UNIVERSIDADE ESTADUAL PAULISTA

“JÚLIO DE MESQUITA FILHO”

Instituto de Ciência e Tecnologia

Campus de São José dos Campos

ORIGINAL ARTICLE DOI: https://doi.org/10.4322/bds.2023.e3645

Braz Dent Sci 2023 Apr/Jun.;26 (2): e3645

Frequency of central odontogenic tumors: a retrospective study

in an Iraqi population utilizing 2022 WHO head and neck tumors

classiﬁcation

Frequência de tumores odontogênicos centrais: um estudo retrospectivo em uma população iraquiana utilizando a

classiﬁcação de tumores de cabeça e pescoço da OMS de 2022

Osama Mohammed GHAZI



1 - University of Al-Qadisiyah, College of Dentistry, Department of Conservative Therapy, Al-Diwaniyah, Iraq.

How to cite: Ghazi OM. Frequency of central odontogenic tumors: a retrospective study in an Iraqi population utilizing 2022 WHO head

and neck tumors classication. Braz Dent Sci. 2023;26(2):e3645. https://doi.org/10.4322/bds.2023.e3645

ABSTRACT

Objectives: Odontogenic tumors occupy an important position among head and neck tumors. Although, rarely

encountered in medical practice but they considered increasingly challenging lesions for the clinicians due to their

overlapping clinical and histopathological features. This study was designed to determine the relative frequency

of central odontogenic tumors in an Iraqi population by utilizing 2022 WHO tumor classication. Material and

methods: Sixty cases of central odontogenic tumors from a total of 1869 case records were retrieved retrospectively

from the le archive of the histopathology laboratory in Baghdad medical city from the period of 2016 to 2021.

For each individual case, data regarding age, gender, location, and tumor type were collected and analyzed.

Results: odontogenic tumors constituted 3.2% of the total cases analyzed mostly benign. The male to female

ratio was 1/1. The age of the patients ranged from 11 to 75 years. Most cases were recorded in the third and

fourth decades of life (n=31, 51.6%). The most common benign and malignant tumors were ameloblastoma and

ameloblastic brosarcoma respectively. Most of these tumors located in the mandible (n= 45, 75%). The most

common mandibular tumor was ameloblastoma followed by ameloblastic broma, and odontogenic myxoma.

Regarding maxillary tumors, the predominant tumor was ameloblastoma followed by ameloblastic broma,

ameloblastic brosarcoma, and clear cell odontogenic carcinoma. Conclusions: Odontogenic tumors in an Iraqi

population occurred more commonly in the mandible and showed no sex predilection. Most cases were diagnosed

in third and fourth decades of life and ameloblastoma was the most frequent odontogenic tumor. The relative

frequency of malignant odontogenic tumors was 11.67% of all cases studied mostly ameloblastic brosarcoma.

KEYWORDS

Odontogenic tumors, WHO tumor classication, Frequency, Ameloblastoma.

RESUMO

Objetivos: Os tumores odontogênicos ocupam uma posição importante entre os tumores de cabeça e pescoço.

Embora raramente encontrados na prática médica, eles consideram lesões cada vez mais desaadoras para os clínicos

devido às suas características clínicas e histopatológicas sobrepostas. Este estudo foi desenhado para determinar

a frequência relativa de tumores odontogênicos centrais em uma população iraquiana, utilizando a classicação

de tumor da OMS de 2022. Materiais e métodos: Sessenta casos de tumores odontogênicos centrais de um total

de 1.869 registros de casos foram recuperados retrospectivamente do arquivo do laboratório de histopatologia

na cidade médica de Bagdá no período de 2016 a 2021. Para cada caso individual, dados sobre idade, sexo ,

localização e tipo de tumor foram coletados e analisados. Resultados: os tumores odontogênicos constituíram

3,2% do total de casos analisados em sua maioria benignos. A proporção entre homens e mulheres era de 1/1.

Braz Dent Sci 2023 Apr/Jun.;26 (2): e3645

Ghazi OM

Frequency of central odontogenic tumors: a retrospective study in an Iraqi population utilizing 2022 WHO head and neck tumors classification

Ghazi OM

Frequency of central odontogenic tumors: a retrospective

study in an Iraqi population utilizing 2022 WHO head and

neck tumors classiﬁcation

INTRODUCTION

Residual cells of tooth forming apparatus

may give rise to odontogenic tumors (OTs),

a heterogenous group of lesions with diverse

biological behavior ranging from hamartomatous

tumor like growth to malignant tumors with

metastatic capability. Despite being fortunately

quite uncommon these lesions provide a diagnostic

difculty for clinicians due to their overlapping

clinical, radiographical and histopathological

characteristics [1]. The world health organization

(WHO) classification scheme of tumors in

2017 reclassify (keratocystic odontogenic tumor)

as an odontogenic cyst with “odontogenic

keratocyst (OKC)” designation. This major

modification created a relative change in the

incidence of these tumors among literature [2,3].

The current 5th edition of the WHO classication

of odontogenic tumors, which was introduced

in 2022, was broadly identical to the previous

one with the exception of a newly defined

entity, adenoid ameloblastoma, which was

categorized as a benign epithelial odontogenic

tumor [4]. The purpose of current study was to

investigate the relative frequency of different

histopathological subtypes of central OTs among

Iraqi population within ve-year period.

MATERIALS AND METHODS

Ninety-six odontogenic tumors from a total of

1869 case records were retrieved retrospectively

from the file archive of the histopathology

laboratory in Baghdad medical city from the

period of 2016 to 2021. Thirty-six files were

ignored as they included duplicate entries or

insufcient histological data. Recurrent tumors

were considered individual cases. In addition,

the exclusion included all cases of odontomas

and peripheral odontogenic tumors. Information

including age, gender, and anatomical location,

was gathered for each case. Whenever there was a

doubt regarding the diagnosis, a histopathological

examination was carried out using the available

slides stained with hematoxylin and eosin (H&E).

All data analysis was done via Microsoft Ofce

Excel 2016 sheets.

RESULTS

In this study, 60 cases were odontogenic

tumors, which constituted 3.2% of the total cases

analyzed. Of these (n = 53 cases, 88.33%) were

benign and (n = 7 cases, 11.67%) were malignant.

The male to female ratio was 1:1. Most of these

tumors were epithelial in origin (n = 46, 76.6%),

whereas mixed and mesenchymal tumors were

(n = 4, 6.6%), and (n = 10, 16.6%) respectively.

The age of the patients ranged from 11 to

75 years, with an average of 34.4 years for males

and 35.4 years for females. Most cases were

recorded in the third and fourth decades of life

(n = 31, 51.6%). As shown in Table I, the most

common benign and malignant tumors were

ameloblastoma and ameloblastic brosarcoma.

Mandibular tumors were (n = 45, 75%) while

maxillary tumors were (n = 15, 25%). The most

common mandibular tumor was ameloblastoma

(n = 35, 77.7%), followed by ameloblastic

broma (n = 5, 11.1%) and odontogenic myxoma

(n = 2, 4.4%). Regarding maxillary tumors,

the predominant tumor was ameloblastoma

(n = 5, 33.3%), followed by ameloblastic

broma, ameloblastic brosarcoma, and clear cell

odontogenic carcinoma, respectively.

A idade dos pacientes variou de 11 a 75 anos. A maioria dos casos foi registrada na terceira e quarta décadas

de vida (n=31, 51,6%). Os tumores benignos e malignos mais comuns foram ameloblastoma e brossarcoma

ameloblástico, respectivamente. A maioria desses tumores localizava-se na mandíbula (n= 45, 75%). O tumor

mandibular mais comum foi o ameloblastoma, seguido do broma ameloblástico e do mixoma odontogênico. Em

relação aos tumores maxilares, o tumor predominante foi o ameloblastoma seguido de broma ameloblástico,

brossarcoma ameloblástico e carcinoma odontogênico de células claras. Conclusões: Os tumores odontogênicos

em uma população iraquiana ocorreram mais comumente na mandíbula e não mostraram predileção por sexo.

A maioria dos casos foi diagnosticada na terceira e quarta décadas de vida, sendo o ameloblastoma o tumor

odontogênico mais frequente. A frequência relativa de tumores odontogênicos malignos foi de 11,67% de todos

os casos estudados principalmente brossarcoma ameloblástico.

PALAVRAS-CHAVE

Frequência, Tumores odontogênicos centrais; Ameloblastoma, Classicação tumoral da OMS.

Braz Dent Sci 2023 Apr/Jun.;26 (2): e3645

Ghazi OM

Frequency of central odontogenic tumors: a retrospective study in an Iraqi population utilizing 2022 WHO head and neck tumors classification

Ghazi OM

Frequency of central odontogenic tumors: a retrospective

study in an Iraqi population utilizing 2022 WHO head and

neck tumors classiﬁcation

DISCUSSION

Information derived from literature indicates

that published series regarding specically central

odontogenic tumors in the Iraqi population that

follow the 2017 and 2022 WHO classications

of tumors is limited [5,6]. Odontogenic tumors

(OT) are relatively uncommon lesions with

variable incidence [7]. In those used 1992 WHO

classication of tumors, the frequency recorded

was (3%±2.9%), whereas reports utilizing the

2005 WHO classication documented slightly

higher rates of (4.0% ±1.3%) due to the inclusion

and reclassication of odontogenic keratocyst as

a tumor [8].

The relative frequency of OTs in the current

study was 3.2% of the total oral biopsied specimens

between 2016 and 2021. However, lower rates

were recorded in literature utilizing different

WHO tumor classications worldwide as showed

in (Table II). The disparity of OTs incidence

among different countries may be related to

variations in the environmental, educational,

and socioeconomical status of the population.

In addition, studies may cover only a limited

area of the country or restricted to a few research

or medical centers which provides an incorrect

perception about the frequency. The mean age of

odontogenic tumor cases as this study recorded

was 35.4 years with peak occurrence in the third

Table I - Frequency of odontogenic tumors relative to gender, site, and age

Tumor type

Frequency Gender Site Age distribution

n percentage M F M/F Man Max 0-19 20-39 40-59 60-79

Ameloblastoma 40 66.67% 21 19 1.10 35 5 2 22 11 5

Ameloblastic carcinoma 2 3.33% 0 2 1 1 0 1 1 0

Adenomatoid

odontogenic tumor

1 1.67% 1 0 0 1 1 0 0 0

Clear cell odontogenic

carcinoma

2 3.33% 2 0 0 2 0 0 1 1

Calcifying epithelial

odontogenic tumor

1 1.67% 1 0 1 0 0 1 0 0

Odontogenic ﬁbroma 1 1.67% 1 0 0 1 0 1 0 0

Odontogenic myxoma 3 5.00% 0 3 2 1 1 2 0 0

MOT

Ameloblastic ﬁbroma 7 11.67% 4 3 1.33 5 2 4 3 0 0

Ameloblastic ﬁbrosarcoma 3 5.00% 0 3 1 2 1 1 0 1

Total 60 100% 30 30 1 45 15 9 31 13 7

M, male; F, female; Man, mandible; Max, maxilla; ET, epithelial tumor; MT, mesenchymal tumor; MOT, mixed odontogenic tumor; n, mean number of cases.

Table II - Worldwide studies concerning the frequencies of odontogenic tumors

Total number

of cases

Number of

Odontogenic

tumors

Rate of OTs in

study

number of cases

after exclusion of

odontomas, POT,

COF and OK

Rates of OTs

after exclusion

MOT

Rate of

odontogenic

tumors

Al-Aroomyetal. (2022) [3] 8974 230 2.56% 175 1.95% 5 2.85%

Kauretal. (2021) [9] 8801 345 3.92% 299 3.39% 11 3.67%

Waheedetal. (2021) [5] 7384 64 0.80% 50 0.67% 1 2%

Soluk-Tekkesinetal. (2020) [10] 53869 1231 2.30% 896 1.66% 16 1.70%

Lima-Verde-Osterneetal. (2017) [8] 9170 376 4.10% 156 1.70% 1 0.64%

Nalaboluetal. (2017) [7] 7400 161 2.17% 98 1.32% 0 0.00%

Sekercietal. (2015) [11] 7,942 218 2.74% 110 1.38% 13 11.81%

Ramosetal. (2014) [12] 2600 78 3.00% 23 0.88% 0 0.00%

Chrysomalietal. (2013) [13] 29088 652 2.20% 168 0.57% 1 0.59%

Siriwardenaetal. (2012) [14] 44,720 1677 3.75% 1047 2.34% 23 2.19%

Varkhedeetal. (2011) [15] 2075 120 5.78% 60 2.89% 0 0

Guptaetal. (2010) [16] 11,843 489 4.12% 441 3.72% 15 3.40%

Buchneretal. (2006) [17] 91178 1088 1.10% 245 0.26% 5 2.04%

Ladeindeetal. (2005) [18] 3,337 339 9.60% 314 9.40% 11 3.24%

POT, peripheral odontogenic tumor; COF, cemento-ossifying ﬁbroma; OK, odontogenic keratocyst; MOT, malignant odontogenic tumor.

Braz Dent Sci 2023 Apr/Jun.;26 (2): e3645

Ghazi OM

Frequency of central odontogenic tumors: a retrospective study in an Iraqi population utilizing 2022 WHO head and neck tumors classification

Ghazi OM

Frequency of central odontogenic tumors: a retrospective

study in an Iraqi population utilizing 2022 WHO head and

neck tumors classiﬁcation

and fourth decades of life comparable to that

reported by others [18,19].

Across several reviews for comparison,

ameloblastoma was the most commonly reported

OT [7,9,20,21]. This comes in accordance

with this study. Controversy regarding which

gender predominates in ameloblastoma exists.

Cavalcante et al. 2016 reported slight female

preference [22]. Ramos et al. [12] stated that

ameloblastoma exhibits no gender predilection.

The present study showed a slight prevalence in

male patients (52.5%). Similar conclusion was

documented by other series [23,24]. The jaw

most commonly affected was the mandible,

with a maxilla to mandible ratio of 1:7. This

was consistent with studies from different

countries [2,12,24]. A current study showed that

ameloblastoma was most commonly reported in

the third and fourth decades of life (55%). Equal

predilection was reported worldwide [3,8,25].

Odontoma (a hamartomatous tumor

like lesion) was thought to be one of most

common OT with fluctuating frequencies in

many records [11,13]. Underrating odontomas

and overrating of tumors with aggressive

behavior which required extensive medical

interference, might be responsible for such

discrepancy. Furthermore, the diagnosis of

odontoma can be made with high confidence

using clinical and radiographic methods; as

a result, odontoma biopsies are occasionally

referred for histopathological evaluation, or

the diagnosis is not documented. For all these

reasons, odontoma was excluded in this study.

Ameloblastic broma (AF) represent a rare

benign OT with an epithelial and mesenchymal

neoplastic proliferation [26]. In the current study,

AF was recognized in 7 cases, encompassing

11.6% of the entire sample. The patients ranged

in age from (11 to 33) years. The highest

incidence (57.14%) was recorded in the 2nd

decade. There were (n = 4, 57.14%) males and

(n = 3, 42.86%) females. The site of the lesion

demonstrates a predilection for the mandible

(71.4%). Disparity has been reported among

series globally regarding the frequency of this

tumor [8]. One explanation is that histologically,

a disorganized combination of both dental

epithelium and mesenchyme creates confusion

between an emerging odontoma and lesions

like ameloblastic broma (AF) and ameloblastic

fibro-odontoma, which are considered true

neoplasms thus some ameloblastic broma may

be diagnosed as odontoma which is the most

frequent OT. Clinical and radiographic features

may be required to reach a denite diagnosis.

Odontogenic myxoma (OM) is a benign

mesenchymal tumor histologically composed

of stellate, spindle cells in a plentiful myxoid

stroma [1]. The current study reported

(n = 3, 5%) of the studied sample ranked three

after ameloblastoma and ameloblastic broma.

The mean age of occurrence was 23.6 years, almost

exclusively in females. The mandible was the

predominant site (n = 2, 66.6%), with a mandible

to maxilla ration of 2/1. Buchner et al. [17]

reported significant female preference with a

mandible to maxilla ratio of 2/1 which was

in accordance with this study. However, they

documented a higher mean age of 36.1 years.

Another study reported a higher incidence of

OM (9.7%) [3]. In disagreement with this study,

Lima-Verde-Osterne et al. [8] reported maxillary

predilection (after exclusion of odontoma).

Adenomatoid odontogenic tumor (AOT)

is a rare benign neoplasm of epithelial origin

presenting histologically a characteristic duct

like structure and shows predilection for maxilla.

Variable frequencies were recorded for this

tumor the highest was in the continent of Asia.

AOT was recognized as the fourth or fth most

common OT [27,28]. This study reported one

case representing 1.67% of all sample located in

the maxilla.

The present study excluded cemento-

ossifying fibroma (COF) which was added as

mesenchymal odontogenic tumor in WHO 4th

edition of head and neck classication of tumor

in 2017 to differentiate it from more aggressive

form of ossifying broma (the juvenile subtype).

However, it is discussed in depth along with other

ossifying bromas in the section of bro-osseous

lesions in this edition [2,29].

Papers reported sporadic cases of calcifying

epithelial odontogenic tumor (CEOT) representing

only slight percentage of the total OTs [30].

Present study registered one case of CEOT

representing 1.6% of total cases.

The current study documented 7 malignant

OTs, comprising 11.67% of the total investigated

sample. The most common malignant OT was

ameloblastic fibrosarcoma (n = 3, 42.8%),

followed by ameloblastic carcinoma (AC) and

Braz Dent Sci 2023 Apr/Jun.;26 (2): e3645

Ghazi OM

Frequency of central odontogenic tumors: a retrospective study in an Iraqi population utilizing 2022 WHO head and neck tumors classification

Ghazi OM

Frequency of central odontogenic tumors: a retrospective

study in an Iraqi population utilizing 2022 WHO head and

neck tumors classiﬁcation

clear cell odontogenic carcinoma (CCOC) (n = 2,

28.5%) for both tumors. Fluctuating frequencies

of malignant OT were recorded in other studies

as demonstrated in (Table II). However, current

study demonstrated high rate of prevalence in

comparison to others which may be related to

the patients’ delaying medical treatment, which

might increase the likelihood of transformation

of benign into malignant tumor. We reported

3.33% frequency of ameloblastic carcinoma.

Lower rates were described in reports from

Egypt (1.7%), Brazil (0.64%) and Turkey

(0.33%) respectively [2,3,8]. As previously

mentioned, the 2017 WHO reclassication of

odontogenic keratocyst and inclusion of COF as

an odontogenic tumor beside the exclusion of

odontoma in this study render the comparison

between current study and others more difcult

and complicated.

CONCLUSIONS

This study reported comparable and

divergent ndings with other studies worldwide.

Attention should be paid to the high frequency

of malignant odontogenic tumors in Iraqi

population as this study recorded relative to

benign tumors in a rate that appear higher than

other parts of the world. However, it should be

kept in mind that this study excluded one of

most common odontogenic tumors, odontoma,

which was excluded in this study for the reasons

previously described. In addition 2017 WHO

reclassification of tumors changes somewhat

the frequency and prevalence of odontogenic

tumors globally.

Acknowledgements

The author wishes to thank everyone who

assisted and supported the accomplishment of

this research, especially the administration of

Baghdad Medical City and the Ministry of Health.

Author’s Contributions

OMG: Conceptualization, Writing – Original

Draft Preparation, Writing – Review & Editing.

Conict of Interest

No conicts of interest to mention.

Funding

There are no funding sources to mention.

Regulatory Statement

The study was approved by the Ethical

Committee of the College of Dentistry at the

University of Al-Qadisiyah (REF. 233; Date:

23/5/2022).

Compliance with ethical principles

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Osama Mohammed Ghazi

(Corresponding address)

University of Al-Qadisiyah

Email: osama.ghazi@qu.edu.iq

Date submitted: 2022 Oct 01

Accept submission: 2023 Feb 01