Oral And Maxillofacial Pathology

Pathology of the maxillofacial region can vary from benign to malignant ( cancer) lesions. Proper diagnosis and correct treatment is vital to get best results. Some of the pathology can be treated by medicines alone while others may need surgical intervention with or without reconstruction. Tumours in the head and neck region are more complex to treat as the anatomy is more complex, any scars created cannot be hidden and the ability to speak and chew food must be maintained.

A young lady presented to us with a swelling in her right side mandible for the past 2 years. It was slowly enlarging in size and causing numbness of the lower lip. OPG revealed a large multi-cystic lesion approx 12 x 4 cm in size and extending into the condyle, coronoid and ramus of mandible with root resorption of her teeth. Biopsy confirmed an ameloblastoma.

Ameloblastoma is a locally aggressive tumor which usually doesn't metastasize. There are however reports of metastasis and also reports of carcinomatous changes. These tumors are also usually radio-resistant and also there are also reports of cancer occurring if radiotherapy is given. The treatment of choice for ameloblastoma is resection with a wide margin.

A submandibular approach was done along with a lip split to get good access to the entire tumor. Care was taken to preserve the marginal mandibular branch of the facial nerve and the facial artery and vein was ligated during the approach. Wide resection was done with 1 cm clearance all around including the condyle of the mandible. A recon plate was adapted and plating was done to maintain the occlusion. Meticulous closure was done in layers to prevent any fistula or plate exposure. Postoperatively the patient healed up very well with no plate exposure and the facial deformity was minimal After a year, when it was clear that she was free of tumor, we did a fibula bone free flap transfer. This was followed with dental reconstruction. It is now 14 years post-operative with no evidence of the tumor and she is leading a normal life with a normal diet .

Large Ameloblastoma involving one half of the lower jaw

Wide resection of the ameloblastoma done and recon plating done. This was followed by fibula free flap transfer

14 years post-op— Scars are nearly invisible, there is minimal morbidity with no recurrence till date Patient is able to eat normally

A young girl came to us with a large swelling of her R mandible . Biopsy done showed osteoclastic cells with fibroblasts and a provisional diagnosis of central giant cell granuloma was given. CT scans/ OPG showed a large multilocular lesion occupying entire body of the mandible with perforation on the lingual side. Considering that the patient was very young and to avoid any cosmetic deformity, it was decided to do an enucleation and remove the lesion in-toto completely intraorally and then follow it up with calcitonin therapy to prevent any recurrence. The teeth from canine to the molars were root canal treated in an attempt to save them. This was done by an Consultant in Endodontics.

Under GA, the entire body and ramus of mandible was exposed via an envelope flap incision and the entire tumor was removed. Care was taken to preserve the inferior alveolar nerve during the entire procedure. The impacted wisdom tooth was removed and there was no iatrogenic/ pathological fracture of the mandible. Clinically, the patient recovered well. The beauty of this procedure is that a large tumor has been removed completely intraorally– no scars on the face and she was all her teeth intact and no numbness present– basically the morbidity is very minimal.

Post-op histopathology confirmed this to be an central giant cell granuloma and she has then referred to an Endocrinologist for calcitonin injections. The calcitonin therapy was done over a period of 2 years. It is now 7 years post-op with no recurrence.

Pre-op Central giant cell granuloma with perforation of cortex of mandible lingually and labially

Intra and post-op showing entire tumor has been removed entirely via intraoral approach (no scars on the face )

OPG X-rays showing 7 years follow-up with no recurrence

A 28 year old came to us with pain and swelling in his maxilla with a foul smelling discharge. He had previously been operated elsewhere for an cyst removal in the maxilla 2 years ago. He also had multiple dermal cysts in his foot, hand and mouth .OPG revealed large cystic lesions in all four quadrants CT scans delineated the extent of the lesions and also showed bifid ribs and intracranial calcifications. He was taken up for surgery and had the Odontogenic keratocysts enucleated from all four quadrants along with all the impacted teeth removed at the same time. Marsupilisation was then done to prevent any recurrence. Post-operatively he recovered well with no complications. He is now on regular follow-up

Gorlin- Gotz syndrome is otherwise known as basal cell nevus bifid rib syndrome. It is an autosomal dominant condition due to mutations found in chromosome arm 9q. The characteristics of this syndrome include multiple impacted teeth with Odontogenic keratocysts, bifid ribs, intracranial calcifications of falx cerebri, multiple dermal cysts and most importantly basal cell carcinomas (BCC) of skin. Only 10% of affected patients do not have BCC’s. Fair skin and exposure to sunlight are predisposing conditions to basal cell carcinomas.

Another important point to remember is that the Odontogenic keratocysts have a very high recurrence rate and can recur even after 5 -10 years. Therefore long term follow-up for both the keratocysts and basal cell carcinomas is vital. Luckily this patient did not have any skin cancer lesions.

Pre and post-op OPG X-rays showing Odontogenic keratocysts and impacted teeth removed

Calcified Fax cerebri and Od.keratocysts in all four quadrants of maxilla/ mandible

Bifid Ribs & Multiple dermal cysts

Large Odontogenic keratocysts enucleated and marsupialised from all four quadrants along with removal of all impacted teeth

A 6 year old presented with a swelling in her R orbital region. The swelling was gradually increasing in size and causing the eyeball to be pushed upward and outward ( Hyperglobus and exopthalmos). CT scans revealed a tooth inside the orbit cone and surrounded with abnormal tissues ( teratoma). It was decided to enucleate the lesion. The teratoma was removed under general anesthesia via a subciliary approach. Vision and eye movements were normal . The hyperglobus and exopthalmos were corrected.

Pre-operative photos and CT showing a fully developed tooth in the orbit lying close to the optic nerve

A sub ciliary approach was done and the teratoma was exposed and enucleated in toto and suturing was done.

Pre and post-op pictures with the tooth removed. Note the correction in hyperglobus and exopthalmos ( eyeballs are in the same level post-op