Multicystic Ameloblastoma: Presentation of a Case with Resolution through the Fabrication of a 3D Titanium Prosthesis

   

Guillermo Sica¹, Emiliano Lopez Moris², Sebastian Miguelez³, Christian Oscar Mosca⁴ and Eduardo Rey^5*

 

Abstract

Some Ameloblastomas are benign but turn out to be recurrent tumors, the importance of which lies in their potential to grow to enormous size with consequent bone deformity. At the level of reconstructive options for mandibular continuity defects produced by these entities, the use of free microvascular flaps, free bone graft alloplastic implants, including titanium reconstruction plates and titanium trays, have been considered. In this article we will develop the situation of a 30-year-old patient who suffered from a multicysti came loblastoma that was resected with a safety margin and personalized 3D titanium prosthesis was made.

Keywords

Multicysti; Loblastoma; 3D prosthesis; Tumor of the jaws; Maxillary tumor resection

 

Introduction

In 1868 Broca described the first report of ameloblastoma in the scientific literature, then Falkson completed the first detailed histological description in 1879 and Malassez in 1885 introduced the term adamantinoma, which was later abandoned. Since then, numerous synonyms have been used to refer to these tumors, up to the current name of ameloblastoma [1]. Ameloblastomas are benign, recurrent tumors, the importance of which lies in their potential to grow to enormous size with consequent bone deformity. They are generally classified into unicystic, multicystic, peripheral and malignant subtypes [1,2]. Solid multicystic ameloblastoma is a benign epithelial tumor of odontogenic origin that shows a strong tendency to recurrence and local aggression [3,4].

It is a tumor derived from the residual epithelial components of tooth development, such as: remains of the dental lamina (Serres remains), reduced enamel epithelium, Malassez remains and the basal cells of the maxillary superficial epithelium [5]. In general, its appearance is manifested between the third to the seventh decade of life, except for the unicystic variety, which is diagnosed between the second and third decade, with no differences between the sexes (6). Its manifestation is more frequent in the mandible (85%) than in the upper jaw (15%). In the mandibular location, the premolar, molar and ascending ramus of the mandible are more frequently affected, while in the upper jaw they are concentrated in the molar area, where they tend to extend to the maxillary sinus and the floor of the nostrils [6].

Mandibular masses manifest with malocclusion, loss of teeth, periodontal disease, and facial deformations [7]. At the level of reconstructive options for mandibular continuity defects, they have included the use of microvascular free flaps, free bone grafting and alloplastic implants, including titanium reconstruction plates and titanium trays [8-11]. With the establishment of these reconstructive options, advances in three-dimensional (3D) imaging software, virtual surgical planning (VSP), and computer-aided design/computer-aided manufacturing (CAD/CAM) have further improved the planning and application of these options in the restoration of mandibular defects [12].

The advantages of this technology even include visualization of tumor margins, definition of surgical margins, manufacture of surgical templates or cutting guides, evaluation of continuity defects and identification of the ideal dimensions and shape of the bone for its reconstruction [13]. In this article we will develop the situation of a patient who presented with a multicystic ameloblastoma that was resected with a safety margin and a personalized 3D titanium prosthesis was made.

Materials and Methods

For this study, the rights of the patient were protected, under the consent signed by the same, respecting the ethical principles based on the Declaration of Helsinki.

Clinical Situation

A 30-year-old female patient, referred from her dentist for presenting an increase in volume in the region of the left hemi maxilla, presented to the consultation at the Trinidad de Quilmes Clinic. A medical history and anamnesis of the patient were taken in which she manifested painless and feverish swelling. In the intra and extra oral examination, an increase in volume was observed in the bottom of the sulcus and left hemi maxillary of solid consistency, blurred edges of approximately 5 cm diameter. A routine orthopantomography was performed (Figure 1) in which a radiolucent lesion with radiopaque areas can be observed, giving the image of multicystic or multilocular.

Figure 1: Pre-surgical panoramic radiograph. In it, a lesion with multicystic characteristics can be seen that ranges from distal 36 to the entire ascending branch.

A computed axial tomography was performed, observing a radiolucent image with other radiopaque images of approximately 6 cm in diameter in the body and left maxillary branch (Figure 2a). The 3D reconstruction of the computed axial tomography shows the characteristics of the multi locular lesion of approximately 6 cm in diameter that invades from 36 to the ascending branch (Figure 2b).

Figure 2a: Computed axial tomography was performed, observing a radiolucent image with other radiopaque images of approximately 6 cm in diameter in the body and left maxillary branch.

Figure 2b: Computed Axial Tomography and 3D reconstruction. The size of the lesion can be visualized, covering tooth 36 from distally and occupying almost the entire volume of the ascending branch.

Pre-surgical studies for biopsy are requested, with the result of Ameloblastoma. In our clinical situation, a custom 3D titanium prosthesis was designed from an alloy called the alloy is Ti-6Al-4V. The head of the component is golden since a coating with titanium nitride is applied, in order to improve the hardness of the piece in its articular part and reduce wear with the passage of cycles.

The patient's computed tomography was used to generate a 3D recreation model (Figure 3a). The design of the personalized prosthesis (Figure 3b) was made virtually with the 3D printed cutting guides, fossa templates to obtain condylar resection (Figure 3c) and a better fit of the prosthesis and template of prosthesis to position the holes of the titanium prosthesis. During surgery, the occlusion was ensured.

Figure 3a: The patient's computed tomography was used to generate a 3D recreation model.

Figure 3b: The design of the personalized prosthesis.

Figure 3c: Prosthesis design, glenoid and condylar cavity template.

Surgical Intervention

The patient was admitted to the operating room, and general anesthesia was performed with naso-tracheal intubation, she was positioned in hyperextension by placing a roll at the level of the shoulder blades and rotating the head to the right. Subsequently, antisepsis of the operative field, upper third and middle region of the face, suprahyoid region and neck was performed, with 10% iodopovidone and placement of surgical fields. Comb wires were placed and intermaxillary locking was carried out to preserve the dental occlusion of the right hemimaxilla and correctly place the titanium prosthesis on the side to be resected.

Taking precautions from the Jaffe Nerve, it was approached under a semi lunar incision of about 8 cm in length at 3 cm below the rim of the mandible with a cold scalpel type bad-parker n °3 blade n °15 and electrosurgical knife to generate hemostasis. Skin, subcutaneous cellular tissue is incised, up to the plane of the cutaneous muscle or platysma. In this step, hemostasis of said subcutaneous tissue is carried out, said muscle is sectioned and a skin flap is obtained, visualizing the Jaffe nerve.

Subsequently, it is introduced to the submaxillary gland compartment, detecting the sternocleidomastoid muscle from behind, the parotid gland below the intermediate tendon and anterior belly of the digastric muscle and vessels of the vein and facial artery region that are ligated with flax 100.

Once the triangular muscle of the lips and facial vessels are exposed, the periosteum of the mandibular body and section of the masseter muscle are sectioned, in this way the branch is exposed to the sigmoid notch, exposing the premolar teeth in front of the mental nerve and chin (Figure 4). A section mark of the mandibular bone was made at 1 cm and a half in front of the anterior edge of the tumor using the previously made 3D guide (Figure 5a, 5b), involving teeth 36 and 35. The entire disclosure was carried out. The lingual aspect of the maxilla to cure it from the floor of the mouth and the coronoid process.