Case Report

TREATMENT ALGORITHM FOR

AMELOBLASTOMA
drg. ROBBY RAMADHONIE
Ilmu Bedah Mulut dan Maksilofasial
Universitas Gadjah Mada

Senin, 10 September 2018

 Introduction
• Ameloblastoma is the second most common benign odontogenic tumour (Shafer
et al. 2006) which constitutes 1–3% of all cysts and tumours of jaw, with locally
aggressive behaviour, high recurrence rate, and a malignant potential (Chaine et
al. 2009).
• The treatment algorithm to be chosen depends on size (Escande et al. 2009 and
Sampson and Pogrel 1999), anatomical location (Feinberg and Steinberg 1996),
histologic variant (Philipsen and Reichart 1998), and anatomical involvement
(Jackson et al. 1996).
• Various treatment algorithms for ameloblastoma have been reported; however, a
universally accepted approach remains unsettled and controversial (Chaine et al.
2009)
• Treatment of a patient with an ameloblastoma should be based on accurate
clinical details, radiographs, special imaging, and a representative biopsy,
followed and reviewed by an oral pathologist and a maxillofacial surgeon.
Histologically
1. Follicular
2. Plexiform
3. Acanthomatous
4. Granular
5. Desmoplastic
6. Basilar
Symptoms and Clinical appearance
1. Slow growing
2. Painless expansion of jaw which causes thinning of cortical plates
3. Root resorption
4. Tooth mobility
5. Paresthesia
Radiographically
• It can be unicystic
• Multicystic
• Solid
• Peripheral type

Multicystic or solid type is prevalent in 86% of cases. Unicystic

ameloblastoma is of three subtypes: luminal, intraluminal, and mural
Treatment modalities are based on algorithms
Which are dictated by:
1. Size
2. Anatomical location
3. Histologic variant
4. Anatomical involvement
According to a retrospective study done in Northern California for both
primary management and treatment of recurrences for mandibular
ameloblastoma, specific diagnostic and treatment techniques had been
applied which had resulted in satisfactory results. This has been refined
into an algorithm that allowed the clinician to have an organized
approach to treating these tumours.
Based on a study done in Pitié-Salpêtrière Hospital from 1994 to 2007,
114 patients were studied and consequently divided into three groups:
less than 5 cm, between 5 and 13 cm, and more than 13 cm
(corresponding to the group of the giant ameloblastomas). Then, jaw
locations were studied. Regarding site, the maxilla was divided into
three regions: anterior, premolar, and molar areas. The mandible was
divided into five areas: symphyseal, parasymphyseal, horizontal ramus,
angle, vertical ramus, coronoid process, and cranial base.
Case  1
• A 28-year-old male patient reported to the department with the chief
complaint of pain in the left lower jaw region for the last three
months. Extraoral examination revealed a diffuse hard swelling
measuring approximately 3 cm × 2 cm. On intraoral palpation there
was expansion of buccal and lingual cortical plates. Decompression
and packing with BIPP paste were done to prevent pathological
fracture. After 6 months enucleation with curettage was done.
Incisional biopsy revealed unicystic mural ameloblastoma. The patient
was operated on under LA. A regular follow-up is being done. There is
no sign of recurrence.
Case 2
• A 17-year-old female patient reported to the department two years
back with the chief complaint of swelling in the right lower jaw region
for the last four months. On extraoral examination a nontender
swelling approximately of the size 4 cm× 2.5 cm was appreciated in
the left mandibular region extending from lateral incisor to lower
third molar region. There was expansion of buccal and lingual cortical
plates. Incisional biopsy revealed unicystic mural ameloblastoma. The
patient was operated on under GA. Lesion was completely
enucleated. Impacted teeth (33, 34, 35, and 36) were extracted.
Peripheral osteotomy was done. Primary closure was achieved. A
regular follow-up is being done. There is no sign of recurrence.
Case 3
• 25-year-old male patient reported to the department with the chief
complaint of swelling in the lower left back tooth region for the last
year. On extraoral examination we could palpate a swelling
approximately of the size 6 cm × 3 cm extending from the commissure
of lip to the posterior border of the mandible. On intraoral palpation
there was expansion of buccal and lingual cortical plates and
perforation of lingual cortical plates. Incisional biopsy was done. It
revealed plexiform ameloblastoma. The patient was operated on
under GA. Segmental resection with disarticulation of the left
mandible was done followed by reconstruction with microvascular
fibula free flap using reconstruction plate. A regular follow-up is being
done. There is no sign of recurrence.
Case 4
• A 60-year-old male patient reported to the department of OMFS, Raja
Rajeswari Dental college, Bangalore, with the chief complaint of
swelling on left middle third of face for the past four months. On
extraoral examination a diffuse swelling measuring approximately 5 ×
4 cmwas felt which extended fromala of nose to the tragus of ear and
infraorbital margin to below the commissure of lip. On intraoral
examination a bony hard swelling was present extending from midline
to 1st premolar region and cervical margin to the nasal floor.
Incisional biopsy was done. It revealed follicular type of
ameloblastoma. Partial maxillectomy was done under general
anaesthesia (Table 2). A regular follow-up is being done.There is no
sign of recurrence.
Case 5
• 28-year-old female patient reported to the department with the chief
complaint of swelling in the lower left back tooth region for the last three
months. On extraoral examination, there was a swelling approximately of
the size 4 cm × 4 cm extending from left commissure of lip to the posterior
border of ramus of mandible and from ala-tragus line to 1 cm below the
lower border of mandible. On intraoral examination there was bony
expansion in buccal and lingual cortical plate and perforation of lingual
cortical plate. Incisional biopsy was done. It revealed follicular type of
ameloblastoma. Segmental resection with disarticulation of the left
mandible was done followed by reconstruction with rib graft using
reconstruction plate. A regular follow-up is being done. There is no sign of
recurrence.
References
1. W. G. Shafer, M. K. Hine, and B. M. Levy, Shafer’s Textbook of Oral Pathology, Elsevier, 5th edition, 2006.
2. W. Zemann, M. Feichtinger, E. Kowatsch, and H. Kärcher, “Extensive ameloblastoma of the jaws: surgical
management and immediate reconstruction using microvascular flaps,” Oral Surgery, Oral Medicine, Oral
Pathology, Oral Radiology and Endodontics, vol. 103, no. 2, pp. 190–196, 2007. View at Publisher · View at
Google Scholar · View at Scopus
3. H. P. Philipsen and P. A. Reichart, “Unicystic ameloblastoma. A review of 193 cases from the literature,”
Oral Oncology, vol. 34, no. 5, pp. 317–325, 1998. View at Publisher · View at Google Scholar · View at
Scopus
4. C. Escande, A. Chaine, P. Menard et al., “A treatment algorythmn for adult ameloblastomas according to
the Pitié-Salpêtrière Hospital experience,” Journal of Cranio-Maxillofacial Surgery, vol. 37, no. 7, pp. 363–
369, 2009. View at Publisher · View at Google Scholar · View at Scopus
5. D. E. Sampson and M. A. Pogrel, “Management of mandibular ameloblastoma: the clinical basis for a
treatment algorithm,” Journal of Oral and Maxillofacial Surgery, vol. 57, no. 9, pp. 1074–1077, 1999. View
at Publisher · View at Google Scholar · View at Scopus
6. S. E. Feinberg and B. Steinberg, “Surgical management of ameloblastoma,” Oral Surgery, Oral Medicine,
Oral Pathology, Oral Radiology, and Endodontology, vol. 81, pp. 383–388, 1996. View at Google Scholar
7. I. T. Jackson, P. P. Callan, and R. A. Forte, “An anatomical classification of maxillary ameloblastoma as an
aid to surgical treatment,” Journal of Cranio-Maxillo-Facial Surgery, vol. 24, no. 4, pp. 230–236, 1996.
View at Publisher · View at Google Scholar · View at Scopus
• Supraperiosteal dissection with/without excision of overlying mucosa
is indicated if the tumour perforates cortices
• Recurrences of ameloblastoma commonly occur during the 5-year
postoperative period.5 Hence, patient follow-up using clinical
examination and panoramic radiograph should be done twice a year
in the first 5 years and then once a year for at least 10 years
• Osseous free flaps for mandibular reconstruction can be obtained
from the fibula, ilium, scapula, rib, metatarsus and radius
• Ameloblastomas usually are potent benign tumors of epithelial origin
that could develop out of the enamel organ, remains of dental
lamina, the lining of any odontogenic (dentigerous) cyst, or even
perhaps from the basal epithelial cellular material of the oral
mucosa.[4]
• mented with further application of Carnoy's solution, cryotherapy or
diathermy in order to reduce the recurrence rate
• In accordance with the literature, a more conservative approach to
unicyst lesions, which could be treated with simple enucleation
and/or curettage, was preferred in young patients (18). In solid and
multicystic ameloblastomas we followed the procedure
recommended most in the literature, i.e., radical resection including a
healthy bone margin of at least 1 cm
• In 3 cases presenting with <5 cm mandibular segmental defect,
reconstruction was achieved using a non-vascularized iliac crest graft
• In the present study, an 8 cm defect involving the body, angle and
ramus of the mandible was reconstructed using a fibula free flap.