357
AMELOBLASTOMA MANDIBLE: REPAIR BY ILIAC CREST GRAFT
FOLLOWING HEMIMANDIBULECTOMY
M. Gupta1, G. Motwani2, L. Gupta3
The ameloblastoma is a slow growing, benign but locally invasive neoplasm. Falkson gave the first detailed description of this tumor in 1879 and Churchill introduced the term ameloblastoma.[1] The exact origin of the neoplastic epithelium is unclear although the strong resemblance to ameloblasts supports an odontogenic origin. The predominant opinion is that it is derived from the remnants of the dental lamina. Ameloblastomas are the most common odontogenic tumors. They are usually diagnosed in the fourth and fifth decades. About 80% of the tumors occur in the mandible[2] of which three quarters are in the molar region and the ascending ramus. A 20% occur in premolar region and rest in incisor region. A typical intraosseous ameloblastoma is locally invasive with islands of tumor infiltrating cancellous marrow spaces without causing bone resorption. As a consequence simple curettage is not sufficient and recurrence rates of 55–90% have been reported with enucleation.[1] The recommended treatment is radical resection of the affected part of the jaw. Various methods of reconstruction of mandible have been described. Replacement with cancellous bone and a tray, fibula graft, rib raft, spine of scapula, and iliac crest graft are few of them. We report an interesting case of an elderly male patient who presented with large jaw swelling for which hemimandibulectomy was done with primary repair using iliac crest graft.
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.
CASE REPORT A 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
Figure 1: Postoperative photographs with mouth open and closed
1
Senior Resident, 2Senior Specialist, 3Post Graduate, Department of ENT, Safdarjang Hospital, New Delhi, India Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 4, October-December 2005 357 CMYK
358
Ameloblastoma mandible: repair by iliac crest graft
Figure 2: CECT showing multilobulated right mandibular swelling
Figure 3: Gross appearance of the excised mass
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. DISCUSSION When the results of treatment of ameloblastomas are assessed, several factors are important. First, long term follow up is essential because this neoplasm has the capacity for continued growth. Successful treatment in this context may be defined as treatment that renders an acceptable prognosis, causes minimal disfigurement, and is appropriate on the age and general health of the patient and on the size, location and duration of the tumor. In the study by Mehlisch[3] excision, cautery and curettement – forms of treatment that generally are considered conservative were associated with the highest degrees of recurrence, which was 50% or more in almost all situations. However, when these same forms of treatment were used in combination with each other, effectiveness was increased. Curettement was found to be the least desirable form of therapy, as has been reported in the literature. He also added that the resection, whether enbloc or segmental, with an adequate margin of uninvolved tissue would give the best overall prognosis. As in our case, study by Sehdev[1] also reported 18 of the 92 (20%) patients seen with ameloblastoma gave a history of tooth extraction without recognition of presence of ameloblastoma at that time. He also concluded that curettage was followed by local recurrence in 90% of mandibular ameloblastomas. Subsequent resection could control 80% of recurrences. Marginal resection, in a few cases, might control
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 4, October-December 2005 358 CMYK
Figure 4: Harvested iliac crest graft
Ameloblastoma mandible: repair by iliac crest graft
primary cases but is not a useful procedure for recurrent ameloblastomas. External irradiation therapy was ineffective in controlling their growth or recurrence. Shatkin’s[4] words fit this conclusion perfectly: ‘The so-called ‘conservative’ treatment by curettage, at best, disfigures patient and, at worst, kills him, whereas the so-called ‘radical’ treatment by adequate excision conserves the patients appearance, function and life’. D’Agostino et al.[5] also reported 28.57% recurrence following enucleation and curettage while 0% seen in wide bone resection. He suggested conservative surgical treatment should be considered only in unicystic lesions when extraosseous spread has not yet occurred. In multicystic the most appropriate therapeutical approach appears to be an ‘extended surgical resection’ of the tumor whereby osteotonic lines are placed 5-mm deep in the healthy tissue. In addition, concurrently with tumor excision, the missing bone tissue can be reconstructed through nonrevascularized bone grafts or revascularized free bone grafts depending on the size of the defect. As suggested by Foster et al.[6] nonrevascularized bone grafts are utilized in those cases with bone defect inferior to 5–
359
6 cm usually without interruption of bone continuity, good blood supply and soft tissue bearing. Re-vascularized bone grafts are indicated in all those cases that show a large bone defect (more than 6 cm), with interruption of the bone continuity or with maintenance the cortical aspects, but with soft tissue compromission. REFERENCES 1. 2. 3. 4. 5.
6.
Sehdev MK, Huvos AG, Strong, EW, Gerold FP, Willis GW. Ameloblastoma of maxilla and mandible. Cancer 1974;33:324-33. Cheesman AD, Jani P. Odontogenic tumours of the jaws. Scott- Brown’s Otolaryngology (6th ed.) 5/23: 13-14. Mehlisch DR, Dahlin DC, Masson JK. Ameloblastoma-A clinicopathologic report. J Oral Surg 1972;30:9-22. Shatkin S, Hoffmeister FS. Ameloblastoma-A rational approach to therapy. Oral Surg 1965;20:421-35. D’Agostino A, Fior A, Pacino GA. Retrospective evaluation on the surgical treatment of jawbones ameloblastic lesions- experience with 20 clinical cases. Minerva Stomatologica 2001;50:1-7. Foster RD, Anthony JP, Sharma A, Pogrel MA. Vascularized bone flaps versus nonvascularized bone grafts for reconstruction of mandibular conti5ity defects. J Oral Maxillofacial Surg 1997;55:1200-6.
Address for Correspondance Dr. M. Gupta 24/702 East End Apartments, Mayur Vihar Phase I Extension, New Delhi – 110 096, India E-mail:
[email protected]
Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 57, No. 4, October-December 2005 359 CMYK
