KATHMANDU UNIVERSITY

SCHOOL OF MEDICAL SCIENCES

MIXED TUMORS OF ODONTOGENIC

ORIGIN

Submitted by: Submitted to:

Amod Kumar Yadav Dr. Pratibha Poudel
Roll no 51 Dr. Bhoj Raj Adhikari

………………………….
Teacher in-charge
CONTENTS

1. Classification of odontogenic tumors

2. Ameloblastic fibroma
3. Ameloblastic fibro- odontoma
4. Odontoma
5. Ameloblastic odontoma
6. Dentinogenic ghost cell tumor
7. Primordial odontogenic tumor
 Classification of odontogenic tumors

1.AMELOBLASTIC FIBROMA
Also known as –Soft mixed odontogenic tumor, Soft mixed odontoma Fibroadamantoblastoma

Introduction
Ameloblastic fibroma is considered to be a true mixed tumor in which there is simultaneous
proliferation of both epithelial and mesenchymal tissue without formation of enamel and dentin.
 They are usually uncommon
 Originates From inner enamel epithelium and dental papilla

*Some investigators suggested that the ameloblastic fibroma represent an immature complex
odontoma and that, if the tumor is left undisturbed will ultimately differentiate or mature further
into a lesion known as amelobalstic fibro-odontoma and then continue to mature into a
completely differentiated odontoma. However, this has been contraindicated by the clinical age
of occurance of the above lesions. In conclusion ameloblastic fibroma represents a separate
specific entity that doesnot develop into a more differentiated odontogenic lesion.

Clinical features
 Mostly common in younger patients especially in 2nd decade of life.
 Male are more affected than female.
 Commonly mandible is affected, but most commonly in molar region and ramus of the
mandible.
Clinical presentation
 They are usually asymptomatic with slow clinical
growth.
 About 90% of the cases are associated with impacted
tooth.
 Accidental discovery during radiography. If not patient
visits with pain, tenderness and mild swelling.

Radiographical features
 Well circumscribed radiolucency is seen with size of 1-8.5cm in diameter.
 Sclerotic margin are presentand can be unilocular or multilocular.
 They are associated with impacted tooth in about 75% of the cases.
 Bulging of bone can also be seen.

Histological features
• components
1.Proliferating Odontogenic Epithelial
2.Cell rich Mesenchymal tissue
1.Epithelial component:
 They shows various patterns like: rosettes, strands, islands, nest, cords which are lined by
columnar or cuboidal cells of two cell thickness.
 Stellate reticulum like cells surrounded by peripheral columnar cells is seen.
 They resembles follicular stage of dental lamina.

2. Mesenchymal component:
 Made up of primitive connective tissue that shows closely intertwining fibrils
interspersed by Spindle shaped mesenchymal cells, Resembling that of dental papilla.
 Juxtaepithelial hyalinization
 Shows less blood vessels .
Differential diagnosis
 Ameloblastoma(follicular)
 Dentigerous cyst
 Central giant cell granuloma
 Odontogenic myxoma

Treatment
 Conservative resection is done if incomplete 18.3% chances of recurrence as suggested
by Zallen.
 Repeated recurrence may develop ameloblastic fibrosarcoma.

2. Ameloblastic fibro - odontoma

Before Slootweg represented it as hamartoma as immature complex odontoma. But WHO
defined AFO as‘A neoplasm composed of proliferating odontogenic epithelium embedded in a
cellular ectomesenchymal tissue that resembles dental papilla with varying degree at inductive
change and dental hard tissue formation'.

Clinical features
 Age ranging from 0.5- 39 years are affected but especially occurs below the age of 11.5
years.
 Male are more affected than female.
 Posterior region of the either jaws are usually affected with more association with
impacted tooth.
Clinical presentation
 No clinical manifestation is present
 Accidentally discovers during radiography. If not Patients may visits with swelling and

failure of tooth eruption.

Radiographical features
 Well circumscribed lesion with expansile radiolucency
 Solitary or small multiple radio-opaque masses can be seen.
  Tumor has size of 1-2 cm in diameter,butLarger ones extends up to body and ramus of
mandible.

Histological features
*Identical as Ameloblastic fibroma .
1.Epithelial:
 Cords, strands fingers and rosettes of odontogenic epithelium are seen which are
lined by cuboidal and columnar cells.
 Resembles dental lamina.
2.Mesenchymal:
 Is embryogenic fibrous connective tissue with delicate fibrils, interspersed by
primitive fibroblasts that resembles dental papilla.
*Foci of enamel and dentin matrix formation (composite odontoma).
Differential diagnosis
1.Calcyfying odontogenic cyst
2.Calcfying epithelial odontogenic tumor
3.Adenomatoid odontogenic tumor

Treatment
 Conservative curettage is done.
 Recurrence rate is about 7% and rarely develops into Ameloblastic fibrosarcoma.

#Ameloblastic fibro dentinoma: calcifying component consists only of dentin matrix and
dentinoid.
3.ODONTOMA
It is the most common odontogenic tumor in which both the epithelial and mesenchymal cells
exhibit complete differentiation,with the result that functional ameloblasts and odontoblasts form
enamel and dentin.

Some authorities accept that odontoma is a hamartomatous malformation in which there is

disorganized mass of cells having limited growth potential and limited recurrence.
Odontoma also called as Composite Odontoma because of more than one type of tissue.
It consists of two types
1. Compund composite odontoma
2. Complex composite odontoma

1. Compound Odontome:

•Dental tissues are arranged in orderly pattern.

•It has anatomic resemblance to normal teeth.

2. Complex Odontome:
•Dental tissues are arranged in disorganized pattern.
•It has no anatomic resemblance to normal tooth.
Etiology
 Unknown
 Local trauma
 Infection
 Genetic mutation

Clinical Features-
•Younger people are most common affected.
•Second decade of life is common.
•The Mean age of detection is 14.8 years old.
•A slight predilection for occurance in males (59%) as compared to female(41%) is seen.
•Maxilla has more predilections for occurrence of odontoma than mandible (3:1).
1. Compound Odontoma
•The compound odontoma has a predilection for anterior maxilla (61%).
2. Complex odontoma
•The complex odontoma has a predilection for the posterior jaws (59%), commonly seen in
posterior mandible.
Clinical Presentation
Most odontomas are asymptomatic, although occasional signs and
symptoms relating to their presence do occur. These generally consist of
unerrupted or impacted teeth, retained deciduous teeth, swelling and
evidence of infection. Cyst formation, mostly dentigerous cyst can be
formed around some tumor.

Radiographic Features

1. Compound Odontoma

 The compound odontoma appears as a collection of tooth like structures of varying size
and shape surrounded by a narrow radiolucent zone.

2. Complex Odontoma
 The complex odontoma appears as a calcified mass with the radio density of tooth
structure.
Histopathology

1. Compound odontoma

 Enamel,dentin,pulp are orderly arranged.

 Denticles are embedded in Connective tissue.
 It has a fibrous capsule.

2.Complex Odontoma
 Enamel ,dentin,pulp are arranged in Disorganized
pattern.
 It has Mature tubular dentin.
  One additional interesting feature is the presence of ghost cells in odontoma similar to
calcifying odontogenic cyst.

Differential diagnosis
 Calcifying
epithelial
odontogenic
tumor
 Osteoma
 Ameloblastic
fibrodentinoma
 Ameloblastic
fibro- odontoma


Odontoameloblastoma

We have the difference between compound and complex odontoma as follows:

Compound Odontoma Complex Odontoma

1.Dental tissues orderly pattern 1.Dental tissues disorderly pattern

2.Multiple small tooth like structures 2.Mass of enamel and dentin

3.More common 3.Less common

4.Majority cases before age 20 4.Before age 30

5.Common site: Maxillary anterior 5.Molar mandibular region

6.Clinical presentation: 6.Clinical presentation:

• painless • Painless
• Non aggressive lesion • Expanding lesion
• More limited potential growth • Slow growing
• Associated with unerupted tooth • unerupted teeth

7.Radiologically 7.Radiologically
• Collection of tooth like structures • Calcified mass
• Surrounded by radiolucent zone • Radio density of tooth structure
• Narrow radiolucent rim

8.Histologically 8.Histologically
• Denticles embedded in loose fibrous • Large mature tubular dentin
matrix • Small amount of enamel matrix
• Varying amount of enamel matrix

Treatment
 Surgical removal can be done.
 Prognosis is excellent

4.Ameloblastic Odontoma (odontoameloblastoma)

It is an odontogenic neoplasm characterized by the simultaneous occurance of an
ameloblastoma and a composite odontoma. It is extremely rare neoplasm.

Clinical Features
  The ameloblastic
odontoma appears to occur at
any age between 6 month
and 40 years of age.
 It is more frequently seen in
children with a male
predilection.
 It is more common in
mandible than in the maxilla,
especially at the molar
premolar region.

Radiographic Features

 It is mostly unilocular.
 It has irregular radiopaque mass of calcified tissue.

Histopathology
 It Has features of Ameloblastoma
 It has mainly Plexiform or follicular pattern.
 It has features of odontoma.
 It may have Compound or Complex.
Treatment

 Surgical excision can be done.

*The 2017 WHO classification has emphasized that the appearance of hard tissue formation is
usually the first stage in maturation and more compatible with a DEVELOPING
ODONTOMA.
5.Dentinogenic Ghost cell tumor

 The cystic variant CCOT has been reclassified as COC keeping only DGCT in the tumor
category. (WHO, 2017)

Introduction
Back in 2005:
WHO defined dentinogenic ghost cell tumor as a ‘ benign neoplasm characterized by
ameloblastoma like islands of epithelial cells in mature connective tissue stroma.

Clinical features and presentation

nd rd
• Occurs in 2 and 3 decade of life with equal sex predilection. Maxilla and mandible are
equally affected (mostly between canine and 1st molar).
 Presentation
• They are usually asymptomatic.
• Patients may clinic with pain and discomfort .
Radiographical features
• Well defined radiolucent or radiopaque lesion.
• Unilocular or multilocular.
• Bicortical expansion on occlusal radiographs.
• Ocassionally, root resorption or an impacted teeth may be seen.

Histological features
• Fibrous capsule is lined by 4-10 cell thickness
• Basal cells are cuboidal or columnar with polarized nuclei
• Within epithelial component presence of characterstic “ Ghost cells” undergoing
keratinization.
• Ghost cell are eosinophilic epithelial cells that lacks nuclei with preservation of outline
• Interspersed of dentinoid among epithelium and ghost cells.
Ghost cells
Origin :
• Abnormal keratinization
• Coagulative necrosis
• Abnormal accumulation of enamel protein.
But all these 3 are only hypothesis.
Characteristics:
• Loss of nuclei but may have clear nuclear rim
• Clear preservation of cellular outline
• Resistance to resorption
• Potential to calcify
How they differ from keratinocytes?
• Ghost cells are larger,
• Vacuolated,
• Have more prominent remnant of nuclear membrane
• All of this may be due to intracellular edema and presence of
dilated degenerated organelles.
Also seen in:
• Calcifying odontogenic cyst
• Ameloblastic odontomas
• Craniopharyngioma
• Pilomatricoma
• Odontoma

*In van Geison’s stain ghost cell appears yellow with red dentinoid.
*Ghost cell are called so due to there shadowy appearance in hematoxylin – eosin (H and E)
stain.
Treatment
 Surgical excision for dentinogenic ghost cell tumor
 Recurrence has been reported .

6.Primordial odontogenic tumor

 It is rare recently described odontogenic tumor.
 It is Mostly associated with unerupted tooth.

Clinical features
 Children and adolescents are mostly affected.
 Common in posterior mandible

Clinical presentation
 It is asymptomatic and slow growing mass causing facial symmetry.

Radio graphically
 Large expanding radiolucency area are seen.
 It appears as dentigerous cyst.

Histologically
 Thin layer of ameloblasts around periphery is seen.
 Tumor resembles gaint solid mass of dental papilla.
 It has no odontoblast, dentin or enamel matrix.

Treatment
 Surgical removal can be done.
 No recurrence is seen.
Summary
 Ameloblastic Fibroma is a mixed tumor of odontogenic origin that mostly occurs
in children and teenagers, Often associated with an impacted tooth, Composed of
neoplastic epithelium and neoplastic connective tissue , which can be treated by
curettage or excision and has rare malignant counterpart.

 Ameloblastic Fibro- odontoma same as Ameloblastic fibroma but composed of

neoplastic epithelium and neoplastic myxomatous connective tissue.

 Odontoma is the most common odontogenic tumor but regarded as a hamartoma

rather than a neoplasm mostly occurring in children and are usually
asymptomatic, have two type ie complex and compound odontoma, which can be
treated by enucleation .

 Ameloblastic odontoma is extremely rare mixed tumor of odontogenic origin

having characters of ameloblastoma and composite odontoma.

 Dentinogenic ghost cell tumor is a rare odontogenic tumor of mixed origin which
mostly occurs in middle age, usually are asymptomatic, with characteristic ghost
cells which can be surgically removed.

 Primordial odontogenic tumor rare new tumor mostly associated with unerupted
tooth and are asymptomatic resembling the solid mass of dental papilla which can
be surgically removed.
 MCQs
1. Ameloblastic fibroma originates from:
a) Inner enamel epithelium and dental papilla
b) Rest of Malassez
c) Reduced enamel Epithelium
d) Rest of serres

2. Which is the most common odontogenic tumor?

a) Ameloblastoma
b) Odontoma
c) Adenomatoid odontogenic tumor
d) Squamous cell carcinoma

3. Cyst mostly associated with odontoma is:

a) Radicular cyst
b) Odontogenic keratocyst
c) Dentigerous cyst
d) Glandular cyst

4.In Odontoameloblastoma there is simultaneous occurrence of:

a) Ameloblastoma and dentigerous cyst
b) Odontoma and dentigerous cyst
c) Odontoma and ameloblastic fibroma
d) Ameloblastoma and odontoma

5. Ghost cells are not seen in:

a) Calcifying epithelial odontogenic tumor
b) Craniopharyngioma
c) pilomatricoma
d) Dentinogenic ghost cell tumor
 References

 Shafer, Hine, Levy. Shafer's textbook of oral pathology. 8th edition. New Delhi: Elsevier;
2019
 Neville Brad W. Damm Douglas D. Allen Carl M. Chi Angela C. Oral and Maxillofacial
Pathology. 4th edition. Missouri: Elsevier; 2016
 E.W. odell. Cawson’s essentials of oral pathology and oral medicine. 9th edition. London;
Elsevier; 2017
 Swapan Kumar Purkait. Essentials of oral pathology. 3rd edition. New Delhi; Jaypee;
2011

Past Questions
Q. Short notes on Odontoma, Ghost cells
Q. Describe the etiology, clinical features, radio graphical features and histology of
odontoma.
Q. Define and classify odontomes.

Thankyou