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Table of Contents
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 76-80

Rehabilitation of recurrent unicystic ameloblastoma using distraction osteogenesis and dental implants


1 Nayarana Hrudayalaya Dental Clinic, Bangalore, India
2 HKE's. S.N. Institute of Dental Science and Research, Gulbarga, Karnataka, India
3 Practitioner, Chattishgarh, India

Date of Web Publication10-May-2013

Correspondence Address:
Ramesh Chowdhary
HKE's. S.N. Institute of Dental Science and Research Gulbarga, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-6781.111718

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   Abstract 

The ameloblastoma is a true neoplasm of odontogenic epithelial origin. Surgical resection of the ameloblastoma is well documented and accepted treatment modality. Vertical distraction of alveolar process is an efficient method for augmentation. This method of providing additional bone and soft tissue for implant placement is becoming more common. This clinical report describes the use of distraction osteogenesis and fixed implant supported prosthesis to treat a postsurgical alveolar defect as a result of resection of unicystic ameloblastoma in anterior mandibular region. As a result of alveolar distraction, a segment of mature bone was transported vertically in order to lengthen the crest for better implant anchorage. Further clinical and experimental studies of the technique with long-term followup to confirm bone and implant stability as it relates to alveolar height is needed.

Keywords: Dental implant, distraction osteogenesis, segmental resection, unicystic ameloblastoma


How to cite this article:
Natashekara M, Chowdhary R, Chandraker NK. Rehabilitation of recurrent unicystic ameloblastoma using distraction osteogenesis and dental implants. J Dent Implant 2013;3:76-80

How to cite this URL:
Natashekara M, Chowdhary R, Chandraker NK. Rehabilitation of recurrent unicystic ameloblastoma using distraction osteogenesis and dental implants. J Dent Implant [serial online] 2013 [cited 2022 Jan 25];3:76-80. Available from: https://www.jdionline.org/text.asp?2013/3/1/76/111718


   Introduction Top


Ameloblastoma is a benign, slow growing, and odontogenic neoplasm. It is the second most common odontogenic neoplasm and only odontoma outnumbers it in reported frequency of occurrence. [1],[2],[3] The average age at diagnosis consistently is reported in the range of 33-39 years and most cases cluster between age 20 and 60 years. [1],[2],[3],[4],[5] It mainly affects mandible, but varies with racial groups. [3],[6] Asian seems to have fewer tumor involving ramus than do white or blacks, whereas blacks have an increased frequency of tumor in anterior mandible compared with the other two groups. [1],[3]

The nature of deficiency as a result of segmental resection may present an obstacle to ideal implant positioning, by compromising esthetic and prosthetic needs. To overcome this, various methods have been applied. The technique of distraction osteogenesis is becoming a routine part of the surgeon's armamentarium. Distraction osteogenesis is defined as a biologic process of bone formation occurring between the surfaces of vital bone segments that are gradually separated by incremental traction. [7],[8] This clinical study describes the use of distraction osteogenesis followed with fixed implant supported prosthesis to treat postsurgical defects formed as a result of segmental resection of unicystic ameloblastoma in mandibular anterior region.


   Case Report Top


In 2002, a 56-year-old male visited our dental hospital with a swelling in the mandibular anterior region, which was diagnosed as a unicystic ameloblastoma. Curettage of the lesion was done as a line of treatment. After 4 years, the patient revisited the hospital with an intraoral swelling in the same anterior mandibular region [Figure 1]. Orthopantomograph showed a radiolucency of size approximately 1 × 2 cm in relation to apical region of mandibular incisors and left canine [Figure 2]. Biopsy was done, confirming the diagnosis, the recurrence of follicular unicystic ameloblastoma. Surgical excision of the lesion was made along with mandibular incisors and left mandibular canine which were periodontically compromised. A long with the tumor, 6 mm of surrounding unaffected bone was resected to avoid further recurrence of the lesion. Extraosseous, unidirectional, and alveolar distractor were placed on the buccal surface below the resected margins [Figure 3]. Followed by horizontal bone cut at approximately 14 mm below the resected margin and a vertical bone cut approximately 4 mm from the roots of adjacent teeth, with slight convergence toward each other in apical direction, to allow free movement of transport segment during distraction was made [Figure 4]. Flaps were replaced and sutured. After latency period of 1 week distractor was activated by screw pitch 1 mm per day, for 22 days. An orthopantograph was made at interval of 1 month [Figure 5] and [Figure 6]. After a consolidation period of 3 months, the flaps were exposed and distractor was removed. Distracted site tissue was healthy, but transported segment was marginally tilted toward lingual direction (due to change in vector) [Figure 7]. And was corrected by traction for favorable dental implant placement site, and site was stabilized with titanium plate [Figure 8]. Followed by placement of two single piece endosseous implant of dimension 4.2 × 10 mm each (TRX-OP, Hitec, Isreal), along with hydroxyapatite bone grafting at osteotomy margin [Figure 9]. Flap was replaced and sutured. Recall visit was made after 2 weeks, and a definitive impression was made using polyvinyl siloxane. A cement retained metal ceramic fixed partial denture of four units was made, which were cemented using glass ionomer cement (Type 1, GC, Malaysia). After 2 years of recall, no functional or esthetic difficulties with restoration were found, and adequate bone height was maintained as per the radiographic evaluations.
Figure 1: Intraoral swelling in relation to 31 and 32

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Figure 2: Orthopentography showing radiolucency in relation to 31 and 32

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Figure 3: Vertical and horizontal section of bone with distractor in position

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Figure 4: Radiograph showing alveolar distractor in position

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Figure 5: Radiograph showing the vertical moved bone due to distraction

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Figure 6: Placement of endosseous single piece implants and stabilization of moved segment with plate

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Figure 7: Five unit metal ceramic fixed prosthesis in position

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Figure 8: Radiograph showing the restored implants

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Figure 9: Radiograph after 2 years followup

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   Discussion Top


Three types of ameloblastomas are distinguished based on their gross appearance, the unicystic, multicystic, and solid type. The unicystic ameloblastoma has a fibrous connective tissue capsule, and therefore has much lower rate of recurrence. The solid or multicystic ameloblastomas have a tendency to locally invasive and have a high incidence of recurrence if not adequately removed. [9] Histopathologically, six subtypes of ameloblastomas are recognized: Follicular, acanthomatous, granular cell, basal cell, desmoplastic, and plexiform. [1],[2],[3],[6],[7]

Although often considered benign, ameloblastoma can be aggressive locally and proliferating lesion and malignant transformation have been reported. [10],[11],[12],[13],[14] Not surprisingly, treatment modalities have varied considerably. These have included simple enucleation and more radical resection with reconstruction. [15],[16],[17],[18] In terms of a comparison of recurrence rates of different surgical modalities, relatively high recurrence rates were observed in patient treated by marsupialization followed by enucleation with bone curettage (45.5%) and enucleation with bone curettage (18.2%). [8] Recurrence rates after radical surgery and conservative treatment were 7.1 and 33.3%, respectively. [8]

Despite the extensive literature on ameloblastoma, there is still considerable disagreement concerning the principles of treatment of this tumor. When planning the treatment of ameloblastoma, it is important to understand the growth characteristics and remove the full extent of the tumor, including the surrounding tissue. Otherwise, the remaining tumor cells may lead to multiple morbidities of recurrence. Muller, based on histopathological study on ameloblastoma, recommends a margin of at least 1 cm of healthy bone, should be resected. [19] Gardener and Pecak suggest that a marginal resection with a 1.5 cm border of apparently unaffected bone in even small solid multicystic ameloblastoma. [20] In rare cases, when the lesion is diagnosed early, there may be sufficient bone to resects the tumor with an adequate margin and maintain continuity of the lower border. [21] Understanding of the biologic behavior of ameloblastoma has revealed that the unicystic lesion is well localized by the fibrous capsule of the cyst, with few tumor broaching peripheral tissues, whereas multicystic and solid lesion are characterized by an aggressive infiltration to adjacent tissue. [22],[23] These suggest that surgical margins are based on the assumption of the tumor behavior rather than histopathological studies on the tumor growth and invasiveness. [24]

After tumor resection, one of the most common problems with prosthetic rehabilitation by oral implants is that of insufficient bone height. This is often a contraindication for implant placement and implies that the ratio of crown to implant length is too great, a factor that will probably reduce not only the useful life span of the implant for the perspective of biomechanical functional, but also the esthetic outcome. [25],[26]

Multiple reconstruction and regeneration methods have been applied in order to augment the alveolar ridge. Present day treatment for alveolar ridge reconstruction include autogenous bone grafting, [27],[28],[29] guided bone regeneration (GBR), [30],[31] and use of alloplastic material. [30],[31] When using an autogenous bone graft donor site, morbidity is unavoidable and some resorption of bone graft occurs. GBR technique of ridge augmentation has been extensively documented the difficulty in providing adequate space for regeneration and obtaining sufficient bone volume is a known fact. [30],[31],[32] This technique is useful for limited defects of the alveolar ridge. Alloplastic materials are not suitable for implant placement. [30],[31],[32]

An useful tissue engineering technique that allows the height of the alveolar ridge to be increased effectively has gained increasing acceptances, namely alveolar distraction osteogenesis. [26],[33] Distraction osteogenesis is based on the principal of "tension - stress" with gradual application of tensile forces stimulating new bone formation parallel to the vector of distraction. [34],[35] Vector control is vital for the precision demanded in implant site preparation. [36] In 1970, Wagner used a new distraction to 1.5 mm per day with initiation of distraction at surgery. [36] In 1987, De Bastaini, et al. advocated callous distraction by increasing the latency period to 14 days. [36] Dr Gavriel Ilizarov pioneered distraction osteogenesis. [37] Block, et al. reported the first case of alveolar distraction in beagle dogs. [36] Chin and Toth were the first to describe alveolar distraction in humans in 1996 using an internal distraction device. [38] Gaggle, et al. and Klien, et al. demonstrated a new operative technique for alveolar ridge augmentation using a distraction implant. [39],[40] Alveolar distraction device is intraosseous and extraosseous type. [36] Following an osteotomy, activation of a distractor device led to the formation of a gap between segments. And a regenerate formed among the bones has four zones from center to periphery: Fibrous tissue, extended bone formation, bone remodeling, and mature bone. [41],[36] Distraction osteogenesis takes place in four clinical phases: Latency, distraction, stabilization, and distraction removal. [36] Latency period of 2-5 days was indicated in young patients and adults, when minimal surgical trauma was encountered. A period of 7-14 days was recommended in older patients or when increased surgical trauma was noted. [34],[35]


   Summary Top


Careful thought should be applied and tailored to individual patients and situation based not only on good evidence, but also on experience, availability of time, and resources and compliances. For management of ameloblastoma, growth pattern and the specific jaw in which the tumor is found are most important factors when considering treatment option. A combination of onlay grafting and alveolar distraction is often needed to achieve appropriate three-dimensional reconstruction of segmental defect of alveolar bone. Further study of the technique with long-term followup to confirm bone and implant stability as it relates to alveolar height and width is needed.

 
   References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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