DEPARTMENT OF ORAL AND MAXILLOFACIAL SURGERY

ODONTOGENIC TUMORS COMMON TO THE MANDIBLE

Presented by IRENGBAM VIDYA LAKSHMI

Introduction Variety

of cysts and tumors Uniquely derived from tissues of developing teeth May present to otolaryngologist

Diagnosis Complete Pain,

history

loose teeth, occlusion, swellings, dysthesias, delayed tooth eruption

Thorough

physical examination

Inspection,

palpation, percussion, auscultation

Plain CT

radiographsdental radiographs

Panorex,

for larger, aggressive lesions

Differential Diagnosis Obtain FNA

tissue

r/o vascular lesions, inflammatory Excisional biopsy smaller cysts, unilocular tumors Incisional biopsy larger lesions prior to definitive therapy

Odontogenic TumorsAmeloblastoma Calcifying Epithelial Odontogenic Tumor Adenomatoid Odontogenic Tumor Squamous Odontogenic Tumor

Ameloblastoma Most

common odontogenic tumor Benign, but locally invasive Clinically and histologically similar to BCCa 4th and 5th decades Occasionally arise from dentigerous cysts Subtypes multicystic (86%), unicystic (13%), and peripheral (extraosseous 1%)

Ameloblastoma Radiographic Classic

findings

multilocular radiolucency of posterior mandible Well-circumscribed, soap-bubble Unilocular often confused with odontogenic cysts Root resorption associated with malignancy

Ameloblastoma

Treatment of AmeloblastomaAccording to growth characteristics and type Unicystic

Complete removal Peripheral ostectomies if extension through cyst wall Mandibular adequate normal bone around margins of resection Maxillary more aggressive surgery, 1.5 cm margins Radical surgical resection (like SCCa) Neck dissection.

Classic infiltrative (aggressive)

Ameloblastic carcinoma

Case ReportA 60-year-old male presented at the out patient department with complaints of swelling of the right side of the face of 2 years duration. A history of progressive increase in size, not associated with pain was elicited. He had under gone dental extraction of right lower jaw 1.5 years back for carious/loose tooth at some private setup. There was no history of ulceration, discharge, bleeding, or difficulty opening mouth. On examination there was an irregular swelling of 8 x 8 cm over lower jaw, extending from zygomatic arch to angle of mandible vertically and preauricular region to just short of symphysis. It was nontender, bony hard in consistency, nonpulsatile and neither compressible. There was no sensory or motor deficit on right side of face. There was no cervical lymphadenopathy.

Examination of oral cavity revealed poor orodental hygiene with right lower third molar missing and ulceration present over right buccal area. There was mild right lateral bulge in floor of mouth that was again bony hard. Routine biochemical and hematological investigations were within normal limits. The panoramic view of the jaw revealed expanding multiseptate lesion in the vertical ramus of the right mandible extending up to the horizontal ramus with evidence of break in the cortex and marked soft tissue swelling. CECT [Figure - 1] showed a multilobulated massive cosmetically deforming right suprahyoid swelling replacing mandible, predominantly right entire ramus, coronoid process.

FNAC of the mass revealed fluid with smears showing polymorphs and macrophages. Biopsy of the mass suggested the diagnosis of benign odontogenic tumor with ameloblastic differentiation. The patient was taken up for surgical resection and primary stage mandibular reconstruction with iliac crest graft under general anesthesia. Right lower mandibular margin incision was made with lower lip split in midline. Soft tissue with periosteum cut open and periosteum overlying cystic bony expansion raised both externally and internally along with attached muscles. Oral mucosa incised from lower gingivo-floor of mouth junction. Whole of right hemimandible exposed till condyle and coronoid process above. Right lower first premolar removed, mandible cut with giglis saw. Right tympanomandibular joint disarticulated. The expansile swelling was removed in toto and sent for histopathology.

The right iliac crest was exposed; template marked from left healthy mandible using X-ray plate was placed on inner table of exposed iliac after raising periosteum with muscles. The template was placed in such a way so that lower border of graft matches with crest. Drill, burr was used to excise the inner table of iliac bone along with inner half of crest. Harvested iliac graft [Figure - 2] was placed in such a way so that condyle like process rests in right tympanomastoid joint capsule and anterior free end opposes left mandible. After making holes graft was fastened with mandible anteriorly using titanium plates and screws and condyle fastened with joint capsule with prolene suture. Both the wounds were closed in two layers over romovac suction drain. Ryles tube was inserted and intermaxillary mandibular fixation done on left side using K wire.

The gross appearance [Figure - 3] of the mass was a smooth, nodular, capsulated and cystic which measured 7.5 x 7.5 x 4 cm. Histopathological examination revealed ameloblastoma showing granular cell change. Ryles tube was removed on seventh day and patient was allowed fluids orally, and after 3 weeks intermaxillary - mandibular fixation was also removed and semisolids was allowed. Patient was advised complete bed rest fo3 weeks to avoid stress fracture of iliac crest outer table. Postoperative patient had no complaints in chewing, swallowing or speech articulation. Also mouth opening was normal and jaw was midline with no recurrent swelling in 1-year follow up.

Calcifying Epithelial Odontogenic Tumor a.k.a.

Pindborg tumor Aggressive tumor of epithelial derivation Impacted tooth, mandible body/ramus Chief sign cortical expansion Pain not normally a complaint

Calcifying Epithelial Odontogenic Tumor Radiographic Expanded

findings

cortices in all dimensions Radiolucent; poorly defined, noncorticated borders Unilocular, multilocular, or moth-eaten Driven-snow appearance from multiple radiopaque foci Root divergence/resorption; impacted tooth

Calcifying Epithelial Odontogenic Tumor

Treatment of CEOT Behaves

like ameloblastoma Smaller recurrence rates En bloc resection, hemimandibulectomy partial maxillectomy suggested

Adenomatoid Odontogenic TumorAssociated with the crown of an impacted anterior tooth Painless expansion Radiographic findings

Well-defined expansile radiolucency Root divergence, calcified flecks (target)

Treatment enucleation, recurrence is rare

Adenomatoid Odontogenic Tumor

Squamous Odontogenic TumorHamartomatous proliferation Maxillary incisor-canine and mandibular molar Tooth mobility common complaint Radiology triangular, localized radiolucency between contiguous teeth Treatment extraction of involved tooth and thorough curettage; maxillary more extensive resection; recurrences treat with aggressive resection

Squamous Odontogenic Tumor

Mesenchymal Odontogenic Tumors Odontogenic

Myxoma Cementoblastoma

Odontogenic Myxoma Originates

from dental papilla or follicular mesenchyme Slow growing, aggressively invasive Multilocular, expansile; impacted teeth? Radiology radiolucency with septae Treatment en bloc resection, curettage may be attempted if fibrotic

CementoblastomaTrue neoplasm of cementoblasts First mandibular molars Cortex expanded without pain Involved tooth ankylosed, percussion Radiology apical mass; lucent or solid, radiolucent halo with dense lesions Treatment complete excision and tooth sacrifice

Cementoblastoma

Mixed Odontogenic Tumors Ameloblastic

fibroma, ameloblastic fibrodentinoma, ameloblastic fibroodontoma, odontoma Both epithelial and mesenchymal cells Mimic differentiation of developing tooth Treatment enucleation, thorough curettage with extraction of impacted tooth Ameloblastic fibrosarcomas malignant, treat with aggressive en bloc resection

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