Surgical Management of Odontogenic Tumors

Question 1

Odontogenic Tumors - Introduction
* Variety of Odontogenic
tumors.
* Uniquely derived from
—

Answer 1

tissues of developing
teeth.

Question 2

Tumors of odontogenic epithelium
(5)

Answer 2

A. Ameloblastoma
1. Malignant ameloblastoma
2. Ameloblastic carcinoma
B. Clear cell odontogenic carcinoma
C. Adenomatoid odontogenic tumor
D. Calcifying epithelial odontogenic tumor
E. Squamous odontogenic tumor

Question 3

Mixed odontogenic tumors
(6)

Answer 3

A. Ameloblastic fibroma
B. Ameloblastic fibro-odontoma
C. Ameloblastic fibrosarcoma
D. Odontoameloblastoma
E. Compound odontoma
F. Complex odontoma

Question 4

Tumors of odontogenic ectomesenchyme
(4)

Answer 4

A. Odontogenic fibroma
B. Granular cell odontogenic tumor
C. Odontogenic myxoma
D. Cementoblastoma

Question 5

BENIGN, NO RECURRENCE
POTENTIAL
(5)

Answer 5

• Adenomatoid odontogenic tumor
• Squamous odontogenic tumor
• Cementoblastoma
• Periapical cemento-osseous dysplasia
• Odontoma

Question 6

BENIGN, SOME RECURRENCE
POTENTIAL
(5)

Answer 6

• Cystic ameloblastoma (unicystic)
• Calcifying epithelial odontogenic tumor
• Central odontogenic fibroma
• Florid cementoosseous dysplasia
• Ameloblastic fibroma and
  fibroodontoma

Question 7

BENIGN AGGRESSIVE
(5)

Answer 7

 Ameloblastoma(Multicystic/Solid)
 Clear cell odontogenic tumor (some
consider this a carcinoma)
 Odontogenic ghost cell tumor (COC,
solid type)
 Odontogenic myxoma
 Odontoameloblastoma

Question 8

MALIGNANT
(5)

Answer 8

 Malignant ameloblastoma
 Ameloblastic carcinoma
 Primary intraosseous carcinoma
 Odontogenic ghost cell carcinoma
 Ameloblastic fibrosarcoma

Question 9

Odontogenic Tumors - Diagnosis

Answer 9

• Detailed history
  – Pain, loose teeth, occlusion, swellings, Paresthesia, Dysesthesia,
  delayed tooth eruption
• Thorough Clinical examination
  – Inspection, palpation, percussion
• Conventional Radiographs
  – Panorex, dental radiographs
• C.T Scan - for larger, aggressive lesions

Question 10

Odontogenic Tumors - Diagnosis
* Obtain tissue
– Aspiration –
– Incisional biopsy –
– Excisional biopsy –
Establish Definitive Diagnosis !

Answer 10

r/o vascular lesions, inflammatory
larger lesions prior to definitive therapy
smaller tumors

Question 11

Surgical Management of Odontogenic Tumors
Surgical Management includes:

Answer 11

“Surgical removal” of the odontogenic tumor followed by appropriate
method for reconstruction of the defect.
The type of surgical approach that is going to be employed is mainly
dependant on the type (Biologic behavior) of the tumor and it’s size.
The type of reconstruction is mainly decided based on the size and extent
of the defect (Both Hard and Soft tissue)

Question 12

Odontogenic Tumors - Surgical Treatment Options
* Enucleation
* Resection
(4)

Answer 12

• Marginal(Segmental) resection
• Partial resection
• Total resection
• Composite resection

Question 13

Enucleation of Odontogenic Tumors

Answer 13

Local removal of tumor by appropriate instrumentation in direct
contact with the lesion: used for very benign types of lesions.

Question 14

Surgical resection of odontogenic tumors

Answer 14

• Removal of a tumor by incising through uninvolved tissues
  around the tumor, thus delivering the tumor without direct
  contact during instrumentation (also called as en bloc rection).

Question 15

Marginal (Segmental) resection

Answer 15

• Resection of a tumor without disruption of the continuity of the bone.

Question 16

Partial Resection

Answer 16

• Resection of a tumor by removing full-thickness portion of the
  jaw.

Question 17

Partial Resection
(2)

Answer 17

• In the mandible, this can vary from a small continuity defect to
  a hemimandibulectomy.
• Jaw continuity is disrupted.

Question 18

Total Resection
(2)

Answer 18

• Resection of a tumor by removal of the involved bone.
• Eg., Hemi-Maxillectomy and Hemi-Mandibulectomy

Question 19

Composite Resection

Answer 19

• Resection of tumor with bone, adjacent soft tissues and contiguous
  lymph node channels (This is an ablative procedure used most
  commonly malignant tumors)

Question 20

Rationale for Surgical Reconstruction of the Jaws
* To Restore the:

Answer 20

• Form of the Maxilla and mandible
  – Maintain correct anatomical relation to the jaws
  – Important for dental rehabilitation (endosseous implant placement)
• Function
• Mastication
• Speech
• Aesthetics

Question 21

Free Bone Grafts (Non Vascularized)
(2)
Vascularized Bone Grafts
(2)

Answer 21

Cortical Bone Grafts
Cancellous Bone Grafts

Osteomyocutaneous
(Microvascular free flap)

Question 22

Surgical Management of Common Tumors of
Odontogenic Epithelium
Epithelial odontogenic tumors are composed of odontogenic epithelium
without participation of odontogenic ectomesenchyme.
(2)

Answer 22

• Ameloblastoma
• Adenomatoid Odontogenic tumor (AOT)

Question 23

Tumors of Odontogenic Epithelium
Ameloblastoma
(4)

Answer 23

• Benign, but locally invasive (Except for the Malignant variant).
• It is unencapsulated and infiltrates surrounding bone marrow.
• Even though they are locally infiltrative, they do not metastasize
  (Except for the Malignant variant).
• Occasionally arise from dentigerous cysts.

Question 24

Ameloblastoma

Answer 24

• Clinical Subtypes –
• Multicystic or Solid (86%),
• Unicystic (13%), and
• Peripheral (extraosseous) and Malignant variant (1%)
• It occurs chiefly in middle age people long after odontogenesis
  has ceased.
• They may occur in any part of both jaws but most are in the
  middle and posterior regions of the mandible.

Question 25

Ameloblastoma: Radiographic findings (3)

Answer 25

* They may be unilocular but frequently become multilocular as they increase in size. * The unilocular lesion is indistinguishable from an odontogenic cyst. * Well-circumscribed, “soap- bubble appearance” (Multicystic or Solid variant).

Question 26

Ameloblastoma: Treatment * According to growth characteristics and type * Unicystic Ameloblastoma (2)

Answer 26

– Complete removal (Enucleation) – Peripheral ostectomies if extension through cyst wall

Question 27

* Classic infiltrative (aggressive) – “Solid Ameloblastoma” (2)

Answer 27

– Mandibular – adequate normal bone around margins of resection – Maxillary – more aggressive surgery, 1.5 cm margins

Question 28

* Ameloblastic carcinoma (2)

Answer 28

– Radical surgical resection (like SCCa) – Neck dissection

Question 29

Adenomatoid Odontogenic Tumor (6)

Answer 29

* This is a tumor that is commonly found in teenagers. * It occurs in the middle and anterior portions of the jaws * Commonly associated with the crown of an impacted anterior tooth. * Two-thirds occur in the maxilla and it is more common in females. * The maxillary incisor-cuspids are common sites. * Painless expansion is often the chief complaint.

Question 30

Adenomatoid Odontogenic Tumor Radiographic Findings

Answer 30

The radiographic appearance is a unilocular radiolucency, often around the crown of an unerupted tooth in which case they resemble a dentigerous cyst.

Question 31

Adenomatoid Odontogenic Tumor (AOT) Treatment * Treatment is with simple surgical enucleation and recurrence is

Answer 31

extremely rare.

Question 32

Compound and Complex Odontomas (4)

Answer 32

The tumors in which odontogenic differentiation is fully expressed are the odontomas. In these tumors, the epithelium and ectomesenchyme realize their potential and make enamel and dentin respectively. As a result, these tumors are mostly radiodense. Odontomas are the most common type of odontogenic tumors seen in the oral surgery clinic.

Question 33

Complex Odontoma (2)

Answer 33

* In the complex odontoma, there is little or no tendency to form tooth-like structures. * The dentin and enamel are entwined in a mass that bears no resemblance to teeth.

Question 34

Compound Odontoma In the compound odontoma,

Answer 34

multiple small and malformed tooth- like structures are formed creating a “bag of marbles” radiographic appearance.

Question 35

Complex and Compound Odontomas (5)

Answer 35

* Both types of odontoma are found in the early years, usually in the teens or early twenties. * Compound odontoma is more common in the anterior jaw segment whereas the complex type is found more commonly in the posterior jaws. * Many are associated with an unerupted tooth. * They have a limited growth potential and cause no pain or cosmetic deformity. * Treatment is elective surgery

Question 36

Cementoblastoma (4)

Answer 36

* True benign neoplasm of cementoblasts * This tumor typically occurs around the roots of the lower posterior teeth (First Mandibular molars) * Cortex expanded without pain * Involved tooth ankylosed.

Question 37

Cementoblastoma - Radiographic examination

Answer 37

Radiographically it appears as a ball of dense material attached to the end of the root.

Question 38

Cementoblastoma - Treatment

Answer 38

Complete excision of the lesion along with extraction of the involved tooth.