Calcifying odontogenic cyst A review

and

analysis

of seventy

cases

Paul D. Freedman, D.D.S.,” Harry Lumerman, John K. Gee, D.D.S.,“” Ja,maica, N. Y. DEPARTMENTS CENTER

OF DENTISTRY

OF BROOKLYN

AND

AND

PATHOLOGY,

D.D.S.,‘”

CATHOLIC

and

MEDICAL

QUEENS

Six new cases of the calcifying odontogenic cyst are presented. These and sixty-four previously reported cases have been studied to further delineate characteristic clinical, radiographic, and histopathologic features of the calcifying odontogenic cyst. A review of the literature with emphasis on the possible histogenesis of the calcifying odontogenic cyst and the nature of the “ghost cells” and their products is also presented.

T

he calcifying odontogenic cyst was first presented as a separate entity by Gorlin and his associates1 in 1962. Since that time, additional reports2-26 dealing with this unusual odontogenic lesion have been ‘published. This article reviews and summarizes the sixty-four previously reported cases culled from the world literature and six new cases from the oral biopsy service of the Catholic Medical Center. From this analysis further delineation of the characteristic clinical, radiographic, and histopathologic features of this lesion is made. A discussion of the possible histogenesis of the calcifying odontogenic cyst with reference to the nature and function of the “ghost cells” is presented. MATERIAL,

METHODS,

AND

RESULTS

All publications and case reports concerning the calcifying odontogenic cyst were reviewed. In all, sixty-four casesof this entity were culled from the world literature.1-32 These sixty-four cases include six reports27-32 not originally presented as examples of the calcifying odontogenic cyst but which, because of their histologic characteristics, have been accepted as such in review paper+ I2 *Senior **Chief, ***Chief

Resident in Oral Pathology, 1974-75. Section on Dental and Oral Pathology. Resident in Oral Surgery, 1973-74.

93

94

Freedman,

Fig. placement

Lumerma~n,

1. Case 1. Well-circumscribed of teeth with resorption

and Gee

radioluceney of mandibular of distal root of first molar.

molar

region

Oral July,

8urg. 1975

showing

dis-

concerning this entity. Six new cases from the oral biopsy service of the Catholic Medical Center were added to this series to bring the total number of cases analyzed to seventy. CASE CASE

REPORTS 1

A 15-year-old girl was seen with a chief complaint of %welling inside of mouth.” Oral examination revealed a soft, fluctuant swelling on the lingual aspect of the right mandible in the molar region. Radiographically, a relatively well-eircumseribed unilocular radiolucency was seen. There was resorption of the distal root of the first molar (Fig. 1). At operation a cystic mass which appeared to have eroded both the buccal and lingual cortices was removed. CASE

2

A 45.year-old man was seen with a chief complaint of a “lump on the gum” of 8 months’ duration. Oral examination revealed a firm, raised mass on the labial gingiva in the region of the mandibular left incisors. The overlying mucosa was normal in appearance. On excision, the underlying bone appeared normal. CASE

3

A 39-year-old woman had a swelling lingual to the mandibular left lateral incisor, canine, and first premolar. On palpation, the swelling was soft. The patient stated that the swelling had been present for 3 months. Radiographs revealed a rarefied area between the lateral incisor and canine. irregular resorption of the canine root was seen (Fig. 2). All teeth were vital to electric pulp testing. CASE

4

A 71.year-old man who had in the right premolar region. measuring 1.5 by 0.8 cm. CASE

been edentulous for 15 years had a swelling of the mandible Radiographs revealed a poorly circumscribed radiolucency

5

A 74-year-old man had a “swelling of the floor of the mouth” of 1 year’s duration. Physical examination revealed that in the same area there was hyperplastic tissue covering the alveolar ridge. This tissue clinically resemhled denture hyperplasia. There was cystlike enlargement of the tissue lingual to the genial tubercles. Radiographs revealed a multilocular radiolucency in the midline of the mandible extending on both sides to the area of the canines. Spotty areas of calcification were seen throughout the radiolucency.

Volume 40 Number 1

Fig. 8. Case 3. Well-delineated radiolucency resorption of lateral incisor and canine. CASE

Calcifying

of anterior

odontoggenic ctyst 95

mandible

showing

irregular

root

6

A U-year-old man presented with a chief complaint of pain and swelling in the edentulous right mandibular premolar area. Radiographs revealed a radiolucent lesion extending from the right canine to the right first molar area.

MACROSCOPIC APPEARANCE

All lesions were described as tannish brown to black in color and were gritty and cystic on cross section. The tissue in Case 5 was multicystic and contained a brown cheesy material. The specimens ranged from 1.3 cm. to 5.5 cm. in diameter. MICROSCOPIC FINDINGS

All specimens had the characteristic histologic appearance of the calcifying odontogenic cyst, as described later in the section on microscopic anatomy. TREATMENT AND FOLLOW-UP

All cases were treated by curettage. No patients rence during periods ranging from 1 to 3 years. Table I summarizes the six cases.

have experienced

a recur-

AGE

The mean age at presentation of the calcifying odontogenic cyst in the seventy casee studied is 38.4 years. The youngest patient was 7 years old; the oldest was 82 years old. The mean age is deceptive in that only eight of the seventy patients were between the ages of 31 and 40. In Table II it can be seen that 58.4 per cent of the patients were younger than 41 years of age. Forty-seven per cent were younger than age 31. Also, there is a decrease in frequency of

Oral July,

Table

Surg. 1975

I. Summary of findings in six casesof calcifying odontogenic cyst site 15

F

Mandibular molar nre:t

Soft, painless! fluctuant swelbng on lingual of mandibular molar region

45

M

Firm raised on gingiva

39

I?

Labial gingiva, mandibular left incisor area Mandibular left incisor to premolar area

71

M

Mandibular premolar region

74

M

AnterioT mandible

51

M

Mandibular premolar area

mass

-

\~ell-circunlscribed unilocular radiolucency showing irregular rrsorption of distal root of first molar 8 mos. Untlerlying bone norm:~l

Curettage, no recurrence 3 yrs. after treatment

Currettage, no recurrence 26 mos. after treatment Soft swelling on Curettage, no 3 mos. Rntliolucent area lingual mandible recurrence 26 between lateral in left incisor to incisor and caIIlOS. after premolar area treatment nine causing irregulxr root resorption of canine Smelling of manCurettage, no Poorly rircumdible in right scribed rxdiorecurrence 18 premolar region mos. aft,er lucency treatment Pluctuant swelling 1 yr. Multilocular radio- (‘urettage, no of floor of mouth lucency in midrecurrence 14 with enlnrgemos. after lino of mandible ment of tissue extending on treatment lingual to genial both sides to tubercles canine area Pain and swrlling Well-circumscribed Curettage, no in edentulous recurrence 12 radiolucency mandibular mos. after premolar area treatment

occurrence of the calcifying odontogenic cyst in the fifth decade. Twenty of the seventy cases(28.6 per cent) occurred in the second decade. SEX

PREVALENCE

Thirty-eight of the seventy cases (54.2 per cent) occurred in females, and thirty-two (45.8 per cent) were seen in males. Interestingly, before the age of 41, the calcifying odontogenic cyst is much more common in females while after age 41 it is much more common in males. In the forty-one casesoccurring before age 41, 63 per cent were in females, Of the casesoccurring after the age of 41, 58.7 per cent were in males. ANATOMIC

LOCATION

Thirty-five of the seventy lesions were associated with the maxilla, thirtyfour with the mandible, and one with the parotid gland. Seventy-five per cent of the lesions were located anterior to the first molar. Again, differences in the lesions occurring before and after the age of 41 are noted. Seventy per cent of the lesions occurring before the age of 41 were associated with the maxilla, while 79.5 per cent of the lesions in patients older than 41 were associated with the mandible (Table III).

Volume

40

Number

1

Calcifying

Table II. Age distribution Age

at discovery 1 11 21 31 41 51 61 71

of the calcifying

(yrs.)

/

No. of reported

to to to to

10 20 30 40 to 5Q to 60 to 70 to 80

odontogenic

cyst

cm-es

Per cent of reported

Table Ill. Age comparison

Location

Male Female Maxilla Mandible Anterior

to first

oyst

97

mes

2.8 15.6 12.6

8.5 1.4

of patients with the calcifying Before (per

Sex

(

3 20 10 8 2 11 9 6 1

81 to 90

odontogenic

age 41 cent) 37 63 70 30 87

molar

odontogenic After (per

cyst age 41 cent) 59 41 20 80 60

This discrepancy in sex prevalence and location of the calcifying odontogenic cyst before and after age 41 is difficult to evaluate. Reference to this will be made later. Of the reported caSes of calcifying odontogenic cyst, fifty-five of seventy lesions (78.5 per cent) have been intraosseous. The remainder (21.5 per cent) involved only soft tissue. Of the fifty-five intraosseous lesions, thirteen (23.6 per cent) were associated with embedded teeth, while six (11 per cent) were associated with odontomas. CLINICAL

AND

RADIOGRAPHIC

FINDINGS

Swelling of the jaw or of the soft tissues of the jaws was the most common presenting complaint, occurring in 50 per cent of all cases. In the intraosseous lesions, the swelling was usually hard and noncompressible with no apparent erosion of the bony cortices in most cases. Soft-tissue lesions were described as firm and nontender. Eleven patients (16 per cent) complained of pain in association with the swelling. This varied from tenderness on palpation to persistent aching pain. Radiographically, all intraosseous lesions appeared as either unilocular or multilocular radiolucencies. Most were well circumscribed, although some were described as poorly demarcated. In fifteen cases, spotty radiopacities were seen throughout the radiolucency (Fig. 2). Resorption of the roots of the teeth associated with the lesion was noted in ten of the seventy patients (Figs. 1 and 2). The mean size of the lesions (when mentioned) was approximately 3 cm., although the size ranged from 1 to 8 cm. The time elapsed between the patients’ awareness of the lesion and the time treatment was sought ranged from 2 days to 7 years. The mean time elapsed

98

Freedman,

Lumerman,

and. Gee

Oral July,

Surg. 1975

Fig. 3. Case 6. Cyst lining exhibiting intrnepithelial ghost-cell formation and prominent low columnar basal-cell layer. (Magnification, x50.) Fig. 4. Case 4. Early ghost-cell formation exhibiting peripherally placed pyknotic nucleus (arrow). Note area of early granular calcification in lower right corner (C). (Magnification, x225.)

(11 months) was deceptive, because 73 per cent of the lesions were present 6 months or less before the patients sought help. TREATMENT

AND

for

PROGNOSIS

Most lesions were treated conservatively by surgical excision or curettage. Some eases originally diagnosed as atypical ameloblastomas were treated more aggressively. To date, only one patient treated for a calcifying odontogenic cyst has experienced a recurrence.l” This occurred in a 63-year-old woman who had a “cystic lesion” in the third molar area of the right mandible. A solid tumor 1 cm. in diameter was removed. Recurrence followed 2 years after the original

Volume Number

Calcifying

40 1

Fig. 5. Case 2. Sheets of fused ghost cells with focal areas lumen. Note focal area of stromal calcification (nrrozo). (Magnification, Fig. 6. Case 4. Lining of calcifying odontogenic cyst showing into underlying connective tissue. (Magnification, x225.)

odontogenic

of calcification x2.5.) penetration

of

cyst

99

filling

cyst

ghost

cell

operation. The mandible was eventually resected from the ramus to the second premolar area. From the above, it appears that, with conservative but adequate treatment, recurrence should not be anticipated. HISTOLOGIC

CHARACTERISTICS

Of the seventy lesions, sixty-two (88.5 per cent) were described as cystic by the pathologist (Fig. 3). The remainder (11.5 per cent) were described as solid tumors. Characteristically, the lesion presents as a multicystic mass in which the cysts are lined with an irregular layer of epithelium exhibiting, in some areas,

Oral July,

Surg. 1975

Fig. 7. Case 3. Large multinucleated giant cell of foreign body type immediately adjacent to sheet of fused ghost cells. (Magnification, x225.) Fig. 8. Case 1. Area of calcifying odontogenic cyst showing ghost cells set in sheets of whirling plump to spindled cells, some forming ductlike structures resembling the adenomatoid odontogenic tumor. (Magnification, x50.)

a striking resemblance to ameloblastic epithelium. At least a portion of the epithelial lining exhibits a prominent basal-cell layer of cuboidal to columnar cells. A prominent feature of the calcifying odontogenic cyst is the presence of “ghost cells” which form from the epithelial cells in the central portion of the epithelial lining. The first sign of cellular change is the appearance of a lightly eosinophilic homogeneous cytoplasm. Eventually, the cytoplasm becomes more deeply eosinophilic and granular, displacing the now pyknotic nucleus to the periphery of the cell (Fig. 4). Later the nucleus disappears and the characteristic ovoid, deeply eosinophilic, granular “ghost cell” appears.

Volume 40 Number 1

Calcifying

Table IV. Occurrence

odontogenic

of adenomatoid

odontogenic

Location

101

tumor33 and calcifying

cyst Adenomatoid

Sex

odontogenic cyst

Male Female Maxilla Mandible Anterior to first molar

odontogenic

tumor (per cent) 36 64 65 35 95

Calcifying odontogenic cyst (per cent)

37 63 70 30 87

The early appearance of calcification can be seen within the ‘Lghost cells” as powdery, small, deeply basophilic granules (Fig. 4). Eventually the “ghost cells” fuse and form sheets of amorphous, acellular eosinophilic material which may fill the cystic lumina (Fig, 5). The “ghost cells” also penetrate the basement membrane into the underlying connective tissue (Fig. 6). When this occurs, a foreign-body giant-cell reaction may be elicited (Fig. 7). In these areas, dystrophic calcifications are often present. Areas of some lesions may show histologic variations resembling the adenomatoid odontogenic tumor (Fig. 8). Melanin pigmentation was seen within the epithelial cells in five of the seventy cases reported. Islands of proliferating ameloblastic epithelium suggestive of ameloblastoma may also be noted. DISCUSSION

As has been shown earlier in this study, there is a difference in both the sex predilection and the location of the calcifying odontogenic cyst occurring before and after age 41. Of patients less than 41 years of age, 63 per cent are female, and 70 per cent of the lesions are associated with the maxilla. Eighty-seven per cent of these lesions occurred anterior to the first molars. These figures closely coincide with those presented by Giansanti and associates33 in their survey of 111 cases of the adenomatoid odontogenic tumor (Table IV). Here it was found that 64 per cent of the patients were female, 65 per cent of the lesions were associated with the maxilla, and 95 per cent were found anterior to the first molars. These statistical similarities between the adenomatoid odontogenic tumor and the cases of calcifying odontogenic cyst occurring before age 41 may be just a curious coincidence. However, it is interesting to note that, in our six cases, the only one with areas showing a marked resemblance to the adenomatoid odontogenic tumor occurred in our youngest patient (15 years old) and in a female (Case 1) (Fig. 8). Closer scrutiny of the histologic features of the calcifying odontogenic cyst in young patients and comparison with those features seen in older patients may help to shed some light on this matter. In 1962 Gorlin and associates1 proposed the following histogenesis for the calcifying odontogenic cyst : Initially, a cyst forms which is lined with a thin layer of a multilayered epithelium having a prominent basal-cell layer. Some of these epithelial cells develop

102

Preedmten, Lume7wwki, m4i Gee

Old Surg. July,

1975

into “ghost cells.” Thcsc cells increase in size. The basal layer then becomes columnar and the cyst lining takes on the appearance of ameloblastic cpithelium. At this point, the cyst wall bc~omes irregularly thickened. 13vcntually, the basal cells begin to participate in “ghost cell” formation and the cpithelial-conncctivc tissue interface becomes indistinct,. Connective tissue grows between the “ghost cells,” initiating the formation of justacpit,helial homogcnrous tlcntinlikc areas. The “ghost cells” are treated like l’orcign bodies and may bccomc surrounded by giant cells. As the massesof “ghost cells” become more homogeneous, they start to calcify. Three of the original cases rcportcd hp Gorlin and his colIcagues showed development of the calcifying otlontogenic cyst, from the dental e&helium of a developing or uneruptcd tooth. Gorlin considcrcd the possibility of the calcifying odontogenic. cyst being the first stage in the formation of a complex odontoma but added that this is probably not the case because extraosscous calcifying odontogenic cysts have been reported whcrcas cxtraosscous odontomas have not. In 1965 Bhaskar” proposed the name keratinizing clnzelo7)6astol)lcfor the calcifying odontogenic cyst. Both of his casesinvolved the soft tissue only and he believed that these lesions were derived from extraosseous odontogenie epithelium. Chaves and Pessoa” proposed, in 1968, that most if not all of the calcifying odontogenic cysts are formed from immature pluripotcntial ~11s that have the potentiality to form dental tissues. Herd’” observed t,hat the calcifying odontogenic cyst hat1 clinical and histologic features that were closer t,o the adenomatoid odontogcnic tumor than to the calcifying odontogcnic epithelial tumor or amcloblastoma. Ho stated that the calcifying odontogcnic cyst may arise from aetivc odontogenic epithelium in which some factor has caused interference with certain enzyme systems leading to aberration in cell function. Abrams and Howell,” in 1968, described two patterns of degeneration of the epithelial cells seen in this lesion. The first consists of the transformation of large mural squamous cells into “ghost cells” by becoming cosinophilic and leaving only the outline of’ the original nucleus remaining. In the second pattern, individual or small groups of stellate and basal cells enlarge and their nuclei a.re displaced to the peripher.v. The nuclei then disappear. The cytoplasm becomes eosinophilic and presumably keratinizctl. Ahrams and IToweIl further stated that the massesof “ghost cells” induce the granulation tissue to lay clown juxtaepithelial osteoid which may calcify. Direct calcification of the epithclial cells within the cyst, lining into small round bodies was also described. Sauk2’ contended that the juxtaepithelial ostcoid or dentinoid found in areas of the calcifying odontogenic cyst that were free of granulation tissue or “ghost cells” was due to a. t,ruc inductive phenomenon and not to an inflammatory response. In 1967 Seward and Duckworthz2 observed that it was the incorporation of pyknotic nuclei within the massesof “ghost cells” that caused a superficial

Volume 40 Number 1

Calcifying

odontogenic cyst

103

resemblance to cellular cementum or bone. They described the presence of both tubular and atubular dentin in their cases. To this date, controversy still exists as to the nature of the “ghost cells” in the calcifying odontogenic cyst. Most authors consider them as atypically keratinized bodies and the sheetswhich they form as atypical keratin. In 1964 Gorlin and his associates12studied two calcifying epitheliomas of Malherbe, two craniopharyngiomas, and three calcifying odontogenic cysts, employing various stains to determine the nature of the “ghost cells” seen in these tumors. Some differences in staining intensity were seen, but all three lesions were similar in their reaction to the stains employed. The conclusion was that the “ghost cells” and calcified areas in the three lesions represented a form of incomplete or abnormal keratinization. Some small areas appeared to be fully keratinized. Komiya and co-workers,16 in 1969, showed, by the use of similar stains, that the “ghost cells” have few if any S-H groups but do have S-S groups in their proteins. This implies that they have been keratinized. They also stated that the calcified substances of the calcifying odontogenic cyst were not alien from such normal calcified tissue as bone, cementum, and dentin from the standpoint of ground substance component. The findings of Fejerskov and Krogh,lO in their ultrastructural study of the calcifying odontogenic cyst, raise some questions as to the proposed keratinized nature of the “ghost cells.” They found that the fibers dominating the cytoplasm of the “ghost cells” are not identical to the keratin pattern seen in epidermis and oral epithelium. They also state that “because cells of tissues take up stain as a keratinized cell layer, it does not necessarily mean that the cells demonstrate a true keratin pattern at the ultrastructural level.” The epithelial cells responsible for keratinization and amelogenesis both produce keratin. The keratins produced by the ameloblasts and epidermal cells differ in their amino acid content. 34 Because of this similarity between the products of ameloblasts and keratin-producing cells, t,he possibility that the epithelial cells of the calcifying odontogenic cyst are producing a form of pre-enamel or enamel matrix has to be considered. St,udies involving the transplantation of enamel epithelium have yielded results relevant to this question. In 1967, Zussnlan35v36 transplanted enamel epithelium devoid of odontoblasts and connective tissue into experimental animals and observed the growth of this tissue at measured intervals. He found that when the enamel epithelium was examined 1 or 2 days after transplantation, the epithelial cells were swollen and exhibited homogeneous eosinophilia of the cytoplasm. The cell nuclei were smaller than usual and hyperchromatic. After 6 days, proliferating epithelial cells were seen; these were surrounded by a hyalinized material that separated them from the stroma. Calcified foci not related to the epithelial cells were seen. As time passed, the epithelial cell nuclei became smaller and dense and the cytoplasm became indistinguishable from the surrounding connective tissue. Zussman stated that the calcified material formed in the area represented neither bone nor enamel but could be compared to the dystrophic calcification

Oral July,

Surg. 1975

of epithelial rests, as described by Villa. 57 The inability of the transplanted ameloblasts to form mature prismatic enamel was expected because prismatic enamel is deposited only when it has been preceded by, and is in the presence of, already formed dentin. An important finding by Zussman was that ameloblasts are capable of proliferating and secreting what he considered to be enamel matrix without the presence of odontoblasts and dentin. Furthermore, Fleming’s38 study showed that when ameloblasts alone were transplanted into the anterior eye chambers of experimental animals, they failed to form prismatic enamel and, upon this failure, underwent morphologic changes. These ameloblasts lost their tall columnar structure and formed clusters or cords of cells, epithelial pearls, and sometimes cysts. These three studies suggest that the cell of origin of the calcifying odontogenie cyst may be the well-differentiated ameloblast. These ameloblasts are capable of proliferating and producing enamel matrix but not calcified mature enamel, because of the absence of odontoblasts and dentin. This lack of dentin leads to the changes described in the transplantation experiments cited above, including the cystification and calcifications seen in the calcifying odontogenic cyst. The well-differentiated nature of these ameloblasts helps to explain the innocuous biologic behavior of the calcifying odontogenic cyst. CONCLUSION It is suggested that the calcifying odontogenic cyst is a lesion of welldifferentiated ameloblasts with a prominent cystic component. The cells appear to elaborate enamel matrix represented by swollen individual “ghost cells” and by sheets of fused “ghost cells.” The accumulation of the enamel matrix within the cells may be due to their inability to secrete their products. The inability of the matrix to mature into prismatic enamel is due to the absence of dentin and of odontoblasts. This is supported by experiments, which demonstrated independent proliferation of ameloblasts and elaboration of enamel matrix without the laying down of prismatic enamel, following transplantation of enamel organ epithelium.“‘> 38 The calcifications present in the calcifying odontogenie cyst are probably dystrophic in nature and not the result of physiologic maturation and mineralization of enamel matrix. Finally, perhaps a more appropriate name for this lesion would be cystic calcifying odontogenic tumor. This name is proposed because, biologically, the behavior of the lesion resembles that of a benign odontogenic tumor more than that of a cyst in that, in certain instances, irregular root resorption, erosion of bony cortices, and a moderate amount of bone destruction are seen. SUMMARY 1. Six new cases of calcifying odontogenic cyst are presented. 2. These six cases and sixty-four cases from the world literature are studied to delineate further the characteristic clinical, radiographic, and histopathologic features of the calcifying odontogenic cyst. 3. A review of the literature, with emphasis on the possible histogenesis of

Volume Number

10 1

Calcifying

odontogenic

105

cyst

the calcifying odontogenic cyst and nature of the “ghost cells” and their products, is presented. 4. A new name for the lesion, cystic mlcifying odontogenic hmor, is proposed. Special acknowledgments are due Dr. Anthony Becker, and Dr. Nathan Rosenfield for permission paper.

Di Mango, to use their

Dr. Julius Baer, cases in prrparation

Dr.

Meyer of this

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Sela,

J.:

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30. 31. 32. 33. 34. 35.

1975

Boss, H. : A Rare Variant of Ameloblastoma, Arch. Pathol. 68: 299-305, 1959. Duckworth, R., and Seward, G. R.: A Melxnotic Ameloblastic Odontoma, ORAL S~RG. 19: 73-85, 7965. Lurie, 11. I. : Congenital Melanocarcinoma, Melanotic Adamantinoma, Retinal Anlage Tumor, Progonoma and Pigmented Epulis of Infancy: Summary and Review of Literature and Report of First Case in Adult, Cancer 14: 1090-1108, 1961. Maitland, G. R.: Atypical Adamantinomn of the Maxilla; Report of a Case, J. Oral Surg. 5: 351-355, 1947. Spirgi, M.: Un cas d’epithelioma adamantin calcifi@ au niveau de la muqueusc buccalc, Schmeiz. Monatssdrr. Zahnheikd. 70: 1077-1090, 1960. T~OUM, K. H., and Goldman, I-1. M.: Odontogenic Tumors: Classification Based on Observations of Epithelial, Mesenchymal and Mixed Varieties, Am. J. Pathol. 22: 433.471, 1946. Giansanti, J. S., Someren, A., and Waldron, C. A.: Odontogenic Adenomatoid Tumor (Adenoameloblxstoma), ORAL SURG. 30: 69-86, 1970. Toto, P. D., O’Malley, J. J., and Grandel, E. P.: Similarities of Keratinization and Amelogenesis, J. Dent.. Res. 46: 602-607, 1967. Zussman, IV. V.: Transplantation of the Enamel-Forming Epithelium, ORAT, SURG. 21:

217-224, 1966. 36. Zussman,

W. V.:

The

Intcraetion

of Ameloblasts

and

Odontoblasts

in

Transplants,

Our,

SURG.~~: 388.396,1966.

V. G.: Calcification of the Epithelial Rests and 37. Villa, Epithelium in the Tooth Follicle of an Embedded Molar, H. S.: Homologous and Heterologous Intraocular 38. Fleming, Germs, J. Dent. Res. 31: 166-188, 1952.

Reprint requests to: Dr. Harry Lumerman Chief, Section of Drntal and Oral Pathology Departments of Dentistry and Pathology The Catholic Medical Center of Brooklyn and X8-25 153rd St. Jamaica, E. Y. 11432

Queens

Portion

of

the

Reduced

EnameI

ORAI, SURG. 4: 877-885, 1951. Growth

of Transplanted

Tooth