Oral Surgery

Management of Abstract
|| Brief Background
Ameloblastoma Ameloblastoma is true neoplasm of odontogenic epithelium.
It is unicentric non-functional, intermittent in growth,
arising from anatomically benign, clinically persistant. It is second most
common odontogenic neoplasm and represents 1% of all oral

Dentigerous cyst - odontogenic epithelial tumors and 11% of all odontogenic

tumors.8 we present a rare case of 23 year old female patient
in which postoperative dentigerous cyst resulted in plexiform

A case report amelobastoma of mandible.

|| Materials and Methods

Surgery was performed under general anaesthesia. Extra oral
incision was given in submandibular region extending to the
left angle of mandible. Lesion was exposed which was involving
body of mandible extending from lower left second premolar to
the ascending ramus till sigmoid notch measuring 52 (length)
×23 (width) mm with involvement of 36, 37 teeth. Lesion was
removed with the resection of mandible from 35 tooth to the
ascending ramus involving coroniod process. 7cm iliac crest
graft was harvested from right side and positioned along with
reconstruction plate. Intermaxillary fixation was done to have
proper occlusion.

|| Discussion
We report a rare case in which ameloblastoma developed
from enucleated dentegerous cyst after 2 years. The lesions
which appears as dentigerous cyst may have component of
ameloblastic changes in the lining if not enucleated or removed
properly.

|| Summary and Conclusions

Dr. Jyotsna Galinde
Maxillofacial Surgeon The purpose of this case report is to highlight the fact that
Panel Consultant BARC Hospital regular follow up every six months after the enucleation of
dentegerous cyst is mandatory as it has high potential to change
Correspondence Address to ameloblastoma.
Dr. Julli Bajaj
Bahaba Atomic Research Center and Hospital, || Key Words
Mumbai
Unicystic Ameloblastoma, Dentegerous cyst, Ameloblastoma.

32 Clinical Dentistr y, Mumbai • March 2015

CD March 2015.indd 32
 || Introduction
The most common tumor of odontogenic origin is
ameloblastoma which develops from epithelial cellular
elements and dental tissues. It is a slow-growing,
persistent and locally aggressive neoplasm of epithelial
origin. Its peak incidence is in the 3rd to 4th decades of
life and has no sex predilection. Ameloblastomas are
rarely malignant or metastatic, and progress slowly;
the resulting lesions can cause severe abnormalities
of the face and jaw. Additionally, because abnormal
cell growth easily infiltrates and destroys surrounding
bony tissues, wide surgical excision is required to
treat this neoplasm. The lesion has a tendency to
expand the bony cortices because slow growth rate
of the lesion allows time for periosteum to develop
thin shell of bone ahead of the expanding lesion.
Radiographically, it appears as lucency in the bone of
varying size and features; sometimes it is a single, well-
demarcated lesion whereas it often demonstrates as a
multiloculated "soap bubble" appearance. Resorption
of roots of involved teeth can be seen in some cases,
but is not unique to ameloblastoma. The disease is
most often found in the posterior body and angle of
the mandible, but can occur anywhere in either the
maxilla or mandible.
According to the World Health Organization,
ameloblastomas can be classified into four groups:
(1) solid/multicystic, (2) extraosseous/peripheral, (3)
desmoplastic, and (4) unicystic.1 Histopathologically,
it occurs in six patterns: plexiform, follicular,
acanthomatous, granular cell, basal cell, and
desmoplastic type. Mixtures of different patterns are
commonly observed and the lesions are usually classified
based on the predominant pattern present.3,10 Because
abnormal cell growth easily infiltrates and destroys
surrounding bony tissues, wide surgical excision is
required to treat this disorder. While chemotherapy,
radiation therapy, curettage and liquid nitrogen have
been effective in some cases of ameloblastoma, surgical
resection or enucleation remains the most definitive
treatment for this condition. In a detailed study of
345 patients,6 chemotherapy and radiation therapy
seemed to be contraindicated for the treatment of
ameloblastomas. Thus, surgery is the most common
treatment of this tumor. Because of the invasive nature
of the growth, excision of normal tissue near the tumor
margin is often required. Follicular ameloblastomas
appear to reoccur more often than the plexiform
Clinical
CD March 2015.indd 33
type.6 Unicystic tumors reoccur less frequently
than "non-unicystic" tumors. Persistent follow-up
examination is essential for managing ameloblastoma
Follow up should be at regular intervals for at least
10 years. Follow up is important, because 50% of
all recurrences occur within 5 years postoperatively.6
Recurrence is common, although the recurrence rates
for block resection followed by bone graft are lower
than those of enucleation and curettage.2 Seeding to
the bone graft is suspected as a cause of recurrence.4
The recurrences in these cases seem to stem from
the soft tissues, especially the adjacent periosteum.5
Recurrence has been reported to occur as many as 2
to 36 years after treatment.4 To reduce the likelihood
of recurrence within grafted bone, meticulous surgery
with attention to the adjacent soft tissues is required.2
|| Case Report
A 23-year-old female patient reported to Dental Unit
of BARC (Bhaba Atomic Research Centre and hospital)
with a painful swelling on the left posterior region of
mandible and difficulty in deglutition from past seven
days. Her medical history was not significant. Past
dental history of patient revealed dentegerious cyst
involving mandibular left third molar which was being
operated 2 yrs back at Surat (Fig.1) Postoperatively
Fig 1: OPG Dentegerous cyst involving lower left third molar with
resorption of mesial and distal roots of 37
Fig 2: OPG showing radiolucent multilocular lesion in the left side of
mandible with resorption of mesial and distal roots of 36, 37 teeth
Dentistr y, Mumbai • March 2015
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 after enucleation of dentegerious cyst patient
developed painful swelling in lower left side of jaw,
redness, fever and pain during deglutition after 20
days. Patient was referred to ENT surgeon. Patient was
admitted in the hospital at Surat with final diagnosis
of cellulitis of left face and upper neck. Patient was
treated and discharged after four days. There after
patient had on and off pain in the left side of the
mandible frequently and was treated with antibiotics
and analgesics at Surat.
After 2 years patient reported to the BARC dental unit
with slight swelling and redness in lower posterior
left side of the jaw. Intra oral examination revealed
left alveolar region swelling having normal mucosa Fig 3: CT with 3D technology showing, multilocular cortical bone
expansion with resorption of roots of adjacent teeth
measuring 52 (length) × 23 (width) mm. The buccal
and lingual cortices were expanded with egg shell
crackling on palpation of swelling. Patient was
asked for a Panaromic radiograph and Cone beam
computed tomography .Clinically there was slight
facial asymmetry, intra oral examination revealed left
alveolar region swelling in 36,37 region having normal
mucosa. The buccal and lingual cortices were expanded
and with egg shell crackling on palpation of swelling.
A panaromic radiograph (Fig.2) revealed a multilocular,
radiolucent area in the left mandibular ramus, which
extended 1cm below the sigmoid notch to the lower
border of the mandible, superioinferiorly involving the
anterior border of the ramus and extending anteriorly
along the alveolar crest, from the distal of second
premolar. Posteriorly, the lesion was found to extend Fig 4: Radiological investigation: CT scan revealed multilocular (soap
to the posterior border of the ramus, leaving 0.5 cm of bubble,honey comb) appearance with cortical bone expansion and
resorption of adjacent tooth roots
the posterior border of the ramus intact, tooth no 35
was root canal treated with porcelain fused to metal
crown without any peri-radicular radiolucency
Radiological investigation CT with 3D technology
mandible (Fig.3, Fig.4) revealed multilocular (soap
bubble, honey comb) appearance with cortical bone
expansion and resorption of adjacent tooth roots. An
expansile osteolytic well defined lesion involving body
(parasymphygeal region) and left angle of mandible
measuring 52 (length) × 23 (width) mm with marked
thinning and scalloping of both buccal as well as
lingual cortex with focal areas of breach. Involvement
of mesial and distal roots of 36, 37 molar teeth.
Aspiration biopsy was done which showed the
amber coloured cyctic fluid. Patient did not take
any treatment for six months due to her studies and Fig 5: CT scan revealed extensive destruction of body of mandible
and ramus of the mandible with lingual cortical plate expansion

34 Clinical Dentistr y, Mumbai • March 2015

CD March 2015.indd 34 3/24/2015 3:42:57 PM

 when she reported she had a complete growth in the
second and third molar area (Fig.4,5). Immediately the
incisional biopsy was taken which revealed plexiform
ameloblastoma.

|| Method
The surgery was performed under general anaesthesia
with antibiotic coverage. Intermaxillary fixation was
done to have proper occlusion. Extra oral incision was
given in submandibular region extending beyond left
angle of mandible. After the dissection lesion was Fig 7: Reconstruction with iliac crest graft along with reconstruction
exposed. (Fig.6) Resection of mandible was carried out titanium plate

from lower left second premolar to the subcondylar

region. Reconstruction of the defect was done with
7 cm iliac crest graft of right side of pelvis. Bone graft
was positioned along with reconstruction plate (Fig.7).
Intraoral and extra oral facial absorbable sutures were
placed patient was discharged after ten days of surgery
and was kept on liquid diet for six weeks.
Microscopic description: Histopathological report
shows features of plexiform ameloblastoma (Fig. 8).
Multiple sections studied from the tumour shows
features of plexiform ameloblastoma. Cystic
degeneration is seen within the tumour. Tumour
Fig 8: Plexiform pattern shows foamy histocytes within the stroma
involves bone extensively with in thin cortical bone
surrounding tumour.Post operative OPG after six weeks

Fig 9: Post Operative OPG showing IMF and reconstruction plate

Fig 10: Showing the patient occlusion and the alveolar ridge after
Fig 6: Specimen showing resected mandible nine months

Clinical Dentistr y, Mumbai • March 2015

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Fig 11: Showing contour of the left side of the mandible
with Intermaxillary Fixation was taken (Fig.9). Patient
was followed after every three months. Patient was
asymptomatic. No swelling, no pain on swallowing
was detected occlusion was well maintained. Follow
up after nine month showing the patient occlusion
and the alveolar ridge,showing contour of the left side
of the mandible( Fig.10, Fig.11).
|| Discussion
A dentigerous cyst or follicular cyst is an odontogenic
cyst developmental in origin associated with the
Co-authors
Dr. Julli Bajaj
Consultant
|| References
1. L. Barnes, J. W. Everson, P. Reichart, and D. Sindransky,
Eds.“WHO classification of tumours,” in Pathology and
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2. Vasan,NT JE: N Z Dental "Recurrent ameloblastoma in an
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1995, 91(403) : 12-3.
3. Gruica B, Stauffer E, Buser D, Bornstein M, JE:
Quintessence Int. Ameloblastoma of the follicular,
36 Clinical Dentistr y, Mumbai • March 2015
crown of an unerupted (or partially erupted) tooth.
The cyst cavity is lined by epithelial cells derived from
the reduced enamel epithelium of the tooth forming
organ. Follicular space more than 5 mm is to be
considered a dentigerous cyst.
A dentigerous cyst is often treated by enucleation
along with the extraction of the associated tooth.
Enucleation of a dentegerious cyst is curative and
recurrences are almost unheard of, unlike the
odontogenic keratosis. If a portion of dentegerious
cyst linning remains, it will lie dormant and not retain
its stimulation to form another cyst. Because the cell
seems to be more independent in their proliferation
and more active. This case report highlights the fact
that the lesions which appear as dentigerous cyst may
have component of ameloblastic changes if the lining
is not excised properly.
|| Conclusion
The purpose of this case report is to highlight the fact
that the lesions which appears as dentigerous cyst
may have component of ameloblastic changes in the
linning if not enucleated or removed properly. Regular
follow up after every six months is must in first year of
the surgery.
plexiform, and acanthomatous type in the maxillary
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 Recurrence of an ameloblastoma in an autogenous iliac
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7. Gardner DG, Corio RL, JE: Oral Surg, Oral Med, Oral Path.
The relationship of plexiform unicystic ameloblastoma
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