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Ameloblastic Fibroma: Management of a Patient with an Extensive Tumor
C L IN IC A L
Dr. Suzuki is assistant professor, department of p e r io d o n tic s , B a ltim o re C o lle g e of D en tal Surgery, Dental School, University of Maryland, and lecturer, department of periodontics, Loyola University School of Dentistry, Maywood, 111; Dr. DePaola is assistant professor, department of oral diagnosis, and Dr. Nauman is associate professor, department of microbiology, Baltim ore College of Dental Surgery, Dental Sch ool, U niversity of Maryland, Baltim ore, 21201. Address requests for reprints to Dr. Suzuki at the University of Mary land. 1. Karnofsky, D.A., and others. An evaluation of methyl-bis (B-chloroethyl) amine hydrochlor ide and tris (B-chloroethyl) amino hydrochloride (nitrogen mustards) in th e treatm ent of lym phomas, leukemia and allied disease. In Moulton, F.R., ed. Approaches to tumor chemotherapy. W ashington, DC, Am erican Association for the Advancement of Sciences, pp 319-337. 2. G u ggen h eim er, J., and oth ers. C lin ico pathologic effects o f cancer chem otherapeutic agents on hum an b u cca l m ucosa. Oral Surg 44:58-63, 1977. 3 . G i l l e s p i e , G .M . R e n e w a l o f b u c c a l epithelium . Oral Surg 2 7 :8 3 -8 9 ,1 9 6 9 . 4. Page, R.C., and Ammons, W .F. Collagen turnover in gingiva and other mature connective
tissues of the marmoset. Arch Oral Biol 19:6516 5 8 ,1 9 7 4 . 5. Bottom ley, W.K.; Perlin, E.; and Ross, G.E. Antineoplastic agents and their oral manifesta tions. Oral Surg 44:527-534, 1977. 6. Dreizen, S. Stomatotoxic m anifestations of cancer chemotherapy. J Prosthet Dent 40:650-655, 1978. 7. Dreizen, S.; Body, G.P.; and Brown, L.R. Op portunistic gram-negative bacillary infections in leukemia. Postgrad Med 55 :1 3 3 -1 3 9 ,1 9 7 4 . 8. Schim pff, S.C. Therapy of infection in pa tients with granulocytopenia. Med Clin North Am 61:1101-1118, 1977. 9. Schim pff, S.C.; Aisner, J.; and Wiernik, P.H. Infection in acute nonlym phocytic leukemia: the alimentary canal as a major source of pathogens. Amsterdam, Excerpta M edica, 1979, pp 12-29. 10. Lindquist, S.F.; Hickey, A.J.; and Drane, J.B. Effect of oral hygiene on stom atitis in patients receiving cancer chemotherapy. J Prosthet Dent 4 0 :3 1 2 -3 1 4 ,1 9 7 8 . 11. Peterson, D.E., and Overholser, C.D. Dental m anagem ent o f leukem ic patients. Oral Surg 47:40-42, 1979. 12. Cohen, D., and Morris, L. Periodontal man ifestations of cy clic neutropenia. J Periodontol 32:159-164, 1959. 13 . C ia n cio la , L.J., and o th ers. D efectiv e
REPORTS
polym orphoneuclear leukocytes function in a human periodontal disease. Nature 265:445-447, 1977. 14. Lusk, S .S., and others. Effects of an oral rinse on experim ental gingivitis, plaque forma tion and formed plaque. } Am Soc Prev Dent 4:31-37, 1974. 15. Johnson, R., and Rozanis, A. A review of chem oth erap eu tic plaque co n tro l. Oral Surg 47:136-141, 1979. 16. Parson s, S .J. C hem otherapy o f dental plaque— a review . J P eriod on tol 4 5 :1 7 7 -1 8 6 , 1974. 17. Listgarten, M.A.; Lindhe, J.; and Hellden, L. Effect of tetracycline and I or scaling on human periodontal disease. Clinical, m icrobiological, and histological observations. J Clin Periodontol 5:246-271, 1978. 18. Ciancio, S. Tetracyclines and periodontal therapy. J Periodontal 4 7 :1 5 5 -1 5 9 ,1 9 7 6 . 19. Aisner, J., and others. T o ru lo p sis g la brata infections in patients with cancer: increasing in cidence and relationship to colonization. Am J Med 6 1 :2 3 -2 8 ,1 9 7 6 . 20. Loe, H., and Sch iott, R.C. T he effect of m o u t h r in s e s an d t o p ic a l a p p l i c a t i o n o f ch lo rh ex id in e on th e developm ent of dental plaque and gingivitis in m an. Periodont Res 5:79-83, 1970.
Ameloblastic fibroma: management of a patient with an extensive tumor Wayne S. Harrison, DDS Warren C. Sordill, DMD James J. Sciubba, DMD, PhD Robert M. Liebers, DDS
The surgical treatment and management of the resultant surgical defect of this odontogenic tumor are described.
T
J L he ameloblastic fibroma is a rela tively uncommon neoplasm of odon togenic origin comprising 2.5% of the odontogenic lesions of the jaw s .1'3 Also known as a soft mixed odon togenic tumor, soft mixed odontoma,
or fib ro a d a m a n to b la s to m a , th e ameloblastic fibroma is composed of epithelial and mesenchymal elements and is therefore a true mixed tumor .1 The tumor is often asymptomatic and is detected during routine dental ex amination; or pain or swelling may be the initial symptoms. The lesion oc curs most commonly in the molarpremolar region of the mandible and in the 5- to 20-year-old age group .4No apparent sex predilection exists .1'4 Radiographically, the neoplasm is in distinguishable from the simple amel
oblastoma, appearing as a unilocular or multilocular radiolucent area .3 The lesion is generally well defined; ex pansion of the cortex indicates that it is an expansive, not an invasive pro cess .5'7Resembling a dentigerous cyst, the ameloblastic fibroma is frequently associated with unerupted teeth .1,2,5
Report of case A 17-year-old white girl initially had pain in the maxillary left posterior quadrant. The patient reported some swelling, intermit
H arrison-O thers : MANAGEMENT O F PATIENT WITH AMELOBLASTIC FIBRO M A ■ 475
C L IN IC A L
REPO RTS
mediately beneath the floor of the orbit, with possible thinning of the orbital floor. Expansion and thinning of the medial an tral wall and complete destruction of the lateral portion of the posterior inferior wall of the left antrum were evident (Fig 3). Findings of a CBC and SMA-12 were normal.
Fig 1 ■ P reoperative photograph o f patient shows intraoral swelling caused by am eloblastic fibroma.
Incisional biopsy Profound local anesthesia was obtained, and a small amount of straw-colored fluid was aspirated through a 19-gauge needle. After a full-thickness mucoperiosteal flap was created, a thick-walled, fibrous soft tis sue mass was encountered. A wedge of tis sue for histologic examination was re moved, prompting a flow of a straw-colored fluid tinged with a darker fluid, which ceased after a short interval. Tissue was prepared for routine microscopic examina tion and electron microscopy. Hematoxylin and eosin stained slides prepared from the biopsy tissue showed a preponderance of dental papilla-like tissue, composed of proliferating odontogenic epithelium and a richly cellular mesoder mal component. Cells reminiscent of a stel late reticulum were enclosed by groups of columnar cells resembling primitive odon togenic epithelium. These cellular groups were arranged in islands, strands, and nests. The cell-rich mesenchymal element was poorly collagenized, resembling the primitive connective tissue of the dental papilla. The histologic appearance of this tissue was characteristic of the ameloblastic fibroma (Fig 4). Accurate diagnosis is es sential, as occasional misdiagnosis of the lesion as a type of ameloblastoma results in over-treatment.
Fig 3 ■ Preoperative W a ters’ view shows impacted tooth immediately below orbital floor and complete destruction of lateral por tion of posterior inferior left antral wall.
S u rgica l therapy
tent pain for a month, and difficulty breath ing through the left nostril. On clinical ex amination, facial asymmetry with enlarge ment in the region inferior to the left malar eminence was seen. Intraorally, there was swelling of the left maxillary mucobuccal fold and alveolar ridge extending from the region of the second premolars posteriorly (Fig 1). The palate was expanded to the midline in the same region. The first, sec ond, and third molars were not evident. The patient’s dental history included extrac tions in this quadrant because of caries. 476 ■ JADA, Vol. 104, April 1982
Panoramic and periapical radiographs showed a large hazy radiolucent area oc cupying the area of the left maxillary sinus. Associated with this area was a tooth that was grossly displaced superiorly, and mul tiple fine radiopaque areas not resembling tooth structure were evident inferiorly (Fig 2 ).
Advanced root resorption of the second premolar and presence of a supernumerary tooth were also noticed. Waters’ and lateral skull views and tomograms of the maxilla indicated that the impacted tooth was im
The extent of the lesion and surgical con siderations required the patient to be hos pitalized and treated under general anes thesia. Admitting laboratory values were within normal limits, and the medical workup disclosed no other pertinent find ings. Surgical management of this patient was based on the histopathology of the tumor and prosthodontic reconstruction considerations. Because the tumor has a slow growth rate and low incidence of re currence, complete but conservative exci sion with preservation of overlying soft tis sue flaps could be possible. If this were ac complished, then primary closure of the surgical wound might be achieved, thus eliminating an oroantral communication. More importantly, if periosteal integrity could be maintained along with the overly ing soft tissue, a degree of osseous regenera tion might permit support of a denture base without a subsequent bone grafting proce dure.
CLINICAL REPORTS
F ig 4 ■ Islands and cords of am eloblastic odon
five days. The antral pack was removed after eight days, anterior sutures were re moved in 12 days, and posterior sutures were removed in 14 days. The surgical site healed without complication.
togenic epithelium are surrounded by cellular im mature mesenchymal cell population. Hyaline cell-free zone at epithelial-m esenchym al interface can be seen in som e areas (arrow) (H&E, mag X 180).
Prosthetic m a n a g em e n t Clinical examination six months postoperatively indicated that tissue healing was well advanced. There was no evidence of oroantral communication, and the left pos terior maxillary alveolar ridge was firm to palpation (Fig 5). It was thought that this degree of ridge firmness would provide suitable support for a free-end denture base. Mouth preparations were performed and a cast chrome-cobalt removable partial den ture was fabricated. An RPI clasp was used on the maxillary left canine and two crib clasps on the contralateral side. The pros thesis was functional, esthetic, and well tolerated by the patient (Fig 6).
Summary
Fig 6 ■ Postoperative intraoral view o f patient with prosthesis in place.
The alternative to maintaining the soft tissue flaps and attaining a primary closure of the surgical wound would be treating a large postsurgical oroantral communica tion. This would probably require a skin graft and alter the prosthodontic manage ment, compromising the functional result. After induction of anesthesia, the patient was prepared in the usual manner for in traoral surgery. An incision was then made over the crest of the edentulous left maxil lary alveolar ridge. The incision extended from the posterior aspect of the tuberosity to the mesial aspect of the left canine, where a releasing incision was placed. A full thickness mucoperiosteal flap was elevated anteriorly and carried posteriorly to the margin of the bony defect created by the le sion. During dissection of the soft tissue, the lesion peeled easily away from the re sidual periosteum. In a similar manner, a palatal flap was elevated and the lesion was separated from overlying mucosa. The maxillary left second premolar was re moved because of the root erosion evident radiographically. As this toot] was being removed, the supernumerary tooth was avulsed and was found to be Unattached to the lesion. To gain greater access to the lesion and
the medial aspect of the left antrum, the maxillary left first premolar, along with overlying residual bone of the lateral antral wall, was removed. Using gentle countertraction, the lesion was stripped away from the remaining bony walls of the sinus with a large curet. At the superior aspect of the surgical site the third molar was attached to the inner margin of the lesion. Posteriorly, the lesion had to be dissected from soft tis sue. The tumor was then removed via the mouth. The specimen was grayish-brown, rubbery, and measured 7.8 x 3 x 2 cm. The residual cavity was visually inspected for Remnants of tumor and then thoroughly ir rigated with sterile saline solution. A half-inch vaseline gauze pack was placed in the sinus and exteriorized via a left nasal antrostomy. The anterior margins of the wound were then coapted over bone and secured using no. 3-0 black silk inter rupted sutures. The posterior margins of the wound were coapted using multiple no. 3-0 black silk vertical mattress sutures to create eversion of the wound edges and a broad interface of periosteum in an attempt to ensure primary closure. The patient had an uncomplicated post operative course and was discharged after
A case of ameloblastic fibroma in a 17-year-old white girl is reported. The tumor was in the maxilla in the area of the left sinus. The second premolar and a supernumerary tooth were in volved. Clinical features, histopathology, surgical therapy, and pros thetic management are discussed.
Dr. Harrison, formerly senior dental resident, St. Clare’s Hospital, Schenectady, NY, is in pri vate practice in Ballston Spa, NY. Dr. Sordill is di rector of dental education and attending oral and m axillofacial surgeon, St. Clare’s Hospital. Dr. Sciubba is associate chairman, department of dentistry, Long Island Jewish-Hillside M edical Center, New Hyde Park, and associate professor of oral biology and pathology, School o f Dental M edicine, State University of New York at Stony Brook. Dr. Liebers is chief of dentistry, Ellis Hos pital, and attending oral and m axillofacial sur geon, St. Clare’s Hospital, Schenectady, NY. Ad dress requ ests for rep rin ts to Dr. H arrison, Pinewood Lane, Ballston Spa, NY 12020. 1. Bhaskar, S.N. Synopsis of oral pathology, ed 4. St. Louis, C. V. Mosby Co, pp 256-258. 2. Shafer, W.G.; Hine, M.K.; and Levy, L.M. A textbook of oral pathology, ed 3. Philadelphia, W. B. Saunders Co, 1974, p 273. 3. Hager, R.D., and others. Am eloblastic fi broma. J Oral Surg 36(l):66-69, 1978. 4. Gorlin, R.J., and Goldman, H.M. Thom a’s oral pathology, ed 7. St. Louis, C. V. Mosby Co, 1970, pp 495-496. 5. Pindborg, J.J., and Hjorting-Hansen, J. Atlas of diseases of the jaws. Philadelphia, W. B. Saun ders Co, 1974, p 279. 6. Zegarelli, E.V., and others. Diagnosis o f dis eases of the mouth and jaws, ed 2. Philadelphia, Lea & Febiger, 1978, p 279. 7. M ille r, A .S ., and oth ers. A m e lo b la stic fibro-odontoma. J Oral Surg 41(3):354-365, 1976.
H arrison-O thers : MANAGEMENT OF PATIENT WITH AMELOBLASTIC FIBRO M A ■ 477
Dr. Suzuki is assistant professor, department of p e r io d o n tic s , B a ltim o re C o lle g e of D en tal Surgery, Dental School, University of Maryland, and lecturer, department of periodontics, Loyola University School of Dentistry, Maywood, 111; Dr. DePaola is assistant professor, department of oral diagnosis, and Dr. Nauman is associate professor, department of microbiology, Baltim ore College of Dental Surgery, Dental Sch ool, U niversity of Maryland, Baltim ore, 21201. Address requests for reprints to Dr. Suzuki at the University of Mary land. 1. Karnofsky, D.A., and others. An evaluation of methyl-bis (B-chloroethyl) amine hydrochlor ide and tris (B-chloroethyl) amino hydrochloride (nitrogen mustards) in th e treatm ent of lym phomas, leukemia and allied disease. In Moulton, F.R., ed. Approaches to tumor chemotherapy. W ashington, DC, Am erican Association for the Advancement of Sciences, pp 319-337. 2. G u ggen h eim er, J., and oth ers. C lin ico pathologic effects o f cancer chem otherapeutic agents on hum an b u cca l m ucosa. Oral Surg 44:58-63, 1977. 3 . G i l l e s p i e , G .M . R e n e w a l o f b u c c a l epithelium . Oral Surg 2 7 :8 3 -8 9 ,1 9 6 9 . 4. Page, R.C., and Ammons, W .F. Collagen turnover in gingiva and other mature connective
tissues of the marmoset. Arch Oral Biol 19:6516 5 8 ,1 9 7 4 . 5. Bottom ley, W.K.; Perlin, E.; and Ross, G.E. Antineoplastic agents and their oral manifesta tions. Oral Surg 44:527-534, 1977. 6. Dreizen, S. Stomatotoxic m anifestations of cancer chemotherapy. J Prosthet Dent 40:650-655, 1978. 7. Dreizen, S.; Body, G.P.; and Brown, L.R. Op portunistic gram-negative bacillary infections in leukemia. Postgrad Med 55 :1 3 3 -1 3 9 ,1 9 7 4 . 8. Schim pff, S.C. Therapy of infection in pa tients with granulocytopenia. Med Clin North Am 61:1101-1118, 1977. 9. Schim pff, S.C.; Aisner, J.; and Wiernik, P.H. Infection in acute nonlym phocytic leukemia: the alimentary canal as a major source of pathogens. Amsterdam, Excerpta M edica, 1979, pp 12-29. 10. Lindquist, S.F.; Hickey, A.J.; and Drane, J.B. Effect of oral hygiene on stom atitis in patients receiving cancer chemotherapy. J Prosthet Dent 4 0 :3 1 2 -3 1 4 ,1 9 7 8 . 11. Peterson, D.E., and Overholser, C.D. Dental m anagem ent o f leukem ic patients. Oral Surg 47:40-42, 1979. 12. Cohen, D., and Morris, L. Periodontal man ifestations of cy clic neutropenia. J Periodontol 32:159-164, 1959. 13 . C ia n cio la , L.J., and o th ers. D efectiv e
REPORTS
polym orphoneuclear leukocytes function in a human periodontal disease. Nature 265:445-447, 1977. 14. Lusk, S .S., and others. Effects of an oral rinse on experim ental gingivitis, plaque forma tion and formed plaque. } Am Soc Prev Dent 4:31-37, 1974. 15. Johnson, R., and Rozanis, A. A review of chem oth erap eu tic plaque co n tro l. Oral Surg 47:136-141, 1979. 16. Parson s, S .J. C hem otherapy o f dental plaque— a review . J P eriod on tol 4 5 :1 7 7 -1 8 6 , 1974. 17. Listgarten, M.A.; Lindhe, J.; and Hellden, L. Effect of tetracycline and I or scaling on human periodontal disease. Clinical, m icrobiological, and histological observations. J Clin Periodontol 5:246-271, 1978. 18. Ciancio, S. Tetracyclines and periodontal therapy. J Periodontal 4 7 :1 5 5 -1 5 9 ,1 9 7 6 . 19. Aisner, J., and others. T o ru lo p sis g la brata infections in patients with cancer: increasing in cidence and relationship to colonization. Am J Med 6 1 :2 3 -2 8 ,1 9 7 6 . 20. Loe, H., and Sch iott, R.C. T he effect of m o u t h r in s e s an d t o p ic a l a p p l i c a t i o n o f ch lo rh ex id in e on th e developm ent of dental plaque and gingivitis in m an. Periodont Res 5:79-83, 1970.
Ameloblastic fibroma: management of a patient with an extensive tumor Wayne S. Harrison, DDS Warren C. Sordill, DMD James J. Sciubba, DMD, PhD Robert M. Liebers, DDS
The surgical treatment and management of the resultant surgical defect of this odontogenic tumor are described.
T
J L he ameloblastic fibroma is a rela tively uncommon neoplasm of odon togenic origin comprising 2.5% of the odontogenic lesions of the jaw s .1'3 Also known as a soft mixed odon togenic tumor, soft mixed odontoma,
or fib ro a d a m a n to b la s to m a , th e ameloblastic fibroma is composed of epithelial and mesenchymal elements and is therefore a true mixed tumor .1 The tumor is often asymptomatic and is detected during routine dental ex amination; or pain or swelling may be the initial symptoms. The lesion oc curs most commonly in the molarpremolar region of the mandible and in the 5- to 20-year-old age group .4No apparent sex predilection exists .1'4 Radiographically, the neoplasm is in distinguishable from the simple amel
oblastoma, appearing as a unilocular or multilocular radiolucent area .3 The lesion is generally well defined; ex pansion of the cortex indicates that it is an expansive, not an invasive pro cess .5'7Resembling a dentigerous cyst, the ameloblastic fibroma is frequently associated with unerupted teeth .1,2,5
Report of case A 17-year-old white girl initially had pain in the maxillary left posterior quadrant. The patient reported some swelling, intermit
H arrison-O thers : MANAGEMENT O F PATIENT WITH AMELOBLASTIC FIBRO M A ■ 475
C L IN IC A L
REPO RTS
mediately beneath the floor of the orbit, with possible thinning of the orbital floor. Expansion and thinning of the medial an tral wall and complete destruction of the lateral portion of the posterior inferior wall of the left antrum were evident (Fig 3). Findings of a CBC and SMA-12 were normal.
Fig 1 ■ P reoperative photograph o f patient shows intraoral swelling caused by am eloblastic fibroma.
Incisional biopsy Profound local anesthesia was obtained, and a small amount of straw-colored fluid was aspirated through a 19-gauge needle. After a full-thickness mucoperiosteal flap was created, a thick-walled, fibrous soft tis sue mass was encountered. A wedge of tis sue for histologic examination was re moved, prompting a flow of a straw-colored fluid tinged with a darker fluid, which ceased after a short interval. Tissue was prepared for routine microscopic examina tion and electron microscopy. Hematoxylin and eosin stained slides prepared from the biopsy tissue showed a preponderance of dental papilla-like tissue, composed of proliferating odontogenic epithelium and a richly cellular mesoder mal component. Cells reminiscent of a stel late reticulum were enclosed by groups of columnar cells resembling primitive odon togenic epithelium. These cellular groups were arranged in islands, strands, and nests. The cell-rich mesenchymal element was poorly collagenized, resembling the primitive connective tissue of the dental papilla. The histologic appearance of this tissue was characteristic of the ameloblastic fibroma (Fig 4). Accurate diagnosis is es sential, as occasional misdiagnosis of the lesion as a type of ameloblastoma results in over-treatment.
Fig 3 ■ Preoperative W a ters’ view shows impacted tooth immediately below orbital floor and complete destruction of lateral por tion of posterior inferior left antral wall.
S u rgica l therapy
tent pain for a month, and difficulty breath ing through the left nostril. On clinical ex amination, facial asymmetry with enlarge ment in the region inferior to the left malar eminence was seen. Intraorally, there was swelling of the left maxillary mucobuccal fold and alveolar ridge extending from the region of the second premolars posteriorly (Fig 1). The palate was expanded to the midline in the same region. The first, sec ond, and third molars were not evident. The patient’s dental history included extrac tions in this quadrant because of caries. 476 ■ JADA, Vol. 104, April 1982
Panoramic and periapical radiographs showed a large hazy radiolucent area oc cupying the area of the left maxillary sinus. Associated with this area was a tooth that was grossly displaced superiorly, and mul tiple fine radiopaque areas not resembling tooth structure were evident inferiorly (Fig 2 ).
Advanced root resorption of the second premolar and presence of a supernumerary tooth were also noticed. Waters’ and lateral skull views and tomograms of the maxilla indicated that the impacted tooth was im
The extent of the lesion and surgical con siderations required the patient to be hos pitalized and treated under general anes thesia. Admitting laboratory values were within normal limits, and the medical workup disclosed no other pertinent find ings. Surgical management of this patient was based on the histopathology of the tumor and prosthodontic reconstruction considerations. Because the tumor has a slow growth rate and low incidence of re currence, complete but conservative exci sion with preservation of overlying soft tis sue flaps could be possible. If this were ac complished, then primary closure of the surgical wound might be achieved, thus eliminating an oroantral communication. More importantly, if periosteal integrity could be maintained along with the overly ing soft tissue, a degree of osseous regenera tion might permit support of a denture base without a subsequent bone grafting proce dure.
CLINICAL REPORTS
F ig 4 ■ Islands and cords of am eloblastic odon
five days. The antral pack was removed after eight days, anterior sutures were re moved in 12 days, and posterior sutures were removed in 14 days. The surgical site healed without complication.
togenic epithelium are surrounded by cellular im mature mesenchymal cell population. Hyaline cell-free zone at epithelial-m esenchym al interface can be seen in som e areas (arrow) (H&E, mag X 180).
Prosthetic m a n a g em e n t Clinical examination six months postoperatively indicated that tissue healing was well advanced. There was no evidence of oroantral communication, and the left pos terior maxillary alveolar ridge was firm to palpation (Fig 5). It was thought that this degree of ridge firmness would provide suitable support for a free-end denture base. Mouth preparations were performed and a cast chrome-cobalt removable partial den ture was fabricated. An RPI clasp was used on the maxillary left canine and two crib clasps on the contralateral side. The pros thesis was functional, esthetic, and well tolerated by the patient (Fig 6).
Summary
Fig 6 ■ Postoperative intraoral view o f patient with prosthesis in place.
The alternative to maintaining the soft tissue flaps and attaining a primary closure of the surgical wound would be treating a large postsurgical oroantral communica tion. This would probably require a skin graft and alter the prosthodontic manage ment, compromising the functional result. After induction of anesthesia, the patient was prepared in the usual manner for in traoral surgery. An incision was then made over the crest of the edentulous left maxil lary alveolar ridge. The incision extended from the posterior aspect of the tuberosity to the mesial aspect of the left canine, where a releasing incision was placed. A full thickness mucoperiosteal flap was elevated anteriorly and carried posteriorly to the margin of the bony defect created by the le sion. During dissection of the soft tissue, the lesion peeled easily away from the re sidual periosteum. In a similar manner, a palatal flap was elevated and the lesion was separated from overlying mucosa. The maxillary left second premolar was re moved because of the root erosion evident radiographically. As this toot] was being removed, the supernumerary tooth was avulsed and was found to be Unattached to the lesion. To gain greater access to the lesion and
the medial aspect of the left antrum, the maxillary left first premolar, along with overlying residual bone of the lateral antral wall, was removed. Using gentle countertraction, the lesion was stripped away from the remaining bony walls of the sinus with a large curet. At the superior aspect of the surgical site the third molar was attached to the inner margin of the lesion. Posteriorly, the lesion had to be dissected from soft tis sue. The tumor was then removed via the mouth. The specimen was grayish-brown, rubbery, and measured 7.8 x 3 x 2 cm. The residual cavity was visually inspected for Remnants of tumor and then thoroughly ir rigated with sterile saline solution. A half-inch vaseline gauze pack was placed in the sinus and exteriorized via a left nasal antrostomy. The anterior margins of the wound were then coapted over bone and secured using no. 3-0 black silk inter rupted sutures. The posterior margins of the wound were coapted using multiple no. 3-0 black silk vertical mattress sutures to create eversion of the wound edges and a broad interface of periosteum in an attempt to ensure primary closure. The patient had an uncomplicated post operative course and was discharged after
A case of ameloblastic fibroma in a 17-year-old white girl is reported. The tumor was in the maxilla in the area of the left sinus. The second premolar and a supernumerary tooth were in volved. Clinical features, histopathology, surgical therapy, and pros thetic management are discussed.
Dr. Harrison, formerly senior dental resident, St. Clare’s Hospital, Schenectady, NY, is in pri vate practice in Ballston Spa, NY. Dr. Sordill is di rector of dental education and attending oral and m axillofacial surgeon, St. Clare’s Hospital. Dr. Sciubba is associate chairman, department of dentistry, Long Island Jewish-Hillside M edical Center, New Hyde Park, and associate professor of oral biology and pathology, School o f Dental M edicine, State University of New York at Stony Brook. Dr. Liebers is chief of dentistry, Ellis Hos pital, and attending oral and m axillofacial sur geon, St. Clare’s Hospital, Schenectady, NY. Ad dress requ ests for rep rin ts to Dr. H arrison, Pinewood Lane, Ballston Spa, NY 12020. 1. Bhaskar, S.N. Synopsis of oral pathology, ed 4. St. Louis, C. V. Mosby Co, pp 256-258. 2. Shafer, W.G.; Hine, M.K.; and Levy, L.M. A textbook of oral pathology, ed 3. Philadelphia, W. B. Saunders Co, 1974, p 273. 3. Hager, R.D., and others. Am eloblastic fi broma. J Oral Surg 36(l):66-69, 1978. 4. Gorlin, R.J., and Goldman, H.M. Thom a’s oral pathology, ed 7. St. Louis, C. V. Mosby Co, 1970, pp 495-496. 5. Pindborg, J.J., and Hjorting-Hansen, J. Atlas of diseases of the jaws. Philadelphia, W. B. Saun ders Co, 1974, p 279. 6. Zegarelli, E.V., and others. Diagnosis o f dis eases of the mouth and jaws, ed 2. Philadelphia, Lea & Febiger, 1978, p 279. 7. M ille r, A .S ., and oth ers. A m e lo b la stic fibro-odontoma. J Oral Surg 41(3):354-365, 1976.
H arrison-O thers : MANAGEMENT OF PATIENT WITH AMELOBLASTIC FIBRO M A ■ 477