence: None.
Site predilection: Anterior maxilla.
Signs & symptoms:
n Mostly asymptomatic, small, seldom exceeding the size of tooth missing in the region.
n Larger lesions may cause jaw expansion.
ODONTOMA (COMPOUND)
n Gross pathological specimen showing a mass of more than 20 tooth like malformed structures.
n ODONTOMA (COMPOUND)
RADIOLOGICAL FEATURES: -
n This type is composed of multiple, small tooth like structures.
n The entire mass appears surrounded by a radiolucent rim.
n An unerupted tooth is usually associated with both types of odontomes which impedes normal eruption of the tooth.
ODONTOMA (COMPLEX)
RADIOLOGICAL FEATURES:
n Complex odontoma comprises of a single conglomerate mass of tooth like material.
n It bears no anatomic resemblance to any tooth.
n Appears as a ‘opaque mass surrounded by a narrow ‘lucent rim.
ODONTOMA (COMPOUND)
HISTOLOGICAL FEATURES: -
n Microscopically, it shows discrete tooth like denticles in a fibrous stroma.
n Being a decalcified specimen, enamel appears as spaces around normal looking dentin and pulp which bear normal anatomic relationship to each other.
ODONTOMA (COMPLEX)
HISTOLOGICAL FEATURES: -
n Consist of largely tubular dentin enclosing clefts / hollow circular spaces that contained enamel prior to decalcification.
n Thin layer of cementum sometimes may be present at the periphery.

3 comments:

  1. All thanks to this great herbal doctor who cured me from (LUPUS DISEASE) his name is dr imoloa.  I suffered lupus disease for over 8 years with pains like: joints, Skin rash,  Pain in the chest,  swollen joints and many more.  The anti-inflammatory drugs couldn’t cure me, until I read about his recommendation. 2 months ago, I contacted him through his email address. drimolaherbalmademedicine@gmail.com . and he sent me the herbal treatment through DHL courier service and he instructed me on how to drink it for good two weeks. after then,  And I was confirmed cured and free at the hospital after taken his powerful herbal medications You too can be cured with it if interested, he also uses his powerful herbal healing medicine to cure disease like: parkison disease, vaginal cancer, epilepsy,  Anxiety Disorders, Autoimmune Disease,  Back Pain,  Back Sprain,   Bipolar Disorder,  Brain Tumour,  Malignant,  Bruxism, Bulimia,  Cervical Disk Disease, cardiovascular disease, Neoplasms,  chronic respiratory disease,  mental and behavioural disorder,  Cystic  Fibrosis,  Hypertension, Diabetes, asthma,  Inflammatory autoimmune-mediated arthritis.  chronic kidney disease, inflammatory joint disease, back pain,  impotence,  feta  alcohol spectrum,  Dysthymic Disorder,   Eczema, skin cancer,  tuberculosis,  Chronic Fatigue Syndrome, constipation, inflammatory bowel  disease, bone cancer, lungs cancer,  mouth ulcer,  mouth cancer, body pain, fever, hepatitis A.B.C.,   syphilis,  diarrhea,  HIV/AIDS,  Huntington's Disease,  back acne,  Chronic renal failure,   addison disease,  Chronic Pain,   Crohn's  Disease,  Cystic Fibrosis,  Fibromyalgia,   Inflammatory Bowel Disease,  fungal  nail disease, Lyme Disease, Celia disease, Lymphoma, Major  Depression,  Malignant Melanoma,   Mania,  Melorheostosis,   Meniere's  Disease,  Mucopolysaccharidosis , Multiple Sclerosis,  Muscular  Dystrophy,  Rheumatoid Arthritis, Alzheimer's Disease, bring back relationship spell.      Contact him today  and get a permanent cure. contact him via... email- drimolaherbalmademedicine@gmail.com  /whatssapp-+2347081986098.
    website-http/www.drimolaherbalmademedicine.wordpress.com

    ReplyDelete
  2. I was diagnosed as HEPATITIS B carrier in 2013 with fibrosis of the
    liver already present. I started on antiviral medications which
    reduced the viral load initially. After a couple of years the virus
    became resistant. I started on HEPATITIS B Herbal treatment from
    ULTIMATE LIFE CLINIC (www.ultimatelifeclinic.com) in March, 2020. Their
    treatment totally reversed the virus. I did another blood test after
    the 6 months long treatment and tested negative to the virus. Amazing
    treatment! This treatment is a breakthrough for all HBV carriers.

    ReplyDelete

Share

+1 this blog

you might also like

Related Posts Plugin for WordPress, Blogger...