Surgical challenges in the treatment of advanced cases of ameloblastoma in the developing world: The authors’ experience

Abstract

Total mandibulectomy was carried out in 32 patients with extensive oro-facial lesions histologically diagnosed as ameloblastoma in four specialist centres in south-eastern Nigeria from January 2001 to December 2006. All the patients presented at an advanced stage with the whole mandible affected so the treatment of choice was total mandibulectomy. The patients gave informed consent for surgery. The standard surgical procedure was the same in all cases and was performed by the same surgeons. Of the 32 mandibles removed, there were 13 male (41%) and 19 female (59%) patients, giving a male-to-female ratio of 1:1.6. Three (9%) patients died due to problems relating to anaesthesia while five (16%) had postsurgical-related psychosomatic problems. Generally, the postoperative recovery was characterized by reduction in the quality of life of these patients because immediate jaw reconstruction was not feasible. This article highlights the challenges in the surgical management of advanced cases of ameloblastoma in the developing world and proposes a middle ground for professional interactions and exchange programmes among oral and maxillofacial surgeons across the world to assist poorer countries in the management of these advanced cases of oro-facial tumours.

Ameloblastoma is the most common odontogenic jaw tumour, accounting for 1% of all cysts and tumours of the jaw and 11% of all odontogenic tumours . It is an aggressive benign tumour of epithelial origin, which may arise from the enamel organ, the dental follicle, the periodontal ligaments and the lining of odontogenic cysts . It has a tendency for aggressive invasion of the mandible and a high rate of recurrence . Authors have expressed different opinions on the site, sex and age distributions. Akinosi & Williams reported that both sexes are affected equally, as did Reichart et al. . Adekeye and Arotiba et al. observed that males are affected more than females and that the anterior part of the mandible is the commonest site of occurrence. Mitchel & Mitchel found men more affected than women but the commonest site of occurrence was the posterior part of the mandible.

When ameloblastoma presents late, as is often the case in Nigeria and other West African countries, it can affect the whole mandible ( Figs 1–4 ). The treatment of choice at this stage is total mandibulectomy, which involves the resection of the musculature of the floor of the mouth to which the tongue is attached. Serious aesthetic and functional problems are encountered, necessitating the reconstruction of the lost tissues. There is a serious reduction in the quality of life of the patients following total mandibulectomy, regarding feeding, speech, appearance and saliva control as a result of lack of lip support. In cases of subtotal mandibulectomy it is easier for surgeons to reconstruct the lost hard tissue immediately after the surgical procedure for improved aesthetics and to improve the quality of life of the patient . Following total mandibulectomy, the means for reconstructing lost tissues is very limited, especially in a developing country, and the overall result is an increase in postoperative morbidity ( Figs 5 and 6 ). Many studies on ameloblastoma have been carried out by several surgeons across the world , but little has been directed to the surgical challenges involved in its management when the whole mandible is affected . This article presents a review of the authors’ experience of the total burden of ameloblastoma, regarding the treatment challenges and outcome, in 32 total mandibulectomies carried out on patients with long-standing cases in eastern Nigeria.

Fig. 1
Patient with extensive ameloblastoma of 8 years duration.

Fig. 2
Patient with extensive ameloblastoma of 16 years duration.

Fig. 3
Patient with extensive ameloblastoma of 11 years duration.

Fig. 4
Radiological appearance of the advanced tumour.

Fig. 5
Patient after mandibulectomy (female).

Fig. 6
Patient after mandibulectomy (male): the tracheostomy site is evident.

Patients and methods

Total mandibulectomy was carried out in 32 patients with extensive oro-facial lesions diagnosed histologically as ameloblastoma. The surgery took place at the oral and maxillofacial surgery units of four specialist centres in south-eastern Nigeria over a 6-year period from January 2001 to December 2006.

The patients were referred to the units by dental surgeons, medical practitioners and health centres in the catchment areas of the hospitals. The catchment areas are the south-eastern states, the Delta State and the Benue State of the Federal Republic of Nigeria. Most patients came from remote and rural areas, had little or no formal education and lived at a subsistence level. The age range was 20–59 years (mean 38 ± 6.4 SD years). Preoperative radiological evaluations and clinical and laboratory findings, including biopsies of the ameloblastoma, were carried out before the surgery. The tumour size, the sex and the patient’s age group at the time of presentation were categorized. All the patients were informed of the risks and benefits of the operation, after which they signed consent forms for the operation. The standard surgical procedure was the same in all cases and was performed by the same surgeons. Total mandibulectomy was carried out under general anaesthesia. In some patients, after a blind nasotracheal intubation in general anaesthesia has failed, tracheostomy was carried out. For patients with nasotracheal intubation, a technique of tongue fixation after total mandibulectomy was employed after the surgical procedure to prevent the tongue from falling backwards and blocking the patients airway . The authors fixed the tongue extra-orally by piercing the middle of the anterior third of the tongue with 1/0 silk and tying it to the middle of a horizontally placed wooden spatula that stretched across and beyond the commissures ( Fig. 7 ). Exposure of the distorted mandible was achieved by an incision made along the inferior border of the mandible from angle to angle. After careful exposure of the mandible extra-orally and intra-orally, disarticulation of the head of the condyles on both sides was carried out. The mandibles were completely removed with the affected musculature ( Fig. 8 ). The authors do not have the means for immediate reconstruction of the lost hard tissue, so the remaining soft tissue was sutured intra-orally and extra-orally making sure that a reasonable degree of sulcus depth was maintained. The authors are still following up some of these cases.

Fig. 7
Tongue fixation following total mandibulectomy.

Fig. 8
The mandible after the total mandibulectomy.

Results

32 total mandibulectomies for ameloblastoma were carried out within the 6-year study period. All the patients were Nigerians from the lower economic class of society. All 32 patients were at an advanced stage of ameloblastoma at presentation with the whole mandible affected ( Figs 1–3 ). There were 13 males (41%) and 19 females (59%), giving a male-to-female ratio of 1:1.6; the age range was 20–59 years (mean 42 years for males and 36 years for females) ( Table 1 ). The authors were successful with nasotracheal intubation in 5 (16%) patients, of whom 3 (9%) patients were lost due to problems relating to anesthesia. Tracheostomy was carried out in the remaining 27 patients to facilitate anaesthesia. The postoperative recovery of all the patients was characterized by complaints. Inability to masticate, occasional drooling of saliva, and gross facial distortion were the major complaints. None of the patients had mandibular reconstruction because the means for performing reconstruction do not exist in Nigeria, which meant that most patients were badly affected psychologically. Five patients (19%) had psychiatric problems, including personality disorder, depression, social phobia, and body dysmorphobic disorder. They were referred to the psychiatrist hospital for evaluation. They never reported again for a maxillofacial review. 16 (73%) patients of the remaining 22 were also lost to follow-up ( Table 2 ).

Feb 8, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Surgical challenges in the treatment of advanced cases of ameloblastoma in the developing world: The authors’ experience
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