Unsuspected Ameloblastoma: Report of Case

Unsuspected Ameloblastoma: Report of Case

Unsuspected am eloblastom a: report of case John J. Tarsitano, DDS, MS, W iesbaden, Germany d e fin a b le Philip J. Holmes, DDS, Dayton, O hio t ...

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Unsuspected am eloblastom a: report of case

John J. Tarsitano, DDS, MS, W iesbaden, Germany

d e fin a b le

Philip J. Holmes, DDS, Dayton, O hio

t w e e n th e a p e x e s o f th e r ig h t la te r a l in c is o r , c a ­

s m a ll n in e ,

s o ft

s h re d s and

tis s u e

n o s is

w as

a

h o s p ita l

o ra l

s u rg e ry

s e rv ic e

fo r

e v a lu a t io n

cyst

w e re

Som e

fro m

be­

s u b m itte d

P r o v is io n a l d ia g ­

or

tr a u m a tic

(h e m ­

w a s p la c e d s e c o n d b e c a u s e th e p a t ie n t ’ s a g e a n d th e

lo c a tio n

w ith

th is

o f th e

e n tity .

le s io n

The

w e re

n o t c o n s is te n t

p a th o lo g is t r e p o r t e d

t h e tis s u e w a s c o n s is te n t w it h

th a t

a p e r ia p ic a l, r a ­

d ic u la r , o r r e s id u a l c y s t ( F ig 3 ). I n J u ly

M a y o f 1 9 7 0 , a 5 0 -y e a r -o ld m a n w a s s e e n a t

and

e x a m in a tio n .

p e r ia p ic a l

seen.

s c ra p e d

o r r h a g ic ) c y s t . T h e d ia g n o s is o f t r a u m a t ic c y s t

1 9 7 0 , th e p a tie n t r e tu r n e d f o r f o llo w -

u p e x a m in a tio n In

w as

w e re

fir s t p r e m o la r ,

f o r m ic r o s c o p ic

A p a th o lo g is t reported an excised cystic lesion to be n o n m a lig n a n t. D uring the next tw o years, the p a tie n t received extensive fo llo w -u p care, b u t co m ­ plained o f pain and sw e llin g in th e m andible. He was referred fo r treatm ent. At th a t tim e, pa n o ra m ic ra d io g ra p h s show ed a m u ltilo c u la r ra d io lu c e n t area in th e a n te rio r m andible.

lin in g

o f tis s u e

a t w h ic h

tim e th e r ig h t c e n tr a l

a n d la t e r a l in c is o r s a n d c a n in e w e r e te s te d a n d fo u n d

n o n v ita l.

S in c e th e p a t ie n t liv e d

s e v e ra l

o f a le s io n o f th e a n t e r io r m a n d ib le . P a n o r a m ic

h u n d r e d m ile s f r o m th e h o s p ita l s e r v ic e , h e w a s

r a d io g r a p h s r e v e a le d a m u lt ilo c u la r r a d io lu c e n t

a d v is e d

a r e a in t h e r ig h t a n t e r io r m a n d ib le ( F i g

v ic e c lo s e r t o h is h o m e .

1 ). T h e

to

seek

e n d o d o n tic

a n d fo llo w -u p

s e r­

p a t ie n t w a s w it h o u t s y m p to m s , a n d a ll m a n d ib u ­

T h e p a t ie n t r e t u r n e d t o h is h o m e a n d s o u g h t

la r a n t e r io r te e th b u t th e r ig h t c a n in e r e s p o n d e d

f o llo w - u p c a r e . H e w a s e x a m in e d in D e c e m b e r ,

to e le c t r ic p u lp te s tin g .

in

W ith

th e

p a tie n t u n d e r lo c a l a n e s th e s ia , th e

M a rc h ,

June,

S e p te m b e r,

N o v e m b e r,

and

D e c e m b e r o f 1 9 7 1 , a n d in F e b r u a r y a n d A p r i l o f 1 9 7 2 . D u r i n g th is p e r io d

th e m a x illa r y

c a v it y w a s f ille d w ith a y e llo w is h flu id , a n d n o

fir s t

p r e m o la r w e r e

Fig 1 ■ Panoramic radiograph taken in May 1970.

Fig 2 ■ Extent of lesion at time of first surgery (May 1970).

a re a

898

w as

exposed

and

e x p lo r e d

• JADA, Vol. 87, October 1973

(F ig

2 ).

The

m o la r a n d

le ft s e c o n d

r ig h t re -

Fig 3 ■ Photomicrograph of biopsy specimen (May 1970). Diag­ nosis based on compressed stratified squamous epithelium. Hematoxylin and eosin. Magnification x40.

Fig 5 ■ Panoramic radiograph taken in May 1972. Compare size of lesion with that in original radiograph (Fig 1).

e x p lo r e d .

The

c a v it y

w as

fille d

w ith

a

s tra w -

c o lo r e d f lu id a n d a la r g e p ie c e o f fib r o u s tis s u e w a s a tta c h e d s u p e r io r ly in th e a r e a o f th e m a n ­ d ib u la r r ig h t c a n in e a n d i n f e r i o r l y in t h e a r e a o f th e

m a n d ib u la r le f t la t e r a l in c is o r .

T h is

tis s u e

w a s n o t p a r tic u la r ly a d h e r e n t a n d w a s s u s p e n d ­ e d in Fig 4 ■ Postoperative periapical radiographs taken June 1971 (left), December 1971 (center), and February 1972 (right).

a

s lin g lik e m a n n e r . T h e

s to r e d , a n d h e w a s g iv e n o r a l p r o p h y la x e s a n d d e n tis tr y

c o u n s e lin g .

d io g r a p h s w e r e ta k e n

P e r ia p ic a l r a ­

o f th e a n t e r io r m a n d ib le

in J u n e a n d D e c e m b e r o f 1 9 7 1 , a n d in F e b r u a r y M a y , th e p a tie n t w a s

ic a l c e n te r .

The

r e fe r r in g

re fe rre d

to

a m ed­

d e n tis t w r o t e ,

“ Pa­

t ie n t g iv e s h is t o r y o f c y s tic a r e a s in l o w e r r ig h t a n t e r io r m a n d ib le . C y s t w a s r e m o v e d M a y 1 9 7 0 . R o u tin e show

X -ra y

little

th e

m a n d ib u la r

le ft

and

r ig h t

fir s t a n d s e c o n d p r e m o la r s , c a n in e s , a n d la te r a l and

c e n tr a l in c is o r s

w e re

re m o v e d

a lo n g

w ith

a ll th e a lv e o la r p r o c e s s in v o lv e d w it h th e le s io n . T h e b o n y w o u n d m a r g in s w e r e e x te n d e d

1 cm

b e y o n d th e b o r d e r s o f t h e tu m o r . T h e le s io n h a d

1 9 7 2 ( F ig 4 ). In

sub­

w a s d ia g n o s e d a s a n a m e lo b la s t o m a . A c c o r d in g ly ,

p r e v e n tiv e

tis s u e w a s

m itte d t o th e p a th o lo g is t f o r f r o z e n s e c tio n a n d

exam s

change.

o v e r th e p a s t tw o

P a tie n t

now

y e a rs

c o m p la in s

of

p e rfo ra te d

th e

lin g u a l c o r t e x , a n d

th e

s o ft tis ­

s u e in th is a r e a w a s a ls o g e n e r o u s ly e x c is e d . A l l tis s u e s

w e re

in a tio n

(F ig

r a d io g ra p h

s u b m itte d 6 ).

The

fo r

m ic r o s c o p ic

p o s to p e r a tiv e

( F ig 7 ) r e v e a le d

th e

exam ­

p a n o r a m ic

e x te n t o f h a rd

t is s u e lo s s .

d u ll p a in a n d s w e llin g in t h e a r e a . P le a s e e v a l­ u a te

and

re c o m m e n d

tre a tm e n t o r tre a t as re ­

D iscu ssio n

q u ir e d .” P a n o r a m ic a

la rg e ,

te n d e d

a t th is t im e

r e v e a le d

m u ltilo c u la r r a d io lu c e n t a re a

th a t e x ­

fro m

r a d io g r a p h s th e

m a n d ib u la r le f t c a n in e

r ig h t s e c o n d p r e m o la r ( F ig

5 ). T h e

to

th e

m a n d ib u la r

T h e o r ig in a l p a th o lo g is t r e p o r t e d th e c y s t to b e n o n m a lig n a n t— a n d

w ith

good

re a s o n — o n

th e

b a s is o f t h e p h o t o m i c r o g r a p h s h o w n i n F i g u r e 3 .

r ig h t c e n t r a l a n d la t e r a l in c is o r s a n d c a n in e d id

T h is

n o t re s p o n d

p a tie n t’ s a n te r io r m a n d ib le ; a r a t h e r r a p id ly e x ­

re s p o n d e d

to e le c t r ic n o r m a lly .

p u lp

T h e re

te s tin g ; a ll o th e r s w as

no

a p p a re n t

In

J u n e , w it h th e p a tie n t u n d e r s e d a tio n a n d a n e s th e s ia ,

th e

le s io n

w as

v e ile d

th e tr u e c o n d itio n

in

th e

p a n d in g le s io n , a lm o s t a c la s s ic a l a g g r e s s iv e e n ­ t i t y , w a s r e p e a t e d ly in t e r p r e t e d a s n o r m a l h e a l­

s w e llin g o r te n d e r n e s s in th e a re a . lo c a l

d ia g n o s is

exposed

and

in g . P e r h a p s in o u r c o n c e r n w it h

th e m e c h a n is m

Tarsitano—Holmes: UNSUSPECTED AMELOBLASTOMA ■ 899

Fig 7 ■ Postoperative panoramic radiograph showing extent of hard tissue loss.

e i t h e r w a x e s o r w a n e s , a n d i f n o t t h e l a t t e r , is s u s p e c t.

A nd

th e

c h r o n o lo g y

is

not

y e a rs

or

m o n th s , b u t w e e k s a n d d a y s !

■ On

a m e lo b la s to m a s : T h e

a m e lo b la s to m a

is

th e m o s t a g g r e s s iv e o f th e o d o n to g e n ic tu m o r s a n d r e p r e s e n ts a b o u t 1 % o f a ll tu m o r s a n d c y s ts o f th e ja w s . P a tie n ts a r e u s u a lly b e tw e e n 2 0 a n d 5 0 y e a r s o f a g e ; t h e r e is n o s i g n i f i c a n t s e x o r r a c e p r e d ile c t io n . A b o u t 8 0 %

o f th e s e tu m o rs o c c u r

in t h e m a n d ib le , p r e d o m in a n t ly in t h e m o la r a n d r a m u s a r e a s , a n d a lth o u g h th e r a d io g r a p h ic a p ­ p e a ra n c e

o f th e

a m e lo b la s to m a

is

v a r ie d

i t is

m o s t c o m m o n ly s e e n a s a m u ltilo c u la te d r a d io ­ lu c e n t a re a

o f bone. A b o u t 25%

to

30%

a r is e

in p r e e x is tin g f o llic u la r c y s ts . T h e tu m o r s g r o w s lo w ly a n d d o n o t m e ta s ta s iz e .1 I n

s p ite o f th e

d e b a te

i t is

c o n c e r n in g

th is

n e o p la s m ,

a g re e d

t h a t a m e lo b la s to m a s a r e u s u a lly u n ic e n t r ic , n o n ­ Fig 6 ■ Photomicrographs of biopsy specimen. Hematoxylin and eosin. Top, many islands of epithelial cells are visible. Magnifi­ cation, x40. Center, epithelial islands are bordered by segment­ ed columnar cells that resemble ameloblasts. Magnification, x100. Bottom, note tall epithelial cells with nuclei tending to be basally placed. Structure begins to resemble enamel organ. Magnification, x250.

a n d e v o lu tio n fo rg o tte n

th a t

o f p a th o lo g ic a l le s io n s , w e h a v e th e

p h y s io lo g ic a l

r e s o lu tio n

of

w o u n d d e f e c t s is a n o r d e r l y a n d p r o g r e s s i v e s e ­ quence. tio n

C e r ta in ly

s o c k e t h e a lin g

lie v e

o u r e x p e r ie n c e w o u ld

t h a t le s s t i m e t h a n

have

tw o

w ith le d

us

e x tra c ­ to

900

w o u n d o r le s io n , m e a s u r e d c h r o n o lo g ic a lly , ■ JADA, Vol. 87, October 1973

b e n ig n , a n d c lin ic a lly p e r s is te n t .2

The views expressed herein are those of the authors and do not necessarily reflect the views of the US Air Force or the De­ partment of Defense. Dr. Tarsitano is a colonel in the US Air Force Dental Corps. His address is USAF Hospital Wiesbaden, Box 305, APO New York, 09220. Dr. Holmes Is a lieutenant colonel in the US Air Force Dental Corps, at the Medical Center, Wright-Patterson AFB, Ohio 45433.

be­

y e a r s is r e q u i r e d

t o f i l l in a n i n t r a b o n y d e f e c t . A

fu n c t io n a l, in t e r m it t e n t in g r o w t h , a n a t o m ic a lly

1. Bhaskar, S.N. Synopsis of oral pathology. St. Louis, C. V. Mosby Co., 1961. 2. Robinson, H.B.G. Ameloblastoma: survey of 379 cases from literature. Arch Pathol 23:831 June 1937.