Oral Pathology 2 - Odontogenic Tumors - PDF

DOPA412: ORAL PATHOLOGY 2 MIDTERM LECTURED BY: DR. IDA I. BALANAG Heterotropic epithelium in other parts of the body ODONTOGENIC...

DOPA412: ORAL PATHOLOGY 2 MIDTERM LECTURED BY: DR. IDA I. BALANAG Heterotropic epithelium in other parts of the body ODONTOGENIC TUMOR o (pituitary gland) **dentigerous cyst has a tendency of tumor formation which is ODONTOGENIC ameloblastoma ▪ Derived from a tooth-related apparatus ▪ Odontogenesis Clinicoradiologic Groups o Enamel organ – oral ectoderm Multicystic or solid ameloblastoma 86% o Dental follicle – ectomesenchyme **most common o Dental papilla – ectomesenchyme Unicystic ameloblastoma\cystice 13% **ectoderm or epithelial in origin Peripheral (extraosseous) ameloblastoma 1% **rarest **ectomesenchyme – connective tissue in origin or mesodermal in origin  MULTICYSTIC OR SOLID AMELOBLASTOMA ▪ Age Classification of Odontogenic Tumors → Rare: younger than 10 yrs old ▪ Tumors Of Odontogenic Epithelium → Uncommon: 10-19 yrs old (2nd decade) o Ameloblastoma → Common: 3rd to 7th decades of life o Clear Cell Odontogenic Carcinoma ▪ Gender o Adenomatoid Odontogenic Tumor → No sex predilection o Calcifying Epithelial Odontogenic Tumor ▪ Location o Squamous Odontogenic Tumor → 80% mandible ▪ Tumors Of Odontogenic Ectomesenchyme → 20% maxilla o Odontogenic Fibroma → Mandible – molar-ascending ramus area o Granular Cell Odontogenic Tumor → Maxilla – posterior regions o Odontogenic Myxoma **it may or may not be associated with impacted tooth o Cementoblastoma ▪ Often asymptomatic ▪ Mixed Odontogenic Tumor ▪ May have suggestive symptoms during tumor growth o Ameloblastic Fibroma → Pressure symptoms o Ameloblastic Fibro-Odontoma → Paresthesia o Ameloblastic Fibrosarcoma → Pain in larger lesions o Odontoameloblastoma o Compound Odontoma o Complex Odontoma **naming tumors 1. Location → Intraosseous (within bone) – we use central → Extraosseous (soft tissue lesion overlying bone) – we use peripheral 2. Tissue origin → Osteoma (osteo-bone) ▪ Radiograph → Lipoma (fat cells) → Soap bubble appearance\honeycombed or 3. Behavior unilocular radiolucent with irregular scalloping → Oma - if benign in nature → Root resorption of adjacent teeth → Malignant → Associated with impacted teeth, mandibular third - Carcinoma – epithelial in origin molar - Sarcoma – CT ▪ Histopathologic variants Osteoma – benign 1. Follicular ameloblastoma Osteo sarcoma – malignancy of bone 2. Plexiform ameloblastoma 4. Histologic composition 3. Acanthomatous ameloblastoma → Fibroma – made up of fibrous connective tissue 4. Granular cell ameloblastoma → Granuloma – granulation tissue 5. Basal cell ameloblastoma → Peripheral giant cell granuloma - soft tissue lesion 6. Desmoplastic ameloblastoma 5. People 1. Follicular ameloblastoma AMELOBLASTOMA ▪ Recapitulate earlier stages of tooth development ▪ Most common form of odontogenic tumors ▪ Peripheral columnar differentiation with reverse ▪ A true neoplasm of enamel organ-type that did not undergo polarization differentiation to the point of enamel organ ▪ Central zones resembling stellate reticulum ▪ A benign, slow-growing but locally invasive **common type **the lining of cystic lesion, ▪ Origin histologically we want to see o Cell rests of enamel organ the stratified squamous (flat o Epithelium of odontogenic cysts lining) o Disturbances of the developing enamel organ o Basal cells of the surfaces epithelium of the jaws 1|D M D 4 Y 1 - 5 YANDOC  DOPA412: ORAL PATHOLOGY 2 MIDTERM LECTURED BY: DR. IDA I. BALANAG 2. Plexiform ameloblastoma - Periapical cyst (nonvital ▪ Does not recapitulate a recognized - Primordial cyst (congenitally missing, mand 3rd area) stage of odontogenesis - Odontogenic keratocyst (located on mand 3rd area like ▪ Epithelium proliferates in a fishnet or cystic ameloblastoma) mesh arrangement 3. Acanthomatous ameloblastoma ▪ Central cells are transformed to squamous cells that produce keratin ** cystic lesion - stratified squamous epithelium **odontogenic keratocyst – parakeratinized stratified epithelium **cystic ameloblastoma – columnar cells with reverse polarity and 4. Granular cell ameloblastoma stellate reticulum ▪ Central cells appear swollen and densely packed with ▪ Histopathologic variants eosinophilic granules → Luminal Unicystic Ameloblastoma → Intraluminal Unicystic Ameloblastoma → Mural Unicystic Ameloblastoma ** mural – most aggressive and has a higher recurrent rate if 5. Basal cell ameloblastoma treated conservatively since lumalabas na sya sa capsule ▪ Only densely packed, large proliferating cuboidal-shaped basaloid cells exist in narrow strands ▪ Without stellate reticulum 6. Desmoplastic ameloblastoma ▪ Epithelial islands and stands Intraluminal Unicystic are small and have cuboidal Ameloblastoma – papillary and darkly strained cells thickened projections ▪ Epithelial components are extending into the lumen widely separated by fibrous tissue **rarest and most severe Mural Unicystic Ameloblasto – thickend lining penetrates the Multicystic ameloblastoma adjacent capsular tissue Management Recurrence rate Curettage – conservative 50-90% Enucleated with peripheral ostectomy (1.0-1.5 cm) Resection 15% Unicystic ameloblastoma **cut the jaw on normal area Subtypes Management Luminal Enucleation  UNICYSTIC AMELOBLASTOMA Intraluminal Enucleation ▪ Origin Mural Resection → De novo as a neoplasm → Neoplastic transformation of nonneoplastic cyst epithelium  PHERIPHERAL AMELOBLASTOMA ▪ Age: second decade of life ▪ Purely soft tissue **10-19 yrs old ▪ Extraosseous ▪ Location: Mandible, posterior regions ▪ Painless nonulcerated sessile or pedunculated gingival ▪ Often asymptomatic, although large lesions may cause or alveolar mucosal lesion a painless swelling of the jaw ▪ Age: middle age ▪ Gender: male predilection 90% - associated with the crown of ▪ Location: mandible, posterior gingival and alveolar impacted third molar resembling mucosa dentigerous cyst **sessile – broad base **pedunculated – narrow base 10% resemble - Residual cyst (history of tooth extraction) - Lateral periodontal cyst (located on mand 3rd area) 2|D M D 4 Y 1 - 5 YANDOC  DOPA412: ORAL PATHOLOGY 2 MIDTERM LECTURED BY: DR. IDA I. BALANAG → Extrafollicular type – well-delineated unilocular radiolucency between the root of erupted teeth Peripheral odontogenic fibroma Peripheral giant cell granuloma Adenomatoid Odontogenic tumor Pyogenic granuloma Dentigerous cyst **to differentiate this to peripheral ameloblastoma take note of the lining **Fibroma – fibrous connective tissue **Granuloma – just granulation, no lining Peripheral odontogenic fibroma ▪ Presence of dysplastic dentin or cementum-like element ▪ Lack of peripheral columnar epithelial cells showing reverse polarity of their nuclei Has radiopacity ODONTOGENIC TUMORS OF EPITHELIAL IN ORIGIN ▪ Histopathologic o Surrounded by a thick, fibrous  MALIGNANT AMELOBLASTOMA capsule ▪ A tumor shows the histopathologic features of o Spindle-shaped epithelial cells ameloblastoma both in the primary tumor and in the that form sheets, strands, or metastatic deposits whorled masses of cells in a ▪ A variant that has a tendency to metastasize scant fibrous stroma → Aspiration or implant metastasis o Tubular or ductlike structures → Hematogenous route → Central space → Lymphatic route → Columnar or cuboidal epithelial cells ▪ Sites for metastasis → Nuclei polarized away from the central space → Lungs - most common → Not true ducts → Cervical lymph nodes → Vertebrae or other bones o Small foci of calcification – **primary tumor and the metastatic deposit histologically would abortive enamel formation have the usual benign amelo features o Larger areas of calcification – dentinoid or  AMELOBLASTIC CARCINOMA cementum ▪ Ameloblastoma that has cytologic features of malignancy in the primary tumor in a recurrence or in o Differential diagnosis: presence of calcifications any metastatic deposits → Calcifying epithelial odontogenic tumor – ▪ Cytologic feature of malignancy driven snow appearance → Increased nuclear to cytoplasmic ratio → Odontoma - present as calcification → Nuclear hyperchromatism → Calcifying odontogenic cyst – salt’s and → Mitoses pepper appearance  ADENOMATOID ODONTOGENIC TUMOR (AOT)  CALCIFYING EPITHELIAL ODONTOGENIC TUMOR (CEOT) ▪ A variant of ameloblastoma – ADENOAMELOBLASTOMA ▪ Pindborg tumor ▪ Age: younger patient 10-19yr.old ▪ Age: 30-50 yr old ▪ Gender: females, 2:1 ratio ▪ Gender: no sex predilection ▪ Location: maxilla, anterior portion ▪ Location: mandible, molar-ramus area **adeno – glands ▪ Behaves exactly like ameloblastoma ▪ Asymptomatic ▪ painless, slow-growing swelling ▪ Relatively small, less than 3 cm ▪ Radiograph ▪ Larger lesion can cause painless expansion of bone o Unilocular or multilocular radiolucency ▪ PERIPHERAL FORM - small, sessile masses on the facial o Unilocular more common in maxilla gingiva of the maxilla → Purely radiolucent ▪ Types: → Calcifications within the radiolucency – “driven → Follicular type - circumscribed, unilocular radiolucency snow” appearance that involves the crown of an unerupted tooth, canine o Margins usually scalloped and well defined 3|D M D 4 Y 1 - 5 YANDOC  DOPA412: ORAL PATHOLOGY 2 MIDTERM LECTURED BY: DR. IDA I. BALANAG o Frequency associated with an impacted tooth o Fibroblast and myofibroblasts with variable amounts of **cyst and tumor that associated with impacted tooth collagen in mucopolysaccharide matrix 1. Dentigerous cyst o Bony islands and capillaries scattered throughout the 2. Odontogenic keratocyst (OKC) lesion 3. Ameloblastoma o With large amounts of collagen are evident 4. Adenomatoid Odontogenic Tumor (AOT) ODONTOGENIC FIBROMYXOMA 5. Calcifying Epithelial Odontogenic Tumor (CEOT) Management ** cyst and tumor that shows calcification o Surgical excision is the treatment of choice 1. COC o Reasons for recurrence 2. Adenomatoid Odontogenic Tumor (AOT) → Incomplete removal because of its loose gelation 3. Calcifying Epithelial Odontogenic Tumor (CEOT) consistence 4. Odontoma → Absence of encapsulation o Prognosis is very good ▪ Histopathology o Polyhedral epithelial 2 types cells in a fibrous  PERIPHERAL FIBROMA stroma ▪ Reactive hyperplastic mass that occurs on the gingiva o Giant nuclei may be and is derived from connective tissue of the submucosa seen or periodontal ligament o Amyloid-like extracellular material ▪ Age: any age, predilection for young adults o Concentric rings of calcification – LEISEGANG ▪ Gender: females RINGS (other name ▪ Location: gingiva anterior to the permanent molars ▪ Clinical ▪ Management o Firm, slow-growing o Conservative local resection including a narrow rim o Sessile or pedunculated mass of surrounding bone that is similar in color to the o Lesion in maxillary to be treated more aggressively surrounding connective tissue o Recurrence rate: 15% o Covered b intact mucosa ECTOMESENCYME ▪ Histology MIXED TUMORS o Peripheral Ossifying Fibroma → A gingival mass in which islands of woven bone Odontogenic tumors ectomesenchyme and osteoid are seen 1. Odontogenic Fibroma → Bone is within a lobular proliferation of plump, 2. Granular Cell Odontogenic Tumor benign fibroblast 3. Odontogenic Myxoma → Chronic inflammatory cells 4. Cementoblastoma **if there will be additional histologic component which is bony like structure, woven bone and osteoid that makes it ossifying type Mixed odontogenic tumors **radiographically it will give a suggestion that the peripheral 1. Ameloblastblastic Fibroma ossifying fibroma compared to other type of fibroma is the 2. Ameloblastic Fribro-Odontoma presence of radiopacities within soft tissue swelling 3. Ameloblastic Fribrosarcoma 4. Odontoameloblastoma o Peripheral Odontogenic Fibroma 5. Odontoma → A gingival mass composed of well- circumscribed, nonencapsulated fibrous ODONTOGENIC MYXOMA connective tissue A benign mesenchymal lesion that mimics microscopically → Presence of odontogenic epithelium the dental pulp or follicular connective tissue throughout the connective tissue Age: 10 – 50 yrs old → Amorphous hard tissue resembling reactive No gender predilection dentin = DENTINOID Location: anywhere in the mandible and maxilla with equal frequency o Giant Cell Fibroma Radiograph → a fibrous hyperplasia with mesenchymal cells o Lucent that may be well- larger than normal fibroblast (giant cells) and circumscribed or diffuse assume a stellate shape o Often multilocular with a → color: pink, pale pink or same color as normal honeycomb pattern, soap bubble adjacent mucosa or tennis racket o Cortical expansion or perforation o Root displacement or resorption Histopathology o Composed of bland relatively acellular myxomatous connective tissue 4|D M D 4 Y 1 - 5 YANDOC  DOPA412: ORAL PATHOLOGY 2 MIDTERM LECTURED BY: DR. IDA I. BALANAG o Pyogenic Granuloma simply a hyperplastic dental follicle and not an → Excessive proliferation odontogenic tumor of granulation tissue → Etiology: 2. It is a lesion of fibrous connective tissue, with - Calculus scattered islands of odontogenic epithelium, - hormonal changes bearing some resemblance to the dental follicle, → pregnancy tumor\ but because of the size which it may attain granuloma gravidarum appearing to constitute a neoplasm (if pregnant pt) 3. It is a lesion which has been described by the WHO ** soft tissue lesion but the color is red, it’s soft, spongy, and bleeds as a fibroblastic neoplasm containing varying easily and radiographically it’s just a soft tissue shadow amounts of odontogenic epithelium, and in some **causes by: calcular deposits, presence of local factor such as cases, calcified materials resembling dysplastic calcular deposit and hormonal changes (during puberty, dentin or cementum like material. It is histologically pregnancy or menopausal stage) identical to the peripheral odontogenic fibroma as described by the WHO group except for location o Peripheral Giant Cell Granuloma (also pyogenic granuloma) ▪ Radiograph → An extraosseous nodule composed of a o Multilocular often causing cortical expansion proliferation of mononuclear and multinucleated giant cells with an associated prominent vascularity found on the gingival or alveolar ridge → Originate from periodontal ligament or mucoperiosteum → 0.5 -1.5cm ▪ Histologic → 30 – 40 years, female, more in the mandible o Simple Central Odontogenic Fribroma → Made up of mature collagen fibers interspersed by many plump fibroblasts that are uniform in their placement and equidistant from each other **color: red or red blue lesion o WHO-type Central Odontogenic Fibroma → Consists of relatively mature but quite cellular fibrous connective tissue with few to many islands of odontogenic epithelium → Osteoid, dysplastic dentin or cementum like material PERIAPICAAL CEMENTAL DYSPLASIA **radiographically: may cause superficial erosion of bone but id Aka Periapical Cemento-Osseous Dysplasia, Cementoma doesn’t mean the bone is involved with the tumor but because of Due to mild chronic trauma the abortive activity of the giant cell then it can cause superficial Asymptomatic erosion or PERIPHERAL CUFFING in edentulous jaw Middle age rarely before age 20, women Peripheral cuffing – there is erosion or resorption of bone Occurs in and near the periodontal ligament around the teeth usually mandibular incisors o Epulis Granulomatosum 3 stages → Proliferation of granulation 1. Osteolytic stage tissue out of a recent → Periapical lucency that is extraction site continuous with the PDL space → Cause: → Simulates radiographically a - Bone sequence periapical granuloma or cyst - Necrotic debris in → Vital teeth the socket ** the CAP will give us a negative vitality test but if a tooth is positive, very much vital DON’T do root canal  CENTRAL ODONTOGENIC FIBROMA treatment ▪ Intraosseous counterpart of peripheral odontogenic fibroma 2. Cementoblastic stage ▪ Age: all age group → Mixed or mottled pattern because of bone ▪ Gender: female repair ▪ Location: both in mandible and maxilla 3. Mature stage ▪ 3 basic concepts about the tumor → solid, opaque mass that is surrounded by a thin, 1. It is a lesion around the crown of an unerupted lucent ring tooth resembling a small dentigerous cyst, but this is → takes moths to years to reach the final stage 5|D M D 4 Y 1 - 5 YANDOC  DOPA412: ORAL PATHOLOGY 2 MIDTERM LECTURED BY: DR. IDA I. BALANAG **chronic condition and takes months to years for the area to AMELOBASTIC FIBROMA reach mature state Mixed tumor condensing osteitis – aka chronic focal sclerosing osteomyelitis There is simultaneous proliferation of both epithelium → associated with non vital tooth with big carious lesion (ameloblastoma that will form ameloblast) and mesenchymal tissues (dental follicle and should formed Histopathology dentin) but in this stage they did not proceed to enamel and o Mixture of benign fibrous tissue, bone and cementum dentin formation o Calcified tissue arranged in trabeculae, spicules, or Location: mandibular ramus area larger irregular masses Radiograph o Reversal lines are seen, and osteoblasts, cementoblasts o Well-circumscribed radiolucency surrounded by a or both line the islands of hard tissue sclerotic margin o Chronic inflammatory cells o Unilocular or multilocular o Location: area of mandibular anterior o May be associated with the crown of an impacted tooth FLORID CEMETO-OSSEOUS DYSPLASIA Exuberant variant of periapical cemento-osseous dysplasia Asymptomatic, except when complication of osteomyelitis occurs **asymptomatic except if it becomes secondary infected and its infection can have abscess formation or osteomyelitis and the area can be symptomatic Women, 20-60 yrs of age AMELOBLASTIC FIBRO-ODONTOMA Mandible, bilateral and may affect all 4 quadrants Combined lucent-opaque Teeth vital Presence of odontoma **can look like Chronic diffuses sclerosing osteomyelitis – since it is widespread Radiograph o Diffuse radiopaque asses throughout the alveolar segment of the jaw o Ground-glass or cystlike appearance may be seen ODONTOMA o Confused with chronic diffuse sclerosing osteomyelitis Both the epithelial and mesenchymal cells exhibit complete differentiation → functional ameloblasts and odontoblast → enamel and dentin but are laid in as abnormal pattern Types 1. Compound odontoma 2. Complex odontoma Clinical signs: retained deciduous teeth, impacted tooth, alveolar swelling BENIGN CEMENTOBLASTOMA Aka true cementoma Large mass of cementum or cementum-like tissue on roots, fused to the root, causes root resorption Mandible 1st permanent molars Associated tooth is vital Radiograph Compound odontoma o well-circumscribed dense o Numerous miniature or rudimentary radiopacity surrounded by thin teeth o Anterior of maxilla Mixed Tumors o No gender predilection AMELOBLASTIC FIBROSARCOMA o Clinical sign: retained deciduous Origin teeth, impacted tooth, alveolar o De novo swelling o From preexisting or recurrent ameloblastic fibroma **benign first which is ameloblastic fibroma and then it undergo Complex odontoma malignancy transformation and becomes ameloblastic Amorphous conglomeration of hard fibrosarcoma tissue 30 yrs of age, mandible Posterior of the jaw Symptoms of pain and paresthesia Locally aggressive lesion has metastatic potential **cant see the miniature teeth but still composed of dentin and enamel **prevent tooth to erupt and remain impacted 6|D M D 4 Y 1 - 5 YANDOC