DEN 032: Oral Pathology 1 Lab

Students’ Activity Sheet #11

Name: Class number: _______

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Lesson title: Epithelial Odontogenic Tumors Materials:

Lesson Objectives: Ballpen, pencil, drawing materials
At the end of this lesson you will be able to:
1. Get acquainted with the different epithelial odontogenic References:
tumors. Regezi, J.A.; Sciubba, J.J.; and
2. Learn and identify its cause, radiographic presentation, and Jordan, R.C.K. (2017). Oral
how to manage the lesion. Pathology: Clinical Pathologic
Correlations. 7th Edition.
www.ncbi.nlm.nih.gov
Productivity Tip:
Review your week every Friday. “Review your diary at the end of each week. Literally, print it out
and review it. It will transform how you spend your time.” Some people go to bed at night with a
whirlwind of thoughts rushing through their mind. They hardly have any time to process wha t they
have just done simply because they are so stressed out about what’s directly ahead.

A. LESSON PREVIEW/REVIEW
Introduction
This lesson will broaden your knowledge more about oral pathology. We will be talking here about
odontogenic tumors that are epithelial in origin. Here, you will be able to know and learn how these
lesions look like in the dental radiograph and how they differ from each other based on their
locations and radiographic appearance.

Activity 1: What I Know Chart, part 1

First let’s try to check if you have any idea about our topic. So with that, please answer the following
questions written on the second column, and write down your answers on the first column.
What I Know Questions: What I Learned (Activity 4)

1. What is odontogenic tumor?

2. What is ameloblastoma?

3. What is Pindborg tumor?

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 DEN 032: Oral Pathology 1 Lab
Students’ Activity Sheet #11

Name: Class number: _______

_________________________________________________________________
Date:
Section: ____________ Schedule: ________________
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B. MAIN LESSON
Activity 2: Content Notes

ODONTOGENIC TUMOR
Odontogenic tumors are derived from the epithelial and/or mesenchymal remnants of the tooth-forming
apparatus. Therefore, they are found exclusively in the mandible and maxilla (and occasionally in the
gingiva). The origin and pathogenesis of this group of tumors are unknown. Clinically, odontogenic
tumors are typically asymptomatic, although they may cause jaw expansion, movement of teeth, root
resorption, and bone loss. Knowledge of typical basic features such as age, location, and radiographic
appearance of the various odontogenic tumors can be extremely valuable in developing a clinical
differential diagnosis.
Similar to neoplasms elsewhere in the body, odontogenic tumors tend to microscopically mimic the cell
or tissue of origin. Histologically, odontogenic tumors may resemble soft tissue components of the
enamel organ or dental pulp, or they may contain hard tissue elements of enamel, dentin, and/or
cementum.

EPITHELIAL ODONTOGENIC TUMORS

ODONTOGENIC TUMORS
DISEASES CLINICAL FEATURES CAUSES RADIOGRAPHIC
FEATURES
Ameloblastoma Ameloblastomas may occur This neoplasm Radiographically,
anywhere in the mandible or originates within the ameloblastomas are
maxilla, although the mandibular mandible or maxilla osteolytic, typically
molar-ramus area is the most from epithelium found in the tooth-
common site. In the maxilla, the involved in the bearing areas of the
molar area is more commonly formation of teeth. jaws, and they may be
affected than the premolar and Less commonly, the unicystic or multicystic.
anterior regions. Lesions usually ameloblastoma may Because
are asymptomatic and are arise at a soft tissue ameloblastomas are
discovered during routine location within the slow growing, the
radiographic examination or gingiva of tooth- radiographic margins
because of asymptomatic jaw bearing areas. usually are well defined
expansion. Occasionally, tooth Potential epithelial and sclerotic.
movement or malocclusion may sources include the
be the initial presenting sign. enamel organ,
In cases in which connective odontogenic rests
tissue desmoplasia occurs in (rests of Malassez,

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 DEN 032: Oral Pathology 1 Lab
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conjunction with tumor rests of Serres),

proliferation, ill-defined reduced enamel
radiographic margins are epithelium, and the
typically seen. This variety, epithelial lining of
known as desmoplastic am- odontogenic cysts,
eloblastoma, also has a especially dentigerous
predilection for the anterior jaws cysts. The trigger or
and radiographically may stimulus for neoplastic
resemble a fibro-osseous lesion. transformation of
The generally slow tumor growth these epithelial
rate may be responsible for the residues is unknown.
movement of tooth roots. Root
resorption occasionally occurs in
association with ameloblastoma
growth.
Calcifying Calcifying epithelial odontogenic The cells from which Radiographically, the
Epithelial tumor (CEOT), also known as these tumors are lesions are often asso-
Odontogenic Pindborg tumor, after the oral derived are unknown, ciated with impacted
Tumor pathologist who first described although dental lamina teeth. The lesions may
(Pindborg the entity, is a benign tumor of remnants and the be unilocular or
Tumor) odontogenic origin that shares stratum intermedium multilocular. Small
many clinical features with of the enamel organ loculations in some
ameloblastoma. Microscopically, have been suggested. lesions have prompted
however, there is no re- use of the term
semblance to ameloblastoma, honeycomb to describe
and radiographically distinct this lucent pattern. A
differences will often be noted. CEOT may be
The mandible is affected twice completely radiolucent,
as often as the maxilla, and a or it may contain
predilection for the molar-ramus opaque foci, a
region has been noted, although reflection of the
any site may be affected. calcified amyloid seen
Jaw expansion or incidental microscopically. The
observation on a routine lesions are usually well
radiographic survey is the usual circumscribed
way in which these lesions are radiographically,
discovered. although sclerotic
margins may not
always be evident.
Adenomatoid Adenomatoid odontogenic tumor The adenomatoid Radiographically, the

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Odontogenic (AOT) was formerly termed odontogenic tumor is follicular AOT is a well-
Tumor adenoameloblastoma because it an odontogenic tumor circumscribed
was believed to be a subtype of arising from unilocular lesion that
ameloblastoma that contains the enamel usually appears around
ductlike or glandlike structures. organ or dental the crown of an
Clinically, microscopically, and lamina. impacted tooth; the
behaviorally, it is clearly different extrafollicular type
from ameloblastoma, and the usually presents as a
term adenoameloblastoma is not well-defined unilocular
used. radiolucency above,
Lesions often appear in the between, or
anterior portion of the jaws, superimposed over the
more often in the anterior roots of an unerupted
maxilla, generally in association tooth. Lesions typically
with the crowns of impacted are radiolucent but may
teeth. Three variants of this have small opaque foci
tumor have been identified: distributed throughout,
follicular (73% of cases), reflecting the presence
extrafollicular (24%), and of calcifications in the
peripheral (3%). AOT is rarely tumor tissue. When
seen in association with other they are located
benign odontogenic tumors and between anterior teeth,
cysts. divergence of roots
The peripheral type is may be seen.
characterized by a painless,
nontender gingival swelling.
Squamous It occurs in the mandible and the Because squamous Radiographically, this
Odontogenic maxilla with equal frequency, odontogenic tumor lesion typically is a well
Tumor favoring the anterior region of involves the alveolar circumscribed, often
the maxilla and the posterior process, the lesion is semilunar lesion
region of the mandible. Multiple believed to be derived associated with the
lesions have been described in from neoplastic cervical region of roots
about 20% of affected patients, transformation of the of teeth.
as have familial multicentric rests of Malassez. Although proliferation is
lesions. robust, some similarity
Patients usually experience no to proliferating
symptoms, although tenderness odontogenic rests has
and tooth mobility have been been noted.
reported.
Microscopically, it has some

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 DEN 032: Oral Pathology 1 Lab
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Name: Class number: _______

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similarity to ameloblastoma,
although it lacks the columnar
peripherally palisaded layer of
epithelial cells.
Clear Cell Clear cell odontogenic tumor The origin is unknown, Well-defined
Odontogenic (carcinoma) is a rare neoplasm but the location and radiolucency.
Tumor of the mandible and maxilla. histologic appearance
(Carcinoma) Metastases to lung and to of this lesion suggest
regional lymph nodes have been an odontogenic
reported. The microscopic source.
differential diagnosis includes
other jaw tumors that may have
a clear cell component, such as
CEOT, central mucoepidermoid
carcinoma, metastatic acinic cell
carcinoma, metastatic renal cell
carcinoma, hyalinizing clear cell
carcinoma, and ameloblastoma.
Dentinogenic Calcifying odontogenic cyst Radiographically the
Ghost Cell (COC) refers to a category of dentinogenic ghost cell
Tumor lesions that occurs in three tumor is circumscribed
(Calcifying forms: as a cyst (also called with a mixed lucent and
Odontogenic calcifying cystic odontogenic opaque quality.
Cyst) tumor), as a locally infiltrative
benign neoplasm referred to as
dentinogenic ghost cell tumor,
and a very rare malignant
variant termed dentinogenic
ghost cell carcinoma. The dis-
tinctive feature of all these forms
is of an ameloblastomatous
epithelium containing “ghost
cells” within the epithelial com-
ponent. Ghost cells are relatively
large, eosinophilic cells that
contain the outline of a nucleus
centrally and represent aberrant
keratinization. The keratin may
undergo dystrophic calcification
and may cause a foreign body

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 DEN 032: Oral Pathology 1 Lab
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Name: Class number: _______

_________________________________________________________________
Date:
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reaction in the wall.

Figure 1: Ameloblastoma of the mandible Figure 2: Ameloblastoma of the mandible with oral presentation. Clinical
producing marked cortical expansion. manifestations (left photo); radiographic presentation (right photo).
©Regezi et al ©Regezi et al

Figure 3: Unilocular ameloblastoma of the anterior

Figure 4: Cystic ameloblastoma with a
mandible. ©Regezi et al
loculated appearance in retromolar
mandibular bone. ©Regezi et al

Figure 5: Calcifying epithelial

Figure 6: Adenomatoid odontogenic tumor surrounding the crown of an
odontogenic tumor. The multiloculated
impacted tooth (left photo); Adenomatoid odontogenic tumor with opaque
lesion extends from the third molar to
foci (right photo) ©Regezi et al
the condyle. (Courtesy Dr. Bruce A.
Shapton.) ©Regezi et al
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 DEN 032: Oral Pathology 1 Lab
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Figure 7: Squamous Figure 8: Dentinogenic Ghost Cell Tumor (Formerly Calcifying

Odontogenic Tumor Odontogenic Cyst) ©sciencedirect.com
©benthamopen.com

TREATMENTS/MANAGEMENTS OF EPITHELIAL ODONTOGENIC TUMOR

ODONTOGENIC TUMORS
DISEASES TREATMENTS/MANAGEMENTS
Ameloblastoma No single standard type of therapy can be advocated for patients with
ameloblastoma. Rather, each case should be judged on its own merits.
Prime considerations are whether the lesion is solid, cystic, extraosseous, or
malignant, and its location. Solid ameloblastoma requires at least surgical
excision, because recurrence follows curettage in 50% to 90% of cases.
Block excision or resection followed by immediate surgical reconstruction
generally is reserved for larger lesions. Cystic ameloblastomas may be
treated less aggressively, but with the knowledge that recurrences are often
associated with simple curettage. For cystic ameloblastoma, treatment op-
tions can range from enucleation to resection, although recurrences are more
likely if enucleated. Peripheral ameloblastomas should be treated in a more
conservative fashion. Malignant lesions should be managed as carcinomas.
Patients with all forms of central ameloblastoma should be followed
indefinitely because recurrences may be seen as long as 10 to 20 years after
primary therapy. Ameloblastomas of the maxilla generally are more difficult to
manage than those of the mandible because of anatomic relationships, as
well as the comparatively higher content of cancellous bone compared with
the mandible. Thus, intraosseous maxillary ameloblastomas are often
excised with a wider normal margin than mandibular tumors.

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 DEN 032: Oral Pathology 1 Lab
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_________________________________________________________________
Date:
Section: ____________ Schedule: ________________
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Radiotherapy has rarely been used in the treatment of ameloblastomas

because it is generally believed that these tumors are radioresistant. Until
more is known about tumor responsiveness, radiation should be reserved for
exceptional cases that are difficult or impossible to control surgically.
Calcifying Epithelial This tumor has a locally infiltrative potential but apparently not to the same
Odontogenic Tumor extent as ameloblastoma. It is slow growing and causes morbidity through
(Pindborg Tumor) direct tumor extension. Various forms of surgery, ranging from enucleation to
resection, have been used to treat CEOTs. The overall recurrence rate has
been less than 20%, indicating that aggressive surgery is not indicated for
the management of most of these benign neoplasms. Very rare examples of
malignant transformation of this tumor
Adenomatoid Conservative treatment (enucleation) is all that is required. AOTs are benign,
Odontogenic Tumor encapsulated lesions that do not recur.
Squamous Squamous odontogenic tumors have some invasive capacity and infrequently
Odontogenic Tumor recur after conservative therapy. Curettage or excision is the treatment of
choice.
Clear Cell Stains often need to be performed to rule out other local clear cell
Odontogenic Tumor carcinomas that produce mucin or glycogen, and a metastatic survey needs
(Carcinoma) to be done to exclude clear cell malignancies from other sites in the body.
Dentinogenic Ghost The benign tumor may be locally infiltrative and as such is treated by local
Cell Tumor resection especially if the margins are poorly defined radiographically. The
(Calcifying extraosseous variant is treated by enucleation. The rare malignant variant is
Odontogenic Cyst) managed in a similar manner to other intraosseous carcinomas.

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 DEN 032: Oral Pathology 1 Lab
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Name: Class number: _______

_________________________________________________________________
Date:
Section: ____________ Schedule: ________________
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Activity 3: Skill-building Activities

Case report

A 23-year-old man was referred by his general dental practitioner. One year ago the dentist diagnosed
a cyst with an ectopic lower right canine tooth by an x-ray. Beside an uneventful medical history the
patient presented no conspicuous intraoral clinical findings except the absence of the tooth 43.
Radiologically, he showed a 3 cm unicystic radiolucent image with a comparatively clear demarcation.
The tooth 43 was located on the floor of this process. No resorption of the root apices was observed.

Histologically, the tumor is solid and there is a cyst formation. The epithelium is in the form of whorled
masses of spindle cells as well as sheets and plexiform strands. Rings of columnar cells give rise to
duct-like appearance. Calcification is sometimes seen and may be extensive.

Questions:
A. What is the patient’s condition based on the diagnostic results?
B. How should this case be treated?

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 DEN 032: Oral Pathology 1 Lab
Students’ Activity Sheet #11

Name: Class number: _______

_________________________________________________________________
Date:
Section: ____________ Schedule: ________________
________________________________________

Activity 4: What I Know Chart, part 2

Now, let’s assess if you have learned something new today. Go back to the “What I Know Chart” in
Activity 1 and answer the “What I Learned” column.

Activity 5: Check for Understanding

To check how well you understand the topic, please answer the following questions by encircling the
letter of the correct answer.

1. For cystic ameloblastoma, treatment options can range from enucleation to resection, although
recurrences are less likely if enucleated. Peripheral ameloblastomas should be treated in a more
conservative fashion.
a. First statement is correct and second statement is incorrect
b. First statement is incorrect and second statement is correct
c. Both statements are correct
d. Both statements are incorrect
2. Squamous odontogenic tumor occurs in the mandible and the maxilla with equal frequency,
favoring the posterior region of the maxilla and the anterior region of the mandible.
Radiographically, this lesion typically is a well circumscribed, often semilunar lesion associated with
the apical region of roots of teeth.
a. First statement is correct and second statement is incorrect
b. First statement is incorrect and second statement is correct
c. Both statements are correct
d. Both statements are incorrect
3. In Pindborg tumor, small loculations in some lesions have prompted use of the term honeycomb to
describe this lucent pattern. A CEOT may be completely radiopaque, or it may contain lucent foci, a
reflection of the calcified amyloid seen microscopically.
a. First statement is correct and second statement is incorrect
b. First statement is incorrect and second statement is correct
c. Both statements are correct
d. Both statements are incorrect
4. The follicular AOT is a well-circumscribed multilocular lesion that usually appears around the crown
of an impacted tooth; the extrafollicular type usually presents as a well-defined unilocular
radiolucency below, between, or superimposed over the roots of an unerupted tooth.
a. First statement is correct and second statement is incorrect
b. First statement is incorrect and second statement is correct
c. Both statements are correct
d. Both statements are incorrect
5. This tumor has a locally infiltrative potential but apparently not to the same extent as
ameloblastoma. It is fast growing and causes morbidity through direct tumor extension.
a. First statement is correct and second statement is incorrect

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 DEN 032: Oral Pathology 1 Lab
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b. First statement is incorrect and second statement is correct

c. Both statements are correct
d. Both statements are incorrect

• Stop and check your answers against the Key to Corrections found at the end of this Activity
Sheet. Write your score/s on your paper.

C. LESSON WRAP-UP
Activity 6: Thinking about Learning
A. Work Tracker
You are done with this session! Let’s track your progress. Shade the session number you just
completed.

B. Think about your Learning

Now that you completed the lesson, take a few minutes to reflect on the quality of your work and the
quality of your effort.

What parts were challenging for you to do? Why do you think was it challenging for you?
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What did you like about this lesson? Why did it make you feel this way? How did this feeling affect your
work?
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FAQs
What's the difference between a tumor and a cyst? Could a cyst be cancerous?
Tumors and cysts are two distinct entities.
Cyst. A cyst is a sac that may be filled with air, fluid or other material. A cyst can form in any part of the
body, including bones, organs and soft tissues. Most cysts are noncancerous (benign), but sometimes
cancer can cause a cyst.
Tumor. A tumor is any abnormal mass of tissue or swelling. Like a cyst, a tumor can form in any part of
the body. A tumor can be benign or cancerous (malignant). (www.mayoclinic.org)

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 DEN 032: Oral Pathology 1 Lab
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Name: Class number: _______

_________________________________________________________________
Date:
Section: ____________ Schedule: ________________
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Do jaw cysts need to be removed?

There are many different kinds of cysts. The most important reason for removing a cyst is that over time
they increase in size and may become harmful. Very large cysts may weaken the lower jaw bone to the
point where it can break more easily. Teeth beside a large cyst may become loose and move around.
(www.med.umich.edu)

KEY TO CORRECTIONS
Activity 3.A

Case condition: AOT (Adenomatoid Odontogenic Tumor)

Treatment: Conservative treatment (enucleation) is all that is required.

Activity 5:
1. B 2. D 3. A 4.D 5. A

_________________

Prepared by:
MIGNONETH GAY P. ESTRERA, DMD
Professor/Clinic Instructor
Southwestern University PHINMA - College of Dentistry

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