SEGMENTAL RESECTION & RECONSTRUCTION OF UNICYSTIC AMELOBLASTOMA OF MANDIBLE: A CASE REPORT

Dr. Hitesh S. Dewan M.D.S., DNB Dr. Hiren Patel M.D.S. Dr. Haren Pandya M.D.S. Dr Urvi Babaria M.D.S., Dr Bijal Bhavsar M.D.S. Dr. Dipak B.D.S., Dr. Chintan B.D.S., Dr. Shirish B.D.S. ABSTRACT Unicystic ameloblastomas are aggressive benign jaw tumours. They mimic cysts but their growth can become enormous .Therapy is radical resection preferably with reconstruction. A 50 year old male having unicystic ameloblastoma involving the left angle of mandible was subjected to segmental resection without condylar disarticulation and titanium plate reconstruction. Key words : Ameloblastoma, Resection, Reconstruction. INTRODUCTION Unicystic ameloblastoma of mandible are aggressive destructive benign mandibular tumours demanding radical therapy1. They commonly show features of cyst but histological criteria help in final diagnosis. They are second most common odontogenic tumours after odontomas2. They can present with variable symptoms of pain, swelling, nerve paresthesia, egg shell crackling, infection, malocclusion, tooth mobility, pathologic fracture, difficulty in mastication and deglutition3. Clinically they may remain silent if confined within the bone but may show symptoms if they encroach the nerve, break the cortex or get infected. Before surgery biopsy is helpful to confirm the diagnosis and decide the line of therapy. CASE REPORT A 50 year old male patient was referred to Department. Of Oral & Maxillofacial Surgery , Faculty of Dental Science, Dharmsinh Desai University, Nadiad with symptoms of mildly tender swelling at the left angle of mandible which had slowly enhanced to its present size more so in the last two months. He had undergone aspiration of the lesion elsewhere and was referred for further diagnosis and management. On clinical examination, he presented with an expansile swelling at left angle of mandible obliterating the submandibular skin fold. Expansion was diffuse, mildly tender, extending from premolar region up to lobule of ear. Intraorally, both buccal and lingual cortices were expanded and left buccal vestibule was obliterated. There was no paresthesia of the lower lip.

Pre operative swelling Fine needle aspiration cytology (FNAC) report showed no evidence of malignancy with mixed inflammatory cell infiltration with plenty of histiocytes over hemorrhagic background. Orthopantomogram and Computerized Tomogram (CT) scan report showed evidence of large expansile osteolytic lesion involving medial aspect of left ramus of mandible with intact buccal cortex, thinning out of lingual cortex and lower border. Maximum size of lesion was 62x43 mm extending into submandibular region. Resorption of 36,37 & 38 molar roots were evident . All preoperative investigations were found to be within normal limits and the patient was deemed fit for surgery.

Preoperative OPG Patient was operated under general anaesthesia. Endotracheal nasal intubation was done. Vital signs were maintained within normal limits. Painting with 5% povidoneiodine and draping was done. Local Anaesthesia (1:80,000) Address for correspondence: Dr. Hitesh S. Dewan 1st Floor, Agrawal Chambers, Opp.Town Hall Ellisbridge, Ahmedabad-380004 e-mail: dewanhitesh@yahoo.co.in Phone: (079)26575509,26578432 M. : (+91) 9825011642 8

Professor & Head Professor Reader Tutors

Oral & Maxillofacial Surgery Department, Faculty of Dental Science, Dharmsinh Desai University, Nadiad

was injected at the incision site.. A large submandibular incision was taken 2 cm below the lower border of mandible extending from midline to 1 cm short of lobule of left ear. Layer by layer supraperiosteal dissection was done preserving rima mandibularis. Facial vessels were identified,clamped,cut & ligated. Tumour and normal lower border of the mandible were exposed anteriorly whereas normal posterior border of bone was identified halfway up the ascending ramus. Excessive vascularity was encountered during dissection which was controlled by judicious use of bipolar cautery. Intraorally, permucosal incisions were made just distal to 34 buccally and lingually .At sites of fluctuation and doubtful perforation overlying mucosa was kept attached to the lesion as it would be sacrificed eventually with the tumour. Segmental resection of the mandible was carried out using oscillating saw and physiodispenser at 2000 rpm but final osteotomy cut was made with osteotome and mallet. Disarticulation of condyle was not done. Inferior alveolar neuro-vascular bundle was identified and ligated on medial aspect of mandible. The final extent of osteotomy was from distal of 35 to half of left ascending ramus of mandible. The intraoral mucosal cuts were joined with external cuts and the tumour was delivered intoto with an intact capsule, normal bone and overlying mucosa. Rough weight of specimen was 200 grams.

Plate adaptation

Post operative OPG Inter maxillary fixation was removed after 15 days. Good resultant facial contours and normal occlusion on the right side were seen.

Post operative facial profile Resected specimen Tissue bed was washed,debrided and all bleeding points were cauterized. Intermaxillary fixation was done on right side to prevent deviation. A left angled 13 holed titanium mandibular reconstruction plate ( thickness 2 mm made with 5832 grade titanium) was adapted and fixed on both stumps with 5 bicortical screws of 2.5mm diameter and 10-12 mm length. Proximal condylar stump was kept in passive position to prevent future hardware migration. Intraoral defect was sutured with vicryl rapide 4-0. Layer by layer closure was done with vicryl 3-0 and skin was closed with ethilon 4-0 suture. Negative drain was kept in situ and removed on 3rd post operative day. Patient was discharged in good physical condition and post operative healing was uneventful .

Post Operative occlusion Histopathology report showed basal cell palisading with cystic degeneration suggestive of unicystic ameloblastoma. Post operative x-ray showed good adaptation of bone plate and normal contour restoration. 6 months follow up was uneventful. Patient is under regular follow-up.

DISCUSSION Unicystic ameloblastomas are commonest in the mandibular molar and ramus region. Differential diagnosis includes giant cell tumours, odontogenic keratocysts and dentigerous cysts4. Aggressive surgery is the mainstay for treating ameloblastomas. Usually the first surgery has to be definitive because recurrent cases show lot of contracture, soft tissue encroachment and fast proliferation. When small lesions are encountered with easily separable margins, enucleation can be carried out5 and Carnoy's solution can be used to minimize chances of recurrence6. Involved mucosa should also be excised along with specimen without trying to separate it. Supraperiosteal dissection without actually exposing the tumour minimizes the chances of seeding. Resection either marginal or segmental should be done only on sound bone with at least 0.5-1cm of free surgical margin9,10. When segmental resection is advocated it is preferable not to disarticulate the condyle as the residual condylar stump provides a good platform for proximal end plate fixation. Reconstruction plate may serve as an interim or a stop gap reconstruction option, but if it does not show any signs of dehiscence, infection, migration or loose hardware, it can be kept in situ for a long time. However, the gold standard for mandibular reconstruction is microvascular free fibula osseo-myocutaneous flap 7, 8 Mantainence of facial contours and occlusion is of paramount importance postoperatively. Conservative therapies of these tumours like curettage and enucleation are strongly discouraged as they lead to almost inevitable recurrence9, 10. REFERENCES 1. Kahairi A, Ahmad RL, Wan Islah L, Norra H: Management of large mandibular ameloblastoma - a case report and literature reviews. Archives of Orofacial Sciences 2008 , 3(2):52-55. 2. Rakesh S Ramesh, Suraj Manjunath, Tanveer H Ustad, Saira Pais, Unicystic ameloblastoma of the mandible - an unusual case report and review of literature Head & Neck Oncology 2010, 2:1doi: 10.1186/1758-3284-2-1

3.

Roos RE, Raubenheimer EJ, van Heerden WF: Clinico-pathological study of 30 unicystic ameloblastomas. J Dent Assoc S Afr 1994 , 49:559-62 Philipsen HP, Reichart PA: Classification of odontogenic tumors and allied lesions. In Odontogenic tumors and allied lesions. Quintessence Pub. Co. Ltd; 2004:21-3. Pizer ME, Page DG, Svirsky JA: Thirteen-year followup of large recurrent unicystic ameloblastoma of the mandible in a 15-year-old boy. J Oral Maxillofac Surg 2002 , 60:211-5 P.K. Leea, N.Sammanaf: Unicystic ameloblastomause of Carnoy's solution after enucleation Int. Journal of Maxillo-facial surgery 2004, vol 33 issue 3: 263-267 Gerzenshtein J, Zhang F, Caplan J, Anand V, Lineaweaver W: Immediate mandibular reconstruction with microsurgical fibula flap transfer following wide resection for ameloblastoma. J Craniofac Surg 2006 , 17(1):178-182. Chana , Jagdeep S, Yang-Ming Chang, Wei , Fu-Chan , Shen , Yu-Fen , Chan Chiu-Po, Lin Hsiu-Na, Tsai ChiYing, Jeng Seng-Feng: Segmental mandibulectomy and immediate free fibula osteoseptocutaneous flap reconstruction with endosteal implants: An ideal treatment method for mandibular ameloblastoma. Plast Reconstr Surg 2004 , 113(1):80-87. Li TJ, Kitano M, Arimura K, Sugihara K: Recurrence of unicystic ameloblastoma: A case report and review of the literature. Arch Pathol Lab Med 1998 , 122:371-4

4.

5.

6.

7.

8.

9.

10. Lau SL, Samman N: Recurrence related to treatment modalities of unicystic ameloblastoma: A systematic review. Int J Oral Maxillofac Surg 2006 , 35:681- 90

10