1
Introduction
The distinctive biological behavior of ameloblastoma, a benign but locally aggressive tumor, has led to varied therapeutic approaches. While surgery is the only currently accepted treatment, management differs among surgical. In general, there are two therapeutic approaches: radical and conservative [ , ].
Radical treatment involves segmental or marginal resection of the lesion, encompassing a measurable perimeter of bone (at least 1 cm), potentially extending to disarticulation if the temporomandibular joint is involved. Conservative treatment includes enucleation and curettage, often combined with Carnoy’s solution application, cryotherapy, and/or peripheral bone milling [ ].
Marsupialization, initially described by Partsch in 1892 for treating large cystic lesions, has been employed and reported as a conservative surgical technique in ameloblastomas [ , ]. Considering the biological behavior and locally infiltrative growth of this tumor, marsupialization and decompression in these lesions should generally be contraindicated. Nonetheless, due to a lack of consensus on applicable conservative treatments for ameloblastoma, the implementation of inconvenient surgical techniques has been allowed, exacerbating joint evaluation with results from radical treatment [ , ].
A recent comprehensive literature review addressing the “radical treatment versus conservative treatment” controversy justifies a preference for radical treatment based on a significantly lower recurrence rate (8 % after radical treatment versus 41 % after conservative treatment [ ]. However, owing to marked heterogeneity in procedures performed and differences in reported conservative treatment surgical techniques, objective comparison of result quality and recurrence rates is impossible.
The number of reports of successful conservative treatment outcomes has increased in recent years [ , , , ]. Different authors suggest conservative treatment may be appropriate as a first measure, particularly in cases affecting the mandible where the risk of spreading to vital structures is lower [ , , ].
With the aim to provide objective data that contribute to the analysis of this controversy, we developed a method to evaluate the efficacy of conservative surgery. We employed a standardized surgical procedure on resected hemi mandibles which we tested in a pilot study [ ].
2
Materials and methods
Ten (10) resected hemimandibles were used in this pilot study ( Fig. 1 ). All hemimandibles had previously been resected with a safety margin of at least 1 cm due to conventional ameloblastoma.
The SCST performed on each hemimandible is equivalent to conservative treatment that could be performed on a patient.
3
Surgical protocol
- 1.
Osteotomy of the buccal cortical plate to expose the entire tumor, following the Sach technique 5 ( Fig. 2 ).
Fig. 2 Photograph showing osteotomy of the buccal cortical plate (Sach technique). Tumor enucleation and extraction of affected teeth. - 2.
Tumor enucleation through cortical fenestration ( Fig. 2 ).
- 3.
Extraction of affected teeth ( Fig. 2 ).
- 4.
Creation of multiple 2 mm deep perforations across the surgical bed surface using a 2 mm diameter round steel bur ( Fig. 3 ).
Fig. 3 Multiple 2 mm deep perforations using a 2 mm diameter round steel bur in the bone remnant. - 5.
Milling of the entire remaining bone cavity to remove all perforations made in the previous step using an 8 mm diameter round steel bur. This step ensures removal of a uniform 2 mm layer of bone across the bone surface ( Fig. 4 ).
Fig. 4 Remove all perforations and expansion of the osteotomy at mesial and distal surgical margins. - 6.
Expansion of the osteotomy at mesial and distal surgical margins, removing 8 mm of cancellous bone (bur diameter used). Integrity of cortical plates is preserved ( Fig. 4 ).
This pilot test was performed by a single operator.
4
Histopathological evaluation
In order to determine SCST efficacy in treated hemimandibles, the following histopathological studies were performed to identify the absence or presence of tumor cells in the bone remnant.
5
Histopathological protocol
- 1.
The 10 treated hemimandibles were sectioned every 5 mm using a 1 mm thick manual saw ( Fig. 5 ).
