Benign Tumors of the Jaws

Hyperplasias (tori, exostosis and enostosis) Odontogenic tumors Epithelial tumors Ameloblastoma Adenomatoid Odontogenic tumor (AOT) CEOT/ Pindborgs tumor Mixed (ecto-mesodermal) Odontoma Ameloblastic fibroma Ameloblastic fibroodontoma Mesodermal tumors Odontogenic myxoma, Benign cementoblastoma Central odontogenic fibroma Non-odontogenic tumors Ectodermal (neurilemoma, neuroma) Mixed tumors (neurofibroma, neurofibromatosis) Mesodermal tumors (osteoma, Gardners syndrome, central hemangioma, A-V fistula,osteoblastoma, osteoid osteoma Pseudotumors: Central giant cell granuloma

ODONTOGENIC TUMORS
Origins / Classification
Odontogenic Epithelium Only Mixed Epithelium and Mesenchyme (with Induction) Odontogenic Mesenchyme Only

Location
Central Peripheral (Rare)

Torus palatinus

ODONTOGENIC TUMORS
General Considerations
Non-Descript Jaw Swelling - Usually Asymptomatic Well-Defined Radiolucent or Mixed
Some Odontomas Opaque Only

Uni- or Multilocular
Well-Defined / Corticated

Often Expand Bone

May Resorb and/or Displace Teeth

Treatment and Prognosis Depend on Specific Tumor Type

Enucleation Resection

Odontogenic Epithelial Tumors

Ameloblastoma
Conventional Solid Ameloblastoma Cystogenic Ameloblastoma Desmoplastic Ameloblastoma Peripheral Ameloblastoma Malignant Ameloblastoma and Ameloblastic Carcinoma

Calcifying Epithelial Odontogenic Tumor ( CEOT / Pindborg Tumor) Squamous Odontogenic Tumor Clear Cell Odontogenic Tumor (Carcinoma)
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Ameloblastoma
- Conventional Solid Type -

Always Radiolucent - Uni or Multilocular Mostly Adults in Posterior Mandible Several Histologic Variations
Most Common and Typical is Follicular

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

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

Ameloblastoma

Arises from the enamel-forming cells of the odontogenic epithelium Most occur in the posterior of the mandible, typically in the third molar region, with associated follicular or impacted teeth Slow growing, painless mass Radiolucent tumor can be unilocular or multilocular with characteristics soap buble-like appearance

Ameloblastoma
Slow growing, non-painful, multilocular, radiolucent lesion Most common clinically significant odontogenic tumor Epithelial origin Average age = 33

Tx: resection beyond the margins (tumor is to difficult to remove, and tends to recur)

Peripheral, palisaded cells with nuclei polarized away from the basement membrane

Unilocular Radiolucency

Ameloblastoma
Clinical Expansion

Multilocular Radiolucency
Multilocular Radiolucency Pericoronal

Desmoplastic Variant may be Mixed Radiographically

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UNICYSTIC (CYSTOGENIC) AMELOBLASTOMA

Younger Patients as Pericoronal Unilocular Radiolucency around Mandibular Third Molar ~10-15% of All Ameloblastomas Lower Recurrence with Enucleation !!

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Unicystic Ameloblastoma

Account for 10-15% of intraosseous ameloblastomas Usually occur in younger patients Because all of the ameloblastoma is inside the lumen of the cyst, Tx. is removal of the cyst (not jaw resection) But If ameloblastoma is in the wall of the cyst, treatment must be standard for ameloblastoma = resection

Can often resemble a dentigerous cyst around an unerupted 3rd molar

PERIPHERAL AMELOBLASTOMA
~1% of All Ameloblastomas Same Follicular Histology Conservative Excision with Low Recurrence

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Malignant Ameloblastoma and Ameloblastic Carcinoma

Malignant Ameloblastoma
Typical Histology with Clinical Metastasis

Ameloblastic Carcinoma
Histologic Malignancy with or without Metastasis

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AOT
Adenomatoid Odontogenic Tumor Most common location : maxillary canine and premolar region. 2:1 female to male ratio. Average age = ~16 yrs Tumors contain specks of calcified material Low recurrence rate

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

Adenomatoid Odontogenic Tumor A.O.T

Young patients Anterior jaws Usually associated with impacted teeth Easily removed, therefore small chance of recurrence Tx: curettage
Gland-like structures in a solid tumor of odontogenic cells

Adenomatoid Odontogenic Tumor

Gross - Thick Capsule AOT with -Opacity

Quit

AOT

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CEOT (Calcifying Epithelial Odontogenic Tumor)

Behaves like ameloblastoma Predilection for mandiblepremolar/ molar area >half of the lesions will have associated impacted or unerupted tooth Periphery well defined to diffuse Cystic lesion with numerous scattered, radiopaque foci of varying size and density giving it the appearance of Driven Snow Presence of amyloid and calcified Liesegang Rings

Calcifying Epithelial Odontogenic Tumor

(Pindborg Tumor)
Uncommon (less than 200 cases reported to date)

Radiolucent lesion with calcified radiopacities inside (calcifications are most often seen in association with an impacted tooth) Tx: local resection

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

Ameloblastic Fibroma
Tumor of both ectodermal and epithelial layers Younger patients Not generally aggressive, easily removed if discovered and treated early
If the lesion contains calcifications, then it is an Ameloblastic Fibro-odontoma

Squamous Odontogenic Tumor

Rare Tumor of WellDifferentiated Squamous Epithelium - Like Rests of Malassez Radiographs Often show Vertical Periodontal-Type Bone Loss
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Squamous Odontogenic Tumor

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

Squamous Odontogenic Tumor

Odontomas
Compound Compound Complex

Odontoma is the most common odontogenic tumor of the mandible, for approximately 67% of all cases The lesion consists of various tooth components Initially radiolucent , contain small calcifications radiopaque mass with lucent rim Most odontomas can cause impaction or resorption of adjacent teeth Compound tooth component Complex multiple masses of dental tissue with amorphous calcifications

Odontoma
Tooth tumor mixed odontogenic tumor A.) Compound: look like little teeth, tooth material is in correct relation B.) Complex: everything mixed together, no normal relation of tooth material

Tx: simple local excision prognosis is excellent

Complex Odontoma

Mesenchymal Odontogenic Tumors

Odontogenic Myxoma Cementoblastoma

Odontogenic Myxoma

Clinically and radiographically indistinguishable from ameloblastoma, appearing as a multiloculated radiolucent lesions with internal osseous trabeculae

Odontogenic Myxoma
soap bubble appearance aggressive- may displace or cause resorption of teeth Derived from odontogenic ectomesenchyme Tx: small lesions can be treated by curattage, but since the lesion is not encapsulated, the site should be closely monitored, and large lesions may require more extensive resection. Hisologically odontogenic myxomas look just like dental papilla

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

Benign Cementoblastoma
Benign cementoblastomas are slow-growing, Mesenchymal neoplasms, Composed principally of cementum. Manifests as a bulbous growth around and attached to the apex of a tooth root. Histologic characteristics are similar to those of osteoblastomas, and it is composed of cementoblasts that arise from the mesenchyme of the periodontal ligament

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

Cementoblastoma

Osteoma

Gardners syndrome: Gardners syndrome, inherited as an autosomal dominant disorder, is characterized by intestinal polyposis, multiple osteomas, fibromas of the skin, epidermal and trichilemmal cysts, impacted permanent and supernumerary teeth, and odontomas.

Related Jaw Lesions

Giant Cell Lesions
Central giant cell granuloma Brown tumor Aneurysmal bone cyst

Fibroosseous lesions
Fibrous dysplasia Ossifying fibroma

Condensing Osteitis

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)

Central Giant Cell Granuloma

Radiographic findings
Unilocular, multilocular radiolucencies Well-defined or irregular borders

Histology
Multinucleated giant cells, dispersed throughout a fibrovascular stroma

Central Giant Cell Granuloma

Fibrous Dysplasia
Monostotic vs. polystotic Monostotic
More common in jaws and cranium

Polystotic
McCune-Albrights syndrome Cutaneous pigmentation, hyper-functioning endocrine glands, precocious puberty

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

Fibrous Dysplasia

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)

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)

Ossifying Fibroma

Ossifying Fibroma
Histologically similar to fibrous dysplasia Treatment
Surgical excision shells out Recurrence is uncommon

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

Condensing Osteitis

MALIGNANT LESIONS
Primary Odontogenic Tumors 1, Odontogenis Carcinoma Rare, aggressive intraosseus lesions, difuse, honeycomb-like radiolucent lessions with cortical destruction, high rate reccurence 2. Ameloblastic CarsinomaMalignant Ameloblastoma Histopatholigics analysis required for definitive diagnosis, cortical destruction, extraosseous extension, extensivecomponents Primary Non Odontogenis Tumors Osteosarcoma, chondrosarcoma, fibrosarcoma, and leiomyosarcoma Symetrically widened periodontal membrane earliest radiologic indications osteogenic sarcoma of the mandible Minor saivary gland of the buccal mucosa mucoepidermoid carcinoma

Clear Cell Odontogenic Tumor / Carcinoma

Rare Odontogenic Tumor of Clear Cells (Pre-Secretory Ameloblasts) Uni- or Multilocular Radiolucent
Not Always Well-Defined

Aggressive Clinical Behavior with Metastatic Potential Difficult for Pathologist to Diagnosis and Classify
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Metastasis
Metastasis to the mandible is four times more common than metastasis to the maxilla Identification of these lesions with accurate identification of the primary site is crucial, since aproximately 30% of jaw metastases originate from a primary lesions

Imaging is not always expected to provide a specific diagnosis but should help narrow the differential diagnosis, thereby to guide patient treatment