Case Report

RECIDIVE PERIPHERAL AMELOBLASTOMA

Arranged by:
dr. Henry Hamonangan Sitanggang, Sp.B

Mentor:
Prof. dr. Sunarto Reksoprawiro, Sp.B(K),Onk(K)KL

SPECIALIST DOCTOR MEDICAL PROGRAM-II

HEAD AND NECK DEPARTMENT OF SURGERY
FACULTY OF MEDICINE
UNIVERSITAS AIRLANGGA / RSU Dr. SOETOMO SURABAYA
2019
 VALIDITY/APPROVAL SHEET

The article with the following criteria:

Title : Recidive Peripheral Ameloblastoma
Type of article : Case Report
Arranged by : dr. Henry Hamonangan Sitanggang, Sp.B
has been approved and validated.

Approved
by Mentor :

Prof. dr. Sunarto Reksoprawiro, Sp.B(K),Onk(K)KL

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 Table of Contents

Cover .............................................................................................................................. i
Validity/Approval Sheet ................................................................................................. ii
Table of Contents ............................................................................................................ iii
List of Figures ................................................................................................................. iv
Abstract ........................................................................................................................... 1
CHAPTER I: Preface ..................................................................................................... 2
CHAPTER II: Case Report ............................................................................................ 4
CHAPTER III: Discussion ............................................................................................. 6
References ...................................................................................................................... 8

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 List of Figures

Figure 1. Clinical photos of patients before surgery ....................................................... 4

Figure 2. Several photos during surgery ......................................................................... 5

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 Case Report
Recidive Peripheral Ameloblastoma
*Henry Sitanggang, Sunarto **
* Resident Of Head and Neck Surgery Program Airlangga Medical University/RSUD
Dr.Soetomo Surabaya
** Teaching Staff Of Head and Neck Surgery Division Airlangga Medical University/RSUD
Dr. Soetomo Surabaya

Abstract
Background: Peripheral ameloblastoma is a rare variant, representing about 2% to 10% of all
ameloblastomas which are locally invasive benign epithelial odontogenic tumors originating
from the putative enamel of the origin organ. Peripheral ameloblastoma (PA) is an exophytic
growing tumor localized to soft tissue in the tooth-bearing areas of the jaw.
Case Report: A 38-year-old male patient presents with a chief complaint of a lump on the
inside of the left cheek. Lumps since 1 year ago, the lump was initially felt as big as a bean,
getting bigger and bigger, and 1 month ago blood leaked out from the lump. Panoramic
photographs showed the result of visible soft tissue mass projected in the left mandible region.
The first FNAB looks malignant tumor suspect muco epidermoid. and the second FNAB shows
a picture of SCC. The result of surgery is a picture of peripheral ameloblastoma.

Conclusion: Peripheral ameloblastoma is a rare variant, representing about 2% to 10% of all

ameloblastomas. So that when done FNAB in areas containing thyroid tissue can cause
misdiagnosis.

Keywords : Ameloblastoma perifer, odontogenic tumor, recidive tumor

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 CHAPTER I

PREFACE

The prevalence of odontogenic tumors is 0.8% of all oral and maxillofacial tumors.
Ameloblastoma accounts for 30% of all odontogenic tumors. Peripheral ameloblastoma (PA)
is a rare variant, representing about 2% to 10% of all ameloblastomas. (1)
Peripheral ameloblastoma is a benign locally invasive epithelial odontogenic tumor
originating from the putative enamel organ of origin. Peripheral ameloblastoma (PA) is an
exophytic growing tumor localized to soft tissue in the tooth-bearing areas of the jaw. The
initial diagnosis is fibrous epulis. (2)
To date, less than 200 cases of peripheral ameloblastoma have been described in the
literature. Peripheral ameloblastoma (PA) generally occurs at age > 50 years. The ratio of men
to women is 2:1. The most common location of ameloblastoma is mandibular. Normal size
ranges from a mean of 1.3 cm and in most cases there is no radiological evidence of bone
involvement. Proposed diagnostic criteria for peripheral ameloblastomain include, origin of the
epithelium above, presence of odontogenic epithelial islands in the lesion, lack of potential
bone infiltration. (3)
Microscopic picture of peripheral ameloblastoma is characterized by ameloblastic
(4)
growth in the squamous epithelial layer, the tumor is composed of loosely connected cells.
In this report we will report a rare case of peripheral ameloblastoma that occurs in the
buccal region, which has residifs after two operations. In this case peripheral ameloblastoma
occurs in 38-year-old men and a lump is found on the left side of the patient's cheek.

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 CHAPTER II

CASE REPORT

A 38-year-old male patient came to the Polyclinic RSU Dr. Dr. Soetomo the Head of
the Neck with the main complaint of a lump on the inside of the left cheek The patient
complained of a lump in the inside of the left cheek since 1 year ago, the lump was initially felt
as big as a bean, getting bigger and bigger, and 1 month ago bleeding came out from lumps.

RPD: Patient had complained of a similar lump appearing 12 years ago (in 1997) and
was operated on in 1998 at Jombang Regional Hospital. Lumps reappeared in 2008 in the lower
jaw, and a lower jaw lift was performed in 2009.

Figure 1. Clinical photos of patients before surgery

Hoarseness, shortness of breath, and swallowing pain are absent. No weight loss, cold
sweat at night, and trembling. No disturbances found in hearing. Family history of experiencing
the same disease is absent. Family history of malignancy does not exist.

On physical examination, the patient's general condition was found, compos mentis,
cooperative, adequate nutrition and vital signs within normal limits. On physical examination
the buccal region showed lumps on the left buccal, the color of the buccal mucosa was the same
as the color of the bumps, humps, no visible pus, on palpation palpable mass on the left buccal,
dense solid consistency, hugging, irregular boundaries, irregular and fixed edges. The patient
was taken a panoramic photo and the result showed visible soft tissue mass projected in the left
mandibular region oval, firm boundary, irregular edges, size 4.1 x 4.5 cm. Amputative lesions
in the condyles up to 1/3 the middle of the left mandibular corpus. On June 10, 2019 patients

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underwent FNAB, and the results showed the appearance and distribution of anaplasia
epithelial cell groups, pleomorphic nuclei, prominent prominent cytoplasmic nuclei with
erythrocyte background mucoid matrix, FNAB conclusion: malignant tumor suspect muco
epidermoid. On June 14, 2019, the patient re-performed FNAB and was presented with a visible
appearance of cells containing the distribution and clusters of anaplasia epithelial cells, oval
rounded nuclei, pleomorphic, hyperchromatic, cytoplasmic fairly bluish, concluded FNAB:
Squamous Cell Carcinoma. PT / APTT is within normal limits.

On July 8, 2019 surgery was performed with a pre-surgical diagnosis of the residual
buccal region region of the ameloblastoma. Meanwhile, the post-surgical diagnosis was
peripheral ameloblastoma residif buccal sinistra region. Surgery was performed in general
narcotics in the form of wide excision accompanied by lingual flap post base. Informed consent
was given to the family for the action to be performed, fasting 6-8 hours preoperatively.

The surgery began with the patient supine on the operating table in general narcotics
with head hyperextension and face up. Aseptic markers were performed in the area to be
operated on.

Figure 2. Several photos during surgery

The operation began with an incision from the former incision, sub-retro mandibular lip
splitting, after that the incision was then deepened layer by layer. Exploration results obtained
a hard solid mass of 6 cm in diameter on the retromolar S side and obtained remnant of the
mandibular S bone. After wide excision and bleeding control, then get an ipsilateral level II

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node 2 CDVA with 2cm diameter fruit and solid, fragile tissue, 2x1 cm to the oropharynx. The
next step was to control the bleeding of the wound, then the wound was closed with a tongue
flap after it had been mounted posteriorbase drain + No. 10. Eventually, the surgical wound
was closed layer by layer.

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 CHAPTER III

DISCUSSION

Peripheral ameloblastoma (PA) is an exophytic growing tumor localized to soft tissue

in the tooth-bearing areas of the jaw. The initial diagnosis was fibrous epulis. Peripheral
ameloblastoma (PA) is a rare variant, representing about 2% to 10% of all ameloblastomas. (1)

In most cases there is no radiological evidence of bone involvement, but superficial bone
(2)
erosion is sometimes found during surgery so it is referred to as saucerization. In this case
there is a saucerization area where the panoramic photo results in an amputative lesion in the
condyles up to 1/3 the middle of the left mandibular corpus.

The mean age of developing peripheral ameloblastoma was 52.1 years. The ratio of men
to women is 2:1 for IA. The most common location of ameloblastoma is mandibular.(3) In this
case we reported a rare ameloblastoma, which was in the buccal region and occured at a young
age of 38 years. Symptoms of peripheral ameloblastoma are usually painless, and are neoplasms
with exophytic growth. Normal size ranges from 0.3 to 4.5cm with an average of 1.3 cm. The
surface is usually smooth but in some cases there are reported variants with "granular" or
"papillary" surfaces.(4) In this case the lesion had a dense, brittle, dense indistinct boundary
consistency, with irregular margins, but the size of the lesions in this case exceeded the normal
size in the literature review where in this case based on the results of the operation a mass of 6
cm was obtained.

Proposed diagnostic criteria for peripheral ameloblastomain include, origin of the

epithelium above, presence of odontogenic epithelial islands in the lesion, lack of potential bone
infiltration. To date, fewer than 200 cases of peripheral ameloblastoma have been reported in
the literature. (5)

Two main hypotheses put forward to explain the pathogenicity of peripheral

ameloblastoma are first how many tumors are embedded in the gingival connective tissue
believed to originate from "Serre Pearl" which represents extraosseous residuals from dental
lamina. The two peripheral ameloblastomas present are closely related to the surface
epithelium. where some parts fail to detect epithelial nests in the submucosal layer, this seems
to provide extraordinary evidence that at least some cases of peripheral ameloblastoma originate
from the surface epithelial layer (6).

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 Microscopic picture of peripheral ameloblastoma characterized by ameloblastic growth
in the squamous epithelial layer, the tumor is composed of loosely connected cells. (6) Another
interesting problem regarding the histology of peripheral ameloblastoma lies in its similarity
with basal cell carcinoma (BCC) and Squamous cell carcinoma (SCC). (7) Apart from basal cell
carcinoma, the differential diagnosis for peripheral ameloblastoma can include mucosal and
submucosal lesions that may occur in the oral cavity, such as pyogenic granuloma, peripheral
ossifying fibroma, peripheral cell granuloma, peripheral giant cell granuloma, odontogenic
gingival epithelial hamartoma. Hyperplastic responses to inappropriate dentures and post-
inflammatory lesions such as inflammatory papillary hyperplasia must also be considered.
Peripheral ameloblastoma showing continuity with surface epithelium must also be
distinguished from epithelial neoplasms such as squamous cell carcinoma or verucous
carcinoma.

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3. Bertossi D, Favero V, Albanese M, De-Santis D, Martano M, Padovano-di-Leva A, et

al. Peripheral ameloblastoma of the upper gingiva: Report of a case and literature review.
J Clin Exp Dent. 2014;6(2):9– 12.

4. Shetty K. Peripheral ameloblastoma: An etiology from surface epithelium? Case report

and review of literature. Oral Oncol Extra. 2005;41(9):211– 5.

5. Aslam-Pervez N, Lubek JE, Rose G, Papadimitriou JC. Peripheral Ameloblastoma: A

case report and concise review of literature. J Oral Maxillofac Surgery, Med Pathol.
2017;29(5):434– 7.

6. Hsu MH, Chiang ML, Chen JK. Unicystic ameloblastoma. J Dent Sci [Internet].
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7. Wu YC, Wang YP, Cheng SJ, Chen HM, Sun A, Chang JYF. Clinicopathological study
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