Primary treatment of mandibular ameloblastoma with segmental resection and free fibula reconstruction: Achieving satisfactory outcomes with low implant-prosthetic rehabilitation uptake

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Summary

Ameloblastoma is a locally aggressive and disfiguring oral cavity tumour and surgical management is the mainstay of treatment. The ideal management of ameloblastoma should minimise recurrence, restore function and appearance and present minimal donor site morbidity. Conservative management is associated with minimal downtime but high recurrence rates. By contrast, segmental mandibulectomy with appropriate margins have much lower recurrence rates but presents the challenge of reconstruction. Osseointegrated (OI) implants and permanent dental prosthesis, while ideal, are not always available. We conducted a retrospective review on 30 consecutive patients at our centre with unicystic and multicystic ameloblastoma who were treated with segmental mandibular resection and free fibula flap reconstruction. Only three patients underwent OI implant insertion, with 40% of the patients not receiving any form of dental rehabilitation. We performed a functional and aesthetic outcome survey to determine patient satisfaction with this form of treatment. At an average follow-up of 5 years, there were no recurrences of tumour in our population. Of the 26 patients who responded to the survey, 96% of the patients reported that they were satisfied with their appearance, 88% reported an absolutely normal diet and 93% of the patients reported no problems with donor site function. Overall, we found that low uptake of dental rehabilitation did not adversely affect patient satisfaction and outcomes.

Introduction

Ameloblastoma is an odontogenic tumour which accounts for 1% of all oral cavity tumours, with 90% of these located in the mandibular region.1 It is a locally invasive polymorphic neoplasm that is clinically classified into multicystic (solid), unicystic, peripheral and malignant subtypes.2 Though the majority of ameloblastomas do not metastasise, they are commonly locally aggressive and disfiguring, leading to problems such as pain, asymmetry and difficulty with speech and agglutination.

Surgical management is the mainstay of treatment of ameloblastomas. It has been proposed that treatment options should be based on clinical presentation, with authors suggesting conservative measures for peripheral and unicystic ameloblastoma and a more radical management for the multicystic subtype.3 Though conservative methods such as enucleation and curettage are associated with minimal downtime, even with the less aggressive unicystic subtypes these approaches are associated with high recurrence rates with the need for repeat procedures.3, 4, 5 By contrast, radical segmental mandibulectomy, while associated with much lower recurrence rates, presents the challenge of reconstruction.6, 7, 8

The ideal management of ameloblastomas should 1) minimise recurrence, 2) restore function, 3) restore appearance, especially in what is essentially a benign condition, and 4) present minimal donor site morbidity. In centres where surgical expertise and cooperation between the head and neck and reconstructive surgeons are available, segmental resection with vascularised bone flap reconstruction comes closest to satisfying these requirements.9 To complete the restoration, osseointegrated (OI) implants with dental prosthesis are recommended and is currently the gold standard.

However, we have found the uptake of implants and prosthesis to be low in our patient population. We thus conducted a retrospective review and patient surveys to determine outcomes and satisfaction in a population where segmental mandibulectomy and free fibula flap reconstruction without OI implants is the primary treatment modality for mandibular ameloblastoma. We describe our technique and present clinical examples to support our results.

Section snippets

Materials and methods

A retrospective review was conducted on all patients with mandibular ameloblastoma segmental resection and free fibula flap reconstruction at our institution over a 10-year period from 2002 to 2011. Patient and operative data were obtained from patient records and a follow-up functional and aesthetic outcome survey was conducted over the phone or in the clinic with the patient's consent. A maximum of three attempts to contact each patient were made. Parameters included in the outcome survey

Results

Over the study period, 30 consecutive patients at our institution were managed in this fashion (Table 1). Of these, 16 patients (53%) were female and 14 (47%) were male with an average age of 27.3 years (range 12–59). There were 29 primary presentations, 28 with jaw swelling and facial asymmetry and one patient with a jaw abscess. One patient presented with recurrence 4 years after curettage at another hospital. In terms of location, 20 patients (66.7%) had ameloblastoma at the retromolar

Patient A

A 30-year-old Chinese male presented with a multicystic ameloblastoma of the right mandibular angle. Segmental resection was carried out leaving a 12-cm right central + lateral mandibular defect. Reconstruction with a left free fibula flap was performed and the patient made an uneventful recovery. He later underwent OI implant insertion and oral rehabilitation. He was disease free and reported full functional recovery with symmetrical facial appearance 10 years post procedure (Figure 2).

Patient B

A

Discussion

The mandibular ameloblastoma is a slow-growing tumour arising from odontogenic epithelium which can lead to cortical bone expansion and perforation and invasion of the surrounding soft tissue. Most patients present when the tumour's size leads to pain, affects oral function or results in facial asymmetry. Surgical management is the treatment of choice and can be divided into conservative versus radical surgical excision. Conservative treatment options such as enucleation, curettage or

Conclusion

With a treatment algorithm of segmental mandibulectomy and reconstruction for all cases of unicystic and multicystic ameloblastoma, we achieved no recurrences at an average follow-up period of close to 5 years. While the placement of OI implants and permanent prosthesis is ideal, the functional and cosmetic results of the reconstruction in our population with low uptake of these are shown to be acceptable, with minimal patient downtime and donor site morbidity. To optimise outcomes in these

Conflicts of interest

The authors declare no conflicts of interest.

Acknowledgements

None.

References (37)

Cited by (34)

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Presented at: Plastic Surgery Congress 24–27 April 2013, Melbourne, VIC, Australia.

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