Wide excision and microvascular reconstruction for maxillomandibular ameloblastomas: local control, functional, and esthetic outcomes

Deepak Balasubramanian; Narayana Subramaniam; Sherry Peter; Latha Rao; Pramod Subhash; Arjun Krishnadas; V Manju; Janarthanan Ramu; Jimmy Mathew; Mohit Sharma; Krishnakumar Thankappan; Subramania Iyer

doi:10.4103/jhnps.jhnps_39_18

ORIGINAL ARTICLE

Year : 2018 | Volume : 6 | Issue : 2 | Page : 82-85

Wide excision and microvascular reconstruction for maxillomandibular ameloblastomas: local control, functional, and esthetic outcomes

Deepak Balasubramanian¹, Narayana Subramaniam², Sherry Peter³, Latha Rao³, Pramod Subhash⁴, Arjun Krishnadas⁴, V Manju⁵, Janarthanan Ramu⁶, Jimmy Mathew⁶, Mohit Sharma⁶, Krishnakumar Thankappan¹, Subramania Iyer⁷
¹ Department of Head and Neck Oncology, Amrita Institute of Medical Sciences, Kochi, Kerala, India
² Department of Head and Neck Oncology, Mazumdar Shaw Medical Centre, Narayana Health, Bengaluru, Karnataka, India
³ Department of Craniomaxillofacial Surgery, Aster Medicity Hospital, Kochi, Kerala, India
⁴ Department of Craniomaxillofacial Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
⁵ Department of Prosthodontics, Amrita Institute of Medical Sciences, Kochi, Kerala, India
⁶ Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India
⁷ Department of Head and Neck Oncology; Department of Plastic and Reconstructive Surgery, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Date of Web Publication

14-Jan-2019

Correspondence Address:
Dr. Deepak Balasubramanian
Department of Head and Neck Surgery and Oncology, Amrita Hospital, Ponnekkara P. O., Kochi - 682 041, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/jhnps.jhnps_39_18

Abstract

Introduction: Ameloblastomas are benign but aggressive odontogenic tumors with have a high propensity for bony destruction. They require to be excised completely to avoid local recurrence, and these resections involve significant functional and esthetic disturbances. With the advent of microvascular reconstruction, they can be excised, and defects are reconstructed with preservation of form and function. This paper presents our experience with wide excision and microvascular reconstruction for maxillomandibular ameloblastomas, and to describe the planning, resection, microvascular reconstruction, and rehabilitation of these patients. Materials and Methods: A retrospective review of records for patients treated with wide excision and microvascular reconstruction for maxillomandibular ameloblastomas at Amrita Institute of Medical Sciences Kochi between 2003 and 2015 was performed. Clinical and pathological features were described, and a literature review was performed. Results: A total of 48 patients were identified with equal sex distribution and mean age at presentation of 35 (range 16–71) years. Half of these patients had primary lesions, and the remaining half had the recurrent disease (range 1–4 previous surgeries). Forty patients (83%) had mandibular lesions and the remaining had the maxillary disease. All patients had wide excision with a gross bony margin of 1 cm and reconstruction with microvascular flaps (fibula free flap = 41, distal circumflex iliac artery flap = 3 and scapular free flap = 2, anterolateral thigh flap = 1 and radial forearm free flap = 1). Mean tumor size was 4.73 (2–14) cm. At a median follow-up of 21 months, all patients were free of recurrence. Successful dental rehabilitation was achieved in 40 patients (83%). Conclusion: This approach leads to results in excellent local control, functional, and esthetic outcomes. Although managing these patients is challenging, multidisciplinary expertise and planning are crucial for successful management.

Keywords: Ameloblastoma, dental rehabilitation, fibula free flap, microvascular reconstruction

How to cite this article:
Balasubramanian D, Subramaniam N, Peter S, Rao L, Subhash P, Krishnadas A, Manju V, Ramu J, Mathew J, Sharma M, Thankappan K, Iyer S. Wide excision and microvascular reconstruction for maxillomandibular ameloblastomas: local control, functional, and esthetic outcomes. J Head Neck Physicians Surg 2018;6:82-5

How to cite this URL:
Balasubramanian D, Subramaniam N, Peter S, Rao L, Subhash P, Krishnadas A, Manju V, Ramu J, Mathew J, Sharma M, Thankappan K, Iyer S. Wide excision and microvascular reconstruction for maxillomandibular ameloblastomas: local control, functional, and esthetic outcomes. J Head Neck Physicians Surg [serial online] 2018 [cited 2023 Mar 29];6:82-5. Available from: https://www.jhnps.org/text.asp?2018/6/2/82/250117

Introduction

Ameloblastoma is a benign tumor of odontogenic epithelial origin, which accounts for 11% of all tumors in the jaw.^[1],[2] The clinicopathological features are suggestive of a benign slow-growing lesion, but these lesions are locally invasive and follow a persistent course, even regarded by some as lying on a spectrum between benign and malignant. However, in view of the seemingly benign nature, several conservative techniques such as curettage and saucerization have been described, leading to a high recurrence rate, and leading to problems for patients and clinicians alike.^[3],[4]

Our institutional policy has been to perform wide excision of these lesions, aiming for a 1 cm margin, with appropriate reconstruction. In doing so, we can offer good local control rates without compromising functional and esthetic outcomes. The purpose of this study was to describe our experience treating either primary or recurrent ameloblastoma of the maxilla or mandible with wide excision and microvascular reconstruction, and report our local control, functional, and esthetic outcomes.

Materials and Methods

A retrospective review of records for patients treated with wide excision and microvascular reconstruction for maxillomandibular ameloblastomas at Amrita Institute of Medical Sciences Kochi between 2003 and 2015 was performed. Clinical and pathological features were described, and a literature review was performed. All patients had preoperative computerized tomography (CT) scans or orthopantomograms (OPG) and histologically proven ameloblastoma of the maxilla or mandible. All patients underwent wide excision of the lesion with a gross 1-cm bony margin and microvascular reconstruction with bony or soft-tissue microvascular flaps. Local control was determined by calculating time elapsed between the date of surgery and date of the first detection of recurrent local disease. Functional outcomes were reported in terms of speech intelligibility, adequacy of oral intake, trismus, and dental rehabilitation. Esthetic outcome for available patients was scored on the visual analog scale (VAS) for esthetic satisfaction.^[5]

Results

Patient characteristics are shown in [Table 1]. A total of 48 patients were identified, with an equal gender distribution. The mean age of the patients was 35 (range 16–71). Half of these patients had recurrent disease. Forty of these patients (83%) had lesions involving the mandible, and the remaining 8 (17%) had the maxilla as the involved subsite. All of our patients underwent wide local excision with gross 1-cm bony margins and reconstructed with microvascular flaps. Median follow-up was 21 (6–84) months.

Table 1: Patients and treatment characteristics

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In all patients with maxillary tumors (n = 8) and mandibular patients having expanded outer cortices that precluded preplating of the mandible intraoperatively before performing the bony cuts (n = 30), we used preoperative planning and modeling with rapid prototyping technology and stereolithographic models. These models were printed based on the craniofacial CT, and a mock surgery was performed on the model to ensure accuracy; the exact extent of resection, and the planned osteotomies on the bone flap. Reconstruction plates were prebent to ensure accuracy and to save operative time. The hardware used for bony reconstruction of the mandible was 1.7-mm profile thickness mandibular reconstruction plates and 1.5-mm size profile screws with a length of 8 mm or 10 mm. For maxillary reconstruction, 1.5-mm profile mini-plates were sufficient as the maxilla is not a load-bearing bone.

The flaps used were fibula free flap in 41 (86%), distal circumflex iliac artery flap in 3 (6%), scapula flap in 2 (4%), radial forearm free flap in 1 (2%), and anterolateral thigh flap in 1 (2%). All flaps survived. Three patients (6%) had minor wound complications who were managed conservatively. No patients had significantly donor site morbidity.

Histological characteristics are shown in [Table 2]. The mean tumor length was 4.73 (range 2–14) cm. Three patients (6%) had positive bony cut margins on histology, and all of them underwent re-excision with final negative margins. The histological variants of ameloblastoma were follicular in 20 (42%), acanthomatous in 10 (21%), desmoplastic in 5 (10%), a basal cell in 2 (4%), and unspecified in the remaining 11 (23%).

Table 2: Histological characteristics

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Functional outcomes are shown in [Table 3]. All patients had good speech intelligibility, as assessed in person or over the telephone. All patients had adequate intake, with a solid or semi-solid diet. Two patients had mild trismus (4%), measured as an inter-incisor distance of <3 cm. Dental rehabilitation was successfully performed 40 patients (83%), with 12 receiving osseointegrated implants and the remaining receiving removable partial dentures. Esthetic outcomes were measured in 30 patients (63%) using the VAS for esthetic satisfaction. 28 of these patients (93%) had a satisfactory score (>8/10). Four patients (8%) had scar revisions subsequently, following which their esthetic satisfaction improved.

Table 3: Functional outcomes

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Discussion

The general agreement that ameloblastoma is odontogenic in origin occurs largely on the basis of the histologic similarities of the tumor and the developing enamel organ.^{[2],[6],[7],[8],[9]} Theoretically, it may arise from the cell rests of the enamel organ, from a developing enamel organ, from the epithelial lining of an odontogenic cyst, or from the basal cells of the oral mucosa.^[9]

In many cases, the diagnosis of ameloblastoma is not established until the lesion is advanced, with a cystic enlargement of the mandible or maxilla, by which time the resection required is significant. Ameloblastoma is a common condition that needs to be diagnosed early with a high degree of suspicion to avoid extensive surgery. Although pathological correlation is necessary, a thorough knowledge of the radiological appearance can help establish the diagnosis early. Lesions are generally expansile and radiolucent, which can be unilocular or multilocular with a typical soap-bubble appearance^[10] on OPG and CT. In addition, cross sectioning imaging demonstrates cystic areas of low attenuation interspersed with isoattenuated areas, which represent the soft-tissue component of a tumor.^[11] Later on, lesions can erode the cortex and tooth roots.

Even if ameloblastoma is considered to be benign, it is locally invasive with a high rate of recurrence.^{[2],[12],[13]} Its biological behavior has caused great controversy in its management. Proposed treatment options for ameloblastomas vary from conservative measures, such as marsupialization, enucleation, and curettage, to radical treatments such as disarticulation, or marginal and segmental resection.^{[14],[15],[16],[17],[18],[19],[20]} Conservative approaches had a high rate of recurrence ranging from 55% to 90%, but radical treatments resulted in lower recurrence rates but were burdened by serious cosmetic, functional, and reconstructive problems.^{[21],[22],[23]} Previously, nonvascularized bone grafts were used to reconstruct these lesions. However, it is well known that the resorption rates are high due to the inability to withstand the physiological stress of the masticatory load.

Re-establishing mandibular integrity needs to be considered the current standard of care. The mandible plays an important role in maintaining facial contour, mastication, speech, and swallowing. Defects resulting from mandibular resections for tumors affect the quality of life in patients with regard to chewing and cosmesis.^[24] With the advent of microvascular reconstruction, the quality of life has greatly improved in patients undergoing segmental mandibulectomies.^[25]

With radical reconstruction and microvascular reconstruction of these defects, we were able to achieve an excellent local control rate, even in recurrent lesions that had recurred up to four times previously. In the small percentage of patients who had final bony margins positive, we performed a re-excision until the final bony margins were negative. Through rapid prototyping and stereolithographic modeling, we were able to achieve alignment of bone flaps, especially in cases where dental rehabilitation was subsequently performed. The ideal configuration of bony and soft-tissue components allowed us to best re-establish normal anatomy and physiology for excellent speech and swallowing outcomes, in spite of radical resection.

It is crucial to note that the success in managing these patients came from the technical proficiency of a large team, which included the head-and-neck surgeons, plastic surgeons, craniomaxillofacial surgeons, prosthodontists, and swallowing therapists. The multidisciplinary approach allowed the patients to benefit from combined expertise for optimal functional and aesthetic outcomes.

Conclusion

Wide excision and microvascular reconstruction for maxillomandibular ameloblastomas, results in excellent local control, functional, and esthetic outcomes. For complex defects, stereolithographic models and rapid prototyping help optimizing reconstruction, especially when dental rehabilitation is planned. Although managing these patients is challenging, multidisciplinary expertise and planning are crucial for successful management.

Financial support and sponsorship

This study has not been funded by any funding agency or sponsor. It was conducted without any financial interest.

Conflict of interest

All authors declare that they have no conflict of interest.

Disclosure

This material has never been published and is not currently under evaluation in any other peer reviewed publication.

Ethical approval

The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

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