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SHORT COMMUNICATION  
Year : 2011  |  Volume : 22  |  Issue : 4  |  Page : 616
Ameloblastic fibro-odontoma masquerading as odontoma


1 Department of Oral and Maxillofacial Pathology, SGT Dental College and Hospital, Gurgaon, Haryana, India
2 Department of Pediatric Dentistry, SGT Dental College and Hospital, Gurgaon, Haryana, India

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Date of Submission02-Jan-2011
Date of Decision23-Feb-2011
Date of Acceptance01-Mar-2011
Date of Web Publication26-Nov-2011
 

   Abstract 

Ameloblastic fibro-odontoma (AFO) is a rare, benign epithelial mixed odontogenic tumor. It occurs as an intraosseous lesion, generally asymptomatic and more prevalent in children and adolescent. AFO is found on radiographic evaluation of patients with unerupted or impacted teeth in many cases. Histological examination reveals a fibrous soft tissue, islands of odontogenic epithelium and a disordered mixture of dental tissues. The treatment modality in most cases involves conservative surgery with enucleation. We present a case of 13-year-old boy with a missing right central incisor, mimicking-like odontoma on radiograph but proved to be AFO and treated with enucleation with preservation of impacted tooth. There was no recurrence after one year of follow-up. This report discusses the clinical, radiographical, histological features and surgical assessment to preserve the impacted tooth associated with AFO.

Keywords: Ameloblastic fibro-odontoma, benign odontogenic tumor, odontoma

How to cite this article:
Nanda KD, Marwaha M. Ameloblastic fibro-odontoma masquerading as odontoma. Indian J Dent Res 2011;22:616

How to cite this URL:
Nanda KD, Marwaha M. Ameloblastic fibro-odontoma masquerading as odontoma. Indian J Dent Res [serial online] 2011 [cited 2019 Nov 13];22:616. Available from: http://www.ijdr.in/text.asp?2011/22/4/616/90332
Ameloblastic fibro-odontoma (AFO) is a rare benign slow growing, expansile epithelial odontogenic tumor with odontogenic mesenchyme. The term ameloblastic fibro-odontoma was first used by Hooker in 1967. [1] It is defined by World health organization (WHO) as a neoplasm composed of proliferating odontogenic epithelium embedded in a cellular ectomesenchymal tissue that resembles dental papilla, and with varying degrees of inductive change and dental hard tissue formation. [2] AFO varies from 0.3% to 1.7% reaching 4.6% when only the cases in children are considered. [3] Radiographic findings are often similar to complex odontoma resembling tiny teeth surrounded by radiolucent capsule. [4] AFO is usually treated by enucleation and prognosis is excellent. [2] Maintenance of impacted teeth are extremely important for the physiological importance. The aim of this article is to report a case of unusual occurrence of AFO in the anterior maxilla with preservation of impacted tooth.


   Case Report Top


A 13-year-old boy presented with missing right maxillary central incisor. The patient had been totally asymptomatic. He reported that his left central incisor had erupted 4 years earlier than right incisor. The patient medical history was non contributory. There was no history of local trauma or infection.

Intra oral examination revealed a dentition normal for the age except for the absence of right maxillary incisor [Figure 1]. Occlusal radiograph revealed that the missing tooth was impacted with a well defined radio-opaque mass surrounded by a thin radiolucent zone [Figure 2]. The differential diagnosis included compound odontoma, calcifying odontogenic cyst, calcifying epithelial odontogenic tumor, and adenomatoid odontogenic tumor.
Figure 1: Intraoral photograph shows missing right maxillary central incisor

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Figure 2: Occlusal radiograph reveals a well-defined radio-opaque mass surrounded by a thin radiolucent zone in relation to right maxillary central incisor

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Excisional biopsy was performed under local anesthesia, since the impacted tooth was separated from the surgical cavity by a fibrous capsule. Thus, only the mass with scanty soft tissue was enucleated and send for histopathological examination. Light microscopic examination with hematoxylin and eosin revealed odontogenic epithelium in a fibrous connective tissue and calcified mass of tooth-like structures. The odontogenic epithelium was in form of isolated islands with peripheral layer of cuboidal cells resembling preameloblast like cells. The connective tissue was moderately cellular with spindle shaped fibroblast cells [Figure 3]. The decalcified section of tooth like structure showed dentinal tubules along with focal area of calcification [Figure 4]. No malignant growth was observed. Based on histopathology diagnosis of AFO was made. Patient was followed up postoperatively for approximately one year with no recurrence and parents were made aware of a delayed eruption of permanent tooth. Presently, patient follow-up is lost.
Figure 3: Microscopic section showing odontogenic epithelium in form of isolated islands and moderately cellular fibrous connective tissue, (H and E stain, original magnification ×100)

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Figure 4: Decalcified section of tooth-like structure showing dentinal tubules along with focal area of calcification

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   Discussion Top


WHO has defined AFO as a lesion similar to ameloblastic fibroma with inductive changes that lead to the formation of dentin and enamel. [2]

The histological features of ameloblastic fibroma (AF) include odontogenic ectomechyme that resemble the dental papilla and strands or islands of odontogenic epithelium. If there is dentin formation, the lesion should be diagnosed as ameloblastic fibro dentinoma (AFD), whereas a lesion similar to ameloblastic fibroma showing inductive changes that lead to the formation of dentin and enamel both is diagnosed as AFO. [2],[3]

AFO is a rare tumor, which represents only 1-3% of all odontogenic tumors. It usually occurs in people less than 20 years of age (mean age 11 year), and thus age is an important characteristic in the differential diagnosis. AFO is mainly found in posterior mandible with male to female ratio as 6:1. [3] It occurs exclusively as an intraosseous tumor. The two most common presenting complaints are swelling and failure of tooth eruption. [1],[4] The case presented in this report was a 13 year old male patient with location of lesion in the anterior maxilla, in contrast to its usual site: the posterior mandible. This case supports Anneroth and Pontes [4],[5] findings and documents the uniqueness of the lesion given the age and location of the tumor.

Radiographically, it usually appears as a radiolucent area that contain variable amount of calcified material. The ratio of radiopaque to radiolucent areas differs from one lesion to another, sometimes the mineralized elements in the tumor predominate and the lesion may be radiographically similar to a odontoma. [6] The case presented in this report had a radiopaque mass surrounded by thin radiolucent zone resembling an odontoma or WHO type II calcifying odontogenic cyst but on histopathology proved to be ameloblastic fibro odontoma. In the present case in spite of large radiopaque mass, proliferation of ectomesenchymal component containing islands of odontogenic epithelium along with dental tissue was observed. Hillmann and his colleagues observed that AFO bear great resemblance to common odontomas and suggested, all odontomas to be sent for microscopic examination. [6]

According to literature, the recommended treatment is conservative surgical excision. Some authors have suggested preserving the impacted tooth associated with the lesion. [5],[7] The fundamental behind the recurrence of AFO is the degree of involvement of the impacted tooth by the tumor and the difficulty to completely remove the lesion. There is very little potential for recurrence. [5],[7],[8] We preserved the impacted tooth because surgical exposure of the tumor did not enclose the impacted central incisor and was separated by a capsule. No recurrence was observed one year after the surgery.

This case is unusual in the sense that a missing tooth in an anterior maxilla giving an appearance of odontoma on radiograph led to the diagnosis of AFO which has a predilection at posterior mandible and conservative surgical treatment preserved the integrity of central incisor.

To conclude, AFO is a rare benign odontogenic tumor found in a young age group. Dental practitioners should be aware that AFO can occur with impacted or missing tooth in the anterior maxilla irrespective of small to large mass. Histopathologic study is needed to exclude other mixed odontogenic tumors in the jaw before reaching a confirmatory diagnosis so that an early diagnosis with prompt treatment can prevent complications.

 
   References Top

1.Sivapathasundharam B, Manikandan R, Sivakumar G, George T. Ameloblastic fibro-odontoma. Indian J Dent Res 2005;16:19-21.  Back to cited text no. 1
[PUBMED]    
2.Barnes L, Eveson J, Reichart P, Sidransky D. World Health Organization classification of tumours. Pathology and genetics head and neck tumours. Lyon: IARC Press; 2005. p. 284-5.  Back to cited text no. 2
    
3.Guerrisi M, Piloni MJ, Keszler A. Odontogenic tumors in children and adolescents. A 15-year retrospective study in Argentina. Med Oral Patol Oral Cir Bucal 2007;12:E180-5.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Anneroth G, Modéer T, Twetman S. Ameloblastic fibro-odontoma in the maxillae. A case report. Int J Oral Surg 1982;11:130-4.  Back to cited text no. 4
    
5.Pontesa FS, Pontesa HA, Sá Nogueirab JE. Ameloblastic fibro-odontoma: Case report with maintenance of the involved teeth. Int J of Pediatric Otorhinolarynglogy 2008;3:48-52.  Back to cited text no. 5
    
6.Hillmann G, Donath K. Clinical course, histology and prognostic assessment of odontomas. Dtsch Zahnarzti Z 1991;46:68-70.  Back to cited text no. 6
    
7.Reis SR, de Freitas CE, do Espírito Santo AR. Management of ameloblastic fibro-odontoma in a 6-year-old girl preserving the associated impacted permanent tooth. J Oral Sci 2007;49:331-5.  Back to cited text no. 7
    
8.Furst I, Pharoah M, Phillips J. Recurrence of an ameloblastic fibro-odontoma in a 9-year-old boy. J Oral Maxillofac Surg 1999;57:620-3.  Back to cited text no. 8
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Correspondence Address:
Kanwar Deep Singh Nanda
Department of Oral and Maxillofacial Pathology, SGT Dental College and Hospital, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.90332

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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