Gerald S. Fine, D.D.S.
Oral and Maxillofacial Surgery
Late this summer I saw and treated two patients at the Newton-Wellesley Hospital for the removal of significant mandibular cysts and the involved impacted third molar teeth. One patient was male, the second patient was female and both were in the fourth decade of life. These two patients shared other similarities. Specifically, both had been told by their general dentists that the impacted third molar teeth present should be left until the patient developed symptoms of either pain or swelling. A panoramic film taken on these patients was suggestive of significant bone loss surrounding the impacted mandibular third molar teeth. A CAT scan obtained prior to their surgeries was interpreted as "along the anterior margin the bone measures between 1 and 2 millimeters and along the posterior margin, the bone is thin to the bone where measurements can not be accurately made and appears to be less than one millimeters in certain areas". The possibility of a spontaneous fractured mandible if left untreated or a fractured mandible at the time of surgery was of significant concern.
The patients were both treated without any nerve damage or fracture of the mandible and the pathology report of the submitted cystic lesions of each patient was that of ameloblastoma. Recent follow-up post surgical panoramic x-ray demonstrates bone regeneration in the surgical sites.
There are three primary tumor types: peripheral, uniystic and multicystic or solid. Peripheral tumors are odontogenic with histological features arising solely in the soft tissue covering the tooth bearing areas of the jaws. Unicystic tumors, referred to as mural ameloblastoma, stemming from dentigerous cysts, most often resemble dentigerous cysts both clinically and radiographically. Multicystic or solid lesions are slow growing and locally invasive tumors with a high rate of recurrence when not adequately excised.
Peripheral ameloblastoma are treated by excision, with a small amount of adjacent tissue, Unicystic ameloblastomas are treated with enucleation. The management of multicystic or solid tumors remains controversial. The basic approach consists of resection of at least 1 cm and up to 2 cm of adjacent uninvolved cancelous bone. Follow-up of at least 10 years is also advised.
In view of the possible severe consequences of the treatment of an ameloblastoma, early and prompt diagnosis and treatment is critical. Any patient who presents with a radiographic area surrounding an impacted third molar tooth should be seen and treated as early as possible. If it is not possible to obtain a periapical film of the ENTIRE impacted third molar tooth, a panoramic film should be obtained from the office of an oral and maxillofacial surgeon.
Gerald S. Fine, D.D.S.
Practice limited to oral & maxillofacial surgery