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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 132-135

Implant-supported rehabilitation of unicystic ameloblastoma: A 2 years follow-upclinical report


1 Department of Prosthodontics and Crown and Bridge, Christian Dental College, CMC, Ludhiana, Punjab, India
2 Department of Oral and Maxillofacial Surgery, Christian Dental College, CMC, Ludhiana, Punjab, India

Date of Web Publication14-Mar-2017

Correspondence Address:
Nirmal Kurian
Roshni House, Parampuzha (PO), Kottayam - 686 002, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2348-3334.201985

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  Abstract 

Ameloblastoma is a rare, benign, epithelial odontogenic tumor that tends to grow slowly in the mandible or maxilla but is locally invasive and can be highly destructive of the surrounding dental anatomy. Osseous resection with clear margins is the recommended treatment modality taking into consideration of 50% rate of recurrence within 5 postoperative years. Loss of the continuity of the mandible destroys the balance and the symmetry of mandibular function, leading to altered mandibular movements and deviation of the residual fragment toward the surgical side. The use of osseointegrated dental implants for rehabilitation is advisable, as it allows the recovery of the masticatory function. This clinical report reveals 2 years follow-up of rehabilitation of a 19-year-old patient who underwent surgical enucleation for the treatment of unicystic ameloblastoma followed by dental implant placement.

Keywords: Ameloblastoma, computer-aided design-computer-aided manufacturing abutments, enucleation


How to cite this article:
Gandhi N, Gandhi S, Kurian N. Implant-supported rehabilitation of unicystic ameloblastoma: A 2 years follow-upclinical report. CHRISMED J Health Res 2017;4:132-5

How to cite this URL:
Gandhi N, Gandhi S, Kurian N. Implant-supported rehabilitation of unicystic ameloblastoma: A 2 years follow-upclinical report. CHRISMED J Health Res [serial online] 2017 [cited 2017 Mar 27];4:132-5. Available from: http://www.cjhr.org/text.asp?2017/4/2/132/201985


  Introduction Top


Ameloblastoma is a true neoplasm of the enamel organ type tissue which does not undergo differentiation up to the point of enamel formation. It represents 1% of all tumors and 18% of tumors of odontogenic origin.[1] It is a slow-growing, locally invasive, polymorphic tumor frequently seen affecting the mandible (80% of all cases), particularly in the angle and ramus region with peak incidence being in the third and fourth decades of life and no known gender predilection.[2] Enucleation followed by curettage is indicated for peripheral and unicystic ameloblastoma which makes postoperative rehabilitation challenging. Careful prosthetic planning with the placement of osseointegrated implants could achieve successful rehabilitation with the restoration of function and esthetics contributing to the patient's perception of an improved the quality of life.[3]

This case report represents patients with mandibular unicystic ameloblastoma, whose surgical treatment was enucleation followed by rehabilitation with dental implants.


  Case Report Top


A 19-year-old boy reported to the Oral and Maxillofacial Surgery Department with a swelling of the left mandibular body and ramus region. On extraoral examination, swelling was hard on palpation with no history of fever or pain. The panoramic radiograph revealed a unilocular radiolucent lesion of approximately 5 cm × 3 cm in the left parasymphysis, body and ramus region of the mandible associated with an impacted #37, 38 [Figure 1]. Incisional biopsy was done, and a histopathological examination of the cystic lining revealed unicystic ameloblastoma. Enucleation of the cystic lining along with #37, 38 was carried out under local anesthesia followed by chemical cauterization using Carnoy's solution which is composed of 100% ethanol, chloroform, and glacial acetic acid in a 6:3:1 ratio [Figure 2]. After approximately 2 years of regular clinical and radiographic follow-up with an open dressing of iodoform pack, satisfactory bone healing was achieved. Complete dental rehabilitation was planned using fixed implant-supported prosthesis.
Figure 1: Preoperative orthopantomogram showing radiolucent lesion extending from left parasymphysis to ramusof mandible

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Figure 2: Postenucleation showing removal of impacted teeth and bony defect

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Three regular dental implants (Biomet) were placed at #35 (5 mm × 11.5 mm), 36 (5 mm × 8.5 mm), and 37 (5 mm × 10 mm) regions [Figure 3]. After a sufficient healing period, second-stage surgery was performed, and provisional restorations were fabricated for the proper development of gingival cuff. Definitive impression was made with polyvinyl siloxane elastomeric impression material (AFFINIS, Coltene, Switzerland) by open tray technique using transfer coping. Computer-aided design-computer-aided manufacturing (CAD-CAM) milled implant abutments were made and the metal framework tried in patient's oral cavity [Figure 4]. The patient was later on rehabilitated with metal ceramic three unit bridge [Figure 5].
Figure 3: Dental implants placed after two year follow up

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Figure 4: Intra oral view of computer-aided design-computer-aided manufacturing milled prosthetic abutments

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Figure 5: Intra oral view of mandibular three unit metal ceramic bridge

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  Discussion Top


Ameloblastoma arises from embryonic remnants of odontogenic cysts, dental lamina, enamel organ, or stratified squamous epithelium of the oral cavity.[4] Although the pathogenesis of ameloblastoma remains unknown, many pathogenic mechanisms have been proposed, and associations with human papillomavirus, chronic trauma and inflammation, malnutrition, and vitamin deficiency have been described. Commonly ameloblastoma is asymptomatic and identified accidentally in orthopantomographs. It is a benign, locally aggressive, disfiguring tumor which leads to an asymmetrical face with swelling, pain and difficulty in speech and gluttition. The diagnosis of ameloblastoma is based on histologic and radiologic findings. Radiologic images often show a “soap-bubble” aspect of large loculations and a “honeycombed” appearance of small loculations. Despite clinical and radiologic suspicion, a biopsy with the patient under local anesthesia is always preferable, especially in case of extensive lesions, to achieve a pathologic diagnosis. Histopathological examination following incisional biopsy was done in this case which confirmed unicystic ameloblastoma.

Most affected patients are young, and dental rehabilitation should be considered in the choice of surgical resection and reconstruction approaches. The treatment of mandibular ameloblastomas includes conservative measures such as marsupialization, enucleation, and curettage and a radical treatment such as marginal and segmental mandibulectomy. Conservative approaches are reported to have a high rate of recurrence ranging from 55% to 90%; whereas, radical treatment resulted in lower recurrence rates but was burdened by serious cosmetic, functional, and reconstructive problems. Sammartino et al. proposed a new treatment algorithm to assist surgeons, which suggested small ameloblastomas to be treated by wide resection which includes at least 1 cm of normal bone at the tumor margin and large lesions without perforation of the cortex to be treated conservatively (curettage) while those with cortical perforation demands resection with overlying soft tissues.[5] The degrees to which dysfunction and disfigurement occur depend on both the location of the mandibular segment removed and the amount of surrounding soft tissue excised.[6] We adopted a conservative approach for the patient, keeping in mind the subsequent defect and its rehabilitation.

Complete oral rehabilitation helps to restore the patient's appearance and ability to chew and provide subjective improvements in self-confidence and social comfort. The efficiency of rehabilitating grafted ameloblastoma patients with dental implants has been reported by several studies with excellent outcomes. Increase in surgical time for an already long microvascular procedure and compromised flap vascularity due to the operative procedure or due to implant malposition are reasons cited to discourage immediate placement of fixtures. Implant placement at least 6 months after the bone reconstruction is recommended. Our patient underwent implant placement after regular follow-up and review for 2 years. The implant placement procedure is no different from that of traditional implant surgery.[5] The minimum dimensions of an implant are generally considered to be 3.5 mm in diameter and 10 mm in length. With this in mind, the minimum dimension of the reconstruction must be 5.5 mm in width and 10 mm in height. Three dental implants placed in this case were adhering to these recommendations which revealed excellent prognosis on later stage. The preformed prosthetic abutments had insufficient height to support the prosthesis and correction of abutment angulations were required to compensate for the implant orientation, and hence CAD-CAM milled custom-made abutments were fabricated. In reconstructed patients, following resection of ameloblastoma high-quality results can be achieved with the use of dental implants and implant-supported prostheses. Zemann et al. reported prosthetic rehabilitation with dental implants in seven patients with ameloblastoma.[6] Christian et al. reported successful implant placement and prosthetic rehabilitation within 1 year of a patient who was treated for ameloblastoma by segmental resection of the mandible with obturator placement.[7] Chiapasco et al. retrospectively evaluated the clinical outcomes following tumor resection in patients with vascularized (iliac crest) or nonvascularized (calvarial) bone grafts and dental implants. All the used grafts successfully healed, and resorption was reported in only one patient. Of the sixty implants placed, only two did not achieve osseointegration.[8],[9] Periodontal maintenance at individually established intervals is vital to the success of implant therapy and hence the patient was regularly followed up and underwent oral prophylaxis every 6 months.[10]

We report complete oral rehabilitation of a postenucleation ameloblastoma patient with dental implants. Prosthetic phase of restoration was initiated after 6 months of clinical and radiographic assessment of osseointegration. Custom made open rays were fabricated, and open tray technique for definite impression was adopted. Two years follow-up has revealed excellent stability of the implants and prosthetic restorations and the long-term prognosis for continued success is good.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Burket LW, Greenberg M, Glick M. Burket's Oral Medicine Diagnosis and Treatment. 10th ed. Hamilton, Ontario: B.C. Decker; 2002.  Back to cited text no. 1
    
2.
Rajendran A, Sundaram S, Rajendran R. Shafer's Textbook of Oral Pathology. India: Elsevier India; 2009.  Back to cited text no. 2
    
3.
Gulinelli JL, Ferreira EJ, Kuabara M, Cascini M, Mattos TB, Mattos JM, dos Santos PL. Rehabilitation using immediate loading in patients with partial resection of the jaw. Rev Clín Periodoncia Implantol Rehabil Oral 2015;21:63-9.  Back to cited text no. 3
    
4.
Cuesta Gil M, Bucci T, Ruiz BD, Vila CN, Marenzi G, Sammartino G. Implant mandibular rehabilitation postoncologic segmental resection: A clinical report. Implant Dent 2012;21:104-7.  Back to cited text no. 4
    
5.
Sammartino G, Zarrelli C, Urciuolo V, di Lauro AE, di Lauro F, Santarelli A, et al. Effectiveness of a new decisional algorithm in managing mandibular ameloblastomas: A 10-years experience. Br J Oral Maxillofac Surg 2007;45:306-10.  Back to cited text no. 5
    
6.
Zemann W, Feichtinger M, Kowatsch E, Kärcher H. Extensive ameloblastoma of the jaws: Surgical management and immediate reconstruction using microvascular flaps. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:190-6.  Back to cited text no. 6
    
7.
Christian J, Grover M, Veeravalli PT. Replacement of mandibular posterior teeth with implants in a postmandibular resection case: A case report. J Oral Implantol 2013;39:210-3.  Back to cited text no. 7
    
8.
Chiapasco M, Colletti G, Romeo E, Zaniboni M, Brusati R. Long-term results of mandibular reconstruction with autogenous bone grafts and oral implants after tumor resection. Clin Oral Implants Res 2008;19:1074-80.  Back to cited text no. 8
    
9.
Netto R, Cortezzi W, Nassif T, Calasans-Maia M, Louro RS. Rehabilitation with dental implants in microvascular iliac graft after solid ameloblastoma resection: A case report. Implant Dent 2013;22:561-5.  Back to cited text no. 9
    
10.
Humphrey S. Implant maintenance. Dent Clin North Am 2006;50:463-78, viii.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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