Ameloblastoma Treatment inCipto Mangunkusumo Hospital /

Dept. OMFS UniversitasIndonesia

Ameloblastoma is the most common benign odontogenic tumor in jaw bone

Origin of Ameloblastoma is from odontogenic epithelial remnants

Ameloblastoma grow slowly but locally invasive, has a high reccurence rate

Background

• Remnants of enamel organ (reduced enamel epithelium) and dental lamina

• Epithelial cell rests of Malassez

• Epithelium from odontogenic cyst, especially dentigerous cyst and odontoma

• Basal cell layer of the oral epithelium

Etiology & Pathogenesis

Ameloblastoma Distribution in Jaw Bone

Neville BW, Damm DD, Chi AC, Allen CM. Oral and maxillofacial pathology. Elsevier Health Sciences; 2015.

Generally, ameloblastoma is asymptomatic

Symptom and clinical features of Ameloblastoma is usually appear when the lession presents jaw swelling and cause facial asymmetry

Lession can cause displacement of teeth, malocclusion, tooth resorption, and pathologic tooth mobility

Clinical Features

Location

• Mostly located in Mandibular ramus

Border of lession

Well defined cortical borders in the mandible

Internal structure

Varies from completely radiolucent to mixed, with the presence of bony septa that provide multilocular or soap bubble patterns

In demoplastic type, internal structure is consist of irregular sclerotic bone

Effect to surrounding tissues

There is a tendency that Ameloblastoma can cause tooth resoption and tooth displacement

Radiographic Features

• Ameloblastoma Multicystic– Folikuler Pattern– Plexiform Pattern– Achantomatous Pattern– Basal Cell Layer Pattern– Granular Cell Layer Pattern

• Ameloblastoma Unicystic– Luminal Pattern– Intraluminal Pattern– Mural Pattern

• Ameloblastoma Desmoplastik

Histopathologic Features

Laskin, Abubakar. Decision Making in Oral and Maxillofacial Surgery. Quintenssence : 2007

Treatment

CASE REPORTS

Physical Examination

Extra Oral

•Facial asymmetry (+)

•Swelling (+) Size 8x8x4 cm

•Tenderness (-)

•Crepitation (-)

•Fistule (-), pus and blood discharge (-)

Mr. DR / Male / 18 y.o

CASE 1

Physical Examination

• Intra Oral:▪ No Limitation of mouth

opening▪ Fistule (-), Tenderness (-)▪ Pus discharge (-)▪ Blood discharge (-)▪ Anterior open bite ▪ Palpable a mass in the region

45-47 with cystic consistency▪ Texture, colour and

temperature same with surrounding

OPG March 18th 2018

MSCTApril 20th 2018

Expansile lytic lesion involves the right ramus mandible, angle mandible and corpus mandible.Size +/- 6.2 x 4.6 x 8.4 cm causing partial erosion of the right anterior ramus cortex , dislocation of right lower M2 to the anterolateral side . The superior edge of the lesion is 1.8

cm from the right TMJ area. The right joint temporomandibullar is still in the fossa

• The specimen was taken from the right mandible, consists of a cyst wall layered with odontogenic epithelium, most of it appears erosive. Follicular odontogenic tumors is seen in one of the specimen between fibrocollagenstroma. The tumor cells are arranged by palisading on the edges and are stellata cells in the middle. Nucleus of the tumor is Hyperchromatic, mitosis are hard to find. Other specimen show a fibrotic connective tissue with a mild chronic inflammatory cells.

• Histologic features represent desmoplastic type of Ameloblastoma and odontogenic cyst dd / cystic ameloblastoma

Histopatological Examination

Working diagnosis

Desmoplastic Ameloblastoma

• Right Mandibular Segmental Resection (hemimandibulectomy) untill region 43 with condyle disarticulation

• Reconstruction with plate and screw

TREATMENT

Patient in supine position, do asepsis and antiseptic, and apply sterile drapes. Draw extraoral incision design on 1 cm below inferior border

of mandible and intraoral incision design on marginal gingival of tooth 44 to ramus ascendens

Strip periosteal from bone until all of tumor mass and its adjacent healthy bone was exposed. The mass was

taken out of oral cavity

Post insertion of reconstruction plate

Suture muscle to the reconstruction plate to prevent exposed plate

The tumor mass was sent for histopathologic examination

Physical Examination

Extra Oral:▪ Asymmetrical on anterior

lower jaw▪ Swelling on the right corpus of

mandible 11x7x5 cm and right buccal

▪ Well defined border▪ Color and temperature same

as surrounding▪ Hard consistency, smooth

surface, immobile▪ Tenderness (-)▪ Massa terfiksir▪ Fistula(-), pus discharge (-)▪ Lymph nodes (-)

Mr. E / Male / 19 y.o

CASE 2

Physical Examination

Intra Oral:

▪ Poor OH▪ Mass on the mandible at

region 31 until 48▪ Well defined border▪ Smooth surface▪ Size in 11x7x5 cm▪ Color and temperature same

as surrounding▪ Hard consistency, immobile▪ Tenderness (-)▪ Pus (-), Darah (-), ulkus (+)▪ Expansion to buccal and

lingual (+)

OPG (5/2/2018)

CT Scan 2D (14/3/2018)

CT Scan 3D (14/3/2018)

3D Printing Model

Stereolithography of patient’s mandible and some part of maxilla was contoured to represent the defect of tumor mass post removal. Reconstruction plate is bended accordingly.

Histopathological Findings (28/3/2018)

• The preparation shows tumor masses composed of islands, consisting of columnar cells to kuboid with a hyperchromatic core arranged palisading around the stelate reticulum undergoing middle squamous metaplasia. Among the tumor mass contained stromal connective tissue chronic inflammatory cells. There is also bone tissue between the preparation

• The preparation consist of fibrocollagenous connective tissue and bones trabecula which contain of tumour mass that built of proliferation of odontogenic cells that shapes flexiform structures. Tumor cells structures of palisading in the perifer, round or oval core, smooth cromatin, parts of vesicular. Sitoplasm eosinophil. Mitosis was hard to find. In the middle of tumour was found reticulum stelata, chronic inflammation cells, parts of miksoid.

Conclusion : Plexiform Ameloblastoma

Working diagnosis

Ameloblastoma of the right mandible (Plexiform type)

Treatment

• Right Mandibular Segmental Resection (hemimandibulectomy) until region 33 with condyle disarticulation

• Reconstruction with plate and screw

Identify facial artery and ligate artery. Strip mucoperiosteum until the tumor mass and its

surrounding healthy bone is exposed

The tumor mass was separated from its adjacent bone

The tumor mass was sent for histopathologic examination

Remove IMF and check patient’s occlusion and mouth opening

Suture intraoral operation wound with continuous interlocking technique with silk 3.0 and suture

extraoral operation wound layer by layer and apply vacuum drain underneath the skin

Post Operative

OPG Post Operative

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