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The pathology and management of aggressive odontogenic tumours
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Abstracts / British Journal of Oral and Maxillofacial Surgery 47 (2009) 338–343
The aim of improvement not perfection is the take home message. Further reading Codner MA, Wolfli JN, Anzarut A. Primary transcutaneous lower blepharoplasty with routine lateral canthal support: a comprehensive 10-year review. Plast Reconstr Surg 2008;121:241–50. Cornette de Saint-Cyr B, Garey LJ, Maillard GF, Aharonic C. The vertical midface lift. An improved procedure. J Plast Reconstr Aesthet Surg 2007;60:1277–86. Flowers RS, Ceydeli A. Mag-5 a magnificent approach to upper and midfacial ‘magic’. Clin Plast Surg 2008;35:489–515. Persing JA, Knoll B, Shin J. The shade procedure: for lower lid deformities. Plast Reconstr Surg 2008;121:1398–404.
doi:10.1016/j.bjoms.2009.04.003 The pathology and management of aggressive odontogenic tumours Robert Ord 1,2 1 Professor and Chairman, Department of Oral and Maxillofacial Surgery, University of Maryland, Baltimore, USA 2 Professor, Oncology Program, Greenebaum Cancer Center, Baltimore, USA Between November 1991–December 2008 2763 new patients were seen on the OMS Oncology Service: 1682 (61%) were malignant tumours, 668 (24%) benign tumours and 413 (15%) other entities. 282 patients presented with benign aggressive jaw tumours representing 9% of all tumours seen and 42% of benign tumours. The majority of these entities were either odontogenic tumours, fibromatoses, giant cell lesions or juvenile ossifying fibromas. The two commonest tumours were ameloblastoma 134 cases and Keratocystic Odontogenic Tumour KOT (WHO 2005) previously named Odontogenic Keratocyst (OKC) 91 cases. This master class will review the current management of these two tumours. Ameloblastoma is divided into multicystic/solid ameloblastoma of the mandible and the maxilla, and unicystic ameloblastoma. Although slow growing and radiologically well demarcated multicystic/solid ameloblastoma is infiltrative and will recur unless completely excised. There is therefore no place for curettage or other so-called conservative treatments. Histologic evidence of microscopic extension 2–8 mm beyond the radiologic margin (average 4.5 mm) dictates a bony resection margin of 1–1.5 cm in the mandible. In most cases this mandates a segmental resection, marginal resection may be utilized in small tumours when a 1-cm bone margin can be obtained and 1 cm of the lower border retained (as for OSCC). When the cortical bone is perforated the next soft tissue anatomical barrier is removed, i.e. periosteum, fat, muscle or even skin. In the maxilla the thin bone and proximity to vital structures requires the tumour to be approached as a true malignancy with partial maxillectomy as the minimal procedure. Once the tumour
has perforated the maxillary bony wall cure is less likely particularly with involvement of the pterygoid plates. Unicystic ameloblastoma is more common in younger patients and may be classified into tumours involving only the cyst lining, tumours with intra luminal growth and tumours involving the capsule (mural ameloblastomas). Although these tumours have a benign reputation with reported recurrence rates of 20% following ennucleation, this is not true for ‘mural’ types with reported recurrence up to 40%. Ennucleation is only recommended for tumours that do not involve the capsule with resection for ‘mural’ tumours. The OKC familiar to all, is renamed Keratocystic Tumour KOT on the basis of its molecular biology including the presence of oncogenes. This lesion is very controversial in its treatment and many modalities have been proposed from ennucleation and curettage, ennucleation with peripheral ostectomy, to radical resection. Currently decompression with a drain or bung for 9–12 months prior to removal has shown much promise. This method, however, has not been associated with zero recurrence as reported in the literature in my own experience. Management decisions for large maxillary lesions in young patients are very controversial and close follow up is required. In multiply recurrent lesions particularly with involvement of soft tissue radical resection may be the best surgical option. Further reading Ackermann GL, Altini M, Shear M. The unicystic ameloblastoma a clinicopathological study of 57 cases. J Oral Pathol 1988;17:541–6. Carlson ER, Marx RE. The ameloblastoma primary curative surgical management. J Oral Maxillofac Surg 2006;64:484–94. Lau SL, Samman N. Recurrence related to treatment modalities of unicystic ameloblastoma a systematic review. Int J Oral Maxillofac Surg 2006;35:681–90. Stoelinga PJ. Long term follow-up on keratocysts treated according to a defined to a defined protocol. Int J Oral Maxillofac Surg 2001;30:14–25.
doi:10.1016/j.bjoms.2009.04.004 Ridge augmentation in implantology G.M. Raghoebar Professor of Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, The Netherlands Patients with a severely resorbed edentulous mandible and maxilla often suffer from problems with their dentures. These problems include insufficient retention of the lower denture, intolerance of the denture bearing mucosa to loading, pain, difficulties with eating and speech, loss of soft tissue support and failing facial appearance. Meanwhile, dental implants, serving as a basis for removable and fixed prostheses, have shown to be a significant tool to reduce these problems. Similar results have been reported for implant supported single tooth replacements and bridges. Thus, during the last decades
Abstracts / British Journal of Oral and Maxillofacial Surgery 47 (2009) 338–343
The aim of improvement not perfection is the take home message. Further reading Codner MA, Wolfli JN, Anzarut A. Primary transcutaneous lower blepharoplasty with routine lateral canthal support: a comprehensive 10-year review. Plast Reconstr Surg 2008;121:241–50. Cornette de Saint-Cyr B, Garey LJ, Maillard GF, Aharonic C. The vertical midface lift. An improved procedure. J Plast Reconstr Aesthet Surg 2007;60:1277–86. Flowers RS, Ceydeli A. Mag-5 a magnificent approach to upper and midfacial ‘magic’. Clin Plast Surg 2008;35:489–515. Persing JA, Knoll B, Shin J. The shade procedure: for lower lid deformities. Plast Reconstr Surg 2008;121:1398–404.
doi:10.1016/j.bjoms.2009.04.003 The pathology and management of aggressive odontogenic tumours Robert Ord 1,2 1 Professor and Chairman, Department of Oral and Maxillofacial Surgery, University of Maryland, Baltimore, USA 2 Professor, Oncology Program, Greenebaum Cancer Center, Baltimore, USA Between November 1991–December 2008 2763 new patients were seen on the OMS Oncology Service: 1682 (61%) were malignant tumours, 668 (24%) benign tumours and 413 (15%) other entities. 282 patients presented with benign aggressive jaw tumours representing 9% of all tumours seen and 42% of benign tumours. The majority of these entities were either odontogenic tumours, fibromatoses, giant cell lesions or juvenile ossifying fibromas. The two commonest tumours were ameloblastoma 134 cases and Keratocystic Odontogenic Tumour KOT (WHO 2005) previously named Odontogenic Keratocyst (OKC) 91 cases. This master class will review the current management of these two tumours. Ameloblastoma is divided into multicystic/solid ameloblastoma of the mandible and the maxilla, and unicystic ameloblastoma. Although slow growing and radiologically well demarcated multicystic/solid ameloblastoma is infiltrative and will recur unless completely excised. There is therefore no place for curettage or other so-called conservative treatments. Histologic evidence of microscopic extension 2–8 mm beyond the radiologic margin (average 4.5 mm) dictates a bony resection margin of 1–1.5 cm in the mandible. In most cases this mandates a segmental resection, marginal resection may be utilized in small tumours when a 1-cm bone margin can be obtained and 1 cm of the lower border retained (as for OSCC). When the cortical bone is perforated the next soft tissue anatomical barrier is removed, i.e. periosteum, fat, muscle or even skin. In the maxilla the thin bone and proximity to vital structures requires the tumour to be approached as a true malignancy with partial maxillectomy as the minimal procedure. Once the tumour
has perforated the maxillary bony wall cure is less likely particularly with involvement of the pterygoid plates. Unicystic ameloblastoma is more common in younger patients and may be classified into tumours involving only the cyst lining, tumours with intra luminal growth and tumours involving the capsule (mural ameloblastomas). Although these tumours have a benign reputation with reported recurrence rates of 20% following ennucleation, this is not true for ‘mural’ types with reported recurrence up to 40%. Ennucleation is only recommended for tumours that do not involve the capsule with resection for ‘mural’ tumours. The OKC familiar to all, is renamed Keratocystic Tumour KOT on the basis of its molecular biology including the presence of oncogenes. This lesion is very controversial in its treatment and many modalities have been proposed from ennucleation and curettage, ennucleation with peripheral ostectomy, to radical resection. Currently decompression with a drain or bung for 9–12 months prior to removal has shown much promise. This method, however, has not been associated with zero recurrence as reported in the literature in my own experience. Management decisions for large maxillary lesions in young patients are very controversial and close follow up is required. In multiply recurrent lesions particularly with involvement of soft tissue radical resection may be the best surgical option. Further reading Ackermann GL, Altini M, Shear M. The unicystic ameloblastoma a clinicopathological study of 57 cases. J Oral Pathol 1988;17:541–6. Carlson ER, Marx RE. The ameloblastoma primary curative surgical management. J Oral Maxillofac Surg 2006;64:484–94. Lau SL, Samman N. Recurrence related to treatment modalities of unicystic ameloblastoma a systematic review. Int J Oral Maxillofac Surg 2006;35:681–90. Stoelinga PJ. Long term follow-up on keratocysts treated according to a defined to a defined protocol. Int J Oral Maxillofac Surg 2001;30:14–25.
doi:10.1016/j.bjoms.2009.04.004 Ridge augmentation in implantology G.M. Raghoebar Professor of Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery, University Medical Center Groningen, The Netherlands Patients with a severely resorbed edentulous mandible and maxilla often suffer from problems with their dentures. These problems include insufficient retention of the lower denture, intolerance of the denture bearing mucosa to loading, pain, difficulties with eating and speech, loss of soft tissue support and failing facial appearance. Meanwhile, dental implants, serving as a basis for removable and fixed prostheses, have shown to be a significant tool to reduce these problems. Similar results have been reported for implant supported single tooth replacements and bridges. Thus, during the last decades