Republic of Iraq
Ministry of higher Education
And Scientific Research
University of Baghdad
College of Dentistry
AMELOBLASTIC FIBROMA
A project submitted to the Council of the College of Dentistry at
the University of Baghdad, Department of Pathology Dentistry
in Partial Fulfillment of the Requirement for B. D. S degree.
Prepared by
Haidar Abdul Karim Hadi
Supervised by
Dr. Omer Shebly
B.D.S M.S.C
Dedication
I dedicate this project to God almight my creator, my source of inspiration,
wisdom, knowledge and understanding.
To my great teacher and messenger Mohammed who taught us the
purpose of life.
To my father, my source of support and encouragement who could not be
here in these special days.
To my mother, who support me all my life and made me the better person
I am today, I can’t find enough words to express my gratitude to you .
To all my family encourage and support me.
To all who teach me even a small lesson or even a word.
To my friends who encourage and support me.
Acknowledgment
We thank God for giving us the patience and strength to accomplish this
work.
I would like to express my gratitude to Dr. Nada Jaafar, dean of College
of Dentistry, University of Baghdad.
My appreciation and deepest gratitude to my supervisor Dr. Omer Shebly
for his thoughtful guidance, suggestion and encouragement.
Abstract
Ameloblastic fibroma is a rare, benign odontogenic neoplasm
comprising about 1.5– 4.5% of all odontogenic tumors.
The prevalence and incidence of the tumor is unknown.
The Ameloblastic fibroma is usually painless, the most common symptom
is swelling, which is found in almost all cases, Because of the insignificant
symptoms, about 20% of the tumors are discovered accidentally on
radiograms.
Radiologically, the tumor appears as a well-defined, uni- or multilocular
radiolucency, often with a radiopaque border. The multilocular
appearance particularly seen in larger lesions, which present with a
swelling.
Macroscopically, the tumor presents as a gray or whitish, rounded or oval
soft mass with a lobular configuration and a smooth surface that seems
covered with a thin capsule-like tissue.
Table of content
Introduction……………………………………………………………1
Clinical feature………………………………………………………...2
Radiographic feature…………………………………………………..3
Histopathology………………………………………………………...4
Treatment and prognosis………………………………………………7
INTRODUCTION
It is a rare, benign odontogenic neoplasm comprising about 1.5– 4.5%
of all odontogenic tumors. (Philipsen HP et al., 1997).
It is defined by WHO as ‘‘consists of odontogenic ectomesenchyme
resembling the dental papilla and epithelial strands and nests resembling
dental lamina and enamel organ. No dental hard tissues are
present.’’(Barnes L et al., 2005).
In the earlier years of the last century, it has recorded under different
headings, with the most common one being the ameloblastoma
(adamantinoma). In 1946, Thoma and Goldman were the first to classify
this tumor as a separate entity (Thoma KH et al., 1946).
The opinion that Ameloblastic fibroma exhibits somewhat slow clinical
growth and well encapsulated and shows most authors supported an
innocuous benign behavior; thus, conservative treatment in keeping with
the behavior of Ameloblastic fibroma recommended. (Hansen LS et al.,
1988).
On the other hand, some authors believed that Ameloblastic fibroma is
more aggressive than it had been thought, and a more radical therapy
needed based on reviewing recurrent or malignantly transformed cases in
the literature (Trodahl JN, 1972).
1
CLINICAL FEATURE
The prevalence and incidence of the tumor is unknown.
In most of the surveys, the percentage has been between 1.2% and 1.8%,
and most of the cases are young age and it found in males more than
females in a small percentage, and the most common site is the posterior
area of the mandible (Barnes L et al, 2005).
The Ameloblastic fibroma is usually painless (Trodahl JN, 1972)
The most common symptom is swelling, which is found in almost all
cases (Chen Y, 2005).
Because of the insignificant symptoms, about 20% of the tumors are
discovered accidentally on radiograms (Chen Y et al. 2007).
Unerupted teeth are associated with the tumors in three out of four cases
(Philipsen HP et al. 1997).
Figure 1: clinical photograph of patient with ameloblastic fibroma
2
RADIOGRAPHIC FEATURE
Radiologically, the tumor appears as a well-defined, uni- or multilocular
radiolucency, often with a radiopaque border. The multilocular
appearance particularly seen in larger lesions, which present with a
swelling (Chen Y et al., 2007).
In 8 of 10 lesions reported by Chen et al. (Chen Y et al., 2005), the
radiolucency was multilocular; in 2 cases measuring 3 × 2 cm and 4.5 × 2
cm, it was unilocular. Among 38 cases from the literature, Chen et al.
(Chen Y et al., 2007) recorded 23 multilocular and 15 unilocular cases.
The asymptomatic cases tended to show unilocular radiolucency.
In about 75% of the cases, the tumors are related to an unerupted tooth. In
the maxilla, the ameloblastic fibroma may encroach the maxillary sinus.
CT scanning is recommended, particularly for large tumors; it improves
the information about the outline of the tumor.
Figure 2 : ameloblastic fibroma of young adult
3
HISTOPATHOLOGY
Macroscopically, the tumor presents as a gray or whitish, rounded or oval
soft mass with a lobular configuration and a smooth surface that seems
covered with a thin capsule-like tissue. The cut surface is uniform; cystic
changes are absent or inconspicuous, apart from the very unusual cases
where the tumor develops in the wall of a cyst (Edwards MB et al., 1980).
Microscopically, the tumor is composed of strands and islands of
odontogenic epithelium growing in a cell-rich mesenchymal tissue with a
histomorphology similar to that of the dental papilla.
The periphery of the tumor is well-demarcated; a thin capsule has been
described in cases, which might rather be early stages of an odontoma
(Trott JR, 1967).
The amount and density of epithelium varies from tumor to tumor and
may vary considerably from area to area within the same tumor. The
strands are usually composed of a double layer of cuboidal cells and
resemble the dental lamina. In some areas, the strands are broader, and the
central area occupied by stellate cells.
The strands are ramifications, a pattern that may be more or less
conspicuous. Buds of varying sizes develop from the epithelial strands;
they are composed of stellate cells bordered by a basal layer of cylindrical
cells with a reverse nuclear polarity and morphology-like preameloblasts.
These bulbous thickenings resemble the early stages of enamel organs.
Cyst formation within the epithelium is very uncommon, and the cysts
remain small. Artefactual splits along the plane between the layers of the
bilaminar epithelial strands are not unusual. Acanthomatous changes are
rare (Odell EW et al., 1998).
4
Islands of tumor epithelium may be found in the adjacent connective
tissue and might represent a growth pattern (Becker J et al., 1992).
The ectomesenchymal tumor component is highly cellular and shows a
striking similarity to the dental papilla. The morphology of the cells
varies, most are stellate with fine cytoplasmic processes and angular
nuclei, others are plumb, and fibroblast-like cells may also be seen.
The matrix is myxoid and contains fine, fibrillary collagen. The cellularity
and matrix composition may vary from tumor to tumor, and within a given
tumor (Odell EW et al., 1998), more mature collagenous fibers may be
present in some areas.
The vascularity is modest. Adjacent to the epithelial strands and mainly
the bulbous extensions, narrow, eosinophilic cell-free zones may be seen.
More pronounced changes in terms of eosinophilic, hyalinized matrix is
seen in some tumors.
Such structural alterations interpreted as the result of aberrant epithelial–
ectomesenchymal inductive effects. Other types of reaction zones have
been described. In some tumors, enclaves of ramified strands of
epithelium surrounded by broad zones of ectomesenchyme characterized
by moderate cellularity are separated by plexiform strands of
ectomesenchyme with high cellularity (Pfluger H, 1956).
Mitoses with normal morphology may be found in the epithelium as well
as in the ectomesenchyme. Together with a high cellularity, it may
provoke suspicion of malignancy. If more than a few scattered mitoses are
present and particularly in case of nuclear atypia, this possibility must be
taken in consideration (Slootweg PJ, 2005).
5
Figure 3 : Section of a tumor from the molar and retromolar area of the left mandible
of a 9-year-old boy. Ramified thin dental lamina-like strands of odontogenic
epithelium are seen in a dental papilla-like ectomesenchyme, which exhibits
variations in cellular density. The vascularity is low. H&E stain.
6
TREATMENT AND PROGNOSIS
Ameloblastic fibroma has been treated with conservative as well as
radical surgery. For many years it has been known that the ameloblastic
fibroma is capable of recurrence (Trodahl JN, 1972), and sometimes even
twice (Monteil RA et al., 1986).
In a few cases, the recurrence has shown a higher differentiation with the
formation of dentin or even enamel, indicating that perhaps the primary
tumor was not a genuine ameloblastic fibroma, but rather an early stage
of ameloblastic fibro-odontoma. In more than 90% of the cases, the
recurrence shows the same or a lower differentiation (Chen Y et al.,
2007), and in some, the recurrence show transformation into an
ameloblastic fibrosarcoma (Williams MD et al., 2007).
Figure 4 : recurrent ameloblastic fibroma
7
Chen et al. (Chen Y et al., 2007) reviewed the available English language
literature since 1891 and selected 123 cases of ameloblastic fibroma with
well-documented follow-up data to evaluate the clinical, pathological, and
behavioral aspects of this tumor.
The treatment recorded as conservative (enucleation, curettage, simple
excision) or radical (marginal resection, segmental resection, semi
resection of the jaw). The treatment mode was detailed in 118 cases.
Conservative procedures primarily treated over 90% (108 cases) of the
patients; 10 patients were treated radically due to the extensive size of the
tumor.
Recurrence was reported in 41 cases (33.3%). The period of follow-up
was stated in 94 cases. The 5- year and 10-year recurrence rate was 41.6%
and 69.2%, respectively.
Recurrence-free period ranged from 1 month to 96 months, with a mean
of 33.2 months. A univariate analysis of all the data showed that only the
treatment mode of the patients was significantly related to recurrence. The
recurrence-free period was significantly longer in patients treated with
radical procedures. Malignant transformation was reported in 14 recurrent
cases (11.4%).
The 5-year and 10-year malignant transformation rate was 10.2% and
22.2%, respectively. The malignant transformation-free period ranged
from 9 months to 264 months, with a mean of 79.0 months.
In 11 cases, follow-up after the treatment of the malignant tumor was
recorded; five patients were alive with no signs of recurrence, the other
six cases recurred following surgery. Only one had extensive distal
metastasis.
Of the six recurrent cases, two died of disease. A statistical analysis of the
recorded data showed that only the age of the patient at the first
8
presentation was significantly related to the malignant transformation of
ameloblastic fibroma.
Patients younger than 22 years were unlikely to develop malignant
transformation in comparison with patients older than 22 years. It could
be argued that the rates of recurrence and malignant transformation were
overestimated because such cases are more likely to be documented.
However, in two series with more than 10 cases reported, the recurrence
rate was 36.4% (Chen Y et al., 2005) and 45.5% (Trodahl JN, 1972),
respectively, and the rate of malignant transformation in a series of 11
cases was even higher, 18.2%. It was concluded that it is reasonable to
treat patients younger than 22 years by conservative surgeries and to apply
a step-wise treatment principle to patients with multiple recurrences
whose age was younger than 22 years.
In patients older than 22 years, radical surgery should be considered when
the tumor is massive in size or when the tumor recurred more than once.
9
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