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Oral surgery—Oral pathology conference no. 5 Walter Reed Army Medical Center
Section of the FEDERAL .
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DENTAL .
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ORALSURGERY-ORALPATHOLOGYCONFERENCENO.5 WALTER REED ARMY MEDICAL CENTER Conducted Lieutenant
CASE
by Colonel Robert B. Xhira’ and Colonel Surindar N. BhaskaP+
REPORT
Clinical History.-A 22.year-old Negro soldier was admitted to Walter Reed General Hospital on Aug. 22, 1960, with the chief complaint of a swelling of the right jaw of 3 months ’ duration. The history revealed that 2 years earlier two teeth had been extracted from the area because of a toothache. However, roentgenograms from that dental treatment were not available. Following the extractions the patient experienced no difficulties until 3 months prior to the present admission, when an enlargement of the right mandible was noted. This gradually increased in size, but there was no pain or discomfort. The patient was a well-developed, well-nourished man in no distress. Pertinent findings were limited to the face and the oral cavity. There was a slight facial asymmetry in the right mandibular region. The patient was able to open his mouth without difficulty, and excursions of the mandible were normal in all positions. Intraoral examination revealed a 4 by 4 cm. swelling in the area of the missing first and second mandibular molars. The mucosa overlying this area was normal in color and was freely movable over the underlying bone., Crepitation was noted on firm palpation, giving the impression of a marked thinning of the underlying bone. No pain or discomfort was produced by the firm palpation. The remainder of the oral Army Walter
*Chief, Medical **Chief, Reed
Oral Surgery and Dental Service, Walter Reed General Hospital, Walter Reed Center, Washington, D. C. Department of Oral Pathology, United States Army Institute of Dental Research, Army Medical Center, Washington, D.C.
1131
cavity lymph
was normal; teeth were in good repair, and there was no paresthesia or ilemonstrable node involvement. Roentgenograms of the mandible rrvealod an expanding multilocular osteolytil~ Jrsion of the mandibular body (Fig. 1). There were numerous circular osteolytic areas of varying size, separated by distinct bony septa. The osteolytic areas were arranged in clusters in a. radial fashion. The mandibular canal had been displaced downward. In the occlusal view it was evident that the bueeal cortical plate was markedly thinned and displaced laterally and that the lingual cortex was involved by the small osteolytic defects. Tn the lateral view the lesion was seen extending to and involving the iuferior border of t,he mandible.
Fig.
l.-Roentgenograms
showing
soap-bubble
appearance
Clinical Impression.-On the basis of the clinical and roentgenologie features, it was apparent that the lesion probably respresented an ameloblastoma. Only a few lesions of the on x-ray examination. The ameloblastoma is the jaw present a ’ ’ soap-bubble ’ ’ appearance foremost among these; the others are the giant-cell reparative granuloma, the myxoma, and the aneurysmal bone cyst. The age of this patient, as well as the nature of the radiolucency, was almost diagnostic. Laboratory Findings.-Laboratory studies revealed a normal hemogram. The urinalysis was normal, and the serum teat for syphilis was negative. Blood chemistry revealed a serum calcium of 9.1 mg. per cent; phosphorus, 4.1 mg. per cent; alkaline phosphatase, 5.0 Bodansky units ; total proteins, 7.4; and cholesterol, 209 mg. per cent. A bone survey was negative except for the findings in the mandible.
Volume 16 Number 9
ORAL
SURGERY-ORAL
PATHOLOGY
CONFERENCE
1133
Under local anesthesia, biopsy was performed via an intraoral approach. A mucoperiosteal flap was reflected from the lateral aspect of the mandible. A portion of the thin lateral cortex of bone was removed, exposing a grayish white, firm, fibrous tissue mass. After representative sections were removed for examination, the flaps were returned and sutured. Microscopic Findings.--Multiple fragments of tissue were embedded and sectioned. These showed a partially solid and partly cystic epithelial tumor (Fig. 2). Islands, cords, and strands, as well as cystic areas, consisted of a peripheral layer of tall columnar ameloblastlike cells and a central area of loosely arranged star-shaped cells. The tumor parenchyma infiltrated the bone marrow spaces. The histologic features WWF: diagnost,ic of an ameloblastoma.
Fig.
2.-Photomicrograph
showing
classic
features
if ameloblastoma.
molar after
were removed the mandibular
Fig.
and an alveolectomy resection the wound
3.-Vitallium
Fig.
prothesis
4.--Grass
specimens
\yas lwformed. This KIS tlone so would not c~ommunicat~~ kvith the
inserted
before
after
and
surgical
rmxw:~l
after
hemisectioning.
OP tumor.
Volume 16 Number 9
ORAL
PATHOLOGY
SURGERY-ORAL
CONFERENCE
1135
On Oct. 15, 1960, under nasal endotracheal anesthesia, the left mandible was resected. A 6 cm. incision was made inferior to the mandible, and the tissues were separated until the inferior border of the mandible was exposed. When the periosteum was reflected it was found that, although the mandible had expanded in the area, the cortical plate had not been destroyed. The tissue overlying the mandible was reflected without creating a communication with the oral cavity. The mandible was sectioned at the symphysis and the angle. The involved portion of the mandible was then removed, and a previously constructed Vitallium prosthesis was inserted to maintain the space (Fig. 3). The wound was closed in layers without a drain.
Fig.
Fig.
%--Mandible
6.-Patient
after
with
rib graft
partial
denture.
The gross specimen, on sectioning, revealed numerous honeycomb-like areas of excavation (Fig. 4). The pathologist reported that the tumor had been removed in its entirety with adequate margins. Two months following the above procedure, the vitallium prosthesis was removed and replaced with a rib bone graft (Fig. 5). An end-to-end anastomosis was made at the symphysis, and an onlay attachment at the angle. The jaws were immobilized for 19 weeks, at the end of which time healing of the graft was complete. A partial denture was constructed to replace the missing teeth (Fig. 6). Three years following treatment, there has been no recurrence of the tumor. DISCUSSION
The treatment of ameloblastoma varies from surgeon to surgeon. Whereas some would consider conservative treatment in selected cases, others suggest
radical resection as the minimal treatment. Obviously, ihc surgeon must rvi~upon his clinical judgment in deciding upon the t.ype of treatment to be gircn. It must be said here, however. that, the amtloblastoma is not capable ol metastasis13 2s,1Although a number of cases of “metastatic ameloblastoma” have been reported in t,he literature, it has been recently shown that these lesions, in all probability, represent adrnocarcinomas of salivaq gland tks;snc included within the jaws3 REFERENCES
1. Bernier, 2. Bhaskar, 3. Rhaskar,
J. L.: Management of Oral Disease, St. Louis, 1959, The C. V. Mosby Company. S. N. : Synopsis of Oral Pathology, St. Louis, 1961, The C. V. Mosby Company. S. N.: Central Mucoepidermoid Tumors of the Mandible, Cancer 16: 721-726, 1963. 4. Thoma, K. H., and Goldman, II. M. : Oral Pathology, ed. 5, St. Louis, 1960, The C. V. Mosby Company.
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.
.
DENTAL .
.
.
SERVICES .
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
ORALSURGERY-ORALPATHOLOGYCONFERENCENO.5 WALTER REED ARMY MEDICAL CENTER Conducted Lieutenant
CASE
by Colonel Robert B. Xhira’ and Colonel Surindar N. BhaskaP+
REPORT
Clinical History.-A 22.year-old Negro soldier was admitted to Walter Reed General Hospital on Aug. 22, 1960, with the chief complaint of a swelling of the right jaw of 3 months ’ duration. The history revealed that 2 years earlier two teeth had been extracted from the area because of a toothache. However, roentgenograms from that dental treatment were not available. Following the extractions the patient experienced no difficulties until 3 months prior to the present admission, when an enlargement of the right mandible was noted. This gradually increased in size, but there was no pain or discomfort. The patient was a well-developed, well-nourished man in no distress. Pertinent findings were limited to the face and the oral cavity. There was a slight facial asymmetry in the right mandibular region. The patient was able to open his mouth without difficulty, and excursions of the mandible were normal in all positions. Intraoral examination revealed a 4 by 4 cm. swelling in the area of the missing first and second mandibular molars. The mucosa overlying this area was normal in color and was freely movable over the underlying bone., Crepitation was noted on firm palpation, giving the impression of a marked thinning of the underlying bone. No pain or discomfort was produced by the firm palpation. The remainder of the oral Army Walter
*Chief, Medical **Chief, Reed
Oral Surgery and Dental Service, Walter Reed General Hospital, Walter Reed Center, Washington, D. C. Department of Oral Pathology, United States Army Institute of Dental Research, Army Medical Center, Washington, D.C.
1131
cavity lymph
was normal; teeth were in good repair, and there was no paresthesia or ilemonstrable node involvement. Roentgenograms of the mandible rrvealod an expanding multilocular osteolytil~ Jrsion of the mandibular body (Fig. 1). There were numerous circular osteolytic areas of varying size, separated by distinct bony septa. The osteolytic areas were arranged in clusters in a. radial fashion. The mandibular canal had been displaced downward. In the occlusal view it was evident that the bueeal cortical plate was markedly thinned and displaced laterally and that the lingual cortex was involved by the small osteolytic defects. Tn the lateral view the lesion was seen extending to and involving the iuferior border of t,he mandible.
Fig.
l.-Roentgenograms
showing
soap-bubble
appearance
Clinical Impression.-On the basis of the clinical and roentgenologie features, it was apparent that the lesion probably respresented an ameloblastoma. Only a few lesions of the on x-ray examination. The ameloblastoma is the jaw present a ’ ’ soap-bubble ’ ’ appearance foremost among these; the others are the giant-cell reparative granuloma, the myxoma, and the aneurysmal bone cyst. The age of this patient, as well as the nature of the radiolucency, was almost diagnostic. Laboratory Findings.-Laboratory studies revealed a normal hemogram. The urinalysis was normal, and the serum teat for syphilis was negative. Blood chemistry revealed a serum calcium of 9.1 mg. per cent; phosphorus, 4.1 mg. per cent; alkaline phosphatase, 5.0 Bodansky units ; total proteins, 7.4; and cholesterol, 209 mg. per cent. A bone survey was negative except for the findings in the mandible.
Volume 16 Number 9
ORAL
SURGERY-ORAL
PATHOLOGY
CONFERENCE
1133
Under local anesthesia, biopsy was performed via an intraoral approach. A mucoperiosteal flap was reflected from the lateral aspect of the mandible. A portion of the thin lateral cortex of bone was removed, exposing a grayish white, firm, fibrous tissue mass. After representative sections were removed for examination, the flaps were returned and sutured. Microscopic Findings.--Multiple fragments of tissue were embedded and sectioned. These showed a partially solid and partly cystic epithelial tumor (Fig. 2). Islands, cords, and strands, as well as cystic areas, consisted of a peripheral layer of tall columnar ameloblastlike cells and a central area of loosely arranged star-shaped cells. The tumor parenchyma infiltrated the bone marrow spaces. The histologic features WWF: diagnost,ic of an ameloblastoma.
Fig.
2.-Photomicrograph
showing
classic
features
if ameloblastoma.
molar after
were removed the mandibular
Fig.
and an alveolectomy resection the wound
3.-Vitallium
Fig.
prothesis
4.--Grass
specimens
\yas lwformed. This KIS tlone so would not c~ommunicat~~ kvith the
inserted
before
after
and
surgical
rmxw:~l
after
hemisectioning.
OP tumor.
Volume 16 Number 9
ORAL
PATHOLOGY
SURGERY-ORAL
CONFERENCE
1135
On Oct. 15, 1960, under nasal endotracheal anesthesia, the left mandible was resected. A 6 cm. incision was made inferior to the mandible, and the tissues were separated until the inferior border of the mandible was exposed. When the periosteum was reflected it was found that, although the mandible had expanded in the area, the cortical plate had not been destroyed. The tissue overlying the mandible was reflected without creating a communication with the oral cavity. The mandible was sectioned at the symphysis and the angle. The involved portion of the mandible was then removed, and a previously constructed Vitallium prosthesis was inserted to maintain the space (Fig. 3). The wound was closed in layers without a drain.
Fig.
Fig.
%--Mandible
6.-Patient
after
with
rib graft
partial
denture.
The gross specimen, on sectioning, revealed numerous honeycomb-like areas of excavation (Fig. 4). The pathologist reported that the tumor had been removed in its entirety with adequate margins. Two months following the above procedure, the vitallium prosthesis was removed and replaced with a rib bone graft (Fig. 5). An end-to-end anastomosis was made at the symphysis, and an onlay attachment at the angle. The jaws were immobilized for 19 weeks, at the end of which time healing of the graft was complete. A partial denture was constructed to replace the missing teeth (Fig. 6). Three years following treatment, there has been no recurrence of the tumor. DISCUSSION
The treatment of ameloblastoma varies from surgeon to surgeon. Whereas some would consider conservative treatment in selected cases, others suggest
radical resection as the minimal treatment. Obviously, ihc surgeon must rvi~upon his clinical judgment in deciding upon the t.ype of treatment to be gircn. It must be said here, however. that, the amtloblastoma is not capable ol metastasis13 2s,1Although a number of cases of “metastatic ameloblastoma” have been reported in t,he literature, it has been recently shown that these lesions, in all probability, represent adrnocarcinomas of salivaq gland tks;snc included within the jaws3 REFERENCES
1. Bernier, 2. Bhaskar, 3. Rhaskar,
J. L.: Management of Oral Disease, St. Louis, 1959, The C. V. Mosby Company. S. N. : Synopsis of Oral Pathology, St. Louis, 1961, The C. V. Mosby Company. S. N.: Central Mucoepidermoid Tumors of the Mandible, Cancer 16: 721-726, 1963. 4. Thoma, K. H., and Goldman, II. M. : Oral Pathology, ed. 5, St. Louis, 1960, The C. V. Mosby Company.