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Ameloblastoma of the maxilla
AMELOBLASTOMA
OF THE MAXILLA
RALPH L. SPAULDING,D.D.S., F.A.C.D., MONTICEL,LO, N. Y. study and diagnosis of tumors of the jaws, the cooperation of the clini Iclinician cian, rocntgenologist, and pathologist is of importance. The cxpc~ric~nct~tl can, in many cases, diagnose a condition by its appearance. N the
ln many instances, the roentgenologist can diagnose a condition by its characteristic involvement of the bony structures. The pathologist, however, more often can make a correct diagnosis by the study of the characteristic cytology and strucdturc of a tumor. He therefore carries the responsibility of the final diagnosis. i\s an cxamplet I am presenting the following ca.se.
Case Beport A white male storekeeper, 55 years old, had, prior to 1952, what he thought, was a toothache. He had some teeth extracted. In 1952 he had an upper left molar extractesl. The x-ray picture taken before the operation is shown in Fig. 1. Prior to 1954, a dentist told him that he had a cyst and should have it removed. He had no discomfort or swelling. and fear of malignancy had made him very apprehensive so that he was not willing to IW examined, but finally he was persuaded to come to my office. History of previous diseases was essentially negative. He feared physicians, but, hall few previous illnesses. He was a heavy cigarette smoker, consumed alcohol occasionall:. and his appetite was good. Extraoral examination was essentially negative, There was no evidencxe of swelling and no adenopathy. Intraoral examination revealed abnormality. The lower teeth were present :tn~l in a good state of hygiene, along with the surrounding tissues. In the maxilla l.herc: were several teeth missing on the right side. On the left side the teeth were missing distal to the canine. There appeared to be some bulging of the buccal plate of the maxilIar> bone, extended from the canine area distally 3 or 4 cm. Upon palpation, there was evidence of thinning out of the cortex but the area was not soft. The palate in this arCa presented the same clinical manifestations. The mucous membrane covering this area presented no deviation from normal, with the exception of an area about 1.5 by 1.5 <‘m. on the ridge in the first molar area. This was of reddish blue color, appeared to be granular, and showed innumerable small vessels. A partial upper denture covering thir area had been worn for some time and may have changed its appearance. X-ray examination (Figs. 2 and 3) showed a round, radiolucent area in the upper 1~Er rm;txilIary region, extending from the upper Ieft canine back for about 3 c,m. It involve
RALPH
Fig.
1.
Fig.
2.
3.
L.
SPAULDIXG
ANELOBL$STOMA
51 1
OF iVAXILLh
and l/150 gr. atropincb Operation.-Premeditation consisted of 1.5 gr. Serubutal Sylocain hydrochloride was the anesthetic of choice, wit.h I: 100,000 epinephrine. sulfate. The incision wad made froui An infraorbital, tuberosity, and palatal injection was given. to the necks of the lateral the mucol~uc~al fold in the central incisor region, downward and canine teeth, aud along the crest of the ridge, cilcumscril~ing the area palatal1.v. that
Fig. 4.
Fig. 6.
I have described previously, and extendifq distall) fat1 the ridge to al)out thci secourl molar and continuing superiorly to the mucobuccal fold in the third molar area. This gen erous flap was retracted and thin buccal cortical boric was fncountrrrd. With rougjcurr. this area was enlarged. Conservation of bone was kept in mind. It was then spt’u that the area of tissue on the ridge previously discussed was really part of the mass. With a large periosteal elevator, the mass, which seemed very definitely enrapsulated. WBS CRWfully disengaged from the overlying bone. Noat of the mass was disengaged 1)~. blunt dissection. In the area of the palate it was uotcd that there was considerable destruction of the palate bone. The palatal section and a mesial superior section had to be srparateJ There was a definite openiug into the antrum. by sharp dissection. The area ~-as cm:trefully debrided and sulfanilamide powder n-as placed in the wound. The flap was sutureIt. 1 Over the area which was not supported hy bone, r placetl the sutures closer together. tla?. placed a small iodoform gauze wick in this area; this \vas removed t,he following
512
RALPH
I,.
SPAULDING
The mass was round and nodular and was buff colored. Its consistency was firm but There was no fluid present. not solid. The area on the crest of the ridge was actually a definite part of the tumor mass. The examination of tissue l)y the New York Institute of C&&al Oral Pathology was as follows: Microscopic : The sectiou shows a tumor which is made up of epithelial strands and This epithelium varies from cylindrical to stratified squamous epithelium occamasses. sionally showing keratinization which appears as lamellated masses. Often within their centers, in some areas, pearl formation is seen. Within, but mostly at the periphery, of the tumor, bone trabeculae are preserved. Those at the periphery are markedly attenuated. In one area near the bone remnants near the periphery, cross sections of ducts of mucous gland are seen. At the opposite edge of the same section, the tumor blends into the In many areas, infiltration multilayered squamous surface epithelium of the mucosa. by lymphocytes, plasma cells, and few polymorphonuclear leukocytes,. occasionally SWrounding cholesterol slits, are seen. Diagnosis: Amelohlastoma showing invasion (Figs. 4 and 5).
Summary and Conclusion A case history has been presented with a pathologic report of ameloblastoma. Clinically, as well as radiographically, a definite diagnosis could not be made. Ameloblastomas are rare in the maxilla, this being the third ever t.o be presented to the New York Institute of Clinical Oral Pathology. A question was asked at the meeting of the society as to why a biopsy was not, taken. I am a firm believer in biopsies. There is no dental pathology service Because of inadequate mail service, available in this immediate locality. several days would have elapsed before a diagnosis could be hoped for. Because of the extreme apprehension of the patient and my fear that if I did not carry the case to completion at once he would becomemore frightened and would again refuse treatment, I did not discuss biopsy with him. Knowing the area to be definitely encapsulated, along with other favorable clinical observations, I did not hesitate to operate within twenty-four hours of his first visit. The postoperative course was uneventful. Pain and swelling did not appear. The patient will be kept under continuous observa.tion for possible recurrence. 236
BROADWAY.
OF THE MAXILLA
RALPH L. SPAULDING,D.D.S., F.A.C.D., MONTICEL,LO, N. Y. study and diagnosis of tumors of the jaws, the cooperation of the clini Iclinician cian, rocntgenologist, and pathologist is of importance. The cxpc~ric~nct~tl can, in many cases, diagnose a condition by its appearance. N the
ln many instances, the roentgenologist can diagnose a condition by its characteristic involvement of the bony structures. The pathologist, however, more often can make a correct diagnosis by the study of the characteristic cytology and strucdturc of a tumor. He therefore carries the responsibility of the final diagnosis. i\s an cxamplet I am presenting the following ca.se.
Case Beport A white male storekeeper, 55 years old, had, prior to 1952, what he thought, was a toothache. He had some teeth extracted. In 1952 he had an upper left molar extractesl. The x-ray picture taken before the operation is shown in Fig. 1. Prior to 1954, a dentist told him that he had a cyst and should have it removed. He had no discomfort or swelling. and fear of malignancy had made him very apprehensive so that he was not willing to IW examined, but finally he was persuaded to come to my office. History of previous diseases was essentially negative. He feared physicians, but, hall few previous illnesses. He was a heavy cigarette smoker, consumed alcohol occasionall:. and his appetite was good. Extraoral examination was essentially negative, There was no evidencxe of swelling and no adenopathy. Intraoral examination revealed abnormality. The lower teeth were present :tn~l in a good state of hygiene, along with the surrounding tissues. In the maxilla l.herc: were several teeth missing on the right side. On the left side the teeth were missing distal to the canine. There appeared to be some bulging of the buccal plate of the maxilIar> bone, extended from the canine area distally 3 or 4 cm. Upon palpation, there was evidence of thinning out of the cortex but the area was not soft. The palate in this arCa presented the same clinical manifestations. The mucous membrane covering this area presented no deviation from normal, with the exception of an area about 1.5 by 1.5 <‘m. on the ridge in the first molar area. This was of reddish blue color, appeared to be granular, and showed innumerable small vessels. A partial upper denture covering thir area had been worn for some time and may have changed its appearance. X-ray examination (Figs. 2 and 3) showed a round, radiolucent area in the upper 1~Er rm;txilIary region, extending from the upper Ieft canine back for about 3 c,m. It involve
RALPH
Fig.
1.
Fig.
2.
3.
L.
SPAULDIXG
ANELOBL$STOMA
51 1
OF iVAXILLh
and l/150 gr. atropincb Operation.-Premeditation consisted of 1.5 gr. Serubutal Sylocain hydrochloride was the anesthetic of choice, wit.h I: 100,000 epinephrine. sulfate. The incision wad made froui An infraorbital, tuberosity, and palatal injection was given. to the necks of the lateral the mucol~uc~al fold in the central incisor region, downward and canine teeth, aud along the crest of the ridge, cilcumscril~ing the area palatal1.v. that
Fig. 4.
Fig. 6.
I have described previously, and extendifq distall) fat1 the ridge to al)out thci secourl molar and continuing superiorly to the mucobuccal fold in the third molar area. This gen erous flap was retracted and thin buccal cortical boric was fncountrrrd. With rougjcurr. this area was enlarged. Conservation of bone was kept in mind. It was then spt’u that the area of tissue on the ridge previously discussed was really part of the mass. With a large periosteal elevator, the mass, which seemed very definitely enrapsulated. WBS CRWfully disengaged from the overlying bone. Noat of the mass was disengaged 1)~. blunt dissection. In the area of the palate it was uotcd that there was considerable destruction of the palate bone. The palatal section and a mesial superior section had to be srparateJ There was a definite openiug into the antrum. by sharp dissection. The area ~-as cm:trefully debrided and sulfanilamide powder n-as placed in the wound. The flap was sutureIt. 1 Over the area which was not supported hy bone, r placetl the sutures closer together. tla?. placed a small iodoform gauze wick in this area; this \vas removed t,he following
512
RALPH
I,.
SPAULDING
The mass was round and nodular and was buff colored. Its consistency was firm but There was no fluid present. not solid. The area on the crest of the ridge was actually a definite part of the tumor mass. The examination of tissue l)y the New York Institute of C&&al Oral Pathology was as follows: Microscopic : The sectiou shows a tumor which is made up of epithelial strands and This epithelium varies from cylindrical to stratified squamous epithelium occamasses. sionally showing keratinization which appears as lamellated masses. Often within their centers, in some areas, pearl formation is seen. Within, but mostly at the periphery, of the tumor, bone trabeculae are preserved. Those at the periphery are markedly attenuated. In one area near the bone remnants near the periphery, cross sections of ducts of mucous gland are seen. At the opposite edge of the same section, the tumor blends into the In many areas, infiltration multilayered squamous surface epithelium of the mucosa. by lymphocytes, plasma cells, and few polymorphonuclear leukocytes,. occasionally SWrounding cholesterol slits, are seen. Diagnosis: Amelohlastoma showing invasion (Figs. 4 and 5).
Summary and Conclusion A case history has been presented with a pathologic report of ameloblastoma. Clinically, as well as radiographically, a definite diagnosis could not be made. Ameloblastomas are rare in the maxilla, this being the third ever t.o be presented to the New York Institute of Clinical Oral Pathology. A question was asked at the meeting of the society as to why a biopsy was not, taken. I am a firm believer in biopsies. There is no dental pathology service Because of inadequate mail service, available in this immediate locality. several days would have elapsed before a diagnosis could be hoped for. Because of the extreme apprehension of the patient and my fear that if I did not carry the case to completion at once he would becomemore frightened and would again refuse treatment, I did not discuss biopsy with him. Knowing the area to be definitely encapsulated, along with other favorable clinical observations, I did not hesitate to operate within twenty-four hours of his first visit. The postoperative course was uneventful. Pain and swelling did not appear. The patient will be kept under continuous observa.tion for possible recurrence. 236
BROADWAY.