Surgical Management of Odontogenic Tumors Flashcards
Odontogenic Tumors - Introduction
* Variety of Odontogenic
tumors.
* Uniquely derived from
—
tissues of developing
teeth.
Tumors of odontogenic epithelium
(5)
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
Mixed odontogenic tumors
(6)
A. Ameloblastic fibroma
B. Ameloblastic fibro-odontoma
C. Ameloblastic fibrosarcoma
D. Odontoameloblastoma
E. Compound odontoma
F. Complex odontoma
Tumors of odontogenic ectomesenchyme
(4)
A. Odontogenic fibroma
B. Granular cell odontogenic tumor
C. Odontogenic myxoma
D. Cementoblastoma
BENIGN, NO RECURRENCE
POTENTIAL
(5)
- Adenomatoid odontogenic tumor
- Squamous odontogenic tumor
- Cementoblastoma
- Periapical cemento-osseous dysplasia
- Odontoma
BENIGN, SOME RECURRENCE
POTENTIAL
(5)
- Cystic ameloblastoma (unicystic)
- Calcifying epithelial odontogenic tumor
- Central odontogenic fibroma
- Florid cementoosseous dysplasia
- Ameloblastic fibroma and
fibroodontoma
BENIGN AGGRESSIVE
(5)
Ameloblastoma(Multicystic/Solid)
Clear cell odontogenic tumor (some
consider this a carcinoma)
Odontogenic ghost cell tumor (COC,
solid type)
Odontogenic myxoma
Odontoameloblastoma
MALIGNANT
(5)
Malignant ameloblastoma
Ameloblastic carcinoma
Primary intraosseous carcinoma
Odontogenic ghost cell carcinoma
Ameloblastic fibrosarcoma
Odontogenic Tumors - Diagnosis
- 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
Odontogenic Tumors - Diagnosis
* Obtain tissue
– Aspiration –
– Incisional biopsy –
– Excisional biopsy –
Establish Definitive Diagnosis !
r/o vascular lesions, inflammatory
larger lesions prior to definitive therapy
smaller tumors
Surgical Management of Odontogenic Tumors
Surgical Management includes:
“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)
Odontogenic Tumors - Surgical Treatment Options
* Enucleation
* Resection
(4)
- Marginal(Segmental) resection
- Partial resection
- Total resection
- Composite resection
Enucleation of Odontogenic Tumors
Local removal of tumor by appropriate instrumentation in direct
contact with the lesion: used for very benign types of lesions.
Surgical resection of odontogenic tumors
- 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).
Marginal (Segmental) resection
- Resection of a tumor without disruption of the continuity of the bone.
Partial Resection
- Resection of a tumor by removing full-thickness portion of the
jaw.
Partial Resection
(2)
- In the mandible, this can vary from a small continuity defect to
a hemimandibulectomy. - Jaw continuity is disrupted.
Total Resection
(2)
- Resection of a tumor by removal of the involved bone.
- Eg., Hemi-Maxillectomy and Hemi-Mandibulectomy
Composite Resection
- Resection of tumor with bone, adjacent soft tissues and contiguous
lymph node channels (This is an ablative procedure used most
commonly malignant tumors)
Rationale for Surgical Reconstruction of the Jaws
* To Restore the:
- Form of the Maxilla and mandible
– Maintain correct anatomical relation to the jaws
– Important for dental rehabilitation (endosseous implant placement) - Function
- Mastication
- Speech
- Aesthetics
Free Bone Grafts (Non Vascularized)
(2)
Vascularized Bone Grafts
(2)
Cortical Bone Grafts
Cancellous Bone Grafts
Osteomyocutaneous
(Microvascular free flap)
Surgical Management of Common Tumors of
Odontogenic Epithelium
Epithelial odontogenic tumors are composed of odontogenic epithelium
without participation of odontogenic ectomesenchyme.
(2)
- Ameloblastoma
- Adenomatoid Odontogenic tumor (AOT)
Tumors of Odontogenic Epithelium
Ameloblastoma
(4)
- 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.
Ameloblastoma
- 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.
Ameloblastoma: Radiographic findings
(3)
- 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).
Ameloblastoma: Treatment
* According to growth characteristics and type
* Unicystic Ameloblastoma
(2)
– Complete removal (Enucleation)
– Peripheral ostectomies if extension through cyst wall
- Classic infiltrative (aggressive) – “Solid Ameloblastoma”
(2)
– Mandibular – adequate normal bone around margins of resection
– Maxillary – more aggressive surgery, 1.5 cm margins
- Ameloblastic carcinoma
(2)
– Radical surgical resection (like SCCa)
– Neck dissection
Adenomatoid Odontogenic Tumor
(6)
- 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.
Adenomatoid Odontogenic Tumor
Radiographic Findings
The radiographic appearance is a unilocular radiolucency, often around
the crown of an unerupted tooth in which case they resemble a
dentigerous cyst.
Adenomatoid Odontogenic Tumor (AOT)
Treatment
* Treatment is with simple surgical enucleation and recurrence is
extremely rare.
Compound and Complex Odontomas
(4)
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.
Complex Odontoma
(2)
- 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.
Compound Odontoma
In the compound odontoma,
multiple small and malformed tooth-
like structures are formed creating a “bag of marbles” radiographic
appearance.
Complex and Compound Odontomas
(5)
- 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
Cementoblastoma
(4)
- 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.
Cementoblastoma - Radiographic examination
Radiographically it appears as a ball of dense material attached to
the end of the root.
Cementoblastoma - Treatment
Complete excision of the lesion along with extraction of the
involved tooth.
