Di Cosola M, Turco M, Bizzoca G, Tavoulari K, Capodiferro S, Escudero-Castao N, Lo Muzio L.

Ameloblastoma of the jaw and maxillary bone: clinical study and report of our experience

Ameloblastoma of the jaw and maxillary

bone: clinical study and report of our
experience
Di Cosola M*, Turco M*, Bizzoca G*, Tavoulari K*, Capodiferro S*, EscuderoCastao N**, Lo Muzio L***
SUMMARY
In order to ameloblastomas cases series, benign tumour of epithelial origin, we will value the histological and
radiographic common findings, its frequent symptomatology, and we will estimate the prevalence variation
according to the age, gender, lesion localization, etc.
In the other hand, we will emphasize the principal risk factors and we will classify the different treatment
according to its histology, clinic and type of lesion.
Key words: Solid-multicystic ameloblastoma, unicystic ameloblastoma.
Receibed: Febrero 2007.
Acepted for publication: Marzo 2007.
*
**
***

Department of Dentistry and Surgery, University of Bari, Italy.

Departament of Oral Medicine and Bucofacial Surgery, Complutense University of Madrid, Spain.
Department of Oral Pathology, University of Foggia, Italy.

Di Cosola M, Turco M, Bizzoca G, Tavoulari K, Capodiferro S, Escudero-Castao N, Lo Muzio L. Ameloblastoma of the jaw and maxillary bone: clinical study and report of our experience. Av. Odontoestomatol 2007; 23
(6): 367-373.

INTRODUCTION
The ameloblastoma is a relatively rare dental tumor,
described for the first time by Broca in 1868, and so
denominated by Churchill in 1934.
According to Larsonn and Almeren (1), its
incidence is 0,6 cases per million, while Shear and
Singh (2) found an incidence of 0.31 cases per
million in a white population of Witwatersrand in
South Africa. Between 1975 and the beginning of
the 80, the concept that the ameloblastoma exists
in three different clinical/histopatological forms was
accepted (3-4): solid-multicystical, unicystical and
peripheral.

Reichart and Philipsen (5), in an analysis of the three

previously mentioned entities, state that the average
age of the patients with ameloblastoma is 36 years.
Gardner critesizing such review( 6), calculated a 39
year-old average age for the solid multicystic ameloblastoma, 22 for that unicystic ameloblastma and of
51 years for the peripheral ameloblastoma. Equal
incidences have been found in the two sexes by
Reichart.
MATERIAL AND METHODS
Ten cases (10) of ameloblastoma were identified in
the department of Dentistry and Surgery of the
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University of Bari-Italy between 1990 and 2006. They

were evaluated and classified clinically, histologically
and radiographycally, based on the cytological criteria
of Vickers and Gorlin (21) and World Health Organization (25) guide lines.
The clinical-pathological data was evaluated: age, sex,
site and dimensions of the lesion, primary and
secondary symptoms and radiographic aspects and
characteristics. Furthermore the possible presence
and entity of recurrence in relationship to the
histological nature of the lesions was examined. The
size of the tumor was measured from the panoramic
radiograph and the greater mesio-distal and apicoocclusal diameters were recorded.
We also considered the type of treatment, results in
relationship to the hystological, clinical and pathological criteria of the various types of lesion, with a
follow-up ranging from 1 to 15 years.
RESULTS
Frequency

maxillary bones, therefore the region in front of the

first molar.
Analysing the three histological types separately we
found that 7 of the 8 cases of solid ameloblastoma
were located in the jaw, 1 of these in the posterior
third, and 1 in the upper maxilla. All the unicystic
ameloblastomas (2) were located in the posterior third
of the jaw.
Size of tumor
In all patients the mesio-distal dimensions were
greater than 2,5 cm (Figs. 1-3).
Symptoms
The symptoms were recorded in all cases: in 8
patients the main symptom was a non aching swelling
of the maxillary bones, 2 were accompanied by pain.
In 4 cases the increase of volume of the lesion was
described up until the hospitalisation; in 1 case pain
was the only symptom. In 2 patients rhizolisi was

10 cases of ameloblastoma were identified during

this study. According to the hystological classification
(25) we found: 8 solid-multicystic, 2 unicystic.
Age and gender: The average age of all the patients,
during the diagnosis, was 39.6 years. The male/
female relationship calculated for the whole group
was 1,3:1, for the solid ameloblastomas 1,4:1 and
1,25:1for the unicisticis ameloblastomas.
All the patients were of Caucasian race and of Italian
nationality.

Fig. 1.

Site distribution
9 cases were located in the jaw and 1 in the upper
maxilla. The ratio between the upper maxilla and jaw
was 9:1. In 7 cases the ameloblastoma was located
in the posterior third of the maxillary bones,
including the area of the molar teeth and the
structures distal to them. In 3 cases the tumor was
found in the anterior and /or middle part of the
368 /AVANCES EN ODONTOESTOMATOLOGA

Fig. 2.

Di Cosola M, Turco M, Bizzoca G, Tavoulari K, Capodiferro S, Escudero-Castao N, Lo Muzio L.

Ameloblastoma of the jaw and maxillary bone: clinical study and report of our experience

Fig. 3.

observed. Paraesthesia was observed only in 1 case

as a secondary symptom. In 2 cases we found the
non aching ulceration of the overlying oral mucosa
(Fig. 4). In 4 cases the discovery of the lesion was
chance, after performing an x-ray for other medical
purposes. The average time between the debut to
the diagnosis was 9,7 months.
Radiographic findings
The radiographic aspect in 8 cases was multilocular
and in 2 cases unilocular. In the case of maxillary
ameloblastoma the opacity of the maxillary sinus was
observed.
Histological findings
The histological diagnosis and the classification
based on the actual criteria (25) allowed us to
indentify 8 solid-multicistic amelobblastomas. The
solid follicolar ameloblastoma were 4 (50%), the
plessiforme 2 (25%), the acantomatosis 1 (12,5%)
and the mixed 1 (12,5%). The 2 cases of unicystic

Fig. 4.

ameloblastoma were recognised and classified based

on the Ackerman classification into: 1 type III (50%)
and 1 type II (50%).
Treatments and recurrence
The cases have been divided into 3 groups based on
the clinical entity ( multicystical or unicystical) and
the treatment received ( conservative or radical):
Group 1: multicystic ameloblastoma with conservative therapy, (cases from 1 to 6).
Group 2: multicystic ameloblastoma with radical
therapy, (cases from 7 to 8).
Group 3: unicystic ameloblastoma with conservative therapy (cases from 9 to 10).
Conservative surgical therapy included enucleation,
curettage, electrocautery, excision and stitching. RaAVANCES EN ODONTOESTOMATOLOGA/369

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dical surgery also includes marginal resection, segmental or total resection of the mandible with wide
margins.
The analysis of the first group (6 patients) showed 3
cases of recurrences. The average time between the
treatment and the recurrences was 3,5 years (range
4 months-10 years).
2 of the 3 recurrences were treated again with
conservative therapy.
In one case the treatment of the recurrence consisted
in the resection of the jaw without continuity of the
inferior edge and a bone autograft, which has not
recurred.
In the second group of solid ameloblastomas the 2
patients were treated with radical surgery.
In this group the only case of recurrence was observed
after 5 years, in spite of the resection of the jaw with
solution of continuity of the inferior edge the
recurrence was diagnosed and treated with a surgical
extension of the borders.
The third group with unicystic ameloblastomas, is
composed of 2 patients with an initial conservative
treatment.
The unicystic ameloblastomas recurred in average
after 3.5 years.
There was one recurrence in this group. It was
possible to reconstruct the following therapeutic
history: first treated with conservative therapy,
recurred for the second time and a jaw resection with
solution of continuity of the inferior edge was
necessary but successful.
Clinical and histological factors of risk for
recurrence
The first group (cases 1-6) had 3 recurrences out of
a total of 6 with dimensions greater than 2 cm at the
moment hospitalisation and 1 recurrences had
dimensions inferior than 2 cm at the time of
hospitalisation. In the second group (cases 7-8), 1
370 /AVANCES EN ODONTOESTOMATOLOGA

lesion out of 2 had dimensions greater than 3 cm at

the hospitalisation.
In the group of the unicystic ameloblastomas (cases
9-10) the only recurrences had with dimensions
greater than 3 cm at hospitalisation were observed.
By each the location, in the first group we have
noticed only 3 recurrences out of a total of 6 with
location in the anterior and middle third of the
maxillary bones, while the remainder 3 lesions were
located in the posterior third recurred. In the second
group there was only one lesion located in the posterior third.
In the group of the unicystic ameloblastoma, we
found one recurrence located in the posterior part of
the jaw.
DISCUSSION
The ameloblastoma is statistically more frequent in
the molar region and branch of the jaw, while in the
maxilla it is more often found in the molar region,
even if in some cases the maxillary cavity is interested.
The 80% of these cases were solid-multicystical and
the remaining 20% unicystic. This data differ from
Reicharts studies (5), which estimates 51% the
incidence of the solid-multicystical lesion and the 49%
for the unicystic. Such discrepancy can only be
determined by the small amount of patients
considered in our study. From the analysis of our
cases an agreement emerged with Kramer and Regezi
et, to the (11), we found no correlation among clinical
symptoms, biological behavior and histological
subtype. According to Reichart (5) the most common
histological type is the follicolar lesion 50% compared
to 33,9% proposed by literature.
According to Shaw and Katsikas (26) none of their
cases followed chemio- or radiotherapy, which are
only indicated in case of remaining tumor tissue after
lesion resection or as a palliative therapy. In case of
upper maxillar lesions radical resection is advised,
due to the spongy osteoarchitecture of the maxilla
which facilitates the diffusion of the tumor to the
sinus ethmoidalis, pterygoidea fossa, temporal fossa
and base of skull (21,25). In our study we had only

Di Cosola M, Turco M, Bizzoca G, Tavoulari K, Capodiferro S, Escudero-Castao N, Lo Muzio L.

Ameloblastoma of the jaw and maxillary bone: clinical study and report of our experience

one case of ameloblastoma located in the upper

maxilla, it were treated with conservative surgery.
Recurrences were encountered in the patients, that
were over 65 years old, for whom this type of
treatment was chosen because of the limited life span
left; but for the young patients the literature suggest
a conservative approach in pediatric patients.
Considering the fact that the conservative treatment
of the maxillar bones offers local recurrence in100%
of the cases and a 60% of mortality rate (26-28-32),
it is important that the patients with this pathology
have a life long follow-up with the help of computer
tomography (CT) and magnetic resonance
tomography (MRT). The therapy of the ameloblastoma is surgical, but it has not been established yet
which is the most suitable operation. The decision to
use a radical or conservative approach depends on
various factors: 1) the dimensions and the location
of the lesion, 2) the growth rate and the relationship
with the nearby structures, 3) the histological type, 4)
the clinical characteristics, in the recurrences, 5) the
general conditions of health and the age of the patient
(14). Among this series of factors the histological
aspect has a decisive role: the solid multicystic ameloblastoma and the unicystic-intramural ameloblastomas, subtype III of Ackerman, need radical
treatment, with the resection of 1-2 cm of healthy
bone (12-15-17), although not all the authors have
found high rates of recurrence after the conservative
treatment of such forms (5). On the contrary the
unicystic intraluminal ameloblastoma rarely recurrers
after conservative therapy, only 10 % according to
Leider (15), Eversole (16), Gardner (17) and 13,7%
according to Reichart (5). Therefore a conservative
aproach it is advisable in the case of a non invasive
and non proliferating cyst wall. The location of the
lesion seems to be an important risk factor for the
recurrence of the ameloblastoma in fact the most
frequent recurrence were located in the third posterior of the jaw.
CONCLUSION
We think that the product of our experience, is useful
for an efficient programming of treatment, taking in
consideration numerous variables of this pathology
and the indications found in literature.

We believe that for the diagnostic phase the instrumental examinations (X-RAY, CT or MRT) are
essential; while intralesional byopsies are inefficient
because they don t offer a whole vision of the tumor
and could lead to diagnostic error. Therefore we think
that it is advisable, considering: the site and extention,
of the lesion, age and general conditions of the
patient, to remove the lesion in a conservative manner
in a first surgical step and according to the histolgical
aspect evaluate a possible radical resection.
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