CC
An 86-year-old male presents with concern of pain and swelling in the lower left jaw adjacent to a previous premolar extraction site that was performed years ago. (Typically, ameloblastomas are often asymptomatic until bone perforation occurs, causing swelling of adjacent mucosa.) He is referred by his general dentist for a suspicious bone lesion.
Ameloblastoma
Ameloblastomas are usually diagnosed in the third to fourth decade of life (this patient’s age of presentation falls outside of what is typically encountered), with no gender or racial predilection; however, unicystic variants tend to occur earlier in life.
HPI
For the past 2 months, the patient has noticed a progressively enlarging “hard mass” in his mandible and a “raw” area on the gums next to the previous extraction site, and he is concerned about a retained root tip. According to his new dentist, the extraction was performed because of radiography findings similar to those seen in Fig. 3.1 (which shows an apical radiolucency on an isolated periapical film that can be mistaken for apical periodontitis associated with necrotic pulp, hence the importance of using orthopantogram imaging). There have been no neurosensory changes associated with the swelling. (Sensory changes are particularly common in malignancies and are not usually seen in benign lesions such as ameloblastomas.) On consultation and after reviewing an orthopantogram film ( Fig. 3.2 ), the patient’s general dentist noticed a significant expansile bony lesion adjacent to the lower left first molar extending toward the left central incisor and swelling of the gingiva near the lower left first premolar. (Ameloblastomas occur most frequently in the mandible [80% of the time], often in the posterior mandible.)
PMHX/PDHX/medications/allergies/SH/FH
He has hypertension and high cholesterol for which he takes lisinopril and atorvastatin.
Examination
General. The patient is well developed and well nourished and appears distressed about his possible diagnosis.
Vital signs. Vital signs are stable, and the patient is afebrile.
Maxillofacial. There is mild left facial enlargement that is most pronounced at the parasymphyseal region of the mandible, with no evidence of trismus. No cervical lymphadenopathy is present. (Ameloblastomas are benign tumors and in general do not cause lymphadenopathy, which may be seen with malignant tumors.) Neurosensory testing reveals normal mandibular nerve (V3) function bilaterally and no other focal neurologic deficits. (Ameloblastomas generally do not invade the neurovascular bundle, but paresthesia can be present if pathologic fracture exists because of excessive tumor growth.)
Intraoral. There is buccal and lingual expansion of the posterior left mandible with mild tenderness along the gingiva in the edentulous lower left first premolar location but no evidence of fluctuance or purulent secretions. No palpable thrill is present (which may suggest underlying vascular anomaly, if present). The lower left second premolar has 1+ mobility with vertical bone loss and recession on the mesial aspect, and the lower left first molar is heavily restored. There is no sign of fracture with bimanual manipulation. (It is important to test for pathologic fracture.)
Imaging
The panoramic radiograph (see Fig. 3.2 ) is the initial imaging study of choice for evaluation of a mandibular mass. Computed tomography (CT) scans are particularly useful for outlining the three-dimensional anatomy to demonstrate the amount of expansion and areas of bony perforation implying subsequent soft tissue involvement. Computerized planning and surgery simulation as well as stereolithographic models can be fabricated from the CT scan and can assist in surgical planning, resection, and reconstruction.
In this patient, the panoramic radiograph demonstrates a multilocular, cystic-appearing lesion extending from the distal aspect of the left first mandibular molar to the lower left central incisor extending inferiorly to the middle aspect of the mandible. The bone at the inferior border of the mandible has a normal appearance, without loss of continuity (see Fig. 3.2 ).
The CT scan in the axial view ( Fig. 3.3 ) and coronal view ( Fig. 3.4 ) shows an expansile lesion of the left body of the mandible extending to the parasymphysis region, with cortical perforation seen on axial and coronal sections. There is no evidence of lymphadenopathy, and no areas of abnormal enhancement are seen. (Contrast-enhanced imaging provides improved delineation of soft tissue and can aid in determining any associated vascular malformations.)
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