Ameloblastoma of Maxilla ASHOK VERMA, VIKAS INDER NATH NEHRU, H. L. GUPTA ~ S. B. S. MAAN

A m e l o b l a s t o m a of t h e maxi l la is a rare t u m o u r as compared to t ha t o f mandib le . We present here t w o cases of a m e l o b l a s t o m a o f maxi l la .

Case 1 Biopsy from the ulcer in the Case 2 bucco-alveolar sulcus was re- ported as ameloblastoma. D. C. 42 years male presented in

the ENT Outpatient Department of postgraduate Institute of Medical Education and Research, chandi- garh, on 28.2.86 with the chief complaints of nasal obstruction and bleeding from the left side of the nose for the last two years and a chronic ulcer at the back of left upper jaw for the last 6 months.

General physical and systemic examination were within normal limits. ENT examination revealed a pinkish pale, polypoidal firm mass filling the left nasal chamber completely. The probe could be passed all around the mass. It did not shrink on application of topical vasoconstrictor. An ulcer, 1 cm x 1 cm in size with everted margins and whitish slough at the base was present in the left upper bucco- alveolar sulcus opposite second molar tooth. Rest of the ENT examination was within normal limits.

Routine haemogram, urinalysis, blood biochemistry and X-ray chest were normal.

X-ray paranasal sinuses (Water's view) showed expansion of left maxillary antrum with thinning of its walls. The left nasal cavity was partially opaque. (Fig.-I).

Ashok Verma, Senior Resident, Depart- ment of E.N.T. Vikas Inder Nath Nehru, Senior Resident, Department of E.N.T. H. L. Gupta, Senior Resident, Department of Pathology. S. B. S. Maan, Associate Professor, Department of E.N.T., Postgraduate Insti- tute of Medical Education 8- Research, Chandigarh.

Reprints request to : Dr. S. B. S. Mann, Associate Professor, Department of E.N.T. P.G.I.M.E.R., Chandigarh-160 012. India.

S. S. 44 years male patient, presented in the E. N.T. Depart- ment of Postgraduate Institute of Medical Education and Research, Chandigarh, on 12.3.86 with chief complaints of nasal obstruction and bleeding from right side of the nose for last 2 years. History dated back

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Fig. 1. X-ray Paranasal Sinuses (Water's View) showing expansion of left maxillary antrum with thinning of its walls and partial opacity of left nasal cavity.

Total maxillectomy was done under General Anaesthesia. The anterior and nasoantral walls of maxillary antrum were eroded and the posterior wall was destroyed. The cavity was filled with a firm polypoidal mass which bled pro- fusely. However, resection mar- gins were clear of the tumour grossly. Histopathological exa- mination revealed that the tu- rnout cells in the periphery were arranged in a pallisading manner while the central cells were orga- nized into solid nests and trabe- culae, which are the characteristic features of ameloblastoma (Fig.2).

Fig. 2. Photo micrograph of the tumour from case 1 revealed characteristic features of ameloblastoma. The tumour cells are organised into solid nests and trabeculae having peripheral pallisading of cells (H Et E 55X).

to 13 years, when the patient had developed a swelling in the region of right upper jaw followed by loosening of upper last three teeth which were extracted. The patient had received 45 exposures of external radiation at that time. Nothing was known regarding the nature of the mass at the time of presentation to us.

General physical and systemic examination were within normal limits. E.N.T. examination revealed a well epithelialised cavity 1½"x 1½" in size in the region of right upper molars and premolars (Fig.3) with few granulations over its posterior wall. The eyes were nor- mal. Rest of the E.N.T. examination was within normal limits.

Post-operative period was uneventful and fol low-up till date has showed no recurrence.

X-ray paranasal sinuses (Water's view) revealed an extensive des- truction of the floor of the Right

24 Indian Journal of Otolaryngology. Volume 40, No. 1, March, 1988

AMELOBLASTOMA OF MAXILLA- -VERMA et al

maxillary antrum. The cavity was clearly demarcated and the sur- rounding bone showed sclerosis (Fig. 4).

Fig. 3. Case-2 clinical photograph. Showing the well epithelialised cavity in the region of right upper molars and premolars.

Fig. 4. X-ray paranasal sinuses (Water's view) showing absent floor of the right maxillary antrum. The cavity outline Js well demarcated and bone around the cavity shows sclerosis.

Biopsy from the granulations on the posterior wall of the cavity was reported as ameloblastoma. Total maxillectomy was performed on 28.3.86. At the time of surgery, besides alveolus the posterior wall of maxilla was found to be destroyed. The tumour was poly- poidal, firm and bled profusely (Fig. 5). It was greyish on cut section. Histopathological exa- mination revealed that the peri- pheral tumour cells were arranged in a pallisading manner whi le the cells in the centre showed stellate appearance. The stroma was fib- rous with slight myxoid background (Fig. 6. HPE 1 4 0 × ) . Under higher magnifications the tumour cells were more or less uniform and there was no evidence of mitosis.

Fig. 5. Maxillectomy specimen--showing absent posterior wall of maxilla and poly- poidal mass removed from the region of posterior wall.

Fig. 6. Photomicrograph of the maxillary tumour of the case--2 showed the characteristic pattern of arrangement of tumour. The peripheral tumour cells are arranged in a pallisading manner while the cells in the centre show stellate appearance in a slight myxoid background (H E~ E 140X).

Post-operative period was un- eventful. Fol low-up till date has revealed no recurrence.

Fig. 7. This photomicrograph showing the detailed histologic appearance of the individual cells. The tumour cells are more or less uniform and mitosis is absent (HEt E 550X).

D i s c u s s i o n Ameloblastoma accounts for

approximately 1% of all oral tumours; 80% of the tumours occur in the mandible, whereas 16.3% occur in the maxilla. Maxillary tu- mours occur more often in the molar area of the antrum and floor of the nose than in the anterior region. Different etiological factors have been mentioned in literature by various authors such as oral infection, dental extraction, injury to teeth or jaw, dietary deficiencies ~f',~Vitamin K, Polyoma virus and chemicals like nitrosoureas.

The ameloblastoma arises from the dental epithelium. The rests of malassez which are the remnants of Hertwig's root sheath are sup- posed to be the site of origin cf the tumour.

Because of the local invasive character of the tumour, recurrence after conservative treatment like curettage is quite common. Complete excision of the tumour wi th adequate safety margin is the treatment of choice particularly in case of mandible which is a compact bone. But where the adjacent margin is of cancellous bone as in maxilla, then it becomes diff icult to assess the extent to which the cancellous spaces might have been infiltrated. In these cases to secure an adequate margin of normal tissue, a larger area has to be excised than the apparant extent of tumour. Although radio-

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A M E L O B L A S T O M A OF M A X I L L A - - V E R M A et al

therapy was considered an alterna- t ive to surgery but studies have shown that ameloblastoma is a radio resistant tumour.

In one of our cases radiotherapy had been given and the pat ient had been symptom free for about eleven years.

We have done tota l max i l l ec tomy in our cases and the pat ients are under close f o l l o w - u p t i l l date w i t h o u t any recurrence.

References 1. Crawley, W.A. and Levin, L.S.

(1978) : Treatment of the amelo- blastoma--A Controversy. Cancer, 42 : 357.

2. Gardner, D.G. and Pecak, A.M. (1980) : The treatment of amelo- blastoma based on pathologic and anatomic principles. Cancer 46 : 2514.

3. Hair, J.A.G. (1963) : Radiosensitive adamantinoma. Brit. Med. J., 1 : 105.

4. Lucus, R. B. (1984): Pathology of tumours of the oral tissues--Fourth Edition.

5. McWhirter, R. (1952) : Symposium on the treatment of adamantinoma. Proc. Roy. Soc. Med., 45 : 701.

6. Robinson, H.B.G. (1937) : Amelo- blastoma. A survey of the three hundred and seventy-nine cases from the literature. Arch. Path., 23 : 831.

7.

8,

Schdev, M.K., Huvos, A.G., Strong, L.W., Gerold, F.P., and Willis, G.W. (1974) : Ameloblastoma of maxilla and mandible. Cancer, 33 • 324.

Vedtofte, P., Hjorting-Hanson, E., Jensen, B.N. and Roed-Petersen, B. (1978) : Conservative Surgical treatment of mandibular ameloblas- tomas. Int. J. Oral Surg., 7 : 156.

26 Indian Journal of Otolaryngology, Volume 40, No. 1, March, 1988