ameloblastic fibroodontomas ( afos ) are slow - growing , benign tumors developing from the odontogenic epithelium and ectomesenchyme .
they are usually found to be asymptomatic and are most often discovered on routine radiography .
the clinical features are painless swelling of the jaw , an asymmetrical face , missing permanent teeth , and displaced or impacted tooth .
radiographically , such a tumor appears as a well - circumscribed , expansile radiolucency that generally contains solitary or multiple small radiopaque foci .
the presence of radiopaque material ranging from small spots to extensive compact masses in the center of the tumor image is common .
we present a case of an 18-year - old female with giant complex odontoma present in the body of the mandible leading to an impacted mandibular third molar .
an 18-year - old female presented to our unit with the complaint of a painless swelling on the left side of the lower jaw for the last 3 years that seemed to show a progressive increase in size . on examination , a firm , diffuse , nontender swelling of size 9  5 cm involving the left body of the mandible was observed [ figure 1 ] .
on intraoral examination , a small hard tissue projecting over the posterior alveolus was present with normal surrounding mucosa . to our surprise ,
the orthopantomogram ( opg ) showed a well - defined radiopaque mass of size 3  6 cm present over the left body of the mandible .
an impacted third molar was present below the mass just above the inferior border [ figure 3 ] .
preoperative photograph showing diffuse swelling over the left side of the lower face intraoral photograph showing missing permanent left mandibular molars and a calcified , toothlike structure protruding from the alveolar mucosa over the retromolar region orthopantomogram revealsa large , well - defined radiopaque lesion with focal radiolucent areas occupying the whole left body of the mandible . an impacted tooth is also visible .
this appearance suggests that the lesion is a complex odontoma we planned surgical removal of the tumor along with the impacted third molar under general anesthesia .
the tumor was approached via submandibular incision , followed by layer - wise dissection to reach the inferior border of the mandible .
after reflection of the periosteal layer , the expanded buccal cortex was seen . with the help of a chisel and mallet , the outer cortical bone overlying the tumor
the lingual cortical bone was found to be intact [ figures 4 and 5 ] .
the reconstruction of the defect was done with nonvascularized corticocancellous iliac crest bone , which was taken from the contralateral side [ figure 6 ] . the fixation of the graft was done with 2 - 0 vicryl sutures to prevent any unnecessary hardware fixation or thermal injury to it . after achieving proper hemostasis , closure was done in layers .
one week post operation , healing over both the donor and recipient sites was found to be satisfactory , and the sutures were thus removed . to our surprise ,
the patient was kept under regular follow - up for 6 months and , to add to our delight , there were nosigns of graft failure or loco regional recurrence .
intraoperative photograph after complete removal of the tumor the tumor specimen showing the presence of both calcified and epithelial components reconstruction of the mandibular defect was done with iliac crest graft photomicrograph stained with h and e reveals the presence of dense fibrous tissue and a few odontogenic epithelial cell islands .
fibrous tissue is of a primitive type containing spindle - shaped fibroblasts , some areas of hyalinization signifying dentin formation , and some clear spaces of enamel formation .
in addition , odontogenic epithelial cells follicles are visualized with a few stellate cells suggestive of afo
according to the world health organization ( who ) , an afo is a benign epithelial odontogenic tumor with odontogenic mesenchyme .
a few authors suggest the ameloblastic fibroma and the ameloblastic fibrodentinoma as its precursors . a long - standing case of afo may progress to complex odontoma .
it is an asymptomatic , slow - growing tumor mostly associated with an unerupted tooth . in our case
slootweg reviewed 50 cases with this condition , for which the mean age was 8.1 years ( range 1 - 20 years ) .
radiographically , it appears as a well - circumscribed , expansile radiolucency that generally contains solitary or multiple small radiopaque foci .
large areas of calcification make it impossible to differentiate an afo radiographically from a complex odontoma .
differential diagnoses include lesions with mixed radiographic features , such as immature complex odontoma , calcifying epithelial odontogenic tumor , adenomatoid odontogenic tumor , and ameloblastoma .
the relative arrangement of the soft tissues and the stage of development of the involved tooth are useful criteria for diagnosis .
the tumor mass is surrounded by a fibrous capsule and is composed predominantly of a fibroblastic connective tissue matrix containing strands of odontogenic epithelium and immature tooth structures , including enamel and dentin .
an afo is an immature variant of complex odontoma , as the clinical and radiographic findings are identical .
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has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s )
has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal .
the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
 an ameloblastic fibroodontoma ( afo ) is a rare odontogenic tumor of mixed dental tissue origin . 
 it exhibits histological features of ameloblastic fibroma and complex odontoma . 
 afos are usually found to be asymptomatic and are most often discovered on routine radiography . 
 sometimes their presence is suspected due to missing permanent dentition . 
 we report a case of an 18-year - old female patient with missing mandibular molars on the left side associated with a giant complex odontoma . 
 treatment included surgical excision of the tumor followed by reconstruction with iliac crest graft . 
 histopathological study revealed it as an afo , to our surprise . 
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