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CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART TWO

J Oral Maxillofac Surg 64:484-494, 2006

The Ameloblastoma: Primary, Curative Surgical Management
Eric R. Carlson, DMD, MD, FACS,* and Robert E. Marx, DDS†
The epithelial odontogenic tumor, ameloblastoma, is a neoplasm of the jaws whose surgical management represents a prototype for the treatment of jaw tumors in general. This notwithstanding, numerous methods of treating this tumor have been proposed in the literature that have served as a source of information and disinformation for surgeons internationally. Earlier reports fail to consider the classification of the ameloblastoma in case series recommending a variety of surgical modes of therapy, while more recent recommendations fail to agree on the biologic behavior of the neoplasm.1 The end result has been polarization of the specialty regarding 2 diametrically opposed categories of treatment, incorrectly termed “conservative” and “radical.” It is our opinion that each of these terms is inaccurate. We believe conservative therapy to be an oxymoron, as it has never been proved that conservative surgery is therapy with any chance of cure. In addition, radical is too strong a word to describe a curative resection for this aggressive neoplasm. While our specialty is divided on the issue of which type of surgery is better, it is our experience that patients may be cured when a scientific approach is followed with regard to the linear and anatomic barrier margins associated with a segmental or marginal resection of this tumor, whose soft and hard tissue margins in the specimen are determined to be histopathologically negative. The literature has referred to this method of treatment as “radical.”2 The management of the ameloblastoma by
*Professor and Chairman, Department of Oral and Maxillofacial Surgery, Director of Residency Program, University of Tennessee Graduate School of Medicine; Chief, Oral and Maxillofacial Surgery, The University of Tennessee Memorial Hospital and the University of Tennessee Cancer Institute, Knoxville, TN. †Professor and Chief, Division of Oral and Maxillofacial Surgery, University of Miami School of Medicine, Miami, FL. Address correspondence and reprint requests to Dr Carlson: Department of Oral and Maxillofacial Surgery, University of Tennessee Medical Center, 1930 Alcoa Highway, Suite 335, Knoxville, TN 37920; e-mail: ecarlson@mc.utmck.edu
© 2006 American Association of Oral and Maxillofacial Surgeons

more conservative measures such as enucleation, enucleation and curettage, surgical excision and peripheral ostectomy, and enucleation with liquid nitrogen cryotherapy has a more unpredictable course with a far lower rate of cure. Cure should clearly be the primary objective of all tumor surgeries of the oral and maxillofacial region, and should be the goal from the outset. To this end, studies document the failure of conservative surgeries for the ameloblastoma and also point to the lack of uniform success of radical surgeries in salvaging these failures.3 These observations form the basis of this controversy in the literature. One consistently concerning aspect of articles advocating so-called “conservative” therapy for the solid or multicystic ameloblastoma is the amount of follow-up. While the time that elapses between surgical treatment of the ameloblastoma and recurrence is approximately 5 years4 in the majority of recurrences, there are numerous reports that document significantly longer times to recurrence.2,5,6 It is the purpose of this article to provide support for primary curative surgical management of the solid or multicystic variant of the ameloblastoma. In so doing, the successes and failures of previously published reports will be quoted, as will our individual personal experiences in managing this tumor.

Classification of the Ameloblastoma
The classification of any pathologic process should, under ideal circumstances, impart implications for treatment. Unfortunately, early literature failed to distinguish the variants of the ameloblastoma, thereby eliminating any meaningful comments as to the efficacy of treatment for any of the variants of ameloblastoma. In fact, treatment and prognosis, including cure rates, are all dependent upon the variant of the ameloblastoma. To this end, there are three variants of this tumor, including the solid or multicystic variant, the unicystic variant, and the peripheral variant. A review of the international literature by Reichart et al in 1995 found the solid or multicystic variant to be most common, comprising 92% of the 3,677 cases of ameloblastoma in their review, while the unicystic 484

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would be managed by anything short of curative surgery in the form of a resection. however. Some authors have pointed to a similar biologic behavior between the solid or multicystic ameloblastoma and the mural subtype of the unicystic ameloblastoma.11 thereby necessitating a similar approach with resection. with “radical” salvage surgery performed on an as-needed basis if the tumor recurs. therefore. as this . THE CONCEPT OF A “BENIGN PROCESS” Neoplasms of the oral and maxillofacial region have been classified into benign and malignant categories based on specific histologic criteria. As such. The adjective benign. and peripheral variants accounted for 6% and 2% of the cases. hence the recommendations to provide “conservative” therapy. and the lack of wide dissemination.10.7 The international literature also points to a vast difference in response to “conservative” treatment between the solid or multicystic ameloblastoma and the unicystic ameloblastoma. been a subject of dispute since the first description of the tumor. Rationale for Recommendations for Conservative Surgical Management The literature is replete with case series and individual case reports of ameloblastomas espousing “conservative” therapy. The accurate description of this tumor. According to Huffman and Thatcher. aggressive.5. they recommend treatment being based on the clinical features of the tumor. therefore. however. In essence.CARLSON AND MARX 485 term falsely imparts a simultaneous designation of “nonaggressive. those who advocate resection of the solid or multicystic ameloblastoma will commonly resort to enucleation and curettage of the luminal and intraluminal subtypes of the unicystic ameloblastoma. Such articles advocating “conservative” therapy. What is intriguing is that the ameloblastoma may be more destructive and life threatening than some malignant tumors of the oral and maxillofacial region. the recurrence is limited to a small area that can be reoperated on “conservatively. slow-growing neoplasm. it is unfathomable that a highly destructive neoplasm such as the solid or multicystic ameloblastoma. with relatively less aggressive behavior associated with the unicystic variant. on close scrutiny. With our belief that primary curative therapy is necessary. while persistence is probably a more accurate reflection of the problem. With this statement in mind.” They reported that recurrence did not imply failure because there is usually regeneration of a significant amount of bone. despite being cytologically benign. in fact. This presumed paradox has become difficult to comprehend.12 Instead. owing to an incomplete removal of the tumor with the initial “conservative” surgery. it was just not thoroughly removed and was later observed clinically and radiographically at a time when the patient might have been erroneously considered cured.8.12-15 The question arises as to why surgeons would provide “conservative” therapy in the presence of significant evidence showing the shortcomings of such therapy for an aggressive neoplasm. with the aggressive designation being refuted by some. tendency to not invade soft tissues. may actually be a disservice to those who undertake its treatment.1 While some authors contend that the ameloblastoma is a lowgrade malignancy.16 Complicating the issue even further is the well-established fact that the solid or multicystic variant of the ameloblastoma is slow growing. the solid or multicystic variant is believed to be the most aggressive of the three variants. often lack sufficient long-term follow-up and scientific nomenclature in their analyses as to the efficacy of their recommended therapy. therefore. recurrence may be a misnomer. is that it is a benign.1 the general consensus is that this tumor is distinctly benign. The cytologic classification of ameloblastoma has. the diagnosis of ameloblastoma should not indicate immediate jaw resection. Labeling the persistent tumor as recurrent disease is a failure of the surgeon to recognize his or her poor judgment in selecting and executing initial surgical therapy. with some approaching this tumor with the philosophy that all benign processes deserve one recurrence. that the classification provides useful information regarding the biologic behavior of the three variants of the ameloblastoma and the necessary surgery for curative intent.9 In general terms. It can be seen. has encouraged a disparity of opinions in our specialty. respectively. The essence of this issue is that a paradox exists when recommending conservative therapy for an aggressive neoplasm. The authors therefore recommended “complete removal of the tumor with preservation of the inferior border of the mandible whenever possible. This is not a sentiment that is at work in their management of malignant processes. the following review analyzes our explanation as to why numerous authors have erroneously advocated conservative therapy when managing the solid or multicystic ameloblastoma. including slow growth. The well-accepted benign designation of this tumor. Moreover.” It is our belief that failure is exactly what is represented by the reappearance of a benign process.” Nothing could be further from the truth when discussing the solid or multicystic variant of the ameloblastoma.10 The tumor did not recur per se. many surgeons believe that the benign and slow-growing nature of the tumor may permit initial “conservative” management. many with curative intent.

Perhaps the most frequently quoted is that of Huffman and Thatcher in 1974. The common denominator of the three previously cited articles is the contention that “conservative” therapy has a role to play in the management of the solid or multicystic ameloblastoma due to the possibility of cure of this neoplasm. as previously reviewed. Vedtofte et al5 also advocated conservative surgical treatment of the ameloblastoma of the mandible in 1978. It is likely that several of these 12 patients had unappreciated unicystic ameloblastomas. and the literature indicates that these patients will show signs of persistent disease at variable times postoperatively. In 1984. and 4 patients with “solid” tumors. Unfortunately. as we know it in the 21st century. Surgical Management of Ameloblastoma. the body of the mandible was recommended as the one site where this method could be justified.6 In his report of 22 cases of recurrent ameloblastoma of the jaws. Hayward reported recurrence of an ameloblastoma that had been enucleated 30 years earlier. although the patient with the longest follow-up occurred by telephone. Recurrence at 30 years postoperatively has been reported after “conservative” therapy. As such. Specifically with regard to follow-up time after “conservative” therapy. Aside from unfavorable follow-up time periods and insufficient numbers of patients in this publication.486 FALSE IMPRESSION (HOPE) THAT “CONSERVATIVE” THERAPY IS CURATIVE SURGICAL MANAGEMENT OF AMELOBLASTOMA The literature is replete with articles reporting “curative therapy” associated with procedures more “conservative” than resection of the mandible. Nonetheless. but lamented that the follow-up period might have been too short to make valid remarks regarding recurrence. In 1973. as it tends to confine the tumor. Three patients experienced recurrence of their neoplasms at a range of 1 to 20 years postoperatively.17 This recommendation for long-term follow-up was not quantified.12 In this article. As such. they stated that conservative therapy should not be overlooked as an acceptable and often preferable method of therapy. the cure rates after curettage are much better than for solid or multicystic ameloblastomas. Those of us who treat ameloblastomas on a regular basis have directly seen ameloblastomas not only invading the inferior border but also totally resorbing it (Fig 1). The authors reported no recurrence of the tumors. Mention is made of 6 patients with “cystic” tumors. with the remaining 5 patients being followed for a shorter period of time. where. Carlson and Marx. Only 7 of the patients were followed for more than 5 years. The patients were followed between 15 months and 15 years postoperatively. the lack of long-term and scientific follow-up of patients cannot justify “conservative” therapy. Panoramic radiograph depicting a large ameloblastoma of the right mandible that shows obvious involvement of the inferior border. Dr Gardner’s assertions. it seems clear that 5 or 10 or even 20 years is not sufficient to state with confidence that conservative therapy is curative. J Oral Maxillofac Surg 2006. 12 patients were treated with enucleation of the tumor in toto. many occurring several decades after conservative therapy. Daramola found the longest time interval to discovery of the recurrence to be 20 years. were not based on first-hand surgical experience. 2 patients with “cysticsolid” tumors. a recom- FIGURE 1. reporting that the compact bone need not be removed.5 . and was therefore not examined clinically or radiographically. These statements are not scientific in terms of the definition of evidence-based medicine.18 In their series of 21 cases of recurrent ameloblastoma of the maxillofacial region. however.17 Specifically. however. He indicated that the clinical and radiologic margins of the tumor are synonymous. mendation was made to perform a marginal resection whenever possible. Dr Gardner emphatically states that the solid or multicystic variant of the ameloblastoma does not invade compact bone. provided that the patient would be followed closely for many years. In this article. The average follow-up was approximately 6 years. followed by curettage with a drill. While Dr Gardner further stated that curettage was not a reliable means of treating ameloblastoma because of the high rate of recurrence associated with this method. 4 patients were presented in which the tumors were removed by curettage through intraoral access followed by either electrocauterization of the tumor bed or removal of surrounding bone with a large bur. the other shortcoming of this article surrounds lack of attention to the classification of these 12 tumors. Gardner published his frequently quoted article regarding his concept of the biologic behavior of the ameloblastoma and how best to treat it. this article does not provide meaningful information regarding “conservative” therapy for the solid or multicystic variant of the ameloblastoma. Adekeye and Lavery report that the average time interval between primary operation and secondary operation was 7.

Up until this point. Surgeons might argue that recurrent ameloblastoma may be salvaged with radiation therapy after “conservative” therapy. however. MacIntosh27 pointed out that the first site of reported ameloblastic metastasis was the lung.24 The ability of a benign neoplasm to metastasize to distant sites is yet another poorly understood concept of the ameloblastoma.22 It is our opinion. 3 of whom underwent surgical salvage. patients have typically undergone “conservative” therapy.CARLSON AND MARX 487 is the possibility of the development of metastatic disease. In 1999. and originally believed to be more the result of aspiration from the oral lesion than a true hematogenous or lymphatic spread. along with that of Vedtofte. These included tumors of long duration with many recurrences and with lateappearing metastases. Nine of the patients responded. malignant oral tumors such as salivary gland tumors and squamous cell carcinoma are not considered to be of aspiration origin in their occurrences in the lungs. While distant metastatic disease does not uniformly follow “conservative” therapy. that the aspiration hypothesis leaves unanswered the questions as to why other locally aggressive. radiotherapy. and relatively unlikely to be due to simple aspiration. Prior to the mid-1980s. yet some have been reported to metastasize. In addition. The sites of metastatic disease seem to be limited to the lung. aggressive and effective management of this tumor should be performed from the outset so as to decrease the likelihood of persistent disease where radiation therapy might be useful. it was believed that the ameloblastoma was radioresistant. In a series of 26 patients. Slootweg and Muller have referred to these primary tumors as malignant ameloblastomas. One additional concern regarding “conservative” therapy . Finally. Laughlin has stated that multiple local recurrences of the primary tumor treated by surgery. They indicate that shelling out an intrabony lesion by enucleation without violating its integrity makes this a poor term.20 These reports. with a mean of 37 months. this complication can probably not be used to support primary curative surgical management of this tumor. the development of postradiation sarcomas23 and carcinomas makes the delivery of radiation therapy for the salvage of persistent ameloblastoma impractical. and regional nodes. Poorly controlled ameloblastomas most commonly display persistent disease locally. Sampson and Pogrel14 published an algorithm for the surgical management of ameloblastoma.5 should alert the oral and maxillofacial surgeon that the combination of a thorough enucleation and curettage as well as slow growth of the remaining neoplasm is such that clinically and radiographically apparent persistent neoplasm may not become evident for several decades. While an elaborate treatment algorithm was proposed. and patients had often had more than one operation in addition to radiation therapy. Indeed.19 Frantz and Stix make anecdotal mention of a case of ameloblastoma that recurred 45 years after initial treatment. the aspiration hypothesis would require a significantly higher frequency of right middle and lower lobe deposits. Of the 10 patients. Furthermore. The real issue here is the higher rate of cure years. These foci of metastatic disease related to a primary. 7 showed no evidence of disease after surgery and/or radiation therapy. clearly the authors would have had false hope that a cure had been established. unfortunately. pleura. He indicates. Clay et al26 reviewed 4 clinical factors shared by most cases of metastatic ameloblastoma. Had long-term follow-up not occurred in this case. One concerning element of this article is the reported follow-up information. Moreover. 22 patients were treated for solid or multicystic ameloblastoma. The length of follow-up since the last extirpative operation ranged from 6 to 100 months. that radiation therapy should not be relied upon as a salvage of recurrent disease caused by ineffective surgery. Additional evidence suggesting the value of radiation therapy in treating the ameloblastoma has been reported by Gardner. with follow-up ranging from 1 to 10 years. because of the rarity of metastasis of this benign tumor. In 1984. Atkinson et al21 published their review of 10 patients undergoing the delivery of megavoltage irradiation. however. when metastases have been diagnosed. such limited follow-up may be insufficient to scientifically justify some of the surgical procedures performed by these authors. the literature was lacking well-documented evidence regarding the relative radioresponsiveness of the ameloblastoma. As previously stated. enucleation and curettage surgeries might liberate neoplastic cells into the upper airway that could find their way into the lower airway. recommendations for treatment were not made based on the histologic classification of the tumors. benign odontogenic tumors have not displayed a similar aspiration phenomenon. Rather. or chemotherapy typically precede the spread of tumor. The odontogenic myxoma and Pindborg tumor that have been treated with enucleation and curettage have not been reported to deposit in the lungs. There was usually extensive local spread at the time of the metastasis. All of this information suggests that the metastatic potential of the ameloblastoma is real.25 He further elaborated that these multiple recurrences could stimulate dissemination through lymphatics or blood vessels. benign ameloblastoma similarly show cytologically benign tumor. with a range of 1 to 23 years. This notwithstanding. which is not where the literature reports their occurrence. the authors criticized the term enucleation due to its confusing and inaccurate nature.

might lead to persistence of the tumor and commit the patient to additional surgery. and few have implications for bone graft reconstruction. Six of these deaths occurred where primary treatment consisted of cautery. our experience. Moreover.29-34 Rationale for Recommendations for Resection of the Ameloblastoma THIS TUMOR IS CAPABLE OF CAUSING THE DEATH OF THE PATIENT In 1965. including the relatively low morbidity associated with available donor site surgeries should permit appropriate ablative surgery for this neoplasm from the outset (Fig 2). The authors of this article have encountered similar cases (Fig 5). From the standpoint of cure. The predictable techniques of jaw reconstruction. Feinberg and Steinberg28 have indicated that “radical” treatment of the ameloblastoma with resultant segmental defects of the mandible represents complex reconstructive cases. several reports have reviewed fatalities related to ameloblastomas of the maxilla and mandible. Cytologically benign ameloblastoma was documented in all tissues removed. Since the original description of the ameloblastoma. can be locally aggressive.45 When the tumor originates within the mandible. Our interpretation of the authors’ statements is that a segmental resection should be strongly considered when managing this tumor. thereby creating airway compromise and potentially life-threatening metabolic abnormalities36-41 (Figs 3. “CONSERVATIVE” SURGERY IS TECHNICALLY EASIER THAN RADICAL SURGERY SURGICAL MANAGEMENT OF AMELOBLASTOMA An enucleation and curettage of an ameloblastoma is a technically easy surgical procedure.43 This disease was further complicated by the development of metastatic disease in the lesser trochanter of the contralateral femur. in fact.42-44 Mehlisch et al2 reported 15 deaths directly attributable to ineffective management of the primary tumor. The authors conclude their study by indicating that ameloblastoma of the maxilla. Bredenkamp et al reported that maxillary ameloblastomas. The patient succumbed to his disease 21 years after the initial treatment of his tumor.2. and indicate that the use of a marginal resection is made possible because the thickness of cortical bone in the symphyseal region is more resistant to infiltration by tumor.” Indeed. while histologically benign. A rather graphic example of death was reported by Oka et al in 1986. ultimately leading to the identification of persistent disease in the infratemporal fossa. as well as numerous reports in the literature. while 3 occurred where the tumor was curetted. external auditory canal. they warn that maintenance of the inferior border. In contrast. Moreover. They report that this tumor behaves more aggressively. They advise that attempts should be made to maintain the inferior border of the symphysis whenever possible. their recommendation for radical surgery executed similarly to cancer surgery cannot be overemphasized. incurable. It is our opinion that subtherapeutic surgery should never be executed in the best interests of avoiding a complex bone graft reconstruction on an immediate or delayed basis. could produce widespread destruction with death resulting from spread to the central nervous system. is the treatment of choice. and has a poorer prognosis. Their series of 11 ameloblastomas of the maxilla treated in this fashion resulted in no recurrences in a follow-up period of 1 month to 12 years. 4). its spread is usually slowed by the thick compact bone. where inability to provide local control of a benign ameloblastoma of the mandible with 6 surgeries occurred in a young man. Most can be performed transorally. identify the ability of this tumor to grow to significant size. adequate excision of the tumor. At the same time. “The concept of curettage as a legitimate ‘conservative’ method of treatment for ameloblastoma is an illusion that is often dispelled by the disfigurement and sometimes the death of the patient. Perhaps the most feared anatomic location of the ameloblastoma is the maxilla. Nastri et al42 reviewed 13 patients with ameloblastoma of the maxilla for whom surgery was the primary treatment over a 40-year period. the thin and fragile bone of the maxilla lacks the thick confining cortical plates of the mandible. and 1 patient was alive with evidence of intracranial disease at the time of publication of this report. although benign. Two patients in this series died of extensive local disease. The overwhelming conclusion of their report is that the maxillary ameloblastoma is potentially lethal. . Such an approach will only allow for a more straightforward reconstruction that might be compromised by the development of persistent disease at an unspecified time period postoperatively. and the middle and posterior cranial fossae. with immediate reconstruction if necessary. the authors indicate that a thin residual rim of bone after marginal resection will be predisposed to fracture. and possibly microscopic tumor. thereby allowing relatively unimpeded spread of the tumor to surrounding vital structures. Jackson et al46 indicate that the maxillary ameloblastoma is a different entity from its mandibular counterpart. as well as appearance and function.488 when performing resections as compared with any other form of surgical management. Shatkin and Hoffmeister35 summarized their rational approach to the treatment of the ameloblastoma by stating.

while 90% of man- dibular tumors recurred after curettage. One hundred percent of maxillary tumors treated by curettage developed recurrences. Dental implants are in place supporting a screw-retained prosthesis and the original titanium reconstruction plate remains. The screw-retained fixed prosthesis in this case is seen to restore excellent occlusion and replace the teeth lost due to the tumor resection. Nine of the 92 patients reviewed in this article died as a direct result of uncontrolled ameloblastoma. B. Seen here is the re-entry and preparation of the tissue bed for a definitive bone graft. E. Occlusal radiograph of this method of staged reconstruction providing the natural curvature of the mandible. and an impressive buccal lingual width. Cancellous marrow graft in place using the same reconstruction plate as a crib containment for the graft by suturing the periosteum and fascia of the neck to the holes in the plate. Sehdev et al3 reviewed 92 patients with ameloblastoma: 72 patients with mandibular tumors and 20 patients with maxillary tumors. The initial reconstruction of the tumor-related segmental defect was accomplished with a rigid titanium plate. and potentially fatal. C. F. a dense bone for dental implant stability. Surgical Management of Ameloblastoma. J Oral Maxillofac Surg 2006. Carlson and Marx. A. The authors concluded by stating “whereas it may not be disastrous to try curettage initially in ameloblastoma in- .5-cm margins in bone and the overlying periosteum as an anatomic barrier. D.CARLSON AND MARX 489 FIGURE 2. Five-year follow-up panoramic radiograph of the resection and delayed bone graft. Resection specimen of an ameloblastoma with 1. Note the bone density and bone height achieved by the graft and its stability over 5 years.

The CT scout film of the patient in A shows the significant radiographic extent of this ameloblastoma. it should be vehemently condemned for ameloblastoma of the maxilla where a prompt adequate resection should be carried out. An anemia of chronic disease was present in this patient. Extremely large ameloblastoma neglected for 16 years shows their potential for unlimited growth. A. A CT scan of this large ameloblastoma shows the bony destruction and the obvious resorption including resorption of the inferior border. B. Surgical Management of Ameloblastoma. J Oral Maxillofac Surg 2006. FIGURE 4. Carlson and Marx. thereby resulting in significant deformation of this patient. Notice the soft tissue expansion and the dilated blood vessels that are accommodations to the tumor’s size and metabolic demands. Surgical Management of Ameloblastoma. J Oral Maxillofac Surg 2006. A large ameloblastoma of the mandible has occurred over a 20-year period of time. Carlson and Marx. B. volving mandible. A.490 SURGICAL MANAGEMENT OF AMELOBLASTOMA FIGURE 3.” Komisar47 points out that once the ameloblastoma of .

cautery. cerebral spinal fluid leakage.3% 8. A review of the international literature regarding the optimal treatment for the ameloblastoma shows that primary resection in the form of segmental or marginal resection is more likely to be curative than when “conservative” therapy in the form of enucleation. enucleation and curettage. etc is performed for this neoplasm (Table 1). COMPARISON OF CONSERVATIVE SURGERY VERSUS RADICAL SURGERY IN TREATING THE AMELOBLASTOMA Author Sehdev et al3 Shatkin and Hoffmeister35 Mehlisch et al2 Muller and Slootweg4 Olaitan et al48 Ueno et al49 Recurrence Recurrence Rate after Rate after # of Conservative Radical Year cases Surgery Surgery 1974 1965 1972 1985 1993 1989 81 22 126 56 93 91 93% 86% 36% 58% 40% 45. is the current treatment of choice and must remain so until consistent long-term evaluation or new knowledge to the contrary is brought to bear. Recurrent ameloblastoma within the nasopharynx and sphenoid sinus with extension into the cavernous sinus. Recurrent ameloblastoma in the retro-orbital tissues seeded by multiple enucleation procedures of a mandibular ameloblastoma. A. it is also clear that not all patients are cured who undergo such aggressive surgical therapy.6% 13% 14% 21% 15% 8. and brain abscesses that were the reasons for this patient’s death. the shortcomings of . a resection with close or positive margins represents an inadequate removal of tumor and amounts to “conservative” therapy at best. Surgical Management of Ameloblastoma. J Oral Maxillofac Surg 2006. may be looked at with a jaundiced eye if the adequacy of the margins is not described. Surgical Management of Ameloblastoma.7% Carlson and Marx.27 He concluded his discussion by stating that aggressive ablative management. FIGURE 5. the chances of a surgical cure drop considerably.CARLSON AND MARX 491 Table 1. The missing element of many articles is histologic correlation of these resections. Notice the radiolucent streaks in the brain that represent meningitis. According to Recommended Protocol for Surgical Management of the Solid or Multicystic Ameloblastoma With the previous information regarding the classification of the ameloblastoma. particularly the adequacy of the margins. as traditionally defined. provides a lastingly superior or even equally good cure rate to that of more aggressive treatment. Resection. This recurrence was a result of seeding via multiple enucleation attempts and eventuated in the death of the patient. the readership of many of these articles reporting recurrences after resection are not informed about the pathologic findings. therefore. Simply stated. Unfortunately. the maxilla has spread beyond the confines of the maxillary bone to involve adjacent structures. J Oral Maxillofac Surg 2006. Carlson and Marx. in which the lesion is neither violated nor directly manipulated. It is incumbent on the authors of such articles to scientifically present and analyze their own research so that meaningful conclusions can be drawn.27 While the literature points to the superiority of resection compared with “conservative” therapy in permanently eliminating the ameloblastoma. These patients are destined to develop persistent disease at some point in their postoperative course. there is no report in the literature that convincingly shows that “conservative” management of ameloblastoma. B. PRIMARY RESECTION IS CURATIVE MacIntosh in 1991.

and the necessity of primary resection of this tumor. THE USE OF SPECIMEN RADIOGRAPHS In a large majority of cases.51 No recurrences were noted with a follow-up of at least 5 years. An ameloblastoma that originates within the medullary component of the mandible will first encounter the anatomic barrier of cortical bone.50 These include the cortical bone. J Oral Maxillofac Surg 2006. Anatomic barriers are soft and hard tissues that function to contain a neoplasm. THE USE OF FROZEN SECTIONS It is clear that great controversy exists regarding the optimal treatment of the ameloblastoma. mucosa. ASSESSMENT OF ANATOMIC BARRIERS SURGICAL MANAGEMENT OF AMELOBLASTOMA After histopathologic diagnosis and accurate classification of a solid or multicystic ameloblastoma. while MacIntosh27 recommended at least 1. Muscle. For example. periosteum. . even when it develops to a massive size.5-CM LINEAR BONE MARGINS FIGURE 6. the anatomic barrier of skin does not become invaded by this tumor. Obtaining an intraoperative specimen radiograph is an opportunity. Consultation with an oral pathologist will be invaluable when concern exists regarding the accurate diagnosis and classification of the ameloblastoma. When a close bone margin is noted on the intraoperative specimen radiograph. the most appropriate linear margin is still debated. the following represents a step-by-step protocol for management of such lesions. mucosa. the periosteum will soon also be invaded by the tumor.to 1. submucosa. Yet. the ameloblastoma is a radiolucent tumor. Gold1 believed that 3 cm is the most acceptable linear margin. It may be appropriate to sacrifice other uninvolved anatomic barriers aside from the periosteum. The pathologist may perform touch preps of this medullary bone. to assess the adequacy of the resection from the standpoint of the proximal and distal linear bone margins (Fig 6). or true frozen sections may be accomplished.5 mm histologically beyond its radiographic demarcation on specimen Most. Surgical Management of Ameloblastoma. RESECTION WITH 1. submucosa. Once this robust anatomic barrier is violated. The conclusion of this study is that a 1. if not all tumor surgeries of the oral and maxillofacial region should involve the routine submission of soft tissue frozen sections to the pathologist. and preferably 2 cm bony margins for cure of this neoplasm. This provides yet another safeguard to assurance that an adequate tumor surgery has been performed. the surgeon is able to remove additional bone so as to improve the chances of cure while the patient is still generally anesthetized. and skin. This should be assessed and determined preoperatively and precisely dissected intraoperatively. muscle. A review of 82 ameloblastoma resections shows that this tumor extends with a range of 2 to 8 mm and a mean of 4. Adherence to this principle of tumor surgery will increase the likelihood of tumor-free margins in the final histopathologic sections. A general principle of tumor surgery of the jaws is that at least one uninvolved anatomic barrier be maintained on the tumor specimen. Owing to the ameloblastoma’s slow growth in combination with relatively rapid regenerative capacity of skin. and dermis may subsequently be invaded provided that treatment is not rendered in a timely fashion. an ameloblastoma that is clinically and radiographically determined to have perforated through the buccal cortex of the mandible should be approached intraoperatively with a supraperiosteal dissection.5-cm bony linear margin provides a margin-free specimen that is curative provided remaining soft tissue margins are negative for tumor as well.5 cm. as stated previously. even when surgeons agree that a resection should be performed. The authors’ unpublished combined experience with approximately 240 cases of ameloblastoma further substantiates these data.TO 1. the surgeon may wish to submit frozen sections of the medullary portion of the stump of bone in the tissue bed rather than resecting additional bone. When the specimen radiograph indicates that a less than acceptable (Ͻ1 cm) bony linear margin has been obtained. therefore. This specimen radiograph gives the surgeon confidence that an appropriate linear bone margin has been obtained in the proximal and distal segments of this ameloblastoma resection. radiographs.492 “conservative” surgical therapy. Carlson and Marx. the surgeon should rely on the prebiopsy physical examination and special imaging studies to assess the violation of anatomic barriers surrounding the tumor. dermis.16.

A reappraisal of the role of megavoltage irradiation. Murti PR. Sehdev MK. (ed 2). Oral Maxillofac Surg Clin North Am 3:73.CARLSON AND MARX 493 9. Plast Reconstr Surg 65:577. Ann Plast Surg 22:160. Decker. 2004. J Oral Surg 30: 9. Frantz VK. Philipsen HP. et al: Conservative surgical treatment of mandibular ameloblastomas. 1965 36. Thomson ERE. Thatcher JW: Ameloblastoma—The conservative surgical approach to treatment: report of four cases. A clinicopathologic study of 66 patients. 1974 13. Shatkin S. Oluwasanmni JO: Recurrent ameloblastoma of the jaws—A review of 22 cases. Masson JK: Ameloblastoma: A clinicopathologic report. 1996 29. 1984 22. 1988 23. Slootweg PJ: The ameloblastoma. Growth factor enhancement for bone grafts. A prognostically distinct entity. Marx RE: Mandibular reconstruction using cancellous cellular bone grafts. Carlson ER: Bone grafting the jaws in the 21st century. Gardner DG. Clay RP. J Oral Maxillofac Surg 51:269. Vedtofte P. Sachs SA: Surgical excision with peripheral ostectomy. Carlson ER. 2000 34. Marx RE: Mandibular reconstruction. Current status of the literature. the effectiveness of radiation therapy. the controversial approach to therapy. Int J Oral Surg 7:156. Muller H. and the high rate of recurrences after relatively conservative therapy. It is interesting to these authors that the dilemma of appropriate treatment for a locally aggressive benign tumor is not isolated to our specialty with regard to the ameloblastoma. 1981 12. Corio RL: Plexiform unicystic ameloblastoma. desmoid tumors (aggressive fibromatosis) share a similar controversy with regard to surgical therapy including adequate margins. 1973 7.52-56 It is clear that the specialty of oral and maxillofacial surgery must create an initiative internationally to prospectively follow patients with the diagnosis of solid or multicystic ameloblastomas with regard to classification of their tumors. 1989 27. 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