TECHNICAL STRATEGY
Conservative Approach: Using Decompression
Procedure for Management of a Large Unicystic
Ameloblastoma of the Mandible
Samuel Porfirio Xavier, DDS, MSc,* Francisco Veríssimo de Mello-Filho, DMD, PhD,†
Willian Caetano Rodrigues, DDS, MSc,‡ Celso Koogi Sonoda, DDS, MSc,‡
and Willian Morais de Melo, DDS, MSc‡
Clinically, ameloblastomas can be classified into 4 groups:
Abstract: Ameloblastoma is a relatively uncommon benign odonto- unicystic, solid or multicystic, peripheral, and malignant. There
genic tumor, which is locally aggressive and has a high tendency to re- are 3 variants of unicystic ameloblastoma, as luminal, intraluminal,
cur, despite its benign histopathologic features. This pathology can be and mural. Therefore, mural unicystic ameloblastoma is locally ag-
classified into 4 groups: unicystic, solid or multicystic, peripheral, and gressive and has a high tendency to recur despite its benign histo-
malignant. There are 3 variants of unicystic ameloblastoma, as lumi- pathologic features.1
nal, intraluminal, and mural. Therefore, in mural ameloblastoma, the Many treatment techniques for ameloblastomas have been
fibrous wall of the cyst is infiltrated with tumor nodules, and for this suggested, which include decompression, enucleation, marginal re-
reason it is considered the most aggressive variant of unicystic amelo- section, and aggressive resection as partial or total resection.2–5 In
this context, mural unicystic ameloblastoma is usually treated by
blastomas. Various treatment techniques for ameloblastomas have
radical procedures4,5 to decrease its recurrence rate. However, liter-
been proposed, which include decompression, enucleation/curettage, ature still shows some debate regarding the most appropriate
sclerotizing solution, cryosurgery, marginal resection, and aggressive method for management of the unicystic ameloblastoma, which
resection. Literature shows treatment of this lesion continues to be a continues to be a subject of intense interest and some contro-
subject of intense interest and some controversy. Thus, the authors versy.2–5 With this in mind, this paper aimed to describe a case of
aimed to describe a case of a mural unicystic ameloblastoma of follic- a mural unicystic ameloblastoma of follicular subtype in a 19-year-
ular subtype in a 19-year-old subject who was successfully treated us- old subject who was successfully treated using conservative approaches,
ing conservative approaches, as decompression. The patient has been such as decompression followed by enucleation associated with Carnoy
followed up for 3 years, and has remained clinically and radiographi- solution application.
cally disease-free.
Key Words: Ameloblastoma, decompression, jaw neoplasms, CLINICAL REPORT
unicystic, recurrence, treatment A 19-year-old female patient was referred to the Oral and
Maxillofacial Surgery and Periodontics Department, Faculty of Den-
(J Craniofac Surg 2014;25: 1012–1014)
tistry of Ribeirão Preto (University of São Paulo, Brazil) with a com-
plaint of a growing swelling in the area of the left mandibular angle
A meloblastoma is a relatively uncommon benign odontogenic tu-
mor, which accounts for approximately 1% of all oral tumors.1
The lesion occurs most frequently in the mandible, with the molar
(Fig. 1A). The patient’s medical history and review of systems were
unremarkable. Upon physical examination, there was a large swelling
and ramus region being the most common site.1 Sometimes, this le- along the left side of the face with no paresthesia. Intraorally, there
sion is associated with expansion of the mandibular cortical bone, was a nontender tumor lesion that expanded the buccal and lingual
causing severe facial disfigurement. surface of the left side of the mandible, and the mucosa overlying
the area was normal.
A panoramic radiography was taken, which demonstrated a ra-
From the *Department of Oral and Maxillofacial Surgery and Periodontics,
diolucent unilocular lesion around the mandibular third molar at the
Faculty of Dentistry of Ribeirão Preto, University of São Paulo, São
Paulo; †Department of Craniomaxillofacial Surgery, Faculty of Medicine
left angle and ascending ramus of the mandible (Fig. 1B). Under local
of Ribeirão Preto, University of São Paulo, São Paulo; and ‡Department anesthesia, aspiration of the lesion was performed, and a thick and
of Surgery and Integrated Clinic, Araçatuba Dental School, Universidade whitish-brown fluid was withdrawn. Then, incisional biopsy was
Estadual Paulista Júlio de Mesquita Filho—UNESP, Araçatuba, São performed, the impacted tooth was removed, and a decompression
Paulo, Brazil. procedure was carried out. The specimen revealed characteristics of
Received December 1, 2013. a mural unicystic ameloblastoma of follicular subtype (Fig. 2). The
Accepted for publication January 6, 2014. patient was instructed to irrigate the cavity twice daily with 10 mL
Address correspondence and reprint requests to Willian Morais de Melo, of 0.12% chlorhexidine using a syringe.
DDS, MSc, PhD, Avenida Feijó, 1309, Apto. 03, Centro, Zip code After 4 months, the facial asymmetry decreased with good
(CEP): 14801-140, Araraquara, São Paulo, Brazil; E-mail:
[email protected] bone healing around the lesion (Fig. 3). After 12 months, acceptable
The authors report no conflicts of interest. facial symmetry was found. Thus, under local anesthesia, full enucle-
Copyright © 2014 by Mutaz B. Habal, MD ation was performed, and after careful curettage, Carnoy solution was
ISSN: 1049-2275 applied into the bone defect during 3 minutes (Fig. 4). Therefore, the
DOI: 10.1097/SCS.0000000000000716 patient has been followed up for 3 years, and has remained clinically
1012 The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014 Decompression for a Large Ameloblastoma
FIGURE 3. A, After 4 months of decompression procedure, the radiolucent
FIGURE 1. A, Upon physical examination, there was a large swelling along the unilocular lesion was diminished. B, After 12 months of decompression
left side of the face. B, Initial radiography image revealed a large radiolucent procedure, good bone healing was found and the lesion decreased in size.
unilocular lesion around the left angle of the mandible.
Literature still shows some debate regarding the most appropri-
and radiographically disease-free, as found in 3-dimensional com- ate method for management of the unicystic ameloblastoma. These
puted tomography scan (Fig. 5). range from conservative2 to radical modes.3,5 The conservative ap-
proach includes marsupialization/decompression, enucleation, curettage,
sclerotizing solution, and cryosurgery. The more radical treatment
DISCUSSION involves marginal resection, segmental resection, or composite resection.
Ameloblastoma is a benign, locally aggressive, slow-growing Therefore, radical resection provides efficient removal of the affected
neoplasm of the jaw, which arises from odontogenic epithelium and bone and soft tissue in continuity with the tumor, which decreases the risk
accounts for 1% of all oral tumors.1 Clinically, ameloblastomas can of recurrence. However, resection of the inferior alveolar nerve and ex-
be classified into 4 groups: unicystic, solid or multicystic, peripheral, traction of the teeth will lead to poorer oral function and causes permanent
and malignant. The unicystic ameloblastoma, first described in 1977 anesthesia of the lower lip. On the other hand, possible disadvantages us-
by Robinson and Martinez,6 is considered a variant of the solid ing conservative approach, as decompression technique, are that it usually
or multicystic ameloblastoma, accounting for 6% to 15% of all requires 2 surgical procedures, and the time necessary for the treatment is
intraosseous ameloblastomas.7 Ameloblastoma is a unique jawbone comparatively long. However, decompression procedure maintains the
tumor found exclusively in the maxillofacial region. It appears more continuity of the mandible and avoids or reduces the damages to the vital
frequently in the mandible, particularly in the angle and ramus, al- structures, such as inferior alveolar nerve.
though it can occur in any mandibular region.4 Decompression treatment, which is simple to perform and gen-
Unicystic ameloblastoma derives from the macro- and micro- erally well accepted by patients, is a reliable method to considerably
scopic appearances,4 which is essentially a well-defined single cav- reduce the volume of mandibular odontogenic tumors, such as
ity lined with ameloblastomatous epithelium, and 3 variants could keratocystic odontogenic and unicystic ameloblastoma tumors.2,9–11
be found: luminal, intraluminal, and mural. In the third type, mural Nakamura et al2 proposed marsupialization/decompression as an ini-
ameloblastoma, the fibrous wall of the cyst is infiltrated with tumor tial step in the treatment of unicystic ameloblastoma. After an appro-
nodules, and for this reason, it is considered the most aggressive priate reduction in its size, the enucleation with curettage can be made,
of these 3 variants, with a recurrence rate as high as 35.7%.8 Thus, and consequently, the complications associated with the more radical
although a benign histologic pattern, mural unicystic ameloblastoma techniques can be avoided, such as nerve damage and encroachment
is locally aggressive and has a high tendency to recur. on facial anatomic structures, causing facial disfigurement.
To decrease recurrence rate of ameloblastomas, some investigators
advise tanning the odontogenic tumor cavity with Carnoy solution
(absolute alcohol, 6 mL; chloroform, 3 mL; glacial acetic acid, 1 mL;
FIGURE 2. After incisional biopsy, specimen revealed characteristics of a mural
unicystic ameloblastoma of follicular subtype (hematoxylin-eosin, original FIGURE 4. A, Enucleation/curettage procedure of the lesion was performed.
magnification 100). B, Carnoy solution was placed into the bone defect, during 3 minutes.
© 2014 Mutaz B. Habal, MD 1013
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Xavier et al The Journal of Craniofacial Surgery • Volume 25, Number 3, May 2014
mural unicystic ameloblastoma could be successfully performed with
good outcomes. When possible, this conservative technique should be
the first-line option to be performed for management of large unicystic
ameloblastoma.
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1014 © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
