Hybrid Odontogenic Tumor With Features of Ameloblastic Fibro-Odontoma, Calcifying Odontogenic Cyst, and Adenomatoid Odontogenic Tumor: A Case Report and Review of the Literature

Unusual Association of Calcifying Cystic Odontogenic Tumor with Compound Odontoma and Ameloblastoma: Case Report and Review of the Literature

Calcifying cystic odontogenic tumor (CCOT) is a rare odontogenic cyst accounts for <2% of all odontogenic cysts. Simple unicystic CCOT is commonly encountered accounts for 65%, whereas other forms of CCOT are <3%. CCOT is associated with two or more odontogenic tumors, it is called combined odontogenic lesions or hybrid lesions. The aim of the present article is to report a rare case of CCOT and highlighting the clinical feature and treatment aspects of combined lesions. A 25-year-old female complained of pain and swelling in the left maxilla for 6 months. Examination revealed diffuse swelling in the maxilla, firm in consistency, and tender on palpation. Panoramic radiograph showed impacted canine with multiple radiopaque structures and well-defined lesion in the maxillary sinus. The lesion was surgically removed and histopathologically diagnosed as CCOT with compound odontoma and ameloblastoma. Pub Med database search from 1978 to June 2020 revealed only three case reports of combined odontogenic tumors associated with CCOT.

Hybrid odontogenic lesions: A case series of a rare entity

Background

The occurrence of hybrid odontogenic lesions with two or more morphologically distinct components is a rare phenomenon and poses a diagnostic challenge. We aimed to study the clinical, radiological, and pathological features and behavior of hybrid odontogenic lesions, to enhance awareness about these rare lesions.

Method

Hematoxylin and Eosin slides of hybrid odontogenic lesions diagnosed between January 01, 2012 and December 31, 2020, were reviewed. Demographic and radiological information were obtained from the patient's medical records.

Results

8 cases were diagnosed with a mean age of 19.1 years and male to female ratio of 1:1.7. Involvement of mandible was more common (n = 5) as compared to maxilla (n = 3). All patients presented with swelling for an average of 9.75 months (3-25 months) duration. Bleeding, loose teeth, pain and facial asymmetry were reported in 5,3, 3, and 2 cases, respectively. Radiologically, 7 cases were well demarcated, 75% cases (n = 6) were radiolucent, and average radiological size was 4.8 cm. All patients were managed with surgery alone. 5 cases (62.5%) underwent enucleation and curettage, while local excision, en-block resection and segmental mandibulectomy were performed in 1 case each. Histologically, ossifying fibroma/cemento-ossifyiong fibroma were the most lesion, occurring in 5 cases (62%), followed by giant cell granuloma like lesions (GCG) i.e., central and peripheral giant cell granuloma (n = 3), Adenomatoid Odontogenic tumor (AOT) (n = 2), and DC (n = 2), ameloblastic fibroma (AF) (n = 1), Ameloblastoma (n = 1), calcifying odontogenic cyst (COC) (n = 1), and complex odontoma (n = 1). No evidence of recurrence was noted after 4-99 months of surgery (mean: 32.9) in cases with available data (n = 7). Long-term complaints included facial asymmetry (n = 2) and pain (n = 1).

Conclusion

Most hybrid odontogenic lesions affect young females in the second decade of life and commonly show COF and OF as hybrid components. A conservative approach to management appears adequate.

Calcifying odontogenic cyst combined with odontogenic keratocyst: report of a case and review of the literature

INTRODUCTION AND IMPORTANCE

Odontogenic lesions composed of two or more separate odontogenic cysts are uncommon. The calcifying odontogenic cyst (COC) and odontogenic keratocyst (OKC) are odontogenic cysts that exhibit some neoplastic features. Concurrence of these lesions is extremely rare. We report a rare case of COC combined with OKC in a patient and review the relevant literature systemically.

CASE PRESENTATION

In this article, we present a case report of an 18-year-old boy patient with no medical history whose chief complaint was facial asymmetry. A painless swelling in the right side of the posterior mandible was observed. Histopathological and radiographic investigations revealed a combined odontogenic lesion composed of inflamed OKC with COC.

CLINICAL DISCUSSION

Long-lasting debates on the true nature of OKC and COC, whether cystic or neoplastic, has been existed so far. Their genetic-derived mechanisms can justify the concurrent occurrence of these cysts in a patient. The treatment plan for this lesion included decompression followed by enucleation, curettage, and application of Carnoy's solution.

CONCLUSION

We reported a rare case of an inflamed OKC with COC-like features. Based on the literature, the coincidence of these two odontogenic cysts has been reported for the third time here.

Developing odontoma arising from calcifying odontogenic cyst: A case report

Developing odontoma is a rare mixed odontogenic tumor that can arise with other odontogenic lesions. The association of COC with ameloblastic fibro-odontoma is extremely rare. We report an extremely rare case of developing odontoma arising from a calcifying odontogenic cyst in a 17-year-old girl.

Hybrid odontogenic lesions: A systematic review of 203 cases reported in the literature

BACKGROUND

Hybrid odontogenic lesions combine histopathological characteristics of two or more odontogenic cysts and/or tumours. The aim of this study was to evaluate the available data on hybrid odontogenic lesions (HOL) and to analyse their epidemiological/clinical features and biological behaviour.

METHODS

An electronic search was done in January 2021 using multiple databases. Eligibility criteria encompassed publications with sufficient clinical and histological information to confirm the tumours' diagnoses.

RESULTS

A total of 147 articles were included in this study, comprising 203 cases. Calcifying odontogenic cyst associated with odontoma (COC/OD) (37/18.2%) was the most common HOL. Females were more affected with a mean age of 24.9 years. Lesions presented as asymptomatic swellings, with a mean evolution time of 8.2 months (0.3-96), and mean tumour size of 4.8 cm (0.3-7). Radiographic aspects frequently showed radiolucent (139/68.4%) and unilocular (52/25.6%) images with well-defined limits (48/23.6%). The lesions mostly affected mandibular pre-molars (69/34%) and mandibular molars (69/34%) regions. Enucleation (89/43.8%) and surgical excision (59/29%) were the most common treatment modalities. The mean follow-up time was 33.8 months (0.5-216 months) and recurrences were observed in four cases (1.9%), all of which were central odontogenic fibroma associated with central giant cell granuloma (COF/CGCG).

CONCLUSION

COC/OD is the most common HOL and recurrence is a rare event, being usually associated with the diagnosis of COF/CGCG.

A Bilocular Radicular Cyst in the Mandible with Tooth Structure Components Inside

Background

A radicular cyst is the most common odontogenic cyst of inflammatory origin. Radiographically, it commonly demonstrates clear unilocular radiolucency; radicular cysts with multilocular radiolucency are quite rare.

Case Presentation

A 64-year-old Japanese man who presented with a bilocular radiolucent lesion in his left mandible was referred by a dental clinic to our oral and maxillofacial surgery department. He had no particular subjective symptoms. Orthopantomography and computed tomography (CT) revealed an 18 mm × 15 mm lesion with well-defined bilocular radiolucency in the left mandible expanding from the distal side of a canine tooth to the bottom of the 2nd premolar. The lesion included the roots of the 1st and 2nd premolars. The root of the 2nd premolar showed knife-edge resorption. Although the 1st premolar was nonvital, the 2nd premolar was a vital tooth. As differential diagnoses, a radicular cyst, ameloblastoma, odontogenic keratocyst, pseudocyst, and others might be considered. We performed a total resection of the bilocular lesion and diagnosed the lesion as a radicular cyst with tooth structure components inside. The tooth structure components represented lamellar structures of cementum; they were located only in the proximal part (under the 1st premolar) of the lesion. The distal part of the lesion presented distinctive inflammation without tooth structure components.

Conclusion

We encountered a rare case of a bilocular radicular cyst with tooth structure components inside.

Unusual microscopic changes of Ameloblastic Fibroma and Ameloblastic Fibro-odontoma: A systematic review

Background

Ameloblastic fibroma (AF) and ameloblastic fibro-odontoma (AFO) are uncommon benign mixed odontogenic neoplasms. Although unusual microscopic changes including hybrid tumors have been documented in publications, their clinical outcome prediction and treatment modality selection are still challenging due to scarcity. Objective: Analysis of AF/AFO’s unusual microscopic variants in order to improve histopathologic diagnosis and to help clinicians in making informed treatment choices.

Material and Methods

An electronic search was performed in PubMed’s database using keywords: “ameloblastic fibroma”, “ameloblastic fibroodontoma”, “ameloblastic fibro-odontoma”. The search scheme was limited to articles in English, dated ‘January 1998’ to ‘October 2018’, with full texts (case reports and series) and human studies. Eligibility criteria included publications having enough clinical, radiological, and histological data to confirm their diagnosis. Age, sex, lesions’ location, radiologic features, signs, symptoms, treatment approaches, and recurrences were recorded and analyzed.

Results

In this systematic review, 11 articles (reporting 14 cases) were selected. Patients’ mean age was 13.75 years (male/female = 1.8). The posterior region of the mandible was the lesions’ commonest location (57.14%). Swelling was reported in 78.57% of the cases, pain in 28.57% but 21.42% were asymptomatic. Radiolucent unilocular appearance was the commonest radiographic feature, but 28.57% of the cases showed a mixed radiolucent-radiopaque appearance. Other reported radiographic findings were impacted tooth (78.57%), root resorption (28.57%), tooth mobility (35.71%), and cortical perforation (14.28%). No recurrences were reported. Calcifying odontogenic cyst (COC) was the commonest lesion associated with AF/AFO (53.33%). Unicystic ameloblastoma and cystic changes without prominent epithelial lining were other reported hybrid lesions. Reported microscopic variations were pigmentation and ghost cell differentiation.

Conclusions

COC was the commonest lesion associated with AF/AFO. Although COC commonly occurs in the jaws’ anterior region, hybrid cases were more common in the posterior area. No malignant transformations were reported. The treatment modality is mostly chosen based on the lesion’s most aggressive part.

Key words:Ameloblastic fibroma, Ameloblastic fibro-odontoma, Odontogenic tumor, Jaw.

Diverse calcification patterns of ameloblastic fibro-odontoma on radiographic examination

The occurrence of ameloblastic fibro-odontoma (AFO) in the oral region is unusual and accounts for 1-3% of all odontogenic tumors. AFO presents mixed radiopaque patterns within the lesion with diverse findings; therefore, it is important to compare this tumor with other odontogenic tumors that radiographically present with calcified bodies. Herein, we observed the calcification patterns within the lesion in seven AFO cases (five males, two females; mean age, 8.3 years; age range, 4-13 years). Periapical and panoramic radiographs were obtained from all seven cases. Five cases underwent conventional computed tomography (CT) scanning, and one underwent cone beam CT. Classification of the calcifications primarily involved the following two characteristics on the X-rays: appearance and location of the lesions. All seven cases were located in the molar regions of the mandible in association with impacted teeth. The calcification patterns of these AFOs were mixed or inhomogeneous within the lesion with various findings, including complex odontoma-like calcifications. However, the patterns differed between panoramic radiography and CT in some cases. The radiolucent lesions in AFO demonstrated varying calcification patterns and were associated with impacted teeth on the CT images.(J Oral Sci 58, 533-537, 2016).

Adenoid ameloblastoma: clinicopathologic description of five cases and systematic review of the current knowledge

OBJECTIVE

To describe the clinicopathologic and immunohistochemical features of five cases of adenoid ameloblastoma.

STUDY DESIGN

Clinicopathologic data were gathered from medical records and compared with those compiled from a systematic review. Slides were also immunohistochemically stained for Ki-67, p16, p53, and cytokeratins (7, 8, 14, 18, and 19).

RESULTS

There were 3 males (60%) and 2 (40%) females. The mean age was 44 ± 10 years. Of the five adenoid ameloblastomas, 4 (80%) occurred in the posterior maxilla. Patients typically complained of asymptomatic swelling. All patients received surgical resection as primary therapy; 1 (20%) patient also received adjuvant radiotherapy. Recurrence was diagnosed in all patients. Immunohistochemically, the tumors stained focally positive for CK7, 8, 14, and 18 and diffusely positive for CK-19, p16, and p53. The mean Ki-67-positive cells were 72.4 ± 24.9 positive cells per high-power field (range 53-111).

CONCLUSIONS

To our knowledge, this is the largest series of adenoid ameloblastoma reported in the literature. Our data suggest that this entity demonstrates aggressive behavior characterized by a high likelihood of recurrence.

Report of Two Cases of Combined Odontogenic Tumors: Ameloblastoma with Odontogenic Keratocyst and Ameloblastic Fibroma with Calcifying Odontogenic Cyst

Combined odontogenic neoplasms have rarely been documented. Such tumors have also been described by other researchers as "hybrid" lesions. The histologic features are often identical to other individually well-established odontogenic neoplasms such as ameloblastoma, adenomatoid odontogenic tumor, ameloblastic fibroma (AF), and ameloblastic fibro-odontoma. Their clinical presentation is variable, ranging from cysts to neoplasms showing varying degrees of aggressive behavior. Most combined tumors contain features of one of the odontogenic tumors in combination with either a calcifying odontogenic cyst (COC) or a calcifying epithelial odontogenic tumor. We present two new cases of combined odontogenic tumors: an ameloblastoma with an odontogenic keratocyst and an AF with COC. Predicting clinical outcome is challenging when a combination tumor is encountered due to the paucity of such lesions. One must understand salient features of these entities and differentiate them from the more common conventional neoplasms to expand classification and provide prognostic criteria.

Bilateral adenomatoid odontogenic tumour of the maxilla in a 2-year-old female--the report of a rare case and review of the literature

Multifocal odontogenic lesions are uncommon and have only been observed in conditions associated with known genetic mutations. To the best of our knowledge, only two cases of multifocal adenomatoid odontogenic tumours (AOT) have previously been reported in the literature. In this study, we report the first case of a bilateral, separate AOT in the maxilla in the midline in a 2-year-old female. The patient presented with bilateral expansile masses in the maxilla on either side of the midline which had been present for 6 months. She was asymptomatic and had occasional difficulty in breathing. The tumour was diagnosed as AOT and was surgically enucleated along with the associated teeth. The patient recovered well and has been on recall for 5 years. The follow-up panoramic radiograph made a fortnight ago revealed evidence of three new radio-opaque lesions with an associated tooth in the region of the anterior mandible, the premolar region of the right maxilla and the molar region of the left maxilla. To acquire additional information about AOT, all reports regarding AOT cited in 'PubMed' from 1995 onward were reviewed and the incidence, clinical features, radiographic features and management of AOT are discussed in this study.

Surgical management of an erupted complex odontoma occupying maxillary sinus

The occurrence of complex odontomas is not considered to be rare in the jaws. But the occurence of large odontomas obscuring the maxillary sinus, or erupting into the oral cavity are considered to be rare. The prognosis is good with surgical excision and recurrence is nil. Most of the times the surgical site can be closed primarily, but sometimes requires local flaps to achieve tension free closure. Here, we report such a case treated by surgical excision trans orally followed soft tissue defect reconstruction with pedicled palatal island flap.

Rare hybrid odontogenic tumor in a 2-year-old child

Hybrid odontogenic tumors are rare conditions that can affect the oral maxillofacial region and usually occur in adults as an asymptomatic swelling. Hybrid odontogenic tumors exclusively involving adenomatoid odontogenic tumor (AOT) and calcifying cystic odontogenic tumor (CCOT) are rare, with only 4 reported cases. In addition, there are only few studies describing the presence of abortive enamel in AOT and, to our knowledge, CCOT was not present in any of them. We described a rare case of AOT associated with CCOT and abortive enamel formation in a 2-year-old child, a condition not well described in the international literature. Secretory cell activity was assessed by periodic acid-Schiff and Congo red stains.