Ameloblastoma

Case contributed by Dr Lawrence Josey

Presentation

Incidental lesion found during routine dental review. Referred for investigation.

Patient Data

Age: 50 years
Gender: Male

The opacities superimposed over the maxillary sinuses are ghost images of the ear piercings. There are recent sockets in the 15, 12 and 46 positions. The irregular multilocular lucency apical to the 45 and edentulous 46 position is suggestive of a developing bone/odontogenic lesion. The 45 root is intact with no obvious indications of resorption. The right inferior dental canal is obscured by the altered bone pattern. There is the suggestion of a residual periapical inflammatory lesion associated with the 46 in the apical region of the 46 mesial root. Comparison with previous radiographs would be of benefit in further assessment of this region. 

The maxillary third molars are impacted and the roots of these teeth appear in close relation to the floors of the respective maxillary sinuses. These teeth may be ankylosed. There is generalized loss of alveolar bone height in both arches and the presence of calculus is noted. Decay is most obvious in the 26, 27, 37 and 45. 

There is pocketing posterior to the 38 crown and a history of pericoronitis or the possibility of developing odontogenic pathology in the posterior left mandible cannot be excluded.

There is a multilocular lesion within the right mandible located at the level of the second premolar tooth. A larger more superiorly directed locule involves the root of the first molar.  There is minor scalloping of the inner surface of the mandible in a couple of areas, but no frank breach of the cortex. There is no soft tissue component beyond the lesions margins. The mandibular canal passes through the medial aspect of these locules. The overall size is approximately 2cm in maximal diameter.

Ameloblastoma diagnosed pre-operatively via biopsy, followed by resection.

Pathology report:

MACROSCOPIC

Right mandible short anterior, long lateral and consists of a segment of mandibular bone with a small amount of mucosa attached superiorly. Two premolars are present towards the anterior
superior end of the specimen. Sectioning reveals a bony lobulated, cystic cavity filled with firm tan to white tissue measuring 18mm in maximal dimension.

MICROSCOPIC

The intra-mandible tumor is confirmed to be a primary epithelial odontogenic tumor showing the features of an ameloblastoma. The tumor occupies and expands bone marrow space and focally extends into the overlying cortex but does not penetrate the cortical surface. The tumor extends around but does not infiltrate the intra-osseous nerve present. The tumor is completely excised with no tumor present in either en-face bone surgical resection margin.

SUMMARY
Right mandible: excised ameloblastoma.

Surgical details:

Tracheostomy through 2nd ring, isthmus divided and secured with silk. Right neck incision, submandibular gland removed. Marginal mandibular, lingual and hypoglossal nerves preserved. Mandibulectomy through canine and lower right second molar after plate prebent. 

Left composite radial free flap harvested inset to defect (4.5cm) tri med plate to left radius, closed. Full thickness skin graft, skin paddle to mouth anastamosis. artery end to end, facial vein 1 end to end, EJV cephalic end to side common facial. Closed. vicryl and clips.

Right mandibulectomy and radial free flap (composite). Alignment is satisfactory. Mandible views not provided.

Case Discussion

This case illustrates the plain films and CT features of an ameloblastoma. 

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