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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 10  |  Issue : 3  |  Page : 161-164

Follicular ameloblastoma: A case report


1 Department of Public Health Dentistry, Dr. B. R. Ambedkar Institute of Dental Sciences and Hospital, Patna, Bihar, India
2 Department of Oral and Maxillofacial Surgery, Sarjug Dental College and Hospital, Darbhanga, Bihar, India
3 Department of Oral Medicine and Radiology, Sarjug Dental College and Hospital, Darbhanga, Bihar, India

Date of Submission06-Apr-2019
Date of Acceptance13-Aug-2019
Date of Web Publication15-Oct-2019

Correspondence Address:
Dr. Abhijeet Alok
Department of Oral Medicine and Radiology, Sarjug Dental College and Hospital, Darbhanga, Bihar
India
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DOI: 10.4103/srmjrds.srmjrds_28_19

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  Abstract 

Ameloblastomas are slow-growing, locally invasive tumor affecting the maxillofacial region. There are various histologic variants of ameloblastoma. Most common being follicular ameloblastoma. Follicular ameloblastoma is commonly seen in elder people. Follicular ameloblastomas have got high recurrence rate. Radiographic finding shows a multilocular radiolucency with well-defined borders. This paper presents a case of follicular ameloblastoma in a 30-year-old female who had a swelling on the right mandible region.

Keywords: Ameloblastoma, follicular, mandible, multilocular, recurrence


How to cite this article:
Singh S, Hasan K, Alok A. Follicular ameloblastoma: A case report. SRM J Res Dent Sci 2019;10:161-4

How to cite this URL:
Singh S, Hasan K, Alok A. Follicular ameloblastoma: A case report. SRM J Res Dent Sci [serial online] 2019 [cited 2019 Nov 23];10:161-4. Available from: http://www.srmjrds.in/text.asp?2019/10/3/161/269211


  Introduction Top


Ameloblastoma is also known as adamantinoma or adamantoblastoma. Malassez introduced the term adamantinoma. The term ameloblastoma is derived from two words, “amel” and “blastos” which mean enamel and germ, respectively.[1] One of the most accepted definitions of ameloblastoma was given by Robinson. Robinson defines ameloblastoma as a tumor that is usually unicentric, nonfunctional, intermittent in growth, anatomically benign, and clinically persistent.[2] Ameloblastomas are tumors of odontogenic epithelium. Ameloblastoma accounts for 1% of all oral tumors and 11% of all odontogenic tumors.[3] Ameloblastomas are encountered in patients across wide age range. Ameloblastoma occurs in the middle age group to older age group individuals. Ameloblastoma begins as a central lesion of the bone which is slowly destructive but tends to expand bone rather than perforate it. The overlying mucosa appears normal. It is frequently discovered during routine dental examination. Based on histological type, ameloblastoma may be classified into follicular, plexiform, acanthomatous, basal cell pattern, unicystic, granular cell pattern, papilliferous ameloblastoma, hemangioma ameloblastoma, desmoplastic, plexiform unicystic, clear cell, dentinoameloblastoma, melanoameloblastoma, and keratoameloblastoma.[4] The most common histologic variant of ameloblastoma is follicular and plexiform variant of ameloblastoma. They both comprise of 27.7% and 21.1%, respectively.[5] Here, we present a case of follicular ameloblastoma in a 30-year-old female patient in the right mandibular region.


  Case Report Top


A 30-year-old female patient reported to the department of oral medicine and radiology with a chief complaint of swelling and pain in the lower right back tooth region for 3 months [Figure 1]. History of present illness revealed that the patient was apparently asymptomatic 3 months back when a swelling appeared in the mandibular right posterior region. Initially, the swelling was smaller in size, but it gradually increased to the present size. There has not been any increase in the size of the swelling for 20 days. The swelling was not associated with pain. There was difficulty in eating food. No history of trauma and pus discharge from that region was noted. On extraoral examination, a diffused swelling is present on the right facial region. Superior-inferiorly, the swelling extended 1.5 cm from the tragus of the ear till 0.5 cm to the inferior border of the mandible. Anteroposteriorly, the swelling extended 1 cm from the corner of the mouth till the angle of the mandible. Overlying surface of swelling was smooth and of normal skin color. On palpation, it was nontender, soft in consistency, and there was no local rise in temperature. The right submandibular lymph node was palpable and nontender. On intraoral examination, an oval swelling roughly 3 cm × 1.5 cm in diameter was present from 44 to 48 regions. There was vestibular obliteration with respect to 44, 45, 46, 47, and 48 regions. On palpation, the swelling was tender, soft to firm in consistency, and not associated with any discharge. There was displacement of 46. Grade II mobility was present with respect to 45 and 46 [Figure 2]. On the basis of history, clinical examinations, a provisional diagnosis of ameloblastoma in the right mandibular region was given. Differential diagnosis of odontogenic myxoma and central giant cell granuloma (CGCG) was considered. Investigations such as orthopantomogram (OPG), fine needle aspiration cytology (FNAC), blood investigations, and histopathology examination were done. OPG showed a well-defined radiolucent lesion in the mandibular posterior region, extending from 44 to 47 regions. It is roughly 4 cm × 3 cm in size. Internal structure appears to be radiolucent with radiopaque internal septa giving a multilocular appearance. Displacement of 46 can be seen. Inferior alveolar canal is displaced inferiorly [Figure 3]. FNAC was done, and the result was negative. Blood investigations were found to be within normal limits. Surgical enucleation of cystic lesion with extraction of involved tooth was planned [Figure 4]. Crevicular incision with anterior releasing incision was given with 15 number blades, and full-thickness mucoperiosteal triangular shape flap is raised [Figure 5]. With the help of straight fissure, bur slight corticotomy was done on the anterior buccal segment to get proper exposure of cystic lesion. With the help of curettes, the cyst was completely enucleated from the cavity with extraction of the involved tooth done [Figure 6]. Open packing was placed in the form of gauge impregnated with betadine ointment to promote the secondary healing. Resorbable sutures were placed in the posterior area. Excised specimen was sent for histological examination [Figure 7]. Histological report was suggestive of follicular ameloblastoma [Figure 8]. Hence, finally, follicular ameloblastoma was given.
Figure 1: Extraoral image of the patient

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Figure 2: Intraoral image of the patient showing swelling in the right mandibular area

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Figure 3: Orthopantomogram of the patient shows radiolucency in the right mandibular area

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Figure 4: Crevicular incision with anterior releasing incision given

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Figure 5: Surgical enucleation of the lesion done

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Figure 6: Image showing excised specimen

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Figure 7: Suture placed

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Figure 8: Histology image of follicular ameloblastoma

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  Discussion Top


Ameloblastoma is a persistent and locally invasive tumor. Most common etiologic factors of ameloblastoma include trauma, inflammation, chronic irritation, and infection with history of traumatic injury or extraction.[6] Equal sex predilection is seen; but, sometimes, male predominance is seen in its occurrence. It most commonly occurs in the molar ramus region. Ameloblastoma may cause bony expansion and sometimes erosion through the adjacent cortical plate with subsequent invasion of adjacent soft tissues. Long-standing cases of ameloblastoma may show expansion which may be disfiguring and fungating and an ulcerative type of growth characteristic of that of carcinoma may be seen. Maxillary lesions are more dangerous because of involvement of vital structures at cranial bases. The mucosa over the mass is generally normal, but the teeth in the involved region may be displaced and become mobile.

Radiographically, appearance of ameloblastoma may vary from totally radiolucent to mixed with the presence of bony septa creating internal compartment as seen in our case. These septa are often remodeled into curved shape providing soap bubble or honeycomb appearance or spider with long legs-like appearance. An ameloblastoma is usually well-defined and frequently delineated by a cortical border. Ameloblastoma shows marked tendency for root resorption. Characteristic “knife edge” pattern of root resorption is seen in ameloblastoma. Among all histopathologic variant of ameloblastoma, follicular histopathologic pattern is the most common variant. Follicular pattern shows islands of epithelium in a mature fibrous connective tissue which resemble as enamel organ epithelium. This epithelium consists of a core of loosely arranged angular cells which resemble as stellate reticulum of enamel's origin. Most common differential diagnosis of ameloblastoma involving the mandibular posterior region are odontogenic keratocyst, CGCG, odontogenic myxoma, primary hyperparathyroidism, secondary hyperparathyroidism, central hemangioma, and aneurismal bone cyst.[7],[8],[9],[10] Treatment of ameloblastoma depends on the size of lesion, its involvement in surrounding structures, etc., Small lesion may be removed by intraoral approach whereas large lesions may require resection of the jaw. Follicular ameloblastoma has a high recurrence rate of 29.5%.[11] No recurrence has been observed in our case even after 18 months of surgery.


  Conclusion Top


Ameloblastoma is an odontogenic tumor affecting most commonly elderly individuals. Ameloblastoma has got lot of variants based on histologic patterns. Ameloblastoma should be treated immediately when diagnosed because long-standing cases may cause facial disfigurement. Ameloblastoma should be diagnosed carefully based on history and investigations. Histologic variant of ameloblastoma should be diagnosed properly and treated accordingly. Long-term follow-up is required in ameloblastoma to check for recurrence. Management depends on the histologic variant and the anatomic structures involved.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kumaresan R, Kotrashetti SM. Management of large mandibular ameloblastoma: A case report. J Dentofac Sci 2013;2:21-5.  Back to cited text no. 1
    
2.
Gupta A, Jindal C. Hybrid ameloblastoma: Report of a rare case and review of literature. Int J Oral Maxillofac Pathol 2011;2:68-72.  Back to cited text no. 2
    
3.
Hasan K, Alok A, Singhal P, Rohatgi N. Plexiform ameloblastoma: A case report and a brief review. MAVEN 2018;2:9-14.  Back to cited text no. 3
    
4.
Karjodkar FR, editor. Essentials of Oral and Maxillofacial Radiology. 2nd ed. New Delhi. Jaypee Brothers Medical Publishers (P) Ltd.; 2019. p. 403-53.  Back to cited text no. 4
    
5.
Eversole LR, Leider AS, Hansen LS. Ameloblastomas with pronounced desmoplasia. J Oral Maxillofac Surg 1984;42:735-40.  Back to cited text no. 5
    
6.
Effiom OA, Ogundana OM, Akinshipo AO, Akintoye SO. Ameloblastoma: Current etiopathological concepts and management. Oral Dis 2018;24:307-16.  Back to cited text no. 6
    
7.
Alok A, Panat SR, Singh ID, Singh S. Non Syndromic Multiple keratocyst odontogenic tumor: A rare case report. J Indian Acad Oral Med Radiol 2015;27:264-7.  Back to cited text no. 7
  [Full text]  
8.
Alok A, Singh ID, Singh S, Kishore M. Central giant cell granuloma: A case series and review of literature. J Indian Acad Oral Med Radiol 2015;27:156-9.  Back to cited text no. 8
  [Full text]  
9.
Choudhary A, Saxena T, Upadhyay N, Alok A. Aneurysmal bone cyst; a rare case report. J Dent Sci Oral Rehabil 2012;3:34-6.  Back to cited text no. 9
    
10.
Alok A, Hasan K, Singh S, Bhattacharya PT. Odontogenic myxoma involving maxilla: A case report. J Indian Acad Oral Med Radiol 2019;31:70-3.  Back to cited text no. 10
  [Full text]  
11.
Robinson L, Martinez MG. Unicystic ameloblastoma: A prognostically distinct entity. Cancer 1977;40:2278-85.  Back to cited text no. 11
    


    Figures

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



 

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