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a 45-year - old male patient reported with a gingival growth on the right anterior region of the mandible for one year and also complained of pain in the same region for 6 to 7 months .
the exophytic lesion was small initially and increased gradually to the current size displacing the adjacent teeth .
extraorally , a diffuse swelling measuring around 1.51.5 cm in size was seen on the right lower portion of the face .
1a ) at the interdental gingiva between canine and the first premolar , which was roughly circular , measuring about 3.53.5 cm in size , extended labially from the attached gingiva to the lingual sulcus of the right mandibular incisors , canine , and premolar .
1b ) was pebbled and rough with indentations of the opposing teeth with mesially displaced canine .
color of the lesion was normal as that of the surrounding mucosa and firm in consistency .
2 ) showed the presence of characteristic multilocular soap bubble appearance in the region of canine and first premolar , and knife edge shaped root resorption pattern in relation to the first premolar .
3 ) showed radiolucency measuring 44 cm in diameter extending from the distal aspect of lateral incisor to the mesial aspect of second premolar .
the follicles were lined by a single layer of tall columnar ameloblast - like cells and little cystic degeneration .
ameloblastoma usually manifests as an intraosseous or central lesion or rarely as a peripheral epulis - like lesion.1 the lesion may arise most commonly from cell rests of enamel organ , epithelium of odontogenic cysts , disturbances of the developing enamel organ , and basal cells of oral epithelium .
clinico - radiographically , ameloblastoma can be divided into 3 distinct patterns : ( 1 ) the conventional solid / multicystic ( 86% of all cases ) , ( 2 ) the unicystic ( 13% of all cases ) , and ( 3 ) the peripheral ( 1% of all cases ) ( extraosseous).2 various histologic forms have been described which include follicular , plexiform , acanthomatous , granular cell , desmoplastic , and basal cell patterns.2 follicular ameloblastoma presents as a painless swelling or slow expansion of the jaws , and it is described as multilocular expansile radiolucency that occurs most frequently in mandibular molar / ramus area.9 desmoplastic variant occurs more frequently in the anterior mandibular region10 and presents a mixed radiopaque and radiolucent appearance .
unicystic ameloblastoma is usually seen in younger age and most commonly associated with pericoronal radiolucency with unerupted 3rd molar ( 38%).11 in this particular case , the clinical presentation of the follicular ameloblastoma was different from the usual presentation , which included exophytic growth , uncommon location , and absence of expansion of the cortex .
clinically differential diagnosis of this exophytic growth included peripheral ameloblastoma , peripheral odontogenic fibroma , peripheral giant cell granuloma , and other peripheral hyperplastic swellings superficial to the alveolar ridge.9 the final diagnosis was made by the clinical , radiological , and histopathological features after the complete excision of the lesion .
kuru first reported an intraosseous ameloblastoma having penetrated through the alveolar bone , fused with the oral epithelium , and eventually presenting itself clinically as a ' peripheral lesion'.6 our case had the similar clinical and radiological features of the previously reported case by kuru but with no expansion of the cortex .
two other similar cases have been reported by tongdee and ganggakavin7 in 1978 and stevenson and austin8 in 1990 , respectively .
the exophytic growth is also a characteristic finding of the peripheral ( extraosseous ) ameloblastoma which is very rare .
radiographically , or at surgery , a superficial erosion of the bone or a superficial bony depression -known as cupping or saucerization- may be noticed , a finding that is thought to be due to pressure resorption , in contrast to resorption caused by neoplastic invasion.5 the diagnostic criteria of peripheral ameloblastoma include the origin from the overlying epithelium , presence of odontogenic epithelium islands in the lesion , and lack of potential to bone infiltration.12 also , peripheral odontogenic fibroma and peripheral giant - cell granuloma share the same clinical characteristic of exophytic growth most commonly at mandibular premolar region , despite the histopathological difference .
however , radiographically , both of them create depression / resorption in the underlying bone very rarely.13 most oral surgeons and pathologists unquestionably consider peripheral ameloblastoma to be a nonaggressive lesion without actual infiltration into the underlying bone.14 one of the main problems regarding peripheral ameloblastoma is its possible origin .
the two main theories are the following : ( 1 ) origin from the extra osseous epithelial remnants of dental lamina and its organ derivatives within the underlying connective tissue ; ( 2 ) origin from the basal cell layer of the oral mucosa , which is believed to have odontogenic potential.15 those lesions that are entirely separated from the overlying surface epithelium probably arise from the odontogenic remnants , however this hypothesis can be questioned if there is continuity between the tumor and the surface epithelium . in conclusion , even though the incidence of intraosseous ameloblastoma manifesting as exophytic lesion is very rare , it may have to be considered in the differential diagnosis of exophytic lesions at the region of mandibular canine premolar region along with peripheral ameloblastoma , peripheral odontogenic fibroma , peripheral giant cell granuloma , and rarely peripheral hyperplastic swellings superficial to the alveolar ridge .
intraosseous ameloblastoma is the most common and simple type of ameloblastoma prevalent among odontogenic tumors . 
 clinico - radiographically intraosseous ameloblastoma presents as slow , painless swelling or expansion of the jaws and described as multilocular expansile radiolucency that occurs most frequently in mandibular molar / ramus area . 
 this article describes a case of follicular ameloblastoma involving 45 year old male which is different from the usual presentation , which includes - exophytic growth , different location and without expansion of the cortex .