 Hello everyone, welcome back to another session on dentistry and more. So today we have a new section in oral pathology that is calcifying epithelial odendogenic tumor or CEOT which is widely known as Pinburg tumor. So we have N number of tumors to cover up. So last sessions we covered various syndromes, we have covered around 9-10 syndromes. Now we are moving on to tumor section and the first one is CEOT or Pinburg tumor. So let's see the details of CEOT. Calcifying epithelial odendogenic tumor CEOT or Pinburg tumor which is benign in nature epithelial in origin and odendogenic one. So odendogenic means it is nothing but which is derived from a specialized dental tissue. So Pinburg tumors are locally invasive epithelial odendogenic neoplasm which is characterized by presence of amylode material that may become calcified. So it has a peculiar amylode material which may become calcified over a period of time and it was first described by Dr. Jens J. Pinburg. Now let's move on to the pathogenesis. So according to various authors the Pinburg himself said it is originated from odendogenic epithelium, some others said it is from reduced enamel epithelium of closely related an uninterrupted tooth or some are saying the possibility that it arises from rest of dental lamina or from basal cells of oral epithelium. So the origin has various theories or various concepts. It could be odendogenic epithelium, reduced enamel epithelium of an uninterrupted tooth and rest of dental lamina or basal cell of oral epithelium and it is associated with mutation of PTCH gene. While moving on to the epidemiology it is most commonly seen among 20 to 60 year old and the mean age is 40 years and the male to female ratio is almost same but a little higher predilection male that is 6 to 5 ratio and it is just 1 percentage of all odendogenic tumors and it has basically two types that is intraoschus or central type and extraoschus or peripheral type. Intraoschus is the most common that is 94 percentage which is seen in mandible region compared to maxilla it is a posterior part of the bone mandible or maxilla so it has mandible have twice more occurrence compared to maxilla and the peripheral type which is seen in anterior part that is extraoschus type. This is intraoschus that is a central one peripheral one is extraoschus. The premolar molar region is a most affected one and while moving on to the clinical features which is a pain less mass with slow growth and it is associated with an impacted or unirrupted tooth there will be nasal congestion epistaxis or headache and this peripheral soft tissue or extraoschus type the CEOT appears most commonly as a pain less firm gingival mass that is this type anterior gingival mass as it appears in peripheral or extraoschus type and it shows little bit of ulceration on overlying mucosa and sometimes if we go for surgical removal an underlying bone in depression or softurization has been seen in some cases so these are the clinical features so we covered pathogenesis epidemiology and clinical features now let's move on to the radiographic features. So radiographic features we can see mixed radiolucent and radio opaque areas and can be unilocular or multi-locular type and the most striking feature of CEOT is honeycomb or soap bubble appearance because of the scattered radio opacities can be wind-driven or snow-falling type so never forget these two honeycomb or soap bubble or snow-falling or wind-driven appearance it coming in radiographic features because of its specular radiolucent or radio opaque areas now we have histopathology what are the cells seen in the staining process that is it is epithelial cells are present so these epithelial cells which are like polyhedral in the form of sheets, strands or nests and these cells usually closely packed with few areas showing intracellular bridges and they may have indistinct outline or isnophilic and a homogeneous cytoplasm and the cells resembles the cells of stratum intermedium of enamel organ so it has epithelial cells and the next one is isnophilic material which is seen between the epithelial cells and the stroma and it is thought to be synthesized by the epithelial cells and next thing is calcified deposit that is the unique feature of this tumor that's why its name came calcifying epithelial odendogenic tumors which are seen to be associated with amyloid deposits and can either be calcified amyloid or calcified collision so this calcification it can be in the form of lamellae formed by the fusion of small calcific deposits at different foci and they are referred to as lisegang rings so this is another unique feature of ceot lisegang rings and how it forms the calcified deposits it the lamellae formed by the fusion of small calcified deposits at different foci so different foci this calcified deposits will form and it becomes lisegang ring and also symptom like deposition is seen only after the amyloid is fully calcified so the next is it can also have nuclear pleomorphism with intercellular bridge and amyloid like material will be there cement and like components and also clear cells and it could be langer hand cells so langer hand cells we had seen we had discussed in our cells that is pathognomic cells we had discussed it already so clear cells and langer hand cells are seen not in every cases but it is reported now we have differential diagnosis so what are the differential diagnosis so it could be amyloblastoma, regional or endodysplasia, dentiturus cyst, or endogenic keratocyst, or endogenic myxoma these all could be the differential diagnosis of ceot and treatment part treatment part is basically surgical enucleation and also in severe widespread cases we should go for hemimantibulectomy or hemimaxylectomy and prognosis is overall prognosis good and there is recurrence rate around 15 percentage so that's summary of calcifying epithelial, endogenic tumor the takeaway points is its radiographic features that is honeycomb or soap bubble appearance and wind driven or falling snow appearance and also the lisagang rings lisagang rings it's very peculiar because it is a calcified ring so calcification happens that is a unique feature of ceot from the name itself you should understand that there is calcification and it is associated with lisagang rings so when you're writing about a tumor so you should go for these subreddings like pathogenesis a little bit about introduction epidemiology clinical features radiographic features histopathology and differential diagnosis treatment and prognosis and always make sure that you highlight all these striking features like honeycomb wind driven or snow falling and lisagang rings so i'll come up with a new tumor in my next session in dentistry and more thank you hello everyone welcome back to a new session on dentistry and more today we have a different tumor that is a denominated or endogenic tumor or aot so last class we have covered ceot that is calcifying epithelial or endogenic tumor from the name itself we'll get an idea about the tumor so this is adenomatode or endogenic tumor anyway or endogenic is something related to tooth or tooth forming tissues that is clear so adenomatode is adenomins something related to gland so this tumor has peculiar gland like appearance or gland like structures that is why this called adenomatode or endogenic tumor now let's get into details of aot so adenomatoid or endogenic tumor as the name suggests it is a gland like structure formation in histological features that's why it got the specular name so we'll come to that later now let's see the basic introduction of this so it is also known as adeno amyloblastoma or amyloblastic adenomatoid tumor so it is always or sometimes in the previous time mistagnosed as amyloblastoma that is why it got this name that is adenomamyloblastoma and amyloblastic adenomatoid tumor so the one of the differential diagnosis is amyloblastoma aot or adenomatode or endogenic tumor which is benign in nature non-invasive type but progressive lesion which is most commonly associated with unerupted maxillary canine so I also mentioned it as hamatomatous lesion hamatomatous is nothing but a disorganized growth which is mimicking a neoplasm but the difference between hamatoma and benign neoplasm is like it's growth rate we cannot measure there is no measurable growth rate is there whereas the benign tumor has growth rate measurable growth rate and it is basically composed of tissues of origin within it is found so it is not a particularly benign lesion hamatomatous is little different from benign lesion so it is most commonly seen I mentioned it is most commonly seen with maxillary canine unerupted maxillary canine and it is the fourth most common odendogenic tumor so among odendogenic tumor it is the fourth most common one and it can be divided into two variants basically one is central that is intraoscious and peripheral which is extraoscious okay so it has basically two types central intraoscious and peripheral extraoscious so the central variant that is the intraoscious type has follicular and extra follicular subtypes follicular and extra follicular the follicular type will be associated with an impacted tooth and is the one which commonly get confused with the dentigerocyst so it has central and peripheral that is intraoscious and extraoscious intraoscious again has subtypes which is follicular and extra follicular follicular is the one which is associated with an impacted tooth and which is commonly get confused as dentigerocyst so sometimes it is also seen that cases with both aot and dentigerocyst sometimes it get confused so sometimes very rarely both aot and dentigerocyst will be there in the same place in the two to three decade that is 20 to 30 years or the 10 to 20 or 20 to 30 years that is a second and third decade and it is most commonly or mostly seen in anterior part of maxilla it is slowly enlarging a swelling type sometimes the gums will be very swollen the ginger will be very swollen and it is associated with an impacted tooth and mostly a maxillary canine so females are most commonly affected than males maxilla is affected than mandible anterior part is affected than the posterior so it is seen in second and third decade anterior maxilla is mostly affected it is a slowly enlarging swelling which is associated with impacted tooth so when you are studying aot that is adenomatoid autentogenic tumor the two key points are it is like a adenomatoid that is a gland leg structures are present and another thing is it is associated with uneruptured maxillary canine so these two are the take away points of aot it has the adenomatoid structures that is gland leg structures adeno is nothing but gland leg and it is associated with uneruptured maxillary canine now we will move on to the radiographic features so radiographic features basically it is a radiolucent lesion and well defined radiolucent lesion and sometimes it gets calcified in some areas or some cases it get calcified few areas the those areas will be shown in radiograph as radio capacities and it is associated with as we know an uneruptured tooth and it sometimes looks like a dentiturus cyst so dentiturus is also associated with aneruptured tooth so it sometimes misdiagnosed as dentiturus cyst now move on to the histology histology part is the most important part there we have this adenomatoid structures so it is a well encapsulated solid or partly cystic lesions so it is well encapsulated solid or partly cystic lesion so on histology it shows sheets strands and whole masses of epithelium which differentiate into columnar amyloblast like cells so can roughly seen the columnar type cells columnar type cells this is not a very good picture I just want to show the duct like structures with columnar cells aligned at the periphery so sheets strands or whole masses of epithelium so epithelium is differentiated so epithelium is changed into columnar amyloblast like cells which forms it so these columnar cells forming the duct or tubular like structures so this is a tubular like structure so that's why it got the specular name that is adenomatoid tumor because of its tubular like structures how this tubular like structure forming because the columnar cells differentiated or arranged themselves like this making a duct like or tubular like structures so it has a central space containing homogeneous ismophilic rim of various thickness so that ring is particularly known as hyaline ring so it forms as a hyaline ring and the other features like stellate reticulum like spindle cells occasional round or polygonal epithelial cell which dominate the tissue between cell rich nodules so that is just a histological characteristics the stellate reticulum like spindle cells occasional round or polygonal epithelial cells which dominate the tissue between cell rich nodules and small amount of ismophilic material or calcification also may be present between the cells so little bit of calcification or ismophilic material also seen between the cells so this is the duct like structure so this is the duct like structures lined by one or two columnar cells so these are the columnar cells which is lining the duct like structure so this is the characteristic feature of AOT so this is the key point this is a takeaway point that is a duct like structure in histology so if you are seeing a histology slide also it is very easy to understand AOT so there will be a duct like structure however this is warming this is by differentiation of columnar cells columnar cells arranged at the periphery one or two columnar cells making a duct like structure so adenomatoid or androgenic tumor is also known as adeno amyloblastoma or amyloblastic adenomatoid tumor so the two key points are which is associated with unelected maxillary canine and it has adenoduct like or tubular like structures with columnar cells at the borders and the treatment is most commonly it is enucleated it is basically a conservative surgical excision rather than the radical one and it is most commonly it does not hello everyone welcome back to a new session on dentistry and more today's topic is amyloblastoma or adenomatoma it is a most important topic in oral pathology that is coming under adenogenic tumors so in adenogenic tumors we have seen AOT that is adenomatoid adenogenic tumor and the next one was the EOT calcifying epithelial adenogenic tumor and the most important one is amyloblastoma so all our adenogenic tumors it is dental related tissues are the cause or the origin it is originated from dental related tissues now let's move on to amyloblastoma or adenomatoma from the name itself we get an idea about the tumor that is amyloblastoma so amyloblast means venomeloblast so it is related to enamel and blastro means germ so it is originating from enamel tissues that is why it got amyloblastoma and another name is adenomatoma because it is adenomatoma another tumor which is seen in the longer bones the histological similarity with that type of tumors with the amyloblastoma gave this name to amyloblastoma that is adenomatoma so the histological similarities between the adenomatoma of longer bones so it got two names amyloblastoma or adenomatoma so Robinson defined this amyloblastoma as unicentric non-functional intermittent in growth anatomically benign and clinically persistent so it is a unicentric non-functional intermittent in growth anatomically benign and clinically persistent tumor so we can classify it under two headings one is clinical classification another one is histological classification in clinical classification the most common is central variant that is the intra-ocious type so in intra-ocious type we have two types that is the most common one that is multi-cystic variant that is conventional or multi-cystic or solid type tumors and the second one is unicistic that is in central or intra-ocious variant the next one is extra-ocious or peripheral and another type is pituitary amyloblastoma and the last one is malignant amyloblastoma this is clinical classification central peripheral pituitary malignant in central we have multi-cystic and unicistic and multi-cystic is the most common type in histological type it is based on the histological appearance follicular plexiform acanthomatous granular basal cell and dysmoplastic so it is follicular plexiform acanthomatous granular basal cell and dysmoplastic now let's see what are the etiological factors for amyloblastoma the common etiologies are traumatic episodes so the trauma happening to these structures and extraction cystectomy and various type of fractures infection and dietary deficiency especially vitamin D and lack of protein intake and viral infections so all these could be etiological factors for amyloblastoma so it could be a trauma extraction cystectomy fractures infection vitamin D deficiency lack of protein intake and viral infection so in pathogenesis it is believed that it is derived either from cell rest of enamel organ remnants of dental lamina heart wicks sheath epithelial rest of malasis so all these could be the originating factor because it is originating from enamel tissues and also could be epithelium of odendogenic cyst most commonly the dentiture assist and otentoma and also it could be from basal cell of surface epithelium of jaw and it could be due to the disturbance of developing enamel organ and also from heterotopic epithelium of pituitary gland so that is about pathogenesis so we discussed the classification that is clinical and histological type etiology and pathogenesis so the clinical features include that most commonly seen between 20 to 50 years of age group and there is no gender prediction it is both the genders are equally affected there is no prediction for a particular gender but the black race people are more affected than the white race and the mandible is almost affected by 80 percentage cases and maxilla only 20 percentage are restricted to maxilla and mandibular molars areas are more prone for ameloblastoma compared to the anterior or premolar areas while moving on to the science and symptoms it is a slow growing painless hard and non-tender avoid swelling okay it is a very slowly growing painless hard non-tender avoid swelling which enlarges in size as it causes little discomfort in early stage so at the early stage it is very asymptomatic it does not cause any pain so any other symptoms so it slowly slowly it enlarges to become a avoid swelling and large mass so facial asymmetry will be a problem there will be mobility of teeth and exfoliation and the dentures will be ill-fitting because of this enlarged size of the maxilla or the mandible and pain or parasitia if any nerve is impinged we have various nerves in these areas we have inferior alveolar nerve we have mandibular nerve we have facial nerve so parasitia will be there affected there will be parasitia pain and there will be inability to occlude and there will be ulcerations so it is a slowly growing painless mass because there will be very little discomfort in the early stages it's so it continuously grows unless it shows any very clinical evidence symptoms in absence of treatment if it is left untreated what happens it will become extremely disfiguring fungating and ulcerative mass with axial cracking and fluctuation so it keep on increasing if it is not treated so there will be disfiguring and fungating and it will become very ulcerative and there will be axial cracking and there will be fluctuation so the palpitation elicit heart sensation on and her crepitus also will be there so crepitus or heart sensation on palpitation also will be seen if it is not treated so it is not an encapsulated tumor and it invades the surrounding tissue and the bone destruction as a very common feature in amyloblastoma also root resorption because it is continuously growing and it invades the surrounding tissues surrounding bones will be destroyed the root resorption will be there so what happens if it is in case of maxilla so it is commonly affecting tuberosity it causes nasal obstruction proptosis of eye damage to the vital structure and it involves cranial base so there will be gross facial distortion if it is in the maxilla maxillary bone mural amyloblastoma is nothing but amyloblastoma from a dentigel assist so the histological features it has tall columnar cell hyperchromatic nucleus palisade nucleus reverse polarity of nuclei and sub nuclear vesicle formation so this is a histological features so amyloblastoma it is a lengthier topic so we have seen the basic features and clinical features science and symptoms what happens if it is not treated and in case of maxilla and about histology parts now we have various histological types of amyloblastoma now let's see the histological classification of amyloblastoma so in histological type so it is divided into six types follicular plexiform acanthameters granular basal cell and dysmoplastic so it is based on the histological picture or histological detailing of amyloblastoma so we have seen based on the clinical features also so now let's see one by one so in follicular pattern it is all explaining the histological pictures so it's not very easy to draw and explain it anyway let me explain it without picture so when you're writing for exam always keep pictures for any syndrome the histological explaining requires pictures so let's see the details follicular type the small discrete islands of tumor cells with peripheral cuboidal or columnar cells nuclei will be polarized and it resembles a amyloblast amyloblast we know the enamel forming cells and cyst formation is relatively common cellate reticulum like cells prominently enclosed by columnar or cuboidal cells so it has nuclei polarized with peripheral columnar cells and the cyst formation is common and follicular type of amyloblastoma the second one is plexiform the cells that is amyloblast like cells arranged in irregular masses okay so here we have small discrete islands of tumor cells here it is irregular masses and network of interconnecting strands of cells and each strand is bound bounded by a columnar cell the columnar cell is common in all type of amyloblastoma so between this cellate reticulum we have less prominent tissues compared to the follicular amyloblastoma so the cellate reticulum like tissues is less prominent and here it is more prominent whereas plexiform it is less prominent and areas of cystic degeneration is also common acanthomatous type the cells occupying the position of cellate reticulum undergo squamous metaplesia so cellate reticulum like cells are present all the types so acanthomatous that is the name itself saying acanthomatous we know what is acantholysis we have seen in pemphigus so acanthomatous is a cell to cell adhesion so here we are getting a squamous metaplesia and keratin formation or keratin pulse is seen whereas granular cells it is marked transformation of stellate reticulum reticula cells it becomes a coarse granular esophilic appearance type with peripheral columnar and also hyperchromatism and also reverse polarity is also seen the basal cell type is why it is known as basal cell type basal cell amyloblastoma because it resembles basal cell carcinoma of skin that is bcc and it is the rarest form of amyloblastoma that is histological type and we can see hyperchromatic less columnar which is arranged in sheets without peripheral palisading nature so that is about basal cell the desmoplastic is we have dense collagen stroma which is hypocellular and hyalinized which is grow in thin strands and chords of epithelium which proliferation seems to be compressed and fragmented by hyalinized stroma so in desmoplastic we have a collagen stroma which is hypocellular and hyalinized and this proliferation compress and fragments the hyalinized stroma so this proliferation will compress and it make the stroma fragmented appearance in desmoplastic so it is more of a content in amyloblastoma if it is asked for a very longer question that is 14 mile question you can build up the content by writing this histological type that is follicular plexiform acanthomatous granular basal cell and desmoplastic so every type you need to have a key point so follicular type it is like nucleus polarized and it resembles amyloblast plexiform it is less prominent follicular amyloblast that is teletreticulum type tissues less prominent here in acanthomatous there is squamous metaplasia in granular cells this teletreticulum becomes coarse granule granular isnophilic appearance in basal cell it looks like basal cell casinoma desmoplastic this compression and fragmentation of hyalinized stroma will be there so most of the features are same for all but it differs that's why it got this name so from the name itself we get an idea how it differs so that is about histology type of amyloblastoma the next variety is unicystic amyloblastoma this we had seen in clinical classification where we had a multisystic that is very common unicystic is not very common type so unicystic amyloblastoma which is nothing but a single cystic cavity unlike the multisystic amyloblastoma it is seen in very younger group that is around 20 years and the gender prediction is same as a multisystic the male and female has equal chances of getting this unicystic and it is most commonly seen in 90 percentage of in mandible and that also in posterior part and it is typically surrounds the crown of uninterrupted third molar so third molar associated amyloblastoma is unicystic one and it has basically three types that is luminal, intraluminal and murals so luminal is nothing but the tumor is confined to the luminal surface of the cyst by fibrous connective tissue partially or totally so this is luminal type it is confined to the luminal surface of the cyst by fibrous connective tissue intraluminal the tumor nodules projects from the cystic lining the tumor nodules projects from cystic lining and the mural one is the tumor infiltrates the fibrous cystic wall so these are the three types of unicystic amyloblastoma in mural type the tumor infiltrates the fibrous cystic wall and coming to the radiographic features so radiographic features are unilocular or multi-locular radiolucency can be seen and there is a striking radiographic appearance in unicystic amyloblastoma or amyloblastoma that is honeycomb or soap bubble appearance okay so honeycomb or soap bubble appearance so it will be like compartments compartment soap bubble we know how soap bubble appears all will be clubbed together a bunch of soap bubbles so the multi-locular radiolucency with compartmentalized appearance due to the bony septa so there will be radiolucency a big radiolucency but there will be compartmentalization due to the bone septum in between so it gives a honeycomb appearance or a soap bubble appearance that is a characteristic radiographic feature of unicystic amyloblastoma now we have investigation that is mostly the radiographs will be taken and we can go for biopsy and also CT MRI or ultrasound so apart from unicystic amyloblastoma we have malignant amyloblastoma pituitary amyloblastoma and peripheral amyloblastoma which are not very much important so peripheral amyloblastoma is like very rare type which develops in soft tissues of ginger and mucosa and it is non-invasive whereas pituitary amyloblastoma is like it is also known as ratkis pouch tumor which involves neoplasma of CNS whereas malignant amyloblastoma it is a malignant transformation of normal amyloblastoma which is a very very rare relation so those are the three types which we have seen in classification I am malignant pituitary and peripheral amyloblastoma now how do we go with the treatment so what are the treatment options we have many treatment options that is radical and conservative surgical excision end block resection segmental resection, curetech, chemical and electrocautery chemotherapy and radiation so simple excision or nucleation is also there so if we have the peripheral amyloblastoma we can do a simple excision a nucleation or curetech is in peripheral amyloblastoma it is a removal of tumor by scraping it from the surrounding normal tissue so that is an ennogulation or curetech end block resection is removal of tumor with a rim of uninvolved bone but maintaining the continuity of jaw so in end block resection we are removing a rim of uninvolved bone but we will continue or maintain the the jaw it will not be completely or it will not be segmented next one is segmental resection it is removal of a segment of maxilla or mandible up to the including hemi section or more so end block resection it will not be segmented only a part of normal bone will be removed in segmental resection the segment of maxilla or mandible removal it may include hemi maxillectomy or hemi mandiblectomy and this is the most commonly used treatment because it has very less chance of recurrence segmental resections so it is noted that the lesion most likely to recur after segmental resection are those over 5 centimeter so more than 5 centimeter will have a chance of recurrence even after the segmental resection so chemotherapy we know we do chemotherapy using platinum agents we can we can use cyclophosphamide cisplatin windblastin and electrocortree is another method and we have also radiation therapy so we finished ameloblastoma it was a very lengthy session because it has various classification classification based on clinical nature and the histological type then we had seen the pathogenesis the clinical features the radiot features and the histological type unisistic and its detailed and various treatment options investigation so ameloblastoma is an odendogenic tumor and one of the most common odendogenic tumor it is along with ceot and aot calcifying epithelial or pinbox tumor and adenomatoid odendogenic tumor ameloblastoma so these are a very common question a commonly asked essay question ceot aot and ameloblastoma so i'll come up with a new session in dentistry and more thank you