Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx

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Journal of Oral and Maxillofacial Surgery, Medicine, and

Pathology
journal homepage: www.elsevier.com/locate/jomsmp

An incipient adenomatoid odontogenic tumor in a 5-year old girl

⁎
Irulandy Ponniah , Sri Kantha Laskhmi Piramanayagam Kannan, Suganya Panneer Selvam
Department of Oral and Maxillofacial Pathology, Tamil Nadu Government Dental College and Hospital, Chennai 600 003, Tamil Nadu, India1

A R T I C LE I N FO A B S T R A C T

Keywords: Adenomatoid odontogenic tumor is an epithelial tumor thought to arise from the cells of enamel organ or
Adenomatoid reduced enamel epithelium. It shows predilection for young children and adolescence and occurs with greater
Odontogenic propensity in the anterior maxilla. The tumor manifests characteristic histological features and has been well-
Tumour described. The purpose of the present report is to document a developing or incipient AOT in the maxillae of a 5-
Incipient
year old girl.
Developing
Amelogenin

1. Introduction excised specimen was submitted for pathological evaluation, Gross

Adenomatoid odontogenic tumor (AOT) is a benign epithelial
odontogenic tumor. This tumor has higher propensity to affect the
anterior maxillae of young female patients [1,2]. Although the litera-
ture provides voluminous information on the nature, distribution and
microscopic configuration of AOT [1–15], there is still a gap in the
literature in so far as how AOT might appear at its inception with re-
ference to the histological manifestation. The purpose of the present
report is to document a developing or incipient AOT in the maxillae of a
5-year old girl.
2. Case report
A 5-year old girl presented with swelling over the left maxilla of
one-month duration. Her medical or dental history was non-con-
tributory. On intra-oral examination, a diffuse swelling was noted in the
region of left maxillary canine and molars. The swelling was soft in
consistency and tender to touch. Initial evaluation with a panoramic
radiograph revealed a radiolucent shadow below the palate, which
extends between left maxillary deciduous canine and second molar
(Fig. 1A). Further evaluation with computed tomography (bone
window) showed an isointense to hypointense lesion with thinning and
destruction of the cortical plates (Fig. 1B & C). Based on the clinical and
imaging features, dentigerous cyst, ameloblastic fibro-odontoma and
adenomatoid odontogenic tumor were considered in the differential
diagnosis. In view of the diagnostic possibilities, excisional biopsy was
planned and the lesion was removed along with the left maxillary de-
ciduous canine, first and second molars and permanent premolars. The
examination of the surgical specimen revealed multiple bits of soft
tissue and deciduous and permanent teeth. On microscopic examina-
tion, the lesion was characterized by partly inflamed connective tissue
containing solid epithelial islands and an epithelial structure of tall
columnar cells supported by polyhedral shaped squamous cells at the
edge of the section (Fig. 2, 3A & C and 4 ). The pathology report was
signed out as developing adenomatoid odontogenic tumor.
2.1. Immunohistochemistry
In view of the rare organization of the epithelial component of the
present lesion, it was decided to perform immunohistochemistry with
marker amelogenin.
For immunohistochemistry, the sections were cut at 3.5 microns
thickness from the tissue blocks of human late bell stage (LBS) tooth
germ (obtained from the archival samples) and the present tumour.
Endogenous peroxidase was blocked in 3% H2O2 for 20 min and washed
properly in distilled water twice, 5 min each. Antigen retrieval was
done with citrate buffer (pH-6) using a pressure cooker at 120 °C for
15 min. The sections were incubated with primary antibody [AMELX
antibody (Rabbit Polyclonal, 1:200 dilution, orb140077 – Biorbyt, UK)
diluted in phosphate buffered solution (PBS) at pH 7.4] for one hour in
a moist chamber at room temperature and washed in PBS twice, 2 min
each. The sections were covered with Poly Detector Plus Link for 10 min
and washed thrice with PBS followed by incubation with Poly Detector
HRP Label for 10 min and then washed again thrice with PBS. The
sections were covered with prepared DAB substrate – chromogen so-
lution (one drop of Poly Detector DAB Chromogen per ml of Poly

⁎
Corresponding author.
E-mail address: salivaryduct@yahoo.co.uk (I. Ponniah).
1
Affiliated to The Tamil Nadu Dr. MGR Medical University No. 69, Anna Salai, Guindy, Chennai 600 032, Tamil Nadu, India.

https://doi.org/10.1016/j.ajoms.2018.06.006
Received 30 January 2018; Received in revised form 10 June 2018; Accepted 20 June 2018
2212-5558/ © 2018 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd All rights reserved.

Please cite this article as: Ponniah, I., Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology (2018),
https://doi.org/10.1016/j.ajoms.2018.06.006
I. Ponniah et al. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx

Fig. 1. A, panoramic radiograph shows a radiolucent shadow between the distal of deciduous maxillary left canine and distal of second molar. B and C, CT (bone
window) shows an isointense lesion in the axial section in B and iso- to hypointense lesion in the coronal section in C. In both sections cortical destruction is evident.
The left maxillary sinus shows mucosal thickening.

Detector DAB Buffer) for 3 min and washed with distilled water. The
sections were counterstained with Ehrlich haematoxylin for 10 s, de-
hydrated and mounted. The human LBS tooth germ with the formation
of enamel matrix was used as the positive control for immunoexpres-
sion of amelogenin. Negative controls were performed as described
above but by replacing the primary antibody and substituting with an
immunoglobulins G isotype.
The evaluation was done based on staining as mild (light brown
colour), moderate (intermediate between light brown and dark brown)
and intense (dark brown colour) by visual identification of the im-
munoreactivity of the cells of interest in the tissue sections using the
Olympus Research Microscope (Model BX43 F). The photomicrographs
were captured with Infinity 1 camera fitted to the Olympus Microscope
and smart phone camera.
Immunohistochemical observation revealed intense positive reac-
tion of amelogenin in the secretory ameloblast and in the enamel matrix
in human tooth germ which served as the control tissue (Fig. 5A & B).
The tumor cells showed an intense positive reaction in the cytoplasm of
tall columnar cells and subjacent squamous cells, with a moderate po-
sitive reaction in the epithelial nodule in the connective tissue (Fig. 5C
& D).
3. Discussion
Adenomatoid odontongenic tumor usually present s as a slow-
growing, painless swelling of the jaw [1]. Of the odontogenic tumors,
AOT has a characteristic distribution in that the anterior maxilla is
frequently involved with a higher predilection for females and is more

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I. Ponniah et al.
Fig. 2. A, part of the scanning magnification view of the lesion shows connective tissue and epithelial component (Box A, epithelial component and Box B, epithelial
nodules in the connective tissue).
reticulum (sr), outer enamel epithelium (oee), dental follicle (df), flattened cells (fc) and polyhedral cells (pd)].
commonly encountered during the second decade of life. About 73% of
cases occur under 20-years of age, but only 3% of cases occur under 10-
years of age [2]. The youngest case of AOT appears to be a 5-year old
girl reported by Gorlin et al. [3] under the terminology “ameloblastic
adenomatoid tumor.” However, neither specific clinical nor histological
features were described in that report [3]. Kearns et al. [4] had reported
a case of peripheral AOT in a 3-year old girl. Although a report has been
published under the designation “Bilateral adenomatoid odontogenic
tumour” in a 2-year old girl, it is inconsistent with AOT on closer ob-
servation of the radiograph and photomicrograph [16]. In this context
the occurrence of the present case in a 5-year old girl is significant. It is
believed that formation of AOT may begin around 4-years of age [5],
and is usually detected when it is small, but occasionally may go un-
noticed before it becomes of considerable size [6]. Radiographically,
AOT present as a unilocular radiolucency associated with an unerupted
tooth associated with and without small radiopacities [1].
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Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx
Fig. 3. A, higher magnification of a field,
which is similar to Box A shown in Fig. 2, re-
veals arrangement of the epithelial component
(tall columnar cells with abundant eosinophilic
cytoplasm, palisading and polarized nuclei
followed by multi-layered squamous cells) and
connective tissue. Note: Compare A with B, an
illustrative higher magnification photo-
micrograph showing arrangement of enamel,
tall columnar cells (secretory ameloblast),
stratum intermedium, stellate reticulum and
outer enamel epithelial cells in a human en-
amel organ. C, shows higher magnification
view of the epithelial nodule in Box B shown in
Fig. 2 [Abbreviations: connective tissue (ct),
multi-layered squamous cells (msq), tall co-
lumnar cells (tc), secretory ameloblasts (sa),
enamel (e), stratum intermedium (si), stellate
3.1. Histogenesis
Histogenetically, it is believed that AOT may arise from the dental
lamina at one end of the spectrum to the reduced enamel epithelium at
the other end of crown morphogenesis and alternatively from the epi-
thelial rests of Malassez or tumorigenesis within an odontogenic cyst
[1,7].
3.2. Histopathology
Microscopically, AOT is characterized by a well-encapsulated partly
cystic structure with intraluminal epithelial proliferation [1,8,9].
However, the partly cystic nature of this tumor is regarded as a sec-
ondary phenomenon in an otherwise solid tumor rather than the de-
velopment of neoplasia in the wall of an originally simple cyst [8]. The
intraluminal epithelial proliferation basically manifests as solid nodular
I. Ponniah et al.
Fig. 4. A, part of the scanning magnification view of the lesion shows connective tissue and epithelial component (Box A, epithelial component and Box B, epithelial
nodules in the connective tissue). B, shows duct – like formation in the epithelial component shown in Box A.
masses of epithelial cells often in a whirling pattern and the trabecular
or cribriform pattern of epithelial proliferations disposed at the per-
iphery of the lesion [1]. The solid nodular masses are composed of
cellular elements that are predominantly polygonal or polyhedral cells
in the core of the nodule and surrounded by circumferentially arranged
flattened or spindle shaped cells. The purely solid cellular proliferation
represent s the undifferentiated spectrum of tumor cells, which with the
beginning of differentiation form circular groups and secrete eosino-
philic material to assume rosette – like structure. On further differ-
entiation, some of the cells become tall columnar in shape bordering
duct – like or convoluted tubule containing a greater quantity of eosi-
nophilic material [10]. The duct – like structures are of two types;
simple duct in which the lining cells are cuboidal (inner enamel epi-
thelium) or columnar (preameloblast and/or ameloblast) cells with
their nuclei aligned away from the lumen of the duct [9,11–14], and
complex duct which is referred to as convoluted tubule in which tall
columnar cells enclose eosinophilic material [15]. The circumferen-
tially arranged flattened or spindle cells around the solid nodular
masses are regarded as stratum intermedium or stellate reticulum cells.
Thus, basically, the orientation of tumor cells in AOT simulates the
enamel organ of tooth germ. In addition, scattered calcifications are
part of the tumor proliferation which may take the form of concentric
or Liesegang pattern or large globular masses of dark bluish red to pale
blue substance [15].
Although there was no correlation to the presence of cystic bag,
either surgically or grossly, the present case appears to arise from an
odontogenic cyst lining which shows the transformation of the lining
epithelium into luminal columnar epithelium overlying polyhedral
shaped squamous cells, which abut the connective tissue containing
solid epithelial nodules. The morphological appearance of the columnar
cells suggests a higher degree of differentiation [10]. In addition, the
present case is unique in the sense that unlike the reported cases of
AOT, the connective tissue is abundant and the rosette and duct – like
structures are not prominent, perhaps an indication of evolving or an
incipient tumour. The literature reveals that the presence of solid
nodular masses are regarded as most prominent and uniform pattern,
while the duct – like structure assumes a minor role in the total mi-
croscopic presentation [1]. On the other hand, the highly elongated
columnar cells with the morphological appearance of a secretory
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Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx
ameloblast, found in the present lesion, are considered relatively rare
finding in AOT [10]. Overall, in the present case, the morphological
appearance and organization of the tumor cells in certain fields closely
mimics the cell layers of enamel organ except for the lack of outer
enamel epithelium.
The literature reveal s that amelogenin reacts negatively with the
columnar or polygonal cells in AOT, but intensely stain the un-
differentiated cells forming the cribriform or trabecular pattern, and
variably with the mineralized products and hyaline droplets [17,18]. In
contrast, amelogenin have been shown to react positively with the tall
columnar cells lining the convoluted tubule and duct – like structures,
but not in the flattened circumferential cells around the columnar cells
[19]. In the present study, all epithelial cells such as those forming the
solid nodules, the tall columnar cells and the squamous cells reacted
positively to amelogenin. The reaction pattern to amelogenin observed
in the present study is at variance from the previous studies on AOT
[17–19].
3.3. Microscopical differential
With regard to the differential diagnosis of the present case, some
authorities might think in terms of adenomatoid odontogenic ha-
martoma or primordial odontogenic tumor [20,21]. However, the
former lesion is characterized by a microscopic organization of tooth
germ-like features but with the presence of adenomatoid configurations
in the epithelial component associated with and without formation of
the dentin and enamel [20]. In contrast, primordial odontogenic tumor
(POT), is characterized by cell-rich ectomesenchyme and an epithelial
lining similar to inner enamel epithelium (IEE) or its more differ-
entiated lineage [21,22]. Thus, the epithelial component of POT re-
sembles early stages of tooth development before full differentiation of
IEE lineage occurs [21]. Therefore, the histomorphological features of
these two lesions are unlike the present case. Furthermore, some au-
thors believe that a cell-rich, primitive stage of a developing amelo-
blastic fibroma or complex odontoma may simulate POT [22–24]. We
also have encountered lesions that simulate POT but actually represent
ameloblastic fibroma or developing complex odontoma as shown in
Figs. 6 and 7. In contrast to POT, the present lesion lacks spindle or
stellate cells embedded in a fibromyxoid stroma reminiscent of dental
I. Ponniah et al. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx

Fig. 5. Shows positive staining with amelogenin in the secretory ameloblasts and enamel matrix in A [Inset: Higher magnification of boxed area in A], and in the
epithelial component of the tumor cells in B and C, which corresponds to the fields shown in Fig. 3A and C [Abbreviations: Secretory ameloblast (sa), enamel (e) and
dentin (d)].

papilla but only shows the formation of the nascent epithelial nodule in
the connective tissue, which is similar to the solid nodules in AOT. In
addition, the elongated tall columnar shaped cells with reversed nu-
clear polarization are found at the surface while the stellate to stratum
intermedium cells abuts the connective tissue. These features distin-
guish the present lesion from the newly described POT in which the
dental papilla – like connective tissue is enveloped by basally located
tall columnar cells [21–23]. Therefore, the present lesion is unique and
may well add information to the understanding of histogenesis of AOT.
regard the authors’ like to quote Courtney et al. [1], that “Since some of
these variants are available in limited numbers for study by any one
group, it seems appropriate to report as many of these cases as possible.
The summation of information gained from these reportings should
provide a more realistic approach to the histogenesis, pathogenesis, and
clinical behaviour of these uncommon odontogenic lesions.”
Funding

This research did not receive any specific grant from funding
4. Conclusion agencies in the public, commercial or not-for-profit sectors.

We report a rare case of evolving AOT in a 5-year old girl. In this

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I. Ponniah et al. Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology xxx (xxxx) xxx–xxx

Fig. 6. Shows a microscopic field in a case of ameloblastic fibroma with features of POT.

Fig. 7. Shows epithelial and ectomesenchymal components in an odontoma similar to POT.

Ethical approval References

The authors wish to declare that all experiments on human subjects
were conducted in accordance with the Declaration of Helsinki. Ethical
approval for this study was obtained from the relevant local ethics
committees and patient consent was obtained.
Conflict of interest
None declared.
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