Ameloblastoma resection with immediate rib reconstruction: addressing the problem of mandibular angle and central bone bulk

Several methods are available to treat mandibular tumours. This case series demonstrates the feasibility of resection and immediate reconstruction with free rib graft in limited resource settings. Innovative technical modifications are described to handle the problem of reconstruction of the angle of the mandible and to provide increased bone bulk in the centre of the mandible. Early postoperative complications are few. Follow-up demonstrates good functional results.

Giant Osteosarcoma of the Mandible

Osteosarcoma is a rare primary malignant bone tumor with considerable variations not only in clinical and histologic appearance, but also in the course and prognosis of the disease. It mainly occurs in the metaphyseal region of long bones. Jaw osteosarcomas are relatively rare as compared to those occurring in long bones and share similar histopathologic features, but biologically behave in a different manner. Early diagnosis and complete resection of the lesion are necessary for better prognosis. This report highlights an aggressive and fatal case of mandibular osteosarcoma in a 23-year male patient, which, if diagnosed earlier, would have added some valuable years to the patient's life.

Intraosseous Leiomyoma of the Jaw in an Adolescent

Leiomyoma is a benign tumor of the smooth muscle that rarely occurs in the mouth as an intraosseous lesion. The purposes of this paper are to: (1) present a case of an intraosseous solid leiomyoma of the mandible in a 13-year-old child, who presented with a well-defined unilocular radiolucency in the right mandible incidentally discovered during a routine dental radiographic examination; and (2) conduct a review of the literature to describe clinicopathological features and management of intraosseous jaw leiomyoma (IJL). A total of 17 articles describing 18 cases of IJL satisfied the selection criteria; including the present patient, to date a total of 19 cases of IJL have been reported. IJL occurs mainly in young patients (36.8 percent), more often in boys (1:5:1 male-to-female ratio), and reaches a larger size in children than in adults. The treatment of choice for IJL is surgical excision, which should be as minimally invasive as possible, especially in children.

Osteosarcoma in a Patient With Pseudohypoparathyroidism Type 1b Due to Paternal Uniparental Disomy of Chromosome 20q

It is assumed that a persistent high level of parathyroid hormone (PTH) might have a relation with bone malignancy. However, there has been no report of osteosarcoma associated with pseudohypoparathyroidism type 1b (PHP1b), which is accompanied by high PTH. PHP1b is the result of resistance to PTH in certain end-organ tissues, especially the kidney; the response in bone is unaffected because it normally expresses stimulatory G protein equally from both parental alleles. A 21-year-old male, presenting with gum swelling at the right mandible, was referred to a dental clinic. A curative surgical resection by segmental mandibulectomy was performed and the pathologic findings of the mass were consistent with osteoblastic osteosarcoma. His laboratory results showed a low calcium level despite high PTH, and he did not have any features of Albright hereditary osteodystrophy; therefore, PHP1b was suspected. Multiplex ligation-dependent probe amplification and microsatellite marker analyses of chromosome 20 confirmed the diagnosis and identified paternal uniparental disomy of chromosome 20q (patUPD20). To the best of our knowledge, this is the first report of osteosarcoma in a patient with PHP1b due to patUPD20. © 2017 American Society for Bone and Mineral Research.

Use of refrigerant spray of a propane/butane/isobutane gas mixture in the management of keratocystic odontogenic tumors: a preliminary study

PURPOSE

Keratocystic odontogenic tumor (KCOT) is an aggressive benign tumor and the management by complete enucleation followed by cryotherapy maintains the inorganic bone matrix, resulting in better repair and reduces the rates of recurrence. A refrigerant spray with a propane/butane/isobutane gas mixture has been pointed to as an alternative to liquid nitrogen, because the device is easy to handle and contain within the cavity, providing better control and lower risk of injury to the adjacent soft tissue. Thus, the aim of this study was to evaluate the outcome of enucleation followed by cryosurgery using a refrigerant spray of this gas mixture in ten patients diagnosed with KCOT.

METHOD

The biggest lesions received a prior treatment consisting of marsupialization to decrease the tumor size. During the surgeries, the lesions were removed by enucleation and the surgical site was sprayed with the gas mixture.

RESULTS

Wound dehiscence was observed in all cases, which healed by the second intention. The mean follow-up period was 64.3 months (range 24-120 months). Eight of the ten patients showed no evidence of clinical or radiographic recurrence. Pathologic fractures and infections were not observed.

CONCLUSIONS

The results obtained suggest that enucleation followed by cryosurgery is an effective therapy for managing KCOT.

Osteogenic Sarcoma of Mandible

Osteosarcoma (OS) is a malignant neoplasm characterised by the formation of osteoid matrix by neoplastic cells. It is the most common primary malignant bone tumor accounting for 20% of all sarcomas, although its occurrence in the jaw is rare. It shows typical clinical behaviour but varied radiological and histopathological features. It presents various histological aspects. We report a case of 30-year male presented with a painful swelling of mandible, diagnosed as OS after histopathological evaluation.

Occult infratemporal fossa neurofibroma presenting with persistent unilateral tinnitus and middle ear effusion: More than meets the eye

Herein, we present the case of a previously healthy 54year-old female who developed several weeks of unilateral tinnitus and aural fullness. She subsequently underwent unilateral pressure equalization tube placement at an outside institution after exam demonstrated a middle ear effusion, conductive hearing loss and normal nasopharyngoscopy. Ultimately, an MRI revealed an occult mass in the infratemporal fossa (ITF), which was successfully removed via an endoscopic transnasal ITF approach. Following resection of a histopathologically confirmed benign neurofibroma, she reported complete resolution of her symptoms. The antiquated diagnostic algorithm of unilateral effusion suggests that normal nasopharyngscopy successfully "rules out" a causative neoplastic process; however, Eustachian tube occlusion by occult skull base lesions may be missed without further investigation. This case highlights the need for additional radiological investigation of unexplained unilateral persistent middle ear effusion in the setting of normal nasopharyngoscopy.

Psammomatoid Juvenile Ossifying Fibroma of Mandible in a 41-Year Male Patient

Juvenile ossifying fibroma (JOF) is a rare fibro-osseous neoplasm that develops among the craniofacial bones at an early age; and in majority of patients, it is diagnosed in the first or second decade of life. We present a case in 41-year male patient having it in the left anterior mandibular region. Peripheral eosinophilic areas resembling psammomatoid bodies along with other features impelled the diagnosis of psammomatoid ossifying fibroma. However, the term juvenile seems to be losing impact with the patients showing such features in old age.

Premolar Cystic Ameloblastoma in a Child

Mandibular swellings may occur as a result of many benign lesions of odontogenic or non-odontogenic origin. Ameloblastomas are benign tumours of odontogenic origin, whose importance lies in its potential to grow into enormous size with resulting bone deformity, it is a slow-growing, persistent, and locally aggressive neoplasm. The unicystic ameloblastoma (UA) represents an ameloblastoma variant, presenting as a cyst clinically and radiographically, but showing typical ameloblastomatous epithelium lining histologically. It commonly occurs in second and third decades of life and is rare in children under 12 years of age, and better response to conservative treatment. It shares many clinical and radiographic features with odontogenic cysts/tumours and/or periapical disease of endodontic origin. Reported here is an unusual case of unicystic ameloblastoma involving the crown of an unerupted mandibular first premolar in a 9-year boy in an uncommon location, which was misdiagnosed as periapical lesion of inflammatory origin clinically, and as a dentigerous cyst radiographically. This highlights the importance to routinely submit the removed surgical specimen for histopathological examination.

What Is Important for Confirming Negative Margins When Resecting Mandibular Ameloblastomas?

PURPOSE

The purpose of this study was to assess the utility of intraoperative radiographs and frozen sections in achieving negative margins and preventing recurrence of mandibular ameloblastomas.

MATERIALS AND METHODS

This was a retrospective cohort study of patients who underwent resection (≥1 cm) of mandibular ameloblastomas from 2005 through 2015. Patients were included if they had at least 1-year follow-up and complete records. Demographic variables included age, gender, and type of resection (segmental vs marginal). Predictor variables were type of margin assessment: 1) frozen section, 2) intraoperative ex vivo specimen radiograph, 3) both, or 4) none. The outcome variables were final margin status and recurrence rate. Accuracy of intraoperative radiographic margins was determined by comparison with histologic margin distance. Descriptive statistics were conducted with the Fisher exact test.

RESULTS

The study sample consisted of 35 patients (47.5 ± 20.4 yr old; 16 men) who underwent 25 segmental and 10 marginal resections. Ten had frozen sections only, 3 had ex vivo specimen radiographs only, 10 had no intraoperative measurements, and 12 had both. There were no positive frozen sections. One patient had a positive posterior bony margin at final pathology despite negative frozen section histology. There was no difference in recurrence rate at latest follow-up among cohorts. The anterior radiographic margin was 11.8 ± 5.9 mm compared with 11.5 ± 7.5 mm by histology (P = .124). The posterior radiographic margin was 12.3 ± 5.3 mm compared with 9.8 ± 6.5 mm histologically (P = .546). Margin distances that were at least 5 mm when measured with specimen radiographs had histologic margin distances of at least 5 mm in 25 of 30 resection margins (83.3%).

CONCLUSION

Resection of ameloblastoma with planned margins of at least 1 cm is sufficient to prevent recurrence of ameloblastoma. Achieving a radiographic margin of at least 5 mm provided a histologic margin of at least 5 mm 83.3% of the time.

Non-vascularised iliac crest bone graft for immediate reconstruction of lateral mandibular defect

INTRODUCTION

Mandibular defect reconstruction is extremely important to achieving an improved quality of life of patients as this bony defect influences facial harmony and aesthetics. Reconstruction of mandibular defects at our centre comprises use of reconstruction plate, non-vascularised anterior iliac crest graft and vascularised fibula flap. Despite the large mandibular defect recorded in our developing environment, non-vascularised iliac crest graft continues to play a role in its exclusive use for lateral mandibular defects. The aim of this study was to analyse the role, complications and outcomes of the use of non-vascularised iliac crest graft for mandibular reconstruction in a free flap-enabled centre.

PATIENTS AND METHOD

This was a retrospective case cohort from study institution's records of mandibular reconstruction following mandibular surgery for benign tumours. Eligibility for study inclusion comprised case cohort with head and neck diseases requiring mandibular surgery and reconstruction with either reconstruction plate, non-vascularised iliac crest graft or vascularised fibula flap.

RESULTS

A total of 18 subjects underwent iliac crest grafting. Of the 18 subjects with iliac crest graft, 7 (39 %) were females while 11 (61 %) were males. Ten of the 18 subjects with iliac crest grafting were diagnosed with ameloblastomas. Six (33.3 %) subjects had class H (Jewer's classification) mandibular defect. The average graft length was 5.4 cm and height was 2.3 cm. Three cases experienced graft site complications of which two grafts were lost. All 18 cases experienced good to acceptable clinical outcomes. Predictors of graft outcome were not statistically significant.

CONCLUSION

Despite our small sample size, it is suggestible that non-vascularised iliac crest graft be considered for lateral mandibular defect reconstruction, considering the reduced graft failure rate and satisfactory clinical outcomes from this study.

An Osteoblastoma of the Mandible: A Case Study

This case study involves a 22-year-old male who experienced moderate pain in the left side of the mandible for two months. He was diagnosed with an osteoblastoma and treated with local excision, curettage and extraction of the involved teeth. Radiographic follow-up indicated that the site healed well. Clinical, radiographic and histopathologic features are discussed. Osteoblastoma requires interdisciplinary care and should be considered in the differential diagnosis of mixed-density lesions detected in the jaws.

Tissue Engineering for Vertical Ridge Reconstruction

This article provides an overview of basic tissue engineering principles as they are applied to vertical ridge defects and reconstructive techniques for these types of deficiencies. Presented are multiple clinical cases ranging from office-based dentoalveolar procedures to the more complex reconstruction of postresection mandibular defects. Several different types of regenerative tissue constructs are presented; either used alone or in combination with traditional reconstructive techniques and procedures, such as maxillary sinus augmentation, Le Fort I osteotomy, and microvascular free tissue transfer. The goal is to also familiarize the reconstructive surgeon to potential future strategies in vertical alveolar ridge augmentation.

Osteosarcoma of the Mandible: A Site-Specific Study on Survival and Prognostic Factors

Osteosarcoma of head and neck is a rare condition comprising of <1% of all head and neck cancers, retrospective studies show difference in survival of mandibular osteosarcoma to other head and neck sites, necessitating investigation into site-specific survival and recurrence rates.

Parapharyngeal Schwannoma of the Mandibular Nerve Associated With Auditory Changes

We present a case of a parapharyngeal schwannoma of the mandibular nerve with intraosseous extension into the mandible. The initial symptoms included decreased auditory acuity, with subsequent magnetic resonance imaging findings suggestive of Eustachian tube obstruction. This represents a rare symptom of schwannomas of the mandibular nerve. Owing to the degree of bony expansion and cortical thinning of the adjacent mandibular ramus, concern existed for a pathologic fracture. Treatment involved complete excision of the lesion using hemimandibulectomy with second stage reconstruction. The patient noted resolution of the preoperative symptoms. No sign of recurrence of the schwannoma was noted at the 2-year mark.

A standardized formula for aesthetic mandibular reconstruction using an osteocutaneous fibular free flap

Ameloblastoma is the most common benign odontogenic tumor of the jaw, and expansional growth of a huge untreated ameloblastoma can result in disturbances in facial aesthetics and function, such as difficulty with mouth opening, swallowing, chewing, breathing, neurologic deficits, and pathologic fractures. Radical wide resection with safety margins and subsequent reconstruction is generally recommended. A fibular free flap (FFF) is commonly used to reconstruct the mandible in order to adequately restore both aesthetic appearance and function. The aim of this brief clinical report is to present a case of huge ameloblastoma after wide resection with free safety margins, and describe the immediate one-step mandibular reconstruction using a vascularized composite FFF. The sterolithographic( rapid prototype, RP) model, a wax pattern of the resected mandible, and a surgical fibular stent made from the wax pattern were constructed preoperatively. We suggest a standardized surgical protocol for mandibular reconstruction with FFF.

FUNDING

Supported by the International Research & Development Program of the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning (NRF-2015K1A3A9A01028230).

[Keratocystic odontogenic tumor: a case report]

First described by Philipsen in 1956, the odontogenic keratocyst is characterized by a large squamous keratinization of its border, an aggressive growth and a high recurrent rate. It is now designated by the World Health Organization as a Keratocystic Odontogenic Tumor (KOT). Clinically, the KOT is manifested by an asymptomatic growth. Radiographically, it appears as a well-defined unilocular or multilocular osteolytic lesion. The diagnostic approach is based on a combined analysis of the medical history, the clinical appearance and the radiographic appearance. The diagnosis may be confirmed by the anatomical pathology report. Finally, treatment consists of surgical excision and follow up is characterized by a high rate of recurrence. The authors report a case of keratocystic odontogenic tumor of the mandible and review the various diagnoses, therapeutics and follow up aspects of this type of tumors.

Central mucoepidermoid carcinoma of the mandible – A case report

INTRODUCTION

Mucoepidermoid carcinoma, compared to other tumors of salivary glands, occurs in 5–10% of cases. Histopathologically, it is divided into a well differentiated tumor that is of low-grade of malignancy, and a medium and poorly differentiated tumor of high grade of malignancy. Central mucoepidermoid carcinoma (CMEC) of the mandible was firstly described by Lepp in 1936, on a 66-year-old female patient. CMEC is characterized by atypical clinical image and radiological manifestation.

CASE OUTLINE

A 55-year-old female patient was examined at the Clinic of Dentistry in Niš, Serbia, with anamnestic data regarding the presence of painless swelling in the right side of the mandible. Considering the histopathological results and presence of enlarged lymph nodes, right hemimandibulectomy and tumour excision from pterygomandibular space followed by supraomohyoid neck dissection was done. In due course, postoperative radiotherapy was applied (60 Gy)

CONCLUSION

CMEC represents a rare tumor, characterized by local tissue destruction and ability to metastasize. Initial biopsy represented the key in preoperative planing. Radical excision with neck lymph node dissection followed by postoperative radiotherapy in our case represent a successful method of treating CMEC of the mandible.

Plasmocytoma, multiple myeloma and plasma cell neoplasms in orofacial region

A neoplastic proliferation of B cell lymphocyte is called plasma cell neoplasms, results from malignant plasma cells transformation in bone marrow. The authors present a clinical study and overview of this pathology in maxillofacial region for six years (Tab. 2, Ref. 14).

Ossifying Fibromyxoid Tumor May Express CD56 and CD99: A Case Report

Ossifying fibromyxoid tumor (OFMT) is an uncommon soft tissue neoplasm characterized by a combination of myxoid and/or fibrous stroma with areas of ossification. Although most authors postulate a neuroectodermal origin for this peculiar tumor, there is no agreement in the literature regarding its histogenesis. In this article, we present the immunohistochemical findings of a case of a 39-year-old white male with an OFMT of the soft tissue in the mandibular region. The tumor was positive to S-100 protein, glial fibrillary acidic protein, CD99, CD56 and negative to smooth muscle actin, cytokeratins AE1/AE3, epithelial membrane antigen, and CD68. To the best of our knowledge, this is the first case reported to be positive to CD56 and CD99. Immunoreactivity to these two antibodies, together with reactivity for S-100 protein and glial fibrillary acidic protein, suggests that OFMT is of a neuroectodermal origin. In our opinion, in the absence of reactivity to at least one neuroectodermal marker one should seriously question a diagnosis of OFMT.

Resection of an ameloblastoma in a pediatric patient and immediate reconstruction using a combination of tissue engineering and costochondral rib graft: A case report

BACKGROUND AND OVERVIEW

Ameloblastoma is an odontogenic tumor predominantly occurring in patients who are in their 20s and 30s. Approximately 10% to 15% of ameloblastomas occur in patients younger than 18 years. Although it is a benign tumor, an ameloblastoma can have a devastating effect on children both physically and emotionally. The aim of this case report is to demonstrate how tissue engineering and surgical techniques can minimize morbidity and recovery time after extirpation and immediate reconstruction of a mandibular ameloblastoma.

CASE DESCRIPTION

An 11-year-old girl was referred for surgical evaluation of a lesion found on a routine dental radiograph. Resection of a mandibular unicystic ameloblastoma resulted, including immediate reconstruction using a costochondral rib graft, allogeneic bone, bone marrow aspirate concentrate, and recombinant human morphogenetic protein-2. One year postoperatively, the patient had no evidence of recurrence as well as excellent mandibular bone height and width with good facial form. The patient has returned to her daily life without any disabilities or disfigurement.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Dentists are typically the first health care providers to discover oral pathology in patients. The coordination of care by the dental care providers and the oral and maxillofacial specialist was key to the successful outcome for this patient. With biotechnology and surgical techniques, the dental surgeon can extirpate an ameloblastoma and reconstruct the mandible defect to the ideal shape and size with minimal morbidity and recovery time.