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Ameloblastoma: A clinicoradiographic and histopathologic correlation of

11 cases seen in Goa during 2008-2012
Nigel R. Figueiredo, Ajit D. Dinkar, Manoj Meena, Sujata Satoskar, Manisha Khorate

Abstract
Objectives: The purpose of this case series was to compare the clinical, radiographic, and histopathologic features of 11 cases of
ameloblastoma that reported to the Goa Dental College and Hospital over a period of 4 years from January 2008 to December 2012.
Study Design: Data with respect to the patients’ ages, sex, location of lesions, radiographic features, histopathologic features and
surgical treatment and follow‑up, was analyzed. Results: The mean age in males was 23.25 ± 6.99 years, while that in females
was 43.43 ± 17.13 years. Seven (63.63%) of the 11 subjects were females, and four (36.36%) were males. 10 (90.9%) of the
11 ameloblastomas were located in the mandible. Swelling was noted in all 11 patients. 10 cases showed radiographic findings,
while one case was a peripheral soft‑tissue variant. Seven (70%) of the 10 tumors were multilocular with a well‑demarcated
corticated border, and three cases (30%) were unilocular. Two cases showed a soap‑bubble appearance. Histologically, five
cases were unicystic, four were multicystic, one was desmoplastic and one was a peripheral variant. Follow‑up ranged from
12 to 34 months and there were no signs of recurrence in any of the patients. Conclusions: Ameloblastomas more commonly
occur in females at an older age, as compared with males. Radiographic features that could help in diagnosing ameloblastomas
include its predominant occurrence in the mandible, multilocular radiolucency with well‑defined, corticated, scalloped margins,
expansion of buccal and lingual cortical plates, root resorption and tooth displacement.

Keywords: Ameloblastoma, desmoplastic, multilocular, peripheral, unilocular

Introduction odontogenic cysts, basal cells of oral mucosa, heterotopic

epithelium in other parts of the body (e.g., pituitary gland).[3]
Ameloblastoma is a neoplasm of odontogenic epithelium,
and represents 11-13% of all odontogenic tumors.[1] It is a Conventional ameloblastomas are usually seen between
persistent and locally invasive tumor that has aggressive 20 and 50 years of age, with an average age of discovery
but benign growth characteristics. [2] There are three of about 40 years,[1,2] while the unicystic variant may occur
different clinicoradiographic types: The conventional solid/ in younger patients (20-30 years of age). Some authors
multicystic intra‑osseous ameloblastoma, the unicystic state a male predilection,[1,2] while others describe it as
ameloblastoma and the peripheral ameloblastoma. In being more common in females.[4] Lesions grow slowly,
addition, the desmoplastic ameloblastoma is regarded as a with few, if any, symptoms in early stages. Patients most
fourth subtype of ameloblastoma because of its biological commonly present with a painless swelling or expansion
behavior, radiographic appearance and unique histology. of the jaw causing facial asymmetry. Ameloblastomas are
Ameloblastomas are tumors of odontogenic epithelial origin. about 5 times more common in the mandible than in the
They may arise from any of the following: Rest cells of the maxilla.[5] Radiographically, the tumor may be unilocular
dental lamina, developing enamel organ, epithelial lining of or multilocular, with a tendency for expansion.[6] Unicystic
lesions however, present more commonly as unilocular
Department of Oral Medicine and Radiology, Goa Dental College radiolucencies. The internal structure varies from totally
and Hospital, Bambolim, Goa, India radiolucent to a mixed radiolucent‑radiopaque caused by
presence of bony septae creating internal compartments,
Correspondence: Dr. Nigel Figueiredo, House No. 685, which may give rise to soap bubble, honeycomb, spider‑like[4]
Santerxette, Aldona, Bardez ‑ 403 508, Goa, India. or mother‑and‑daughter cell[4] appearances. The appearance
E‑mail: nigel_06@yahoo.co.in of septae on the radiograph usually represents differential
resorption of the cortical plate by the tumor and not actual
Access this article online separation of tumor portions.[7] Ameloblastomas have a
Quick Response Code: tendency to cause extensive root resorption and teeth may
Website: be displaced apically.
www.contempclindent.org

There are several histopathological subtypes-follicular,

DOI: acanthomatous, plexiform, desmoplastic, granular cell, and
10.4103/0976-237X.132305 basal cell pattern, which may exist singly or as a combination
of two or more types.[8] A difference in aggressiveness

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Figueiredo, et al.: A clinico‑radiographic and histopathologic correlation of 11 cases of Ameloblastoma

or tendency to recur does not appear to vary according was a 15‑year‑old, while the eldest was 69 years of age.
to histopathologic type. Treatment options range from The mean age in males was 23.25 years, while that in females
conservative surgical therapy (enucleation, curettage, was 43.43 years [Table 1] with a standard deviation of
excision, and marsupialization) to radical surgery (marginal 6.99 in males and 17.13 in females. A statistically significant
resection, segmental resection and total resection of the difference (with P = 0.024) in the mean age of occurrence in
jaw (maxilla/mandible) with wide margins).[5] Peripheral males as compared to that in females was observed.
lesions are usually excised with a small margin of normal
tissue, and the surgical site re‑examined periodically.[9,10] Location
Ten out of eleven cases were seen in the mandible, with six of
The aim of this work was to review a series of eleven these occurring in the posterior mandible. One case involved
cases of ameloblastomas that presented to our only the molar region while five cases involved both the
department in the last 4 years and attempt to correlate molar and ramus regions. Involvement of the entire ramus
the clinico‑radiographic‑histopathologic features of these of mandible was observed in three cases [Table 2].
lesions, to help in diagnosing ameloblastomas based on their
clinical and radiographic characteristics. Clinical presentation
In 10 patients, the initial chief complaint was a swelling of the
Patients and Methods lower jaw and/or face, for a period ranging from 1 to 4 months.
Pain was a feature only in one case. An extra‑oral swelling
This study was carried out on 11 cases of ameloblastoma was noted in 10 patients while all 11 cases presented with
that were diagnosed and treated at our institution in an intra‑oral swelling. None of the patients complained of
the last 4 years. The cases were examined clinically and any tooth mobility or paresthesia [Table 1].
radiographically and were confirmed by preoperative
incisional biopsies. All cases were documented Radiographic features
radiographically with orthopantomograms, while intra‑oral Out of the 11 cases, 10 cases showed radiographic findings. The
periapical and occlusal radiographs were also taken, peripheral variant (Case no. 5) did not show any radiographic
depending on the location of the lesions. The patients were evidence of bone involvement. Seven of the cases appeared
treated conservatively (i.e., with enucleation and curettage, as multilocular radiolucencies [Figures 1‑4] with well‑defined,
or both) or radically (i.e., with partial or complete jaw scalloped margins. Three tumors were found to be large
resection) depending on the location and size of the tumor. unilocular radiolucencies [Figures 5 and 6] with well‑defined
All postoperative surgical specimens were submitted for borders. Nine out of 10 cases showed a predominantly
histopathologic examination. radiolucent internal structure (five of these showed presence
of septae), while two cases had a “soap‑bubble” appearance.
Results 10 out of 10 cases showed expansion of buccal cortical plate,
seven out of 10 cases showed lingual cortical expansion. Four
Age and gender cases showed thinning of inferior border of mandible, while
Of the 11 cases of ameloblastoma in our series, seven expansion of the lower border of mandible was noted in two
cases were diagnosed in females and four in males, with cases. However, no perforation of cortical margins of the
a male‑to‑female ratio of 1:1.75. The youngest patient inferior and/or posterior border (s) of the mandibular body/

Table 1: Gender, age, clinical symptoms and histopathologic appearance of eleven cases histopathologically diagnosed
as ameloblastoma in the present case series
Case no. Gender Age (in years) Extra‑oral swelling Intra‑oral swelling Duration Pain Histopathologic appearance
1 Female 31 Present Present 1 month Present Unicystic
2 Female 31 Present Present 2 months Absent Unicystic
3 Male 32 Present Present 2 months Absent Follicular
4 Female 49 Present Present 4 months Absent Desmoplastic
5 Male 24 Absent Present 1 month Absent Peripheral
6 Male 15 Present Present 1 month Absent Unicystic
7 Female 69 Present Present 3 months Absent Unicystic
8 Female 46 Present Present 2 months Absent Unicystic
9 Female 20 Present Present 2 months Absent Acanthomatous
10 Male 22 Present Present 2 months Absent Follicular
11 Female 58 Present Present 3 months Absent Follicular

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Figueiredo, et al.: A clinico‑radiographic and histopathologic correlation of 11 cases of Ameloblastoma

Figure 1: Multilocular lesion in left posterior mandible with Figure 2: Multilocular lesion in left posterior mandible showing
well-demarcated corticated borders (Case no. 1) soap bubble appearance (Case no. 2)

Figure 3: Multilocular radiolucency with well-demarcated Figure 4: Multilocular radiolucency with well-demarcated
corticated borders in anterior mandible (Case no. 6) corticated borders in posterior mandible (Case no. 8)

Figure 6: Unilocular lesion in right mandibular ramus with well-

Figure 5: Unilocular radiolucency with well-demarcated defined corticated borders (Case no. 9)
corticated borders in posterior mandible, causing expansion
and thinning of inferior border of mandible (Case no. 7) Five cases showed histological features of unicystic
ameloblastomas, while one case was a desmoplastic variant
ramus was noted. The bone adjacent to the lesions showed with one lesion being a peripheral ameloblastoma [Table 1].
a normal appearance in all the cases. Root resorption of
involved teeth was seen in seven cases, and displacement of Treatment and follow‑up
teeth in seven cases. Two cases were associated with impacted Large lesions, including those that involved the ramus of
mandibular third molars [Table 2]. mandible, were treated by radical surgery which included
marginal resection, segmental or total resection of the
Histopathological features mandible with wide margins. Four cases were treated
Four cases were diagnosed as solid/multicystic with conservative surgical therapy including enucleation.
ameloblastomas (three follicular, one acanthomatous). Follow‑up ranged from 12 to 34 months until date. Healing

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Table 2: Radiographic features of ameloblastoma of eleven cases histopathologically diagnosed as ameloblastoma in the present case series
Case Shape of Internal Cortical Teeth showing Tooth/root Impacted Adjacent Inferior
Location Appearance Margins Borders Septae
no. margins structure expansion root resorption displacement seen in tooth bone border of Mn
1 Posterior Multilocular Well‑defined Scalloped Corticated, Thin, Radiolucent Buccal, lingual 3‑4, 3‑5, 3‑6 Absent Absent Normal Thinned
mandible thick curved
2 Posterior Multilocular Well‑defined Scalloped Corticated, Coarse, Mixed, Buccal, lingual, 3‑5, 3‑7 3‑8 Absent Normal Thinned
mandible, thick curved soap‑bubble inferior border
inferior ramus appearance of mandible
3 Anterior Unilocular Well‑defined Smooth Corticated, Absent Radiolucent Buccal, lingual 3‑1, 3‑2, 3‑3, 3‑5 Absent Normal Normal
mandible thick 3‑4, 3‑5, 3‑6,
4‑1, 4‑2, 4‑3
4 Posterior Multilocular Ill‑defined Scalloped Corticated, Thin, Radiolucent Buccal 1‑4, 1‑5 Absent Absent Normal ‑
maxilla thick curved
5 Anterior ‑ ‑ ‑ ‑ ‑ ‑ ‑ ‑ ‑ ‑ ‑ ‑
mandible
6 Anterior Multilocular Well‑defined Scalloped Corticated, Coarse, Radiolucent Buccal, lingual 3‑1, 3‑2, 4‑1 3‑1, 3‑2, 3‑3, Absent Normal Normal
mandible thin curved 4‑1, 4‑2, 4‑3
7 Posterior Unilocular Well‑defined Smooth Corticated, Absent Radiolucent Buccal, lingual, Absent Absent Absent Normal Thinning and
mandible, thick inferior border expansion
inferior ramus of mandible
8 Anterior Multilocular Well‑defined Scalloped Corticated, Coarse, Radiolucent Buccal, lingual 3‑1, 3‑2, 3‑3, 3‑1, 3‑2, Absent Normal Normal
mandible thick curved 3‑4, 3‑5, 4‑1, 4‑1, 4‑2
4‑2, 4‑3, 4‑4
9 Posterior Unilocular Well‑defined Smooth Corticated, Absent Radiolucent Buccal, inferior Absent 4‑8 Present Normal Normal
mandible, thick border of 4‑8
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entire ramus mandible

10 Posterior Multilocular Well‑defined Scalloped Corticated, Thin, Radiolucent Buccal Absent 4‑8 Present Normal Normal
mandible, thick curved 4‑8
entire ramus
11 Posterior Multilocular Well‑defined Scalloped Corticated, Thin, Mixed, Buccal, lingual, 3‑4, 3‑5, 3‑4, 3‑5, Absent Normal Thinning and
mandible, thick curved soap‑bubble inferior border 3‑6, 3‑7 3‑6, 3‑7 expansion
entire ramus appearance of mandible
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was satisfactory in all the patients and there are currently no seen in 70% cases, with displacement of teeth also noted in
signs of recurrence in any of the patients. 70% of our cases. According to White and Pharoah[2] and Kim
and Jang,[12] around 10-15% may be associated with a non-
Discussion erupted tooth, often a mandibular third molar. Two of our
cases (22.22%) were associated with impacted mandibular
Conventional ameloblastomas are usually seen between third molars. Unicystic types of ameloblastoma may cause
20 and 50 years of age, while the unicystic variant may occur extreme expansion of the mandibular ramus and often the
in younger patients (20‑30 years of age).[2] In the present case anterior border of the ramus is no longer visible on the
series, six of the 11 cases were seen in the 2‑3rd decade of panoramic image.[2] This feature was noted in two of the
life, which is in agreement with previous studies by White unicystic cases in this series.
and Pharoah,[2] Reichart et al.,[5] and Cosola et al.[11] We found
a male-to-female ratio of 1:1.75, which is similar to that Histopathologically, we found that the unicystic pattern
reported by Al‑Khateeb and Ababneh.[8] In this case series, was the most common (45.45%), followed by the follicular
we documented the occurrence of ameloblastomas at a pattern (27.27% cases). Six ameloblastomas showed a variable
significantly younger age in males (mean age of 23.3 years), extent of micro‑cyst formation, while four tumors were
when compared to that in females (mean age of 41 years), entirely cystic (unicystic). These unicystic tumors contained
which differs from previously reported cases in the literature. mural and/or intraluminal thickenings that consisted of
tumor cells. None of the cases showed infiltration beyond
Most ameloblastomas develop in the mandible (up to 75%), the cystic confines.
usually in the molar‑ascending ramus region, and 15% in
maxilla (usually in third molar area).[2,5] 10 out of our 11 cases Conclusion
occurred in the mandible (90.9%), with seven cases occurring
in the posterior mandible (ramus and molar region), which In contrast to other reports, we found that ameloblastomas
corroborates with the findings obtained by Cosola et  al.[11] were more common in females at an older age and occurred at
and Kim and Jang.[12] The only maxillary ameloblastoma that a much younger age in males. The diagnosis of ameloblastoma
we found turned out to be a desmoplastic variant. 10 of can be based on the following radiographic features (starting
our cases presented with a chief complaint of a painless with the most common): (1) Occurrence in the mandible,
extra‑oral swelling, which is similar to what has been reported (2) multilocular radiolucency with well‑defined, corticated,
by White and Pharoah[2] and Al‑Khateeb and Ababneh,[8] scalloped margins, (3) expansion of buccal cortical plate,
with pain being a feature in only one case. According to (4) expansion of lingual cortical plate, (5) presence of curved
Worth,[4] the most common radiographic appearance of septae within the lesion, (6) root resorption, (7) displacement
ameloblastoma is a multilocular radiolucency with a corticated of teeth, (8) involvement of ramus of mandible, (9) thinning of
border, and margins, which usually show irregular scalloping. inferior border of mandible, and (10) non‑erupted mandibular
In the present series, a multilocular appearance was seen in third molar.
70% cases, while 30% cases showed a unilocular appearance.
This is in contrast to Reichart, et al.,[5] who found a multilocular References
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Av Odontoestomatol 2007;23:367‑73. Source of Support: Nil. Conflict of Interest: None declared.

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