The incidence of oro-maxillofacial lesions (10 years) in ... · The incidence of oro-maxillofacial lesions (10 years) in the department of oral and maxillofacial surgery, Mahidol

21The incidence of oro-maxillofacial lesions (10 years) in the department of oral and maxillofacial surgery, Mahidol University: Ameloblastoma Kiatanant Boonsiriseth, Sirichai Kiattavorncharoen, Arada Thungrat, Natthamet Wongsirichat

Kiatanant Boonsiriseth1, Sirichai Kiattavorncharoen2, Arada Thungrat3, Natthamet Wongsirichat4 1 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, 6 Yothi Street, Rachathewee District, Bangkok 10400, Thailand. e-mail: [email protected] 2 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, 6 Yothi Street, Rachathewee District, Bangkok 10400, Thailand. e-mail: [email protected] 3 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, 6 Yothi Street, Rachathewee District, Bangkok 10400, Thailand. e-mail: [email protected] 4 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, 6 Yothi Street, Rachathewee District, Bangkok 10400, Thailand. e-mail: [email protected]

The incidence of oro-maxillofacial lesions (10 years) in the department of oral and maxillofacial surgery, Mahidol University: Ameloblastoma

Corresponding author: Natthamet Wongsirichat Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University, 6 Yothi Street, Rachathewee District, Bangkok 10400, Thailand Email: [email protected] Tel: 022007777 ext 3333 Mobile phone: +66818305340 Received: 23 November 2014 Accepted: 13 January 2015

AbstractObjective: To study incidence of ameloblastoma at the Oral and Maxillofacial Surgery Clinic, Mahidol University by analyzing patients’ pathological records for clinical, radiographic, and histological features from 2003 to 2012

Methods and methods: In this 10-year retrospective study, 88 histopathological records of patients with ameloblastoma treated at the Oral and Maxillofacial Surgery Clinic, Department of Oral and Maxillofacial Surgery, Mahidol University were selected. The records were analyzed for demographic data, chief complaint, site of lesion, clinical, radiographic, and histologic features to determine the incidence of ameloblastoma.

Results: The overall incidence of ameloblastoma was 4.49% (88/1962 records). The age range of the patients with ameloblastoma was 8 and 81 years, with a mean age of 38 years. Ameloblastoma occurred more in males (56.82%) than females (43.18%). More than half of the patients (56.81%; 50 cases) presented with painless swellings. The mandible accounted for 88% (78 cases) of all the ameloblastoma. Most radiographs showed multilocular radiolucent lesions (60.23%; 53 cases). The most common histopathological features of ameloblastoma were mixed type (25%; 22 cases) and follicular type (23.86%; 21cases).

Conclusions: This study showed 4.49% incidence of ameloblastoma. Most ameloblastoma occurred in males with a mean age of 38 years. The lesions often presented clinically as painless swellings and histologically exhibited mixed or follicular types.

Keywords: ameloblastoma, incidence, clinicopathologic feature, histopathologic feature, radiographic feature

How to cite: Kiattavorancharoen S, Boonsiriseth K, Thungat A, Wongsirichat N. Incidence of Oro-maxillofacial lesions (10 years) in the department of oral and maxillofacial surgery, Mahidol University: Ameloblastoma. M Dent J 2015; 35: 21-30.

Dental Journal Original ArticleMahidol Dental Journal

22 The incidence of oro-maxillofacial lesions (10 years) in the department of oral and maxillofacial surgery, Mahidol University: Ameloblastoma Kiatanant Boonsiriseth, Sirichai Kiattavorncharoen, Arada Thungrat, Natthamet Wongsirichat

M Dent J Volume 35 Number 1 January-April 2015

Introduction Ameloblastoma is the most common benign odontogenic tumor of the jaw bone that is derived from odontogenic epithelium1. In 2008, Abu-El-Naaj et al. reported that 1% of all cysts and tumors found in the mandible was ameloblastoma.2 It is reported to be derived from epithelium cells:3 rest of dental lamina, epithelium of enamel organ, epithelial lining of odontogenic cyst, basal cells of oral mucosa, and heterotopic epithelium from extra-oral sites, such as the pituitary gland. Mechan i sm and deve l o pmen t o f ameloblastoma is still unknown, but it may originate as a result of alterations or mutations of gene expression. Heikinheimo et al. suggested that some of the genes (FOS oncogene and Tumor-necrosis-factor-receptor1, TNFRSF1) are overexpressed in ameloblastoma as compared to a normal tooth bud.6

In most of the studies, the patients with ameloblastoma have a wide age range from 4-92 years, but it is predominant observed in the 3rd – 5th decades of life. It is found more in males than females with the ratio of 1.4:1 (male:female). Mandible is the most common site of occurrence, which accounts for about 80 – 90% of the total incidence.4,5,8

Radiograph may present unilocular or multilocular radiolucencies, with well-defi ned margins and scalloped borders. In some cases, the lesions have many round multilocules with different sizes that look like soap bubbles. If the round multilocules are small and equal in size, the lesion may appear as honeycombs. Ameloblastoma can be found incidentally with the impacted or embedded tooth. Moreover, the lesion can also displace or resorb the adjacent roots.7

In 2005, WHO classifi ed ameloblastoma into 4 types: solid or multicystic, unicystic, demoplastic, and peripheral. The groups of cells are histologically found in 6 patterns - follicular,

plexiform, acanthomatous, granular cell, basal cell, and desmoplastic. Histologically, follicular and plexiform1,4,5,8 types are the most common. Patients with ameloblastoma have been diagnosed and treated in the Department of Oral and Maxillofacial Surgery, Mahidol University for many years. The incidence of ameloblastoma in the Department of Oral and Maxillofacial Surgery, Mahidol University had been previously reported only between 1979 and 1992. However, there have been no recent studies on the incidence of ameloblastoma. Therefore, this study aimed to gather knowledge on clinical, radiologic, and histologic features of ameloblastoma from the patients’ histopathology reports from the past 10 years between 2003 and 2012.

Materials and methods This retrospective study was collected data from histopathological reports in the Maxillofacial Surgery Clinic, Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Mahidol University from 2003 to 2012. Prior to the study, the permission from the Chairman of the Department of Oral and Maxillofacial Surgery, Mahidol University was obtained. Out of 1,962 histopathological records, 88 cases of ameloblastoma were studied and analyzed in regards to the patient’s age and gender, chief complaint, site of lesion, clinical, radiographic, and histopathological features.

Results Since 2003 to 2012, there were a total 1,962 cases with histopathological reports at the Oral and Maxillofacial Surgery Clinic, Department of Oral and Maxillofacial Surgery. The most common lesion was odontogenic cyst (490 cases; 24.97%) followed by keraocystic odontogenic tumor (109 cases; 5.56%). The other lesions were non-odontogenic cyst (107 cases; 5.45%), squamous cell carcinoma (96 cases; 4.89%), ameloblastoma (88 cases;



4.49%), and fi bro-osseous lesion (45 cases; 2.30%) (Table 1, Figure 1)

Age and Gender The age range of the patients with ameloblastoma was between 8 and 81 years, with a mean age of 38 years. The lesion was most commonly found in patients aged 20 to 29 years (third decade of life) and in males more

than females with the ratio 1.3:1 (Table 2)

Chief complaint and clinical presentation The most common clinical appearance and the chief complaint of the patients were swelling and most of the lesions were incidentally found during routine radiographic investigations. (Table3)

Figure 1 Incidence of oral and maxillofacial lesions from histopathological records

Table 1 Incidence of oral and maxillofacial lesions from histopathological records

Lesion Number Percent Odontogenic cyst 490 24.97

Keratocystic odontogenic tumor 109 5.56 Ameloblastoma 88 4.49 Squamous cell carcinoma 96 4.89 Fibro-osseous lesion 45 2.30 Non-odontogenic cyst 107 5.45 Others 1,027 52.34

Total 1,962 100.00

Odontogenic cyst

Keratocys�c odontogenic tumor

Ameloblastoma

Squamous cell carcinoma

Fibro-osseous lesion

Non-odontogenic cyst

Others



Table 2 Distribution of ameloblastoma by age and gender of the patient

Age (years) Gender

Total Male Female

Number Percent Number Percent Number Percent 0 – 9 1 1.14 2 2.27 3 3.41 10 – 19 6 6.82 5 5.68 11 12.50 20 – 29 7 7.95 12 13.64 19 21.59 30 – 39 11 12.50 1 1.14 12 13.64 40 – 49 10 11.36 8 9.09 18 20.45 50 – 59 7 7.95 8 9.09 15 17.05 60 – 69 4 4.55 1 1.14 5 5.68 ≥ 70 2 2.27 1 1.14 3 3.41 N/A 2 2.27 0 0.00 2 2.27 Total 50 56.82 38 43.18 88 100.00

Table 3 Chief complaint and clinical features of the patients with ameloblastoma Clinical features Number Percent

Swelling, painless 50 56.81

Swelling with pain 8 9.09

Swelling with numbness 3 3.41

Known case KCOT 1 1.14

Referral from other clinic or hospital 4 4.55

Mass 1 1.14

Pain 4 4.55

Delayed extraction wound healing 4 4.55

Radiograph 6 6.82

Not described 7 7.95

Total 88 100.00

Table 4 Distribution of ameloblastoma by site of occurrence

Sites of lesions Maxilla Mandible

Number Percent Number Percent Anterior region 2 2.27 8 9.09 Posterior region 2 2.27 38 43.18 Anterior and Posterior region 5 5.68 32 36.36

Total 9 10.23 78 88.64

Sites of lesion Table 4 shows the sites of the lesion, divided into anterior (central incisor to canine) and posterior regions (from fi rst premolar to

third molar). The mandible accounted for 88% (78 cases) of the total ameloblastoma and it was found most commonly in the posterior region.



Radiographic feature The radiographs showed unilocular, multilocular radiolucency, or mixed radiopaque-radiolucency. Multilocular radiolucent lesions were most commonly. There were 2 cases that

showed no associated bony lesion. There were root resorptions in 28 cases. Some cases were associated with impacted or unerupted tooth. (Figure 2&3) (Table 6)

Table 4 Radiographic featuresRadiographic feature Number Percent

Unilocular radiolucency 22 25.00 Multilocular radiolucency 53 60.23 Mixed radiopaque-radiolucency 5 5.68 Not associated with bone 2 2.27 Not described 6 6.82

Total 88 100.00

Unilocular radiolucency

Mul�locular radiolucency

Mixed radiopaque-radiolucency

Not associated with bone

Not described

Figure 2 Different types of radiographic features seen in ameloblastoma

Figure 3 Features of teeth related to the ameloblastoma

Root resorp�on

Root divergence

Associated with unerupted or impacted tooth



Table 5 Features and number of teeth related to the ameloblastomaRelation with teeth Number

Root resorption 28 Root divergence 3 Associated with unerupted or impacted tooth 11

Total 42

Figure 4 Multilocular radiolucent lesion with bony expansion and root resorption of #45-48

Figure 5A Multilocular radiolucent area alongside an unerupted tooth within the lesion



Histological feature Most lesions of ameloblastoma had mixed type of histological features, which consisted of at least 2 types of ameloblastoma in one lesion. The most common was follicular type. (Table 6 &7)

Discussion This study was a retrospective study that analyzed the pathological reports from the Maxillofacial Surgery Clinic, Department of Oral and Maxillofacial Surgery, Mahidol University between 2003 and 2012. A total of 88 cases of ameloblastoma were observed during the study period.

Figure 5B Panoramic film showing bony expansion related to ameloblastoma

In 1985 Riechart et al 9 reported ameloblastoma to be present in all race, including American (0.04%) and Black (0.33%). From the analysis of histopathological reports, they also found a 6.7% incidence of ameloblastoma in Thai patients. In 2000 Worawongvasu10 found ameoblastoma in 8.01% of all the specimens examined at the Department of Oral Pathology, Mahidol University. This study found 88 cases of ameloblastoma that accounted for 4.49% of the pathological reports since 1962. The fi ndings were similar to the study by Reichart et al but less than the study by Worawongvasu10.



Table 6 Histological featuresHistological feature Number Percent

Follicular 21 23.86 Plexiform 15 17.05 Acanthomatous 1 1.14 Granular cell 1 1.14 Basal cell 0 0.00 Desmoplastic 10 11.36 Mixed 22 25.00 Cystic 14 15.91 Peripheral 1 1.14 N/A 3 3.40

รวม 88 100.00

Table 7 Number of mixed type of histopathological features in ameloblastoma Histological feature Number

Follicular / Plexiform 10 Follicular / Acanthomatous 4 Follicular / Desmoplastic 1 Follicular / Granular cell 1 Follicular / Plexiform / Acanthomatous 3 Follicular / Plexiform / Granular cell 1 Follicular / Plexiform / Acanthomatous / Basalcell 1 Follicular / Plexiform / Acanthomatous / Desmoplastic 1

Total 22

Figure 6 Incidence of ameloblastoma according to histopathological features

Follicular

Plexiform

Acanthomatous

Granular cell

Basal cell

Desmoplas�c

Mixed

Cys�c

Peripheral

N/A



This study found ameloblastoma more in males than females with the ratio of 1.3:1 and the mean age of the patients was 38 years. This fi nding corresponded to previous studies, which have found the mean age as 30 to 40 years. 9,11-14

The most common chief complaint was swelling without any symptoms (pain or numbness), which was also similar to several previous studies.9,18 Posterior region of the mandible accounted for 88.64% of all cases of ameloblastoma, which bared similarities with previous literature that have reported ameloblastoma be to predominantly found (80- 90%) in the mandible.11-15 Philipsen et al.16 reported desmoplastic ameloblastoma to be commonly found in the anterior maxilla but in this study it was found only in 33% (3/15) of the cases. The incidence of multilocular radiolucent radiograph was 60.23%, which was different from a report by Kim and Jang.18 In their study unilocular radiolucency was the most common radiographic feature of ameloblastoma. Curran et al.19 stated that a unilocular radiolucent around the tooth has a high probability towards ameloblastoma, where as in this study a case of ameloblastoma was found with pericoronal radiolucent lesion around the crown of impacted tooth that measured 0.5cm. In many previous studies, the most commonly found histological feature was follicular type of ameloblastoma15, except the study by Kim and Jang18 who noted plexiform ameloblastoma to be the most common. However, in this study mixed types of ameloblastoma were most frequently observed. The most common histopathological pattern found in mixed types was follicular ameloblastoma. Soft tissue ameloblastoma or peripheral type was rare and found only in 1 case (1.14%), similar to a previous study.20

The results of this retrospective study were based on the histopathological reports,

which can be a disadvantage because they are rarely dependent on the information sent by the specimens’ sender. In order to obtain a more complete incidence of ameloblastoma, detailed clinical data should also be collected and analyzed from the patients’ clinical reports.

Funding: NoneCompeting interests: None Ethical approval: None

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World Health Organization classification of tumors: pathology and genetics head and neck tumors. Lyon, France: International Agency for Research on Cancer Press; 2005.

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The incidence of oro-maxillofacial lesions (10 years) in ... · The incidence of oro-maxillofacial lesions (10 years) in the department of oral and maxillofacial surgery, Mahidol