Benign odontogenic tumours of the oral cavity

benign odontogenic tumours of the oral cavity along with classification and treatment

1. Cysts and Tumors

3. Introduction
Variety of cysts and tumors
Uniquely derived from tissues of
developing teeth.

4. Odontogenesis
Projections of dental lamina into
ectomesenchyme
Layered cap (inner/outer enamel
epithelium, stratum intermedium,
stellate reticulum)
Odontoblasts secrete dentin 
ameloblasts (from IEE) enamel
Cementoblasts cementum
Fibroblasts periodontal membrane

5. Odontogenesis

6. Diagnosis
Complete history
Pain, loose teeth, occlusion, swellings,
dysthesias, delayed tooth eruption
Thorough physical examination
Inspection, palpation, percussion,
auscultation
Plain radiographs
Panorex, dental radiographs
CT for larger, aggressive lesions

7. Diagnosis
Differential diagnosis
Obtain tissue
FNA –r/o vascular lesions, inflammatory
Excisional biopsy –smaller cysts,
unilocular tumors
Incisional biopsy –larger lesions prior to
definitive therapy

8. Odontogenic Cysts
Inflammatory
Radicular
Paradental
Developmental
Dentigerous
Developmental
lateral periodontal
Odontogenic
keratocyst
Glandular
odontogenic

9. Etiology
• Preceded by periapical granuloma; arises as
follows:
• Secondary to necrosis of dental pulpal tissue
• Stimulation of epithelial network (Malassez’s rest) at
tooth root apex results in cystification
• Cyst growth continues secondary to effects of
osmotic gradient
across epithelial lining layers, mediators of
inflammation, and epithelial proliferation

10. Clinical Presentation
Most common (75%)
• Asymptomatic unless there is an acute exacerbation
• Usually a limited process at root apex or lateral to
root surface
• Radiograph shows a round and well-defined
lucency, usually
with a sclerotic margin.
• Generally 1 cm or less across, but can be significant
in size
• Root resorption uncommon

11. Microscopic Findings
• Stratified squamous epithelial lining
• Lumen filled with cell debris, fluid,
cholesterol
• Connective tissue wall with mixed
inflammatory infiltrate
Diagnosis
• Documentation of nonvital tooth
• Radiograph shows alteration of apical bone

12. Differential Diagnosis
• Periapical granuloma
• Central giant cell granuloma
• Odontogenic and nonodontogenic
tumors
• Metastatic tumor

13. Treatment
• Endodontic therapy or
• Periapical surgery and biopsy or
• Tooth extraction and biopsy
Prognosis
• Excellent
• Occasional recurrences

14. Radicular (Periapical) Cyst
Most common (75%)
Epithelial cell rests of Malassez
Response to inflammation
Radiographic findings
Pulpless, nonvital tooth
Small well-defined periapical radiolucency
Histology
Treatment –extraction, root canal

15. Radicular Cyst

16. Radicular Cyst

17. Residual Cyst
Well-definedradiolucencywithinthe
alveolarridgeatthesiteofa
previoustoothextraction

18. Residual Cyst

19. Paradental Cyst

20. Dentigerous (follicular) Cyst
Most common developmental cyst
(24%Dentigerous Cyst
Etiology
• A developmental odontogenic cyst arising
subsequent to separation between dental follicle
and the crown of an associated unerupted tooth
• Proliferation of reduced enamel epithelium
lining the follicle,
with fluid accumulation between epithelium and
impacted tooth crown
• Alternatively, degeneration of the stellate
reticulum component of the enamel organ
occurs during odontogenesis.

21. Clinical Presentation
• Most commonly involves frequently
impacted teeth: mandibular third molars,
followed by maxillary canines
• Usually noted during second and third
decades
• Asymptomatic; discovered on routine
radiographic examination
• Painless jaw/alveolar expansion may occur;
cortex is thinned and rarely perforated

22. Radiographic Findings
• Well-defined radiolucency enclosing crown
of unerupted tooth
• Corticated/opaque margins unless infected
• May produce root resorption of adjacent
erupted teeth
• Usually unilocular; less commonly
multilocular

23. Diagnosis: Microscopic
• Cysts without secondary inflammation
• Thin, cuboidal, nonkeratinized
epithelial lining two cell layers thick with
flat epithelial–connective tissue
interface
• Loosely arranged collagen bundles,
occasionally containing

24. scattered odontogenic epithelial rests
• Cysts with secondary inflammation
• Hyperplastic, nonkeratinized
squamous epithelial lining
with epithelial ridge development
• Variable chronic inflammatory cell
infiltrate within condensed collagen
stroma

25. Differential Diagnosis: Radiographic
• Odontogenic keratocyst
• Ameloblastoma
Treatment
• Cyst enucleation and extraction of
associated tooth
• Marsupialization prior to excision may
be considered if the cyst is very large.

26. Prognosis
• Excellent
• Possible complications
• Pathologic fracture with large lesions
• Neoplastic transformation of epithelial
lining
(ameloblastoma and, rarely, squamous
cell carcinoma)

27. Dentigerous Cyst

28. Dentigerous Cyst

29. Developmental Lateral
Periodontal Cyst
From epithelial rests in periodontal ligament
vs. primordial cyst –tooth bud
Mandibular premolar region
Middle-aged men
Radiographic findings
Interradicular radiolucency, well-defined margins
Histology
Nonkeratinizing stratified squamous or cuboidal
epithelium
Treatment –enucleation, curettage with
preservation of adjacent teeth

30. Developmental Lateral
Periodontal Cyst

31. Odontogenic Keratocyst
11% of jaw cysts
May mimic any of the other cysts
Most often in mandibular ramus and
angle
Radiographically
Well-marginated, radiolucency
Pericoronal, inter-radicular, or pericoronal
Multilocular

32. Odontogenic Keratocyst

33. Odontogenic Keratocyst

34. Odontogenic Keratocyst
Histology
Thin epithelial lining with underlying
connective tissue (collagen and epithelial
nests)
Secondary inflammation may mask features
High frequency of recurrence (up to 62%)
Complete removal difficult and satellite
cysts can be left behind

35. Odontogenic Keratocyst

36. Treatment of OKC
Depends on extent of lesion
Small –simple enucleation, complete
removal of cyst wall
Larger –enucleation with/without peripheral
ostectomy
Bataineh,et al, promote complete resection
with 1 cm bony margins (if extension through
cortex, overlying soft tissues excised)
Long term follow-up required (5-10 years)

37. Glandular Odontogenic Cyst
More recently described (45 cases)
Gardner, 1988
Mandible (87%), usually anterior
Very slow progressive growth (CC:
swelling, pain [40%])
Radiographic findings
Unilocular or multilocular radiolucency

38. Glandular Odontogenic Cyst

39. Glandular Odontogenic Cyst
Histology
Stratified epithelium
Cuboidal, ciliated
surface lining cells
Polycystic with
secretory and
epithelial elements

40. Treatment of GOC
Considerable recurrence potential
25% after enucleation or curettage
Marginal resection suggested for larger
lesions or involvement of posterior maxilla
Warrants close follow-up

41. Nonodontogenic Cysts
Incisive Canal Cyst
Stafne Bone Cyst
Traumatic Bone Cyst
Aneurysmal Bone Cyst

42. Incisive Canal Cyst
Derived from epithelial remnants of the
nasopalatine duct (incisive canal)
4
th
to 6
th
decades
Palatal swelling common, asymptomatic
Radiographic findings
Well-delineated oval radiolucency between
maxillary incisors, root resorption occasional
Histology
Cyst lined by stratified squamous or
respiratory epithelium or both

43. Incisive Canal Cyst

44. Incisive Canal Cyst
Treatment consists of surgical
enucleation or periodic radiographs
Progressive enlargement requires
surgical intervention

45. Stafne Bone Cyst
Submandibular salivary gland depression
Incidental finding, not a true cyst
Radiographs –small, circular, corticated
radiolucency below mandibular canal
Histology –normal salivary tissue
Treatment –routine follow up

46. Stafne Bone Cyst

47. Traumatic Bone Cyst
Empty or fluid filled cavity associated
with jaw trauma (50%)
Radiographic findings
Radiolucency, most commonly in body or
anterior portion of mandible
Histology –thin membrane of fibrous
granulation
Treatment –exploratory surgery may
expedite healing

48. Traumatic Bone Cyst

49. Aneurysmal Bone Cyst
Etiology
• Unknown
• Possibly represents a vascular
response/repair to jaw injury
(an arteriovenous malformation)
• Three phases: incipient, destructive,
stabilization

50. Clinical Presentation
• Bony expansion and occasionally mild pain
• Chiefly occurs in mandible
• Female predilection
Radiographic Findings
• Expansile, multiloculated, destructive bony
lesion
• Surrounding bone may be sclerotic
• Angiogram demonstrates intense vascularity

51. Diagnosis
• Radiographic lytic lesion
• Honeycombed quality of large
vascular sinusoidal spaces and bony
septa
• May be confused microscopically with
central giant cell granuloma

52. Differential Diagnosis
• Ameloblastoma
• Odontogenic keratocyst
• Odontogenic myxoma
• Hemangioma
• Giant cell granuloma
Treatment
• Excision to en bloc resection
Prognosis
• Good to excellent

53. Odontogenic Tumors
Ameloblastoma
Calcifying Epithelial
Odontogenic Tumor
Adenomatoid
Odontogenic Tumor
Squamous
Odontogenic Tumor
Calcifying
Odontogenic Cyst

54. Ameloblastoma
Most common odontogenic tumor
Benign, but locally invasive
4
th
and 5
th
decades
Occasionally arise from dentigerous cysts
Subtypes –multicystic (86%), unicystic
(13%), and peripheral (extraosseous –1%)

55. Ameloblastoma
Radiographic findings
Classic –multilocular radiolucency of
posterior mandible
Well-circumscribed, soap-bubble
Unilocular –often confused with
odontogenic cysts
Root resorption –associated with
malignancy

56. Ameloblastoma

57. Ameloblastoma
Histology
Two patterns –plexiform and follicular (no
bearing on prognosis)
Classic –sheets and islands of tumor cells,
outer rim of ameloblasts is polarized away
from basement membrane
Center looks like stellate reticulum
Squamous differentiation (1%) –Diagnosed
as ameloblastic carcinoma

58. Ameloblastoma

59. Treatment of Ameloblastoma
According to growth characteristics and type
Unicystic
Complete removal
Peripheral ostectomies if extension through cyst
wall
Classic infiltrative (aggressive)
Mandibular –adequate normal bone around
margins of resection
Maxillary –more aggressive surgery, 1.5 cm
margins
Ameloblastic carcinoma
Radical surgical resection (like SCCa)
Neck dissection for LAN

60. Calcifying Epithelial
Odontogenic Tumor
a.k.a. Pindborg tumor
Aggressive tumor of epithelial derivation
Impacted tooth, mandible body/ramus
Chief sign –cortical expansion
Pain not normally a complaint

61. Calcifying Epithelial
Odontogenic Tumor
Radiographic findings
Expanded cortices in all dimensions
Radiolucent; poorly defined, noncorticated
borders
Unilocular, multilocular, or “moth-eaten”
“Driven-snow” appearance from multiple
radiopaque foci
Root divergence/resorption; impacted tooth

62. Calcifying Epithelial
Odontogenic Tumor

63. Calcifying Epithelial
Odontogenic Tumor
Histology
Islands of eosinophilic epithelial cells
Cells infiltrate bony trabeculae
Nuclear hyperchromatism and
pleomorphism
Psammoma-like calcifications (Liesegang
rings)

64. Calcifying Epithelial
Odontogenic Tumor

65. Treatment of CEOT
Behaves like ameloblastoma
Smaller recurrence rates
En bloc resection, hemimandibulectomy
partial maxillectomy suggested

66. Adenomatoid Odontogenic
Tumor
Associated with the crown of an impacted
anterior tooth
Painless expansion
Radiographic findings
Well-defined expansile radiolucency
Root divergence, calcified flecks (“target”)
Histology
Thick fibrous capsule, clusters of spindle cells,
columnar cells (rosettes, ductal) throughout
Treatment –enucleation, recurrence is rare

67. Adenomatoid Odontogenic
Tumor

68. Squamous Odontogenic Tumor
Hamartomatous proliferation
Maxillary incisor-canine and mandibular
molar
Tooth mobility common complaint
Radiology –triangular, localized radiolucency
between contiguous teeth
Histology –oval nest of squamous epithelium
in mature collagen stroma
Treatment –extraction of involved tooth and
thorough curettage; maxillary –more
extensive resection; recurrences –treat with
aggressive resection

69. Squamous Odontogenic
Tumor

70. Calcifying Odontogenic Cyst
Tumor-like cyst of mandibular premolar
region
¼ are peripheral –gingival swelling
Osseous lesions –expansion, vital teeth
Radiographic findings
Radiolucency with progressive calcification
Target lesion (lucent halo); root divergence
Histology
Stratified squamous epithelial lining
Polarized basal layer, lumen contains ghost cells
Treatment –enucleation with curettage; rarely
recur

71. Mesenchymal Odontogenic
Tumors
Odontogenic Myxoma
Cementoblastoma

72. Odontogenic Myxoma
Originates from dental papilla or
follicular mesenchyme
Slow growing, aggressively invasive
Multilocular, expansile; impacted teeth?
Radiology –radiolucency with septae
Histology –spindle/stellate fibroblasts
with basophilic ground substance
Treatment –en bloc resection,
curettage may be attempted if fibrotic

73. Cementoblastoma
True neoplasm of cementoblasts
First mandibular molars
Cortex expanded without pain
Involved tooth ankylosed, percussion
Radiology –apical mass; lucent or solid,
radiolucent halo with dense lesions
Histology –radially oriented trabeculae from
cementum, rim of osteoblasts
Treatment –complete excision and tooth
sacrifice

74. Cementoblastoma

75. Mixed Odontogenic Tumors
Ameloblastic fibroma, ameloblastic
fibrodentinoma, ameloblastic fibro-
odontoma, odontoma
Both epithelial and mesenchymal cells
Mimic differentiation of developing tooth
Treatment –enucleation, thorough
curettage with extraction of impacted tooth
Ameloblastic fibrosarcomas –malignant,
treat with aggressive en bloc resection

76. Related Jaw Lesions
Giant Cell Lesions
Central giant cell
granuloma
Brown tumor
Aneurysmal bone
cyst
Fibroosseous lesions
Fibrous dysplasia
Ossifying fibroma
Condensing Osteitis

77. Central Giant Cell Granuloma
Neoplastic-like reactive proliferation
Common in children and young adults
Females > males (hormonal?)
Mandible > maxilla
Expansile lesions –root resorption
Slow-growing –asymptomatic swelling
Rapid-growing –pain, loose dentition
(high rate of recurrence)

78. Central Giant Cell Granuloma
Radiographic findings
Unilocular, multilocular radiolucencies
Well-defined or irregular borders
Histology
Multinucleated giant cells, dispersed
throughout a fibrovascular stroma

79. Central Giant Cell Granuloma

80. Central Giant Cell Granuloma

81. Central Giant Cell Granuloma
Treatment
Curettage, segmental resection
Radiation –out of favor (risk of sarcoma)
Intralesional steroids –younger patients,
very large lesions
Individualized treatment depending on
characteristics and location of tumor

82. Brown Tumor
Local manifestation of hyperparathyroid
Histologically identical to CGCG
Serum calcium and phosphorus
More likely in older patients

83. Aneurysmal Bone Cyst
Large vascular sinusoids (no bruit)
Not a true cyst; aggressive, reactive
Great potential for growth, deformity
Multilocular radiolucency with cortical
expansion
Mandible body
Simple enucleation, rare recurrence

84. Fibrous Dysplasia
Monostotic vs. polystotic
Monostotic
More common in jaws and cranium
Polystotic
McCune-Albright’s syndrome
Cutaneous pigmentation, hyper-functioning
endocrine glands, precocious puberty

85. Fibrous Dysplasia
Painless expansile dysplastic process of
osteoprogenitor connective tissue
Maxilla most common
Does not typically cross midline (one bone)
Antrum obliterated, orbital floor
involvement (globe displacement)
Radiology –ground-glass appearance

86. Fibrous Dysplasia

87. Fibrous Dysplasia

88. Fibrous Dysplasia
Histology –irregular osseous trabeculae in
hypercellular fibrous stroma
Treatment
Deferred, if possible until skeletal maturity
Quarterly clinical and radiographic f/u
If quiescent –contour excision (cosmesis or
function)
Accelerated growth or disabling functional
impairment -surgical intervention (en bloc
resection, reconstruction)

89. Ossifying Fibroma
True neoplasm of medullary jaws
Elements of periodontal ligament
Younger patients, premolar –mandible
Frequently grow to expand jaw bone
Radiology
radiolucent lesion early, well-demarcated
Progressive calcification (radiopaque –6 yrs)

90. Ossifying Fibroma

91. Ossifying Fibroma
Histologically similar to fibrous dysplasia
Treatment
Surgical excision –shells out
Recurrence is uncommon

92. Condensing Osteitis
4% to 8% of population
Focal areas of radiodense sclerotic bone
Mandible, apices of first molar
Reactive bony sclerosis to pulp
inflammation
Irregular, radiopaque
Stable, no treatment required

93. Condensing Osteitis

94. Conclusion

95. Case Presentation
20 year-old hispanic female with several
month history of lesion in right maxilla,
treated initially by oral surgeon with
multiple curettage.
Has experienced recent onset of rapid
expansion, after pregnancy, with
complaints of loose dentition and pain.

96. Physical Examination

97. Physical Examination

98. Radiographs
Plain films –facial series
Computerized Tomography of facial
series

99. Pathology

100. Treatment

101. Treatment