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British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx

Argument for the conservative management of mandibular

ameloblastomas
Jahrad Haq a , Sarah Siddiqui b , Mark McGurk c,∗
a SpR in Oral & Maxillofacial Surgery, King’s College Hospital, Denmark Hill, London, SE5 9RS
b Dental Student, Guy’s Hospital, Great Maze Pond, London, SE1 9RT
c Prof of Oral and Maxillofacial Surgery, University College London, Gower St, London, WC1E 6BT

Accepted 20 July 2016

Abstract

Ameloblastoma is a rare, benign, odontogenic tumour that affects the mandible more commonly than the maxilla. Solid or multicytic variants
are often resected and the defects reconstructed with a free flap. To establish the outcome after enucleation and application of Carnoy’s solution,
irrespective of histological subtype, we used the hospital’s histology database to identify all the patients treated between 2001 and 2014 by
one surgeon. Variables included patients’ characteristics, histological subtype, radiological appearance, follow-up period, and incidence of
recurrence. A total of 27 patients (13 male) were included, mean age 41 years (range 12-79). Fifteen (56%) had solid multicystic lesions, and
there was an overall predominance of the follicular or plexiform variant, or both. Of the 23 preoperative radiographs that were available, 17
lesions were unicystic, 5 multilobular and scalloped with no septa, and one had aggressive features of multilocularity and a poorly defined
peripheral margin. The mean duration of follow up was 38 months (range 3-156). Three patients had recurrence at 20, 27, and 35 months
postoperatively, and each had repeat enucleation and application of Carnoy’s solution. Reconstruction was not necessary, and to date none
has recurred. This study shows the potential benefits of conservative surgery and sterilisation of the cystic cavity with Carnoy’s solution.
Recurrence is low, and with vigilant surveillance, similar repeat procedures have been effective when necessary. A longer follow-up period
and larger numbers of patients are now needed to corroborate these findings.
© 2016 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.

Keywords: Ameloblastoma; Carnoy’s; Enucleation

Introduction a high rate of recurrence (up to 60%-80%) if not ade-

In 2005 the World Health Organization (WHO) described
ameloblastomas as benign, locally invasive, polymorphic
neoplasms that consist of proliferating odontogenic epithe-
lium (usually with a follicular or plexiform pattern) lying
in a fibrous stroma.1 They are slow-growing tumours
with an affinity for bone, not soft tissue, and they have
∗ Corresponding author at: Prof of Oral and Maxillofacial Surgery, Uni-
versity College London, Gower St, London, WC1E 6BT.
E-mail addresses: J.Haq@nhs.net (J. Haq), sarah.siddiqui@kcl.ac.uk
(S. Siddiqui), mark.mcgurk@btinternet.com (M. McGurk).
quately removed.2 They have virtually no tendency to
metastasise.
Ameloblastomas affect young people. They are often diag-
nosed around the age of 36 years and they affect both sexes
equally.3 Tumours present as painless bony swellings or inci-
dental findings on radiological examination, and as they are
difficult to recognise in the early stages, they are often rel-
atively large at diagnosis and can fill the ramus or body of
the mandible. Radiological appearances can be unilocular,
multilobular, or multilocular.4
Histologically, there are four patterns: solid multicystic,
extraosseous peripheral, desmoplastic, and unicystic.1 The

http://dx.doi.org/10.1016/j.bjoms.2016.07.017
0266-4356/© 2016 Published by Elsevier Ltd on behalf of The British Association of Oral and Maxillofacial Surgeons.

Please cite this article in press as: Haq J, et al. Argument for the conservative management of mandibular ameloblastomas. Br J Oral
Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.07.017
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2 J. Haq et al. / British Journal of Oral and Maxillofacial Surgery xxx (2016) xxx–xxx

unicystic variant can be further divided into three subtypes

depending on mural involvement. Subtype 1 cysts are lined
by variable epithelium with no infiltration into the cystic wall.
Those in subtype 2 show intraluminal, plexiform, epithelial
proliferation without infiltration, and those in subtype 3 show
either a follicular or plexiform pattern of invasion by epithe-
lium into the cystic wall. 5 We question the clinical relevance
of these patterns.
Traditionally, treatment has depended on the histologi-
cal features. The solid multicystic, and subtype 3 unicystic
ameloblastomas are considered aggressive with a high poten-
tial to recur, so the approach has been to resect the lesion and
repair the defect with a microvascular graft.6–8 The unicys-
tic forms are thought less likely to recur, but although a more
conservative approach is recommended, in reality it is seldom
adopted.9–11
Evidence now suggests that the natural history of
mandibular ameloblastomas should be reviewed.12,13 Several
small case studies have reported long periods of remission and
potential cure after enucleation and application of Carnoy’s
solution.3 This technique has evolved from the management
of keratocysts, and its use in the treatment of ameloblastomas
is promising with recurrence of 10%.14
We report 27 consecutive patients with ameloblastoma of
the mandible who were treated by enucleation and applica-
tion of Carnoy’s solution. Although the study has limitations,
most notably the number of cases and duration of follow up,
we hope that it will show that there is a safe alternative to
resection of the jaw. We also hope that it will stimulate debate
and act as a catalyst for further research into the management
of these tumours.

Methods

Since 2001 at the head and neck unit at Guy’s Hospital,

we have treated patients with ameloblastoma conservatively.
We retrospectively analysed the case notes from the time
of operation of all patients treated for ameloblastoma of
the mandible by the same surgeon. Those with maxillary
ameloblastomas were excluded. Each patient had clinical
and radiological evaluation by plain film or cone-beam com-
puted tomography (CT). In each case, the in-house pathology
team reviewed the histological examination of the biopsy
specimen. Information collected included patients’ charac-
teristics, histological classification and radiological features
of the lesions before and after operation, operative details,
and status of the disease at the last review. The preopera-
tive radiological features were categorised into three groups
(Fig. 1).
Technique
We excise mucosal fistulas or mucosa attached to the tumour,
but preserve mucosa that is not attached by gently peel-
ing it off the mucoperiosteal flap. In most cases, as part
Fig. 1. Radiological subclassification. (A) Unilocular: no septa, well-defined
margin; (B) mulitlobular: some septa, well-defined margin; (C) multilocular:
multiple septa and satellite lesions, poorly-defined margin.
of the enucleation, we remove the teeth associated with the
lesion. On exposing the mandible we carefully remove the
overlying buccal plate to expose the full extent of the tumour
and avoid leaving a bony overhang. We then carefully enu-
cleate the tumour by creating a plane between it and the bone.
To do this we pack ribbon gauze into the space around the
periphery of the tumour. The remnants of the lingual plate can
be freed with a rotary instrument or chisel so that the tumour
and embedded teeth can be delivered as a unit. This approach
leaves a clear bony cavity with patches of exposed perios-
teum. The cavity is carefully inspected and any lacunae are
drilled back to bleeding bone. The bony cavity is then filled
twice with Carnoy’s solution (1 g of ferric chloride dissolved
in 6 ml of absolute alcohol, 3 ml of chloroform, and 1 ml of

Please cite this article in press as: Haq J, et al. Argument for the conservative management of mandibular ameloblastomas. Br J Oral
Maxillofac Surg (2016), http://dx.doi.org/10.1016/j.bjoms.2016.07.017
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glacial acetic acid), which is left in place for three minutes

each time.
We protect the adjacent soft tissues with gauze and
Vaseline® petroleum jelly (Unilever, Leatherhead, UK) then
wash out the cavity with normal saline before closing the
mucoperiosteal flap directly.

Results

Between 2001 and 2014, 31 patients were treated for

mandibular ameloblastomas. Four of them had traditional
resection of the mandible and 27 (13 male) were managed
conservatively by enucleation and application of Carnoy’s
solution. Initial and definitive histological diagnoses, radio-
logical appearance, follow-up period, and recurrence, are
shown in Table 1. In two cases, the initial diagnosis of uni-
cystic ameloblastoma was changed when the primary sample
indicated the solid multicystic variant. A total of 8 (30%)
involved the left body/ramus, 10 (37%) the right body/ramus,
and 9 (33%) involved the parasymphyseal region or crossed
the midline. The mean dimension of the lesions was 5 dental
units (range 3-13), which meant that most filled the body of
the mandible or ramus.
Assessment of the 23 preoperative radiographs suggested
that 17 showed a unilocular pattern, 5 a multilobular scal-
loped pattern without septa, and one had aggressive features
of multilocularity and a poorly defined peripheral margin.
Radiographs were not available for four patients. The mean
period of follow up was 38 months (range 3-156). Two
patients were lost to follow up, one of whom had moved to
Australia. Attempts to contact them both were unsuccessful.
Fig. 2 shows a typical response to the current conservative
approach.
Recurrence
Three patients (11%) developed recurrence, in all cases the
radiological size was less than 1 cm. The first patient had
had enucleation of a unicystic ameloblastoma and applica-
tion of Carnoy’s solution in 2009 with no dental extractions,
and the initial radiological appearances showed a multilo-
bular lesion. When a 0.5 cm recurrence was noted in 2012
the procedure was repeated and teeth removed. The second
patient had an extensive recurrent solid multicystic, multi-
locular ameloblastoma that crossed the midline and filled
the body of the mandible bilaterally. At 35 months there
was a small focus of recurrent tumour in the area around
the incisors that was easily removed. The third patient had
a multilobular lesion that recurred within 27 months in two
small foci. After repeat enucleation of the sold multicystic
ameloblastoma and sterilisation with Carnoy’s solution there
has been no subsequent re-recurrence to date. No radiological
unilocular lesions have recurred irrespective of histological
subtype.
Fig. 2. Images showing good bony infill after enucleation and sterilisation
with Carnoy’s solution of a large multilobular ameloblastoma. The alveolus
is sufficient for placement of dental implants and rehabilitation without the
need for a bone graft.
Discussion
The recurrence rate of unicystic and solid multicystic
ameloblastomas ranges widely and depends on the treatment
and histological subtype.2,11 In response to the risk of recur-
rence, management has evolved over the last 5 decades from
repeated enucleation to the current standard of mandibular
resection and repair by microvascular graft. It is accepted
that small unicystic lesions are less likely to recur and can be
managed by enucleation, but in reality, as most are silent and
tend to be large when they are discovered, surgeons choose
to resect the jaw. This approach has become more common
as microvascular grafts can reliably repair the defect.
Whether mandibular ameloblastomas merit such an
aggressive approach is questionable. This tumour affects a
relatively young population, and resection with its atten-
dant facial deformity can have a considerable impact at a
time when patients are seeking partners and employment. We
know of no evidence that recurrent ameloblastomas change
in nature and are more difficult to treat if they recur. The
tumour is of odontogenic origin and experience shows that it
has a strong affinity for bone and rarely migrates into soft tis-
sues as the periosteum forms a barrier and stops it. If it does,
then the lesion has changed its nature. Recurrent disease is
therefore contained in the mandible, normally in a discrete
focus, and is easy to manage, particularly if caught early. The
conservative approach is safe, and nothing is lost if a small
recurrent lesion appears in the bone. However, this is not the
case with ameloblastomas of the maxilla, as recurrent tumour

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Table 1
Initial and definitive histological diagnoses, radiological appearance, follow-up period, and recurrence.
Initial histological diagnosis Definitive histological diagnosis Radiological appearance Follow up (months) Recurrence
Ameloblastoma NOS Unicystic Not available 156 No (moved to Australia)
Plexiform Plexiform/follicular Not available 44 No
Plexiform/follicular Plexiform/follicular Unilocular 98 No
Ameloblastoma NOS Plexiform Not available 66 No
Ameloblastic fibrodentinoma Ameloblastic fibrodentinoma Unilocular 87 No
Ameloblastoma NOS Plexiform Unilocular 16 No
Ameloblastoma NOS Follicular Unilocular 71 No
Plexiform Plexiform Unilocular 13 (Deceased - other cause) No
- Unicystic Multilobular 54 Yes
Unicystic Solid/multicystic Unilocular 49 No
Solid/multicystic Solid/multicystic Not available Lost to follow up Unknown
Features of ameloblastoma No evidence of ameloblastoma Unilocular 38 No
Ameloblastoma NOS Solid/multicystic Multilocular 41 Yes
- Solid/multicystic Unilocular 42 No
- Solid/multicystic Multilobular 32 No
- Solid/multicystic Unilocular 27 No
Solid/multicystic Unicystic Unilocular 15 No
Ameloblastoma NOS Solid/multicystic Unilocular 15 No
Solid/multicystic Solid/multicystic Unilocular 26 No
Solid/multicystic Solid/multicystic Multilobular 21 Yes
Solid/multicystic Unicystic Unilocular 17 No
Solid/multicystic Solid/multicystic Unilocular 17 No
- Solid/multicystic Multilobular 11 No
Granular variant Solid/multicystic Multilobular 3 No
Solid/multicystic Solid/multicystic Unilocular 8 No
Solid/multicystic Solid/multicystic Unilocular 9 No
Solid/multicystic Solid/multicystic Unilocular 10 No

NOS: Not Otherwise Specified.

can escape into the labyrinth of bony passages in the ethmoid
and reappear in the base of the skull. Our study is therefore
restricted to mandibular lesions.
Between 1940 and 1970, ameloblastomas were treated
by enucleation because the ability to reconstruct a resected
mandible was limited.15–22 The papers we studied did not
suggest that the tumours threatened life but they acknowl-
edged that recurrence was treated by further enucleation. The
current use of wide excision with resection margins of about
1 cm has arisen because surgeons have sought to achieve
zero recurrence, and not because the tumour is a threat to
life.
The histological subtype of the tumour guides contem-
porary management, and the treatment of solid multicystic
lesions is more aggressive. In practice, however, to obtain
a clear margin of 1 cm there is a low threshold for seg-
mental mandibular resection of large ameloblastomas, and
consequently, the histological subtype has little impact on
management. There is also another diagnostic dimension to
consider. It can sometimes be difficult to obtain a represen-
tative biopsy specimen so a preoperative classification of
ameloblastoma is not reliable. In our series, 4 (15%) initial
preoperative classifications were altered when the main spec-
imen was evaluated, and one diagnosis of ameloblastoma was
completely revised to a dental cyst. If these patients had had
their jaws resected, the situation would have been far more
serious.
The conservative approach challenges a number of
accepted precepts. As the preoperative histological classifi-
cation is not reliable, management must be influenced by the
radiological appearance. Size alone is not a defining factor,
instead it is tumour that is pushing forwards rather than one
that is progressing rapidly. Large, scalloped lesions are ideal
for conservative management, but multiple, small locules can
be difficult to enucleate. We did not consider the histologi-
cal description of the tumour when planning treatment and it
seems to have had little impact on outcome.
Stoelinga reported a reduction in the recurrence of ker-
atocysts from 60% to less than 10% after the use of
Carnoy’s solution,23 and the solution was also beneficial
when used to treat ameloblastomas.24 Our findings support
this view. Conservative management does not eliminate the
risk of recurrence, whereas in most cases, resection does, but
resection can have a considerable impact on young people,
and to our knowledge this has not been evaluated. We have
found that little is lost if a small number of patients develop
recurrence. If kept under review the lesions are single, dis-
crete, and easy to eliminate by a second enucleation, and even
if resection is ultimately required, it can be postponed until
later in life when the patient is settled.
This paper has some important shortcomings. Despite the
number of cases being large for a single surgeon, the overall
number is small. The duration of follow up is inadequate,
and ideally should be at least 10 years, almost a surgical

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lifetime. A prospective randomised controlled trial is needed,
but the cost of such a long-term study is prohibitive, and
funding bodies will not consider paying for research into a
condition that has an incidence of one in a million. The only
practical way forward is to develop national guidelines so
that treatment is uniform, and to establish a central database
on which to record patients and their treatment. The evidence
will then show which treatment is most appropriate.
We hope that this article will stimulate debate and pro-
mote further interest in the management of mandibular
ameloblastoma. We also hope that the gradual accumulation
of experience will result in treatment that is more conserva-
tive.
Conflict of Interest
We have no conflicts of interest
Ethics Statement/confirmation of patient permission
There is no identifying information in this submission
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