DIAGNOSIS AND MANAGEMENT AMELOBLASTOMA / ADAMANTINOMA

Ameloblastoma

A. Definition

Ameloblastoma is a tumor derived from cells - embryonic cells and are formed of cells - the cells berpontesial for the formation of enamel. These tumors are usually slow-growing, histologically benign but clinically malignant neoplasm is, occurs more frequently in the body or ramus of the mandible than the maxilla and can be encapsulated or not encapsulated. (1,3,4,5)


Definition of  Ameloblastoma ( amel, meaning enamel and   blastos, meaning germ) is a rare, benign tumor of odontogenic epithelium (ameloblasts, or outside portion) much more commonly appearing in the lower jaw than the upper jaw. It was recognized in by Cusack. This type of odontogenic neoplasm was designated as an adamantinoma  .
These  tumors are rarely malignant or metastatic (that is, they rarely spread to other parts of the body), and progress slowly, the resulting lesions can cause severe abnormalities of the face and jaw. Additionally, because abnormal cell growth easily infiltrates and destroys surrounding bony tissues, wide surgical excision is required to treat this disorder.

2. Etiology
At this time most experts consider the origin of ameloblastoma with a varied, although the stimulus that causes the tersebutbelum known. Furthermore, the tumor was probably formed from:
A. The remaining cells - the cells of the enamel organ, be it the rest of the dental lamina, the epithelial remnants or remnants Mallasez Hertwig wrapper contained in periondontal ligaments teeth will erupt.
2. Darikista epithelial odontogenic dentigerous cysts terutam
3. Enamel organ developmental disorders
4. Basal cells of the epithelial surface of the jaw
5. Heterotropik epithelium in other parts of the body, especially the pituitary gland.
Stankey and Diehl (1965) to review 641 cases of ameloblastoma, find bahwa108 cases of tumors inidihubungkan with tooth impaction and a follicular cyst (dentigerous). (6,7,8,9)
3. Clinical Overview
   Ameloblastoma is a benign tumor but it is a locally invasive lesion, where growth is slow and can be found after a few years before symptoms develop. Ameloblastoma could occur at an age when most common in people between the ages of 20 to 50 yearsand nearly two-thirds of patients younger than 40 years. Most of the reported cases showed that ameloblastoma is much more common in the mandible than the maxilla. Approximately 80% occur dimandibula and approximately 75% seen in the molar region and ramus, maxillary ameloblastoma is also most common in the molar region. (3,4,6,7,8,9)
At a very early stage, history of asymptomatic patients (without symptoms). Ameloblastoma grows slowly diving for years, and not found until radiographic oral examination on a regular basis. In the early stages, hard bone and normal-colored mucosa above. In the next phase, bone thinning and when teresobsi entirely protruding tumor was soft on the suppression and can have a picture berlobul on radiographs. With a magnifying power, the tumor can expand the area of ​​cortical bone and bone limits and decided to invade soft tissue. Patients become aware of progressive swelling, usually on the buccal mandible, can also experience the expansion of the lingual surface, a picture that is not common in odontogenic cysts. When penetrating the mucosa, tumor surface may be discolored and ulcerated due penguyahan. At a later stage, there may be pain in or around the tooth and neighboring teeth can shake even the date. (3,4,6)
Facial swelling and facial asymmetry is an important discovery of extra-oral. Asymmetric side depending on the main bone or bones involved. Tumor progression is painless unless there is nerve pressure or complications secondary infection. Sometimes letting ameloblastoma patients survived for several years without treatment and in those cases can lead to ulcers, but the expansion of ulcerative type of carcinoma growth is not the case. In advanced stages, a large increase in size can cause penguyahan and swallowing. (4,6,9)
It should be a concern, that the trauma is often associated with the development of ameloblastoma. Some studies suggest that the tumor is often preceded by a tooth extraction, cystectomy, or some other traumatic event. As with other tumor cases of tooth extractions often affects tumor (tumor that causes loss of teeth) instead of the cause itself. (9)
This tumor is at first solid but later became a cyst on spending stelatenya cells. Ameloblastoma is a benign tumor but because of the nature of the invasion and tumor recurrence is becoming more serious tumors and potential complications are feared would otherwise be removed completely. But it has been stated that very few cases have been reported metastasenya. (3.6)

4. Histopathologic picture
A number of histologic patterns described in ameloblastoma. Some of them show a single histologic type, others may show some histological patterns within the same lesion. Common to all these types are polarized cells surrounding a nest shaped like a proliferates into a similar pattern to ameloblas of enamel organ. Roughly speaking, ameloblas consists of a rigid network of grayish showing cystic areas containing clear yellow fluid. (10)
Amelobalstoma secar closely resemble the enamel organ, although the different cases can be distinguished from their resemblance to odontogenesisyang different stages. Because the histologic patterns of ameloblastoma varies widely, a number of different types are generally described (9):
     
4.1 Follicular
Follicular ameloblastoma consisted of epithelial islands with two distinct components. The central part of the island contains a raft of epithelial cells are complex and loosely resembling stelate reticulum of the enamel organ. Around these cells is a layer of high columnar cells with a nucleus and a single berpolarisai away from the basement membrane. Cystic degeneration of the central section generally occur epithelial islands, leaving a clear space and bounded by solid stelate cells. Groups of epithelial cells separated by a fibrous tissue steoma. (7,8,9)

4.2 Pleksiform
At pleksiform ameloblastoma, tumor cells that resemble ameloblas arranged in an irregular mass, or more frequently as a network of thread-related cells. Each of these masses or strands is limited by a layer of columnar cells and is likely to be found between the layers of cells that resemble stalate reticulum. However, the network looks less like stalate reticulum menonjolpada pleksiform type ameloblastoma than in the follicular type ameloblastoma and when it is composed entirely found in the peripheral areas of cystic degeneration. (7,8,9)

4.3 Akantomatosa 

In ameloblastoma akantomatosa, cells placed stalate reticulum had squamous metaplasia, sometimes with the formation keratinpada pualu-central part of tumor islands. Sometimes, epithelial pearls or keratin pearls may be found. (9.11) 

4.4 Granular

In the granular cell ameloblastoma, there are features of the transformation of the cytoplasm, usually cells resembling reticulum stelate thus having the form of eosinophils, a very coarse granular. These cells often spread to involve the columnar cells or peripheral kuboidal. Ultrastructural studies, as did Tandler and Rossi, indicating that the cytoplasmic granules showed lysosomal the cell components which can not be recognized. Hartman has reported a series of cases of granular cell ameloblastoma and estimates that this type of granular cell lesions appear to be aggressive and tend to recur unless the surgery is appropriate at the first operation. (7.9)

Although the different histologic patterns have given rise to a variety of names to describe these lesions, but the clinical picture is similar. (6)

Ameloblastoma perkembangnnya sometimes found within the wall of odontogenic cysts. Depending on the stage of tumor progression, the various terms used to describe the changes as intarluminal, murals and amelobalstoma invasive.

The term used when amelobastoma intraluminal ameloblastoma develops into the lumen and not disturb the cyst wall.

The term used when a mural ameloblastoma amelobalstoma found a cyst wall and is still limited by the walls of the cyst. In the two situations were completely tumor is confined within the cyst, a surgical approach that is more frequent konversatif.

Invasive ameloblastoma term used when the tumor has spread out and cyst wall into the adjacent bone or soft tissue into or when the tumor develops from the epithelium other than the epithelial cysts. A more radical surgical procedure is often recommended for this condition. (7)

5. Radiography picture

Ameloblastoma on radiography is classically described as a lesion that resembles kistamultilokular in the jaw. Involved bone is replaced by a variety of regions bounded radiolucent lesions clear that member a form like a honeycomb or soap bubble. The possibility also exists that clearly shows radiolucent abut a single space. Ameloblastoma produces a wider gear resobsiakar contact with lesions.

There are two types of ameloblastoma that showed the typical picture of a rontgenografi namely:

A. Ameloblastoma monokistik

Seen as a single cyst-like cavity radicular cyst or follicular outer lines are not smooth, rounded but irregular and berlobul and the perifernya often jagged. This type is rarely encountered.

2. Ameloblastoma multikistik

This type produces a typical picture of a rontgenografi. There is a formation of multiple cysts are usually cylindrical and separated from each other by trabecular bone. This round cyst varies in size and number.

Although various types of ameloblastoma radiografidari picture possible, but most have a distinctive image in which a number of loculation found. If ameloblastoma occupy a single cavity or monokistik, the radiographic diagnosis becomes more difficult because of its resemblance to the dentigerous cyst epithelium bounded danterhadap residual cyst in the jaw. On the verge of a cyst epithelium, the tissue is more radiopaque than the liquid, but in many ways the difference is so light to be invaluable diagnostic.

Ameloblastoma radiographically resemble dentigerous cysts have been reported by Chan (1933), Bailey (1951) and others. A cyst cavity in the mandible where the crowns of unerupted second molar. Spherical cavity shape, and position limits are regularly associated with unerupted teeth thought to be a dentigerous cyst, but on microscopic examination, the content of the cavity is shown as an ameloblastoma.

An ameloblastoma that radiographically resemble residualberbatas epithelial cysts. The shape is round and has clear boundaries and orderly. Some minor damage near the top of the alveolar bone to give a picture that can be interpreted radiolucent well as damage after surgery.

Chan (1933) mentions the possibility that an ameloblastoma can be formed from the follicles are not completely removed during the removal of unerupted teeth danmungkin ameloblastoma in this state is formed from the source.

With the increasing size of the lesion, the cortex is involved, vandalized and invaded the soft tissues. In this case, ameloblastoma differ from fibrous lesions that expand and fibroosseus but tends to retain the cortex.

Although X-ray examination of significant value to determine the expansion of its involvement, but this is not always a definite diagnostic value. Small lesions are difficult to interpret, and in some cases have to rely on pathologic examination should be made in all suspected cases.

Diagnosis

a. Clinical examination

At a very early stage, history of asymptomatic patients. Tumors grow slowly over the years and found on the X-ray images. In the next phase, bone thinning and when teresobsi entirely protruding tumor was soft on pressing. Degan scalable, so it can expand tumior cortical bone area and decided to limit the bone and soft tissue invasion. Patients become aware of a swelling, usually on the mandibular buccal and lingual surface can undergo expansion, an image that is not common in odontogenic cysts. One of the most frequent subject is the angle of the mandible with the widespread growth karamus and into the mandibular body. It can be seen the extra-oral facial swelling and facial asymmetry. Side asymmetry tergantungpada bones are involved. Tumor progression is painless unless there is an emphasis on neurological complications or secondary infection. Increasing the size of the tumor can cause chewing and swallowing.

b. Radiological examination

Appears radiolucent or multilokular unilokular with demarcated edges. These tumors can also show the grooved edge of the cortical, and resobsi multilokular a picture of the tooth root is in contact with the gear shift to the lesion without severe than in the cyst. Involved bone is replaced by a variety of regions bounded clear radiolucent lesions and member of a shape such as honeycomb or soap bubble. The possibility also exists that clearly shows radiolucent abut a single space.

c. Examination of anatomic pathology

The content of these tumors can be hard or soft, but usually there is a coffee-colored mucoid fluid or yellowish. Kolesterin rare. There are two types of macroscopic solid type (solid) and cystic types. Type consists of solid soft tissue mass, which is white-gray or gray-yellowish. Cystic type have a thicker layer of connective tissue as compared to a simple cyst. Cystic areas are usually separated by fibrous tissue stroma, but sometimes the bone septum can also be found. Consists of microscopic tumor tissue with epithelial cells arranged like a fence surrounding stromal tissue containing stelate reticulum cells, some showed cystic degeneration.

Diagnosis

Of clinical examination, radiological and pathological anatomidapat that the tumor was diagnosed as ameloblastoma. Usually not difficult to diagnose this tumor growth with the aid of rontgenogram and clinical data, no lymph node involvement.

Management

Ameloblastoma has a reputation for relapse after dsingkirkan.Hal is due to the nature of the lesion is invaded by llokal the exclusion is not adequate.

A. Enucleation

Enucleation is the removal of the tumor to normal tissue erode existing unikistik disekelilingnya.Lesi, especially the smaller enucleation only and should not require excessive care.

2. Block excision

Most of ameloblastoma should be excised than enukleasi.eksisi in a block of bone in the jaw kontunuitas ameloblastoma is recommended if kecil.Apabila to sacrifice considerable mandibular ameloblastoma involved and when it does not cause perforation of the oral mucosa, the possibility of a block excision with bone graft immediately.

3. Peripheral osteotomy

Peripheral osteotomy is a procedure that complete tumor mengeksisi but at the same time a distance is maintained to preserve the bone so kontuinuitas jaw deformity, disability and the need for cosmetic surgery and resorasi sekundser prosthetics can be avoided. The procedure is based on observations which cortical inferior border of the body horizontal, the posterior border of the ascending ramus and the condyles are not as a whole in the process of tumor invasion. The region is resilient and strong because it consists of a dense cortical bone. Bone regeneration will start from the area although only a thin rim of bone is left.

4. Tumor resection

Resection of the tumor itself from total resection and segmental resection including bemimaksilektomi and bemimandibulektomi.Apabila ameloblastoma was found on examination, as well as any changes can be found again and a new lesion activity after the surgery then the case should be resected.

5. Cautery

Cautery or electrocoagulation is draining lesions, including a number of normal tissues disekelilingnya.Kauterisasi not commonly used as a form of primary therapy, but Meru [feed more effective therapies dibandind curettage.

REFERENCES

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2. Ernawati MG. Hubungan Gigi Impaksi Dengan Ameloblastoma. KPPIKG X. FKG UI. Jakarta, oktober 1994 : 29-32.

3. Archer WH. Oral and Maxillofacial Surgery. Vol I; 5th ed. Philadelphia : W B. Saunders Co. 1975 : 273, 735 – 9.

4. Cheraskin E, Langley LL. Dynamic of Oral Diagnosis. 1ST  ed. Chicago : The Year Book Publiser Inc. 1956 : 119 – 22.

5. Harahap S. Gigi Impaksi, Hubungannya dengan Kista dan Ameloblastoma. Dentika Dental Journal. Vol 6. No 1. FKG USU. Medan, 2001 : 212 – 6