DEN 032: Oral Pathology 1 Lab

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Lesson title: Mesenchymal and Mixed Odontogenic Tumors Materials:

Lesson Objectives: Ballpen, pencil, drawing and
At the end of this lesson you will be able to: coloring materials, mirror
1. Know more about odontogenic tumors and its different
classifications according to their different origin. References:
2. Know about the different mesenchymal and mixed Regezi, J.A.; Sciubba, J.J.; and
odontogenic tumors; and how should they be identified Jordan, R.C.K. (2017). Oral
based on their radiographic and clinical presentations. Pathology: Clinical Pathologic
Correlations. 7th Edition.
www.scriencedirect.com
Productivity Tip:
Look back. Learn from every week by looking back and reviewing what you have accomplished. It
will help you learn better time management skills for the future and identify the things that simply
aren’t worth your attention any longer.

A. LESSON PREVIEW/REVIEW
Introduction
Did you know that tumors does not only originate from the epithelium but can also originate from the
mesenchyme, or can be both epithelial and mesenchymal origin? With this lesson, you will know
more about odontogenic tumors aside from epithelial tumors.

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
cementoblastoma?

2. What is the clinical

manifestation of
odontoma?

3. How does Peripheral

Cemento-osseous
Dysplasia appears
radioraphically?

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 DEN 032: Oral Pathology 1 Lab
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B. MAIN LESSON
Activity 2: Content Notes

MESENCHYMAL ODONTOGENIC TUMORS

➢ What is a mesenchymal tumor?

Mesenchymal tumors include entities originating from mesodermal-derived precursor cells that
develop into bone, cartilage, or other connective tissues, such as blood vessels, adipose
tissue, smooth muscle, or fibroblasts; in the CNS they most commonly arise from the
meninges rather than the CNS parenchyma.

ODONTOGENIC TUMORS
DISEASES CLINICAL FEATURES CAUSES RADIOGRAPHIC
FEATURES
Odontogenic Odontogenic myxoma is a benign Odontogenic Radiographically, this
Myxoma mesenchymal lesion that mimics myxomas (OMs) are lesion is always lucent,
microscopically the dental pulp or benign tumors although the pattern may
follicular connective tissue. It is a derived from be quite variable. It may
relatively common odontogenic embryonic appear as a well-
tumor, representing 1% to 17% of mesenchymal circumscribed or diffuse
all tumor types. elements of dental lesion. It often is
The age range in which this anlage. OM appears multilocular with a
lesion appears extends from 10 to originate from honeycomb pattern. Other
to 50 years, with a mean of about dental papilla, radiographic patterns and
30 years. There is no gender follicle, or descriptors include
predilection, and the lesions are periodontal “honeycomb,” “soap
seen anywhere in the mandible ligament. The bubble,” or “tennis racket.”
and maxilla with about equal evidence for its Cortical expansion or
frequency. odontogenic origin perforation and root
arises from its displacement or resorption
almost exclusive may be seen.
location in the tooth
bearing areas of the
jaws, its occasional
association with
missing or

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Central Central odontogenic fibroma is a
Odontogenic rare ectomesenchymal tumor that
Fibroma is regarded as the central
counterpart to peripheral
odontogenic fibroma. It has been
seen in all age groups and is
found in both the mandible and
the maxilla, with a 2:1 female
predilection. It results in a
radiolucent lesion that usually is
multilocular, often causing
cortical expansion.
Approximately 45% of cases
occur anterior to the first molar
region of the maxilla, often with a
cortical bony depression of the
palatal contour. The clinical
differential diagnosis is similar to
that described for
ameloblastoma.
Cementifying It is very closely related to other
Fibroma fibro-osseous lesions like fibrous
dysplasia, cemental periapical
dysplasia and other calcifying
odontogenic cysts and tumour.
Clinically, it presents as painless,
slow-growing mass in the jaws
where displacement of teeth is
the only early clinical feature.
Thus, the lesion is frequently
ignored by the patient until it
produces a noticeable swelling
and facial deformity. If present in
maxilla, it may cause cortical
expansion, obliterating the buccal
sulcus extending into nasal cavity
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DEN 032: Oral Pathology 1 Lab
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unerupted teeth, and
the presence of
odontogenic
epithelium.
The lesion may Radiographically the tumor
evolve from a dental sometimes produces an
germ (dental papilla expansile multilocular
or follicle) or from radiolucency similar to that
the periodontal of the ameloblastoma.
membrane, and
therefore is
invariably related to
the coronal or
radicular portion of
teeth.
Cementifying Radiographic features are
fibroma is of utmost importance as
considered as a they help to distinguish it
benign, osseous from other closely
tumour, which arises mimicking fibro-ossseous
from the periodontal lesions. The lesion may be
ligament and is either unilocular or
composed of varying multilocular. In early
amounts of stages, it appears as a
cementum, bone radiolucent lesion with no
and fibrous tissue. evidence of radiopacity. As
the lesion matures, it
assumes mixed
radiolucent–radiopaque
density with a pattern that
depends on the amount
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and orbital floor and may lead to and form of manufactured

epistaxis and even euphoria. calcified material.
This lesion has a strong female
predilection, affecting females
twice as common as males.
Second, it is more commonly
seen in the mandible than in the
maxilla. The favourite sites in the
mandible are typically areas
inferior to premolars and molars
and superior to the inferior
alveolar canal.
Cementoblas Cementoblastoma, also known Cementoblastoma a Radiographically, this
toma as true cementoma, is a rare rises from neoplasm is an opaque
benign neoplasm of cementoblasts, lesion that replaces the
cementoblasts that which are normally root of the tooth. It usually
microscopically resembles an involved in the is surrounded by a thick
osteoblastoma but is connected formation of uniform radiolucent ring
or fused to the root of a tooth. It cementum. Cement that is contiguous with the
occurs predominantly in the oblastoma is periodontal ligament space
second and third decades of life, commonly located in and the advancing front of
typically before 25 years of age. the mandibular the tumor.
There is no gender predilection. It molar area. There
is seen more often in the are no genetic
mandible than in the maxilla and mutations
more often in posterior than in associated with the
anterior regions. It is intimately development
associated with the root of a of cementoblastoma
tooth, and the tooth remains vital. .
Cementoblastoma may cause
cortical expansion and,
occasionally, low-grade
intermittent pain.
Peripheral As the name implies, periapical This lesion appears It appears first as a
Cemento- cemento-osseous dysplasia to be an unusual periapical lucency that is
osseous represents a reactive or response of continuous with the
Dysplasia dysplastic process, rather than a periapical bone and periodontal ligament
neoplastic one. cementum to some space. Although this initial
When not associated with a tooth undetermined local pattern simulates

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apex, the term focal cemento- factor. radiographically a

osseous dysplasia is used. periapical granuloma or
The mandible, especially the cyst, the teeth are always
anterior periapical region, is far vital. As the condition
more commonly affected than progresses or matures, the
other areas. Often, the apices of lucent lesion develops into
two or more teeth are affected. a mixed or mottled pattern
This condition typically is because of bone repair. In
discovered on routine radio- its final stage, the tumor
graphic examination because appears as a solid, opaque
patients are asymptomatic. mass that is often
surrounded by a thin,
lucent ring. This process
takes months to years to
reach the final stages of
development and,
obviously, may be
discovered at any stage.

Figure 1: Odontogenic myxoma showing characteristic multilocularity (left Figure 2: Central Odontogenic Fibroma
photo); clinical manifestation at the mandible ©Regezi et al; ©sciencedirect of the mandible ©Head and Face Medicine

Figure 3: Cementifying Fibroma. Extraoral presentation (left photo); intraoral presentation (middle photo);
radiographic presentation showing the affected antrum of highmore. ©jisppd.com

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 DEN 032: Oral Pathology 1 Lab
Students’ Activity Sheet #12

Name: Class number: _______

_________________________________________________________________
Date:
Section: ____________ Schedule: ________________
________________________________________

Figure 4: Cementoblastoma Figure 5: Periapical cemento-osseous dysplasia. Radiolucent phase (left

©SpringerLink photo); Radiopaque phase (right photo) ©Regezi et al

TREATMENTS/MANAGEMENTS OF MESENCHYMAL ODONTOGENIC TUMOR

ODONTOGENIC TUMORS
DISEASES TREATMENTS/MANAGEMENTS
Odontogenic Myxoma Surgical excision (conservative to radical) is the treatment of choice.
However, because of its loose, gelatinous consistency and absence of a
capsule, recurrence is more likely if the lesion is treated too conservatively.
Although these lesions exhibit some aggressiveness and have a moderate
recurrence rate, the prognosis is very good. Repeated surgical procedures
do not appear to stimulate growth or metastasis. Follow-up examinations
should be performed for a minimum of 5 years.
Central Odontogenic Treatment of odontogenic fibroma is enucleation or excision, and recurrence
Fibroma is very uncommon. An exception in terms of recurrence potential is the
odontogenic fibroma with a central giant cell lesion component, in which a
23% rate of recurrence has been reported.
Cementifying
Fibroma Treatment of cemento-ossifying fibroma generally has been by conservative
enucleation or curettage or radical surgery depending on the size and
location of the individual lesion. They are characterised by easy shell out
from the surrounding bone. Mandibular central cemento-ossifying fibromas
usually shell out easily at surgery, but maxillary central cemento-ossifying
fibromas are more difficult to remove completely than mandibular central
cemento-ossifying fibromas. This may be attributable to the difference in
bone character between the mandible and maxilla and to the available apace

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 DEN 032: Oral Pathology 1 Lab
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for expansion in the maxillary sinus.

Conservative surgery is therefore recommended even if the tumour is large
with bowing and erosion of the inferior border of the mandible and radical
treatment of the tumour such as an en bloc resection should only be
considered if there are recurrences due to its aggressive nature.
Cementoblastoma Because of the intimate association of this neoplasm with the tooth root, it
cannot be removed without sacrificing the tooth by way of a surgical
extraction procedure. Bone relief typically is required to remove this well-
circumscribed mass. Recurrence is not seen.
Peripheral Cemento- No treatment is required for periapical cemento-osseous dysplasia or FCOD.
osseous Dysplasia Once the opaque stage is reached, the lesion usually stabilizes and causes
no complications. Because teeth remain vital throughout the entire process,
they should not be extracted, and endodontic procedures should not be
performed.

MIXED (EPITHELIAL AND MESENCHYMAL) ODONTOGENIC TUMORS

ODONTOGENIC TUMORS
DISEASES CLINICAL FEATURES CAUSES RADIOGRAPHIC
FEATURES
Ameloblastic Ameloblastic fibroma and Ameloblastic fibro- Radiographically, these
Fibroma and ameloblastic fibro-odontoma are odontoma is a lesion lesions are well
Ameloblastic considered together because they similar to circumscribed and
Fibro- appear to be slight variations of the Ameloblastic Fibroma, usually are surrounded
odontoma same benign neoplastic process. but also showing by a sclerotic margin.
Except for the presence of an inductive changes They may be unilocular
odontoma, people afflicted with that lead to the or multilocular and may
either of these two lesions share formation of both be associated with the
similar features of age, gender, and dentin and enamel. crown of an impacted
location. The biological behaviors of Some lesions tooth. An opaque focus
these lesions are also similar. Both diagnosed as that appears within the
are benign mixed odontogenic ameloblastic fibro- ameloblastic fibro-
tumors composed of neoplastic odontoma are odontoma is due to the
epithelium and mesenchyme with probably developing presence of an
microscopically identical soft tissue odontoma, but the odontoma. This lesion
components. others should not be therefore appears as a
The mandibular molar-ramus area considered as combined lucent-

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is the favored location for these hamartomatous in opaque lesion; the

lesions, although they may appear nature, since there ameloblastic fibroma is
in any region. There is no gender are rare cases of completely lucent
predilection. ameloblastic fibro- radiographically.
odontoma showing
true neoplastic
behavior, and since
the existence of
malignant variant is
evident.
Odontoma Odontomas are mixed odontogenic Overall aetiology is Radiographically,
tumors, in that they are composed unknown. However, compound odontomas
of both epithelial and mesenchymal odontomas have been typically appear as
dental hard tissues. These fully related to numerous tiny teeth in a
differentiated tissues are a local trauma, single focus. This focus
composite of enamel and dentin. inflammatory and/or is typically found in a
These calcified lesions take one of infectious processes, tooth-bearing area,
two general configurations. They hereditary anomalies between roots or over
may appear as numerous miniature such as Gardener's the crown of an
or rudimentary teeth, in which case syndrome and impacted tooth.
they are known as compound odon- Hermanns syndrome, Complex odontomas
tomas, or they may appear as odontoblastic appear in the same
amorphous conglomerations of hard hyperactivity, mature regions, but as
tissue, in which case they are odontoblasts and amorphous, opaque
known as complex odontomas. dental lamina masses. Lesions
They are the most common remnants (Cell Rests discovered during early
odontogenic tumors. of Serres). stages of tumor
The maxilla is affected slightly more development are
often than the mandible. There is primarily radiolucent,
also a tendency for compound with focal areas of
odontomas to occur in the anterior opacity representing
jaws, and for complex odontomas to early calcification of
occur in the posterior jaws. There dentin and enamel.
does not appear to be a significant
gender predilection. Clinical signs
suggestive of an odontoma include
a retained deciduous tooth, an
impacted tooth, and alveolar
swelling. These lesions generally
produce no symptoms.

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 DEN 032: Oral Pathology 1 Lab
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Figure 6: Ameloblastic Fibroma (left photo) and Ameloblastic Fibro-odontoma (right photo) ©hindawi;
©sciencedirect

Figure 7: Compound odontoma blocking the eruption of a

Figure 8: Complex odontoma occupying
permanent tooth seen radiographically(right photo) Retained
most of the mandibular ramus. ©Regezi et
deciduous tooth overlying compound odontoma clinically (left photo)
al
©Regezi et al

TREATMENTS/MANAGEMENTS OF MIXED ODONTOGENIC TUMOR

ODONTOGENIC TUMORS
DISEASES TREATMENTS/MANAGEMENTS
Ameloblastic Fibroma Because of tumor encapsulation and the general lack of invasive capacity,
and Ameloblastic this lesion is treated through a conservative surgical procedure such as
Fibro-odontoma curettage or excision. Recurrences have been documented, but they are
uncommon.
A rare malignant counterpart known as ameloblastic fibrosarcoma has been
documented as arising in the jaws de novo or from preexisting or recurrent
ameloblastic fibroma. In this lesion, the mesenchymal component has the
appearance of a fibrosarcoma, and the epithelial component appears as it

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does in the benign lesion. Clinically, ameloblastic fibrosarcoma occurs at

about 30 years of age and more often in the mandible than in the maxilla.
Symptoms of pain and paresthesia may be present. This locally aggressive
lesion has metastatic potential. Resection is therefore the treatment of
choice.
Odontoma Odontomas have very limited growth potential, although an occasional
complex odontoma may achieve considerable mass. Enucleation is curative,
and recurrence is not a problem.
A rare variant known as odontoameloblastoma has been described. This is
essentially an ameloblastoma in which there is focal differentiation into an
odontoma. Until more is known of the behavior of this rare lesion, it should be
treated as an ameloblastoma.

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Activity 3: Skill-building Activities

Case Report
This was a case report of a 16-year-old male patient who reported to the Department of Oral Medicine,
GDC, Ahmedabad with the chief complaint of swelling and mild pain in the right side of the jaw since 6
months, with a history of extraction of 46 because of pain before 6 months in a private dental clinic.
On clinical examination, there was diffuse bony hard swelling present in the right body of mandible with
normal overlying skin. Intra-orally, there was diffuse bony hard swelling in 46 region with normal
overlying mucosa and expanded buccal and lingual cortical plates. Adjacent teeth were immobile and
undisplaced.
Radiological examination revealed a well-defined round radiopacity with radiolucent rim in the right
body of mandible. Mandibular occlusal radiograph revealed expansion of buccal and lingual cortical
plates. He had pre-extraction intraoral periapical radiography (IOPA) radiograph of 46 region, which
showed a well-defined radiopacity surrounded by radiolucent rim attached to roots of 46.
Histopathologically it showed a well-circumscribed tumor composed of cementum like tissue
surrounded by a fibrous capsule.

Clinical/intraoral presentation Radiographic presentation

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Questions:
1. What is the patient’s condition?

2. Radiographically, what is the most obvious manifestation of this case that lead you to a correct
diagnosis?

3. What should be the management of this case?

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.

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 DEN 032: Oral Pathology 1 Lab
Students’ Activity Sheet #12

Name: Class number: _______

_________________________________________________________________
Date:
Section: ____________ Schedule: ________________
________________________________________

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. Compound odontomas typically appear as numerous tiny teeth in a multiple focus. This focus is
typically found in a tooth-bearing area, between crown or over the root of an impacted 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
2. Peripheral cemento-osseous dysplasia appears first as a percemental lucency that is continuous
with the periodontal ligament space. Cementoblastoma is surrounded by a thick uniform radiolucent
ring that is contiguous with the periodontal ligament space and the advancing front of the tumor.
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. Repeated surgical procedures do not appear to stimulate growth or metastasis of central
odontogenic fibroma. Follow-up examinations should be performed for a maximum of 5 years.
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. Symptoms of pain and paresthesia may be present in ameloblastic fibrosarcoma. This lesion occurs
at about 30 years of age and more often in the maxilla than in the mandible.
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. Central odontogenic fibroma has been seen in all age groups and is found in both the mandible and
the maxilla, but more on the mandible. It results in a radiolucent lesion that usually is multilocular,
often causing cortical compression.
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

● 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.

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

_________________________________________________________________
Date:
Section: ____________ Schedule: ________________
________________________________________

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.

How much does your personal preference for topics and activities affect the quality of your effort and
your output?
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

What is the strategy that you’ve never tried before that you think will help you better understand the
lesson? Describe it.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

FAQs:

What are the difference between cementifying fibroma and fibrous dysplasia?
The differentiating features between cementifying fibroma and fibrous dysplasia are:
• Cementifying fibroma is round in shape and causes nodular or dome shaped jaw expansion
while fibrous dysplasia is rectangular and causes elongated fusiform expansion.
• The margins are sharply defined in cementifying fibroma while the margins are instinct, blending
with normal bone in fibrous dysplasia.
• Cementifying fibroma has a wide age range from 7–58 years while the mean age in fibrous
dysplasia is 20 years.
• Cementifying fibroma is mostly seen in mandible (70%) while fibrous dysplasia shows marked
predilection for maxilla. (www.ncbi.nlm.nih.gov)

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 DEN 032: Oral Pathology 1 Lab
Students’ Activity Sheet #12

Name: Class number: _______

_________________________________________________________________
Date:
Section: ____________ Schedule: ________________
________________________________________

KEY TO CORRECTIONS:
Activity 3

1. Case condition: Cementoblastoma

2. Radiographic Manifestation: well-defined round radiopacity with radiolucent rim in the right
body of mandible
3. Management: Because of the intimate association of this neoplasm with the tooth root, it
cannot be removed without sacrificing the tooth by way of a surgical extraction procedure. Bone
relief typically is required to remove this well-circumscribed mass.

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

_________________

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

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