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Oral Surgery

Authors:-Dr. Arti

Abstract:
Ameloblastoma is a true neoplasm of odontogenic epithelial origin. It is the second most common odontogenic neoplasm. Its incidence combined with its clinical behavior, makes ameloblastoma the most significant odontogenic neoplasm. Unicystic ameloblastoma refers to those cystic lesions that show clinical, radiographic, or gross features of a mandibular cyst, but on histologic examination show a typical ameloblastomatous epithelium lining part of the cyst cavity.1 It accounts for 5-15% of all intraosseous ameloblastomas. This article report a case of 30-year-old female with unicystic ameloblastoma associated with right impacted mandibular molar.

Introduction
Ameloblastoma develops from epithelial cellular elements and dental tissues in their various phases of development. It is a slow-growing, persistent, and locally aggressive neoplasm of epithelial origin. It is the second most common odontogenic neoplasm. The tumor is often asymptomatic presenting as slowly enlarging facial swelling. It is often associated with an unerupted third molar 2. It may be detected during the course of routine radiography. The vast majority of ameloblastomas arise in the mandible, and the majority of these are found in the angle and ramus region. There are three forms of ameloblastomas, namely multicystic, peripheral, and unicystic tumors3. Multicystic ameloblastoma is the most common variety and represents 86% of cases. Peripheral tumors are odontogenic tumors, with the histological characteristics of intraosseous ameloblastoma that occur solely in the soft tissues covering the tooth-bearing areas of the jaws. Unicystic tumors include those that have been variously referred to as mural ameloblastomas, luminal ameloblastomas, and ameloblastomas arising in dentigerous cysts 4. Various treatment methods for the lesion in relation to many factors, such as the tumour size and location, have been suggested. These include enucleation, marginal resection and aggressive resection. When a diagnosis of ameloblastoma is obtained, the treatment must be aggressive and radical. The goal of treatment of ameloblastoma is to achieve complete excision and appropriate reconstruction. We present a case of a large unicystic mandibular ameloblastoma in a 30 year old female.

Case Report
A 30 year old female came with a chief complaint of a slowly growing swelling on the right side of the face since one year (Figure1). Initially, the swelling was small in size but has gradually increased over a period of time to attain the present size. It was not associated with pain or difficulty in opening the mouth, chewing or articulating (Figure2). No abnormality was detected upon systemic examination. On inspection, a diffuse swelling measuring approximately 7x4 cms in size is present on the right side of face extending anteroposteriorly 2 cms from the symphisis mentii to the ramus of mandible and superoinferiorly from alatragal line to the inferior border of mandible. The surrounding oral mucosa was normal. On palpation, the inspection findings were confirmed. The swelling was non tender and hard in consistency. The lymph nodes were non palpable. An orthopantomogram (OPG) was done, which showed large cystic lesion in the right side of mandible. The patient was taken up for enucleation and marsupialisation (Figure3) and after that for surgery under general anaesthesia (Figure 4, 5). A segmental mandibulectomy was done (Figure 6) and reconstruction plate was put (Figure7). The resected specimen (Figure 11, 12) was sent for histopathological examination and it revealed features consistent with that of the unilocular ameloblastoma.
 

Fig 1: Preoperative picture-Swelling right side of face Fig 2: Intraoral view preoperatively Fig 3: Enucleation and Marsupialization done
Fig4:Intraoperatively under General anesthesia Fig5:Intraoperatively under General anesthesia Fig 6: Segmental mandibulectomy done
Fig 7: Reconstruction plate put Fig 8: Suturing done after placement of reconstruction plate intraoperatively Fig 9: Postoperative view of suturing
Fig 10: Postoperative OPG Fig 11:Resected specimen Fig12: Resected specimen



Discussion
Unicystic ameloblastoma, a variant of ameloblastoma was first described by Robinson and Martinez 5 .Unilocular ameloblastoma is a rare type of ameloblastoma, accounting for about6% of ameloblastomas. It usually occurs in a younger age group, with about 50% of the cases occurring in the second decade of life. More than 90% are located in the mandible 6-8. Between 50 and 80% of cases are associated with tooth impaction, the mandibular third molar being most often involved. Patients most commonly present with swelling and facial asymmetry, pain being an occasional presenting symptom. Mucosal ulceration is rare, but may be caused by continued growth of the tumor. Small lesions are sometimes discovered more on routine radiographic screening examinations or as a result of local effects (like tooth mobility, occlusal alterations and failure of eruption of teeth) produced by the tumor 9. Histologically, the minimum criterion for diagnosing a lesion as Unilocular ameloblastoma  is the demonstration of a single cystic sac lined by odontogenic (ameloblastomatous) epithelium often seen only in focal areas. Unilocular ameloblastoma should be differentiated from odontogenic cysts because the former has a higher rate of recurrence than the latter 10 According to Reichart relative frequency has been reported as between 5% and 22% of all subtypes of ameloblastomas. No data is available concerning prevalence and incidence of unicystic ameloblastoma. There have been many debates regarding whether unicystic ameloblastoma develops or arises in an existing cyst 11. Leider et al,proposed three pathogenic mechanisms for the evolution of Unicystic ameloblastoma: reduced enamel epithelium, from dentigerous cyst and due to cystic degeneration of solid ameloblastoma. 11 .It often involves an impacted tooth and the focal area of the cystic tumor lining is often composed of a nonspecific, thin epithelium that mimics the dentigerous cyst lining. 13 In the present case the association with an impacted tooth and presence of non specific thin epithelium lining in focal areas of cystic tumor supporting the second hypothesis i.e. arising from preexisting dentigerous cyst. Based on the character and extent of tumor cell proliferation within the cyst wall, several histologic subtypes of unicystic ameloblastoma are recognized, which include simple cystic type, intraluminal and mural type. Gardner in 1984 has pointed out that there is a difference in biological behaviour between these lesions 14. Till now no recurrence has been seen and patient is still regularly being followed up. Perhaps the most important consideration regarding unicystic ameloblastoma is that of biologic behaviour. It has been widely stated that these lesions are less aggressive than their solid or multicystic counterparts and should be treated by enucleation or curettage. However, Gardner has pointed out that there is a difference in biological behaviour between those lesions that are simply cystic or show intraluminal proliferation and those in which the epithelium penetrated and breaches the fibrous wall, therefore having the capacity to invade the cancellous bone. It has been suggested that recurrence following conservative surgery is more likely to occur in the third group therefore these lesions should be treated in the same manner as solid ameloblastomas. 15 Whatever surgical approach the surgeon decides to take, long-term follow-up is mandatory, as recurrence of unicystic ameloblastoma may be long delayed .16
 

CONCLUSION:
Unicystic ameloblastoma is a tumor with a strong propensity for recurrence, especially when the ameloblastic focus penetrates the adjacent tissue from the wall of the cyst. The ability to predict this potential occurrence prior to surgery would greatly enhance therapeutic strategies for reducing the incidence. Hence, the Pathologist should examine the tissue sections carefully in an attempt to determine whether ameloblastoma has penetrated the wall of the cyst or not so that the complications can be minimized

References

  1. Kalaskar R, Unawane AS, Kalaskar AR, and Pandilwar P. Conservative management of unicystic ameloblastoma in a young child: Report of two cases. Contemp Clin Dent. 2011 Oct-Dec; 2(4): 359–363.
  2. Gerzenshtein J, Zhang F, Caplan J, Anand V, Lineaweaver W. Immediate mandibular    reconstruction with microsurgical fibula flap transfer following wide resection for ameloblastoma. J Craniofac Surg. 2006;17(1):178–182.
  3. Philipsen HP, Reichart PA. Odontogenic tumors and allied lesions. Quintessence Pub. Co. Ltd; 2004. Classification of odontogenic tumors and allied lesions; pp. 21–3.
  4. Chana, Jagdeep S, Yang-Ming Chang, Wei, Fu-Chan, Shen, Yu-Fen, Chan Chiu-Po, Lin Hsiu-Na, Tsai Chi-Ying, Jeng Seng-Feng. Segmental mandibulectomy and immediate free fibula osteoseptocutaneous flap reconstruction with endosteal implants: An ideal treatment method for mandibular ameloblastoma. Plast Reconstr Surg. 2004;113(1):80–87.
  5. Robinson L, Martinez MG. Unicystic ameloblastoma: A prognostically distinct entity. Cancer 1977;40:2278-85
  6. Philipsen HP, Reichart PA. Odontogenic tumors and allied lesions. London: Quintessence Pub. Co. Ltd; 2004. Unicystic ameloblastoma; pp. 77–86.
  7. Pizer ME, Page DG, Svirsky JA. Thirteen-year follow-up of large recurrent unicystic ameloblastoma of the mandible in a 15-year-old boy. J Oral Maxillofac Surg. 2002;60:211–5.
  8. Navarro CM, Principi SM, Massucato EM, Sposto MR. Maxillary unicystic ameloblastoma. Dentomaxillofac Radiol. 2004;33:60–2.
  9. Roos RE, Raubenheimer EJ, van Heerden WF. Clinico-pathological study of 30 unicystic ameloblastomas. J Dent Assoc S Afr. 1994;49:559–62.
  10. Konouchi H, Asaumi J, Yanagi Y, Hisatomi M, Kawai N, Matsuzaki H, Kishi K. Usefulness of contrast enhanced-MRI in the diagnosis of unicystic ameloblastoma. Oral Oncol. 2006;42:481–6.
  11. Ackermann GL, Altini M, Shear M. The unicystic ameloblastoma: A clinicopathological study of 57 cases. J Oral Pathol 1988;17:541-6
  12. Leider AS, Eversole LR, Barkin ME. Cystic ameloblstoma. Oral Surg Oral Med Oral Pathol 1985;60:624-30.
  13. Li TJ, Wu YT, Yu SF, Yu GY. Unicystic ameloblastoma: A clinicopathologic study of 33 Chinese patients. Am J Surg Pathol 2000;24:1385-92
  14. Gardner DG. A pathologist's approach to the treatment of ameloblastoma. J Oral Maxillofac Surg 1984;42:161-6.
  15. Thankappan S, Thomas V, Kandamparambil S, Nair S. Unicystic ameloblastoma: 3 case reports and review of literature. J Indian Acad Oral Med Radiol 2008;20:65-70.
  16. Li TJ, Kitano M, Arimura K, Sugihara K. Recurrence of unicystic ameloblatoma: A case report and review of the literature. Arch Pathol Lab Med 1998;122:371-4.

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Author : Dr. Prit Shah

Introduction
Odontomas are the most common odontogenic tumor. They are considered to be hamartomas rather than neoplasms, and are composed of the tissues native to teeth: enamel, dentin, and cementum and pulp tissue. Odontomas are further sub-classified based upon their gross and radiographic features into compound (small tooth like structures) or complex (a conglomeration of dentin, enamel and cementum).

Case report -
A 14 year old male patient complained of slow growing enlargement of the buccal cortical plate with missing teeth. On radio graphical assessment revealed a presence of radio opaque masses resembling odontome. Surgically impacted teeth and masses excised, Histopathological report confirmed compound odontome. Patient reviewed after 1 month. 6 months. No history of recurrence and wound healing satisfactory.

Surgical management


EXCISION OF LESION AND SURGICAL DISIMPACTION OF CANINE
Discussion
Odontomas are the most common odontogenic tumor. They are considered to be hamartomas rather than neoplasms, and are composed of the tissues native to teeth: enamel, dentin, and cementum and pulp tissue.
It was in 1867 that Paul Broca first used the term “Odontoma.” Broca defined the term as “tumors formed by the overgrowth of transitory or complete dental tissues”.

Classification
According to W.H.O. classification, 1 Odontomas can be divided into three groups:
1. Complex odontome - when the calcified dental tissues are simply arranged in an irregular mass bearing no morphologic similarity to rudimentary teeth.
2. Compound odontome - composed of all odontogenic tissues in an orderly pattern that results in many teeth-like structures, but without morphologic resemblance to normal teeth.
3. Ameloblastic fibro-odontome - consists of varying amounts of calcified dental tissue and dental papilla like tissue, the later component resembling an ameloblastic fibroma. The ameloblastic fibro-odontome is considered as an immature precursor of complex odontome. According to Thoma and Goldman: 5
• Geminated composite odontomes - two or more, more-or-less well-developed teeth fused together.
• Compound composite odontomes - made up of more-or-less rudimentary teeth.
• Complex composite odontomes - calcified structure, which bears no great resemblance to the normal anatomical arrangement of dental tissues.
• Dilated odontomes - the crown or root part of tooth show marked enlargement.
• Cystic odontomes - an odontome that is normally en-capsulated by fibrous connective tissue in a cyst or in the wall of the cyst.

Types
There are essentially two types of odontomes:
  1. Complex composite odontome;
  2. Compound composite odontome. A new type known as Hybrid odontome is also reported by some authors “Complex Composite Odontome”

Etiology and Indication for removal of the tumour
The etiology of odontoma is not known but environmental causes such as infection, trauma, family history and genetic mutation are hypothesized.
Although the Odontomas erupting in the oral cavity is controversial, the reason is attributed to the eruptive forces of the apparently impacted teeth and in cases of absence of teeth, the reasons could possibly be the resorption of alveolar ridge exposing the odontoma, sequestration of overlying bone, alveolar bone remodeling in young adults, reactive growth of the capsule surrounding odontoma in elderly patients. Odontomas have been associated with trauma during primary dentition as well as with inflammatory and infectious processes, hereditary anomalies (multiple Odontomas in Gardner syndrome, Hermann's syndrome), odontoblastic hyperactivity and alterations in the genetic components responsible for controlling dental development Association of this lesion with the unerupted tooth is high and three quarters of impacted teeth related to Odontomas can erupt after removal of the odontoma. Another reason for removing Odontomas is their association with cysts in a significant number of cases (27.6%).

Clinical features
The complex odontoma constitute 5-30% of all odontogenic tumors and are mostly found in the posterior mandible and compound odontoma in anterior maxilla. They are seen with unerupted teeth in 10-44% and about 17% of them are associated with impacted maxillary lateral incisors. Females are affected marginally more than male (1.5:1). Majority of cases (84%) are seen below 30 years but are seen in any age group with peak incidence in second decade. Less than 10% are found in patients above 40 years of age. and most lesions are detected on routine radiographs.
Odontomas are generally asymptomatic, often associated with delayed eruption or impaction of permanent teeth and retained primary teeth. In some occasional cases, pain, infection, regional adenopathies, alveolar bone expansion and tooth displacement may be present.
Odontomas can also manifest as part of syndromes, such as Gardner syndrome, basal cell nevus syndrome, familial colonic adenomatosis, Tangier disease or Hermann syndrome.
In the present case patient was asymptomatic few month back , but later complain of swelling on the left side which on radiographic diagnosis (OPG) ruled out to be multiple harmatomatous radio opaque body around the tooth in glomerulated aggregates.

Management
Odontomas are circumscribed, encapsulated tumors that can be removed successfully by conservative surgery. Spontaneous eruption of the impacted tooth after removal of the obstruction like odontoma has been reported by many authors.
A less conservative approach is advocated by others with exposure of the unerupted tooth at the time of surgery and placement of bonded attachment and ligature/e-chain for orthodontic traction, to facilitate rapid eruption.
This approach, however, may result in poor gingival margin, inadequate gingival tissue attachment and a discrepancy of gingival level between the exposed tooth and its neighboring teeth.
Hence, in the present case, we advocated a more conservative approach of removal of odontoma and its fibrous capsule. Along with that, we removed bone unerupted canine , replaced the flap back in position.

Recurrence rate and association with tumors
A clinical case of CCOT associated with odontoma and a missing deciduous tooth in a 3-year-old female patient. Described by Gorlin et al. in 1962, the calcifying cystic odontogenic tumor (CCOT) may be associated with unerupted teeth, ameloblastomas, adenomatoid odontogenic tumors, and, in many cases, with odontomas.
Prognosis is very favourable because it has no to minimal recurrence.

Reference
  1. Hidalgo-Sánchez O, Leco-Berrocal MI, Martínez-González JM. Metaanalysis of the epidemiology and clinical manifestations of odontomas.Med Oral Patol Oral Cir Bucal.2008;13:E730–42.
  2. Shafer's text book of oral pathology.5th ed. Amsterdam: Elsever; 2006. Cysts and tumors of odontogenic origin.Disturbances of development and growth. Shafer, Hine, Levy; pp. 357–432.
  3. Batra P, Duggal R, Kharbanda OP, Parkash H. Orthodontic treatment of impacted anterior teeth due to odontomas: A report of two cases.J Clin Pediatr Dent.2004;28:289–94.
  4. Prætorius F, Piattelli A. Odontoma, Odontogenic tumors. In: Barnes L, Eveson JW, Reichart P, Sidransky D, editors.WHO Classification of tumors. Pathology and Genetics of Head and Neck Tumors.Lyon France: IARC Press; 2005. pp. 310–11.
  5. Yeung KH, Cheung RC, Tsang MM. Compound odontoma associated with an unerupted and dilacerated maxillary primary central incisor in a young patient.Int J Paediatr Dent.2003;13:208–12.
  6. Jafarzadeh H, Abbott PV. Dilaceration: Review of an endodontic challenge.J Endod.2007;33:1025–30

Author: Dr. MOHAMMAD AKHEEL

Abstract :
Foreign body aspiration can be life threatening clinical situation. Aspiration of foreign body is most common in young children and mentally challenged patients leading to life threatening complications. It can also occur in patients with altered consciousness, exposed to intravenous sedation. Usually symptoms go unnoticed for months to years, if present most of the foreign body can be skillfully be extracted by using appropriate techniques.  We report here a case of incidental identification of a tooth in the right bronchus following a road traffic accident. This article emphasis careful examination , diagnosis and treatment options available for the retrieval of  aspirated foreign body.

Introduction :
Aspiration of tooth is a life threatening situation, relatively common following a maxillofacial trauma.1Aspirated foreign body enters the right bronchus due to its anatomical configuration. It poses a serious problem because the edges of the tooth might damage the mucosal lining. It most commonly occurs in children, mentally challenged patients and patients with altered consciousness disorders.2Aspiration is relatively uncommon then ingestion of foreign bodies.3 The purpose of this case report is to present a case of accidental aspiration of tooth following a maxillofacial trauma, the treatment options available and to emphasize careful oral examination of the oral cavity in a maxillofacial trauma patient.

The earliest symptoms that commonly occur are coughing, choking, wheezing, dyspnoea, laryngeal oedema, perforation and pneumothorax. The purpose of this case report is to emphasize the importance of aspiration of teeth which can occur following a maxillofacial trauma or during any emergency treatment provided to protect the airway of the patient.

Case Report :
A 47 year old male patient was brought to department of emergency following a severe maxillofacial trauma and head injury. Patient was unconscious from 15 min with 2 episodes of vomiting after the accident. Patient was planned for oroendotracheal intubation following low Glasgow Coma Scale. Oral suctioning was done and foreign debris was removed along with 2 fractured crowns of first and second premolar of right side of mandible.  He had a fracture of right angle and left parasymphysis of mandible, dentoalveolar fracture of anterior maxilla, right zygomatic complex fracture and right parietal bone fracture. Oroendotracheal intubation was done to stabilize the patient.  Routine investigations were carried which included complete surgical profile, CT brain, chest x ray, CT pns etc. On radiological interpretation of chest x ray, there was a foreign body in the right bronchus of the lung. It was identified as tooth which was missing from right posterior molar socket of the mandible. Bronchoscopy was planned for retrieval of the tooth but patient died due to excessive subdural hematoma and complete transaction of second and third cervical vertebrae.



Discussion :
Aspiration of tooth most commonly occurs following maxillofacial injuries or procedures.2 It is most commonly seen in children, elderly patients, mentally challenged patients and patients suffering from neurological disorders.3 Aspiration of tooth represents 0.4% of all the foreign bodies.4 Most commonly seen in children which can go unnoticed for months to years causing severe morbidity.5 It is most commonly seen following a dental trauma in patients with loss of consciousness who are most often associated with head injuries. Before intubating the patient, the oral cavity has to be thoroughly inspected to remove any mobile teeth. In our case the tooth was aspirated by the patient since he was unconscious. There could be another reason that forceful intubation might have pushed the teeth in bronchus region. Therefore any resistance during intubation has to be evaluated for any foreign body entering the airway track.

 Complications include immediate and late. Immediate complications include respiratory distress, laryngeal odemea, and pneumothorax. Late complications include lung abscess, pneumonia and asthma.6 Management of aspirated foreign body is done by taking a chest X-ray (lateral and frontal) and CT thorax which reveals a radiopaque foreign body object. It is believed that these foreign body are dislodges more frequently in right bronchus due to its more vertical disposition.

Management is by bronchoscopy which is done under general anesthesia to retrieve the foreign body. Based upon the location of the aspirated object rigid or flexible bronchoscopy can be performed. It is safe technique and provides a good visualization for manipulation of the objects. Aspirated foreign body must be removed within 24 hours to prevent acute life threatening problem and making bronchoscopy technically more difficult. If bronchoscopy fails to remove the tooth, open surgical approach called thoractomy can be done.7

Conclusion :
Careful evaluation of the patient who has maxillofacial injuries has to be done before intubation with thorough examination of oral cavity to rule out aspiration of any fractured tooth, restorations, and dentures. Oral and maxillofacial surgeons who are a part of trauma team plays a vital role to retrieve any foreign bodies from oral cavity , remove all mobile teeth , and temporarily reduce the fracture segments for a comfortable oral intubation.

References :
1. Basuglu OK et al. Pulomonary aspiration of a two unit fridge during deep sleep, J Oral Rehabil 2005;32(6):461-63
2. Leith R et al .Aspiration of an avulsed primary incisor: a case report. Dent Traumatol. 2008; 24:24-6.
3. Gitlin DF et al; Foreign body ingestion in patients with personality disorders. Psychosomatics. 2007; 48:162-6.
4. Brunello DL et al .A denture swallowed: case report. Aust Dent J 1995;40(6):349-51
5. Wiseman NE et al .The diagnosis of foreign body aspiration in childhood. J Pediatric Surg 1984; 19:531-535.
6 .Fields RT et al Aspiration and ingestion of foreign bodies in oral and maxillofacial surgery; a review of literature and report of five cases. J Oral Maxillofac Surg. 1998; 56:1091-8
7. R Ulku et al .Open surgical approach for a tooth aspirated during dental extraction: A case report. Aust Dental J 2005;50(1):49-50

 

Authors : Dr. Fidoski Jasmin, Dr. Spirov Vancho,Dr. Jun Woo Park

Abstract:

Thanks to its thermo-coagulating effect, he was the first laser used in dental practice for surgical procedures.

Absorption of Nd: YAG laser light in water is approximately 10,000 times smaller than that of Er: YAG laser. Because of that, it can not be used for the ablation of hard dental tissues. But in soft tissues, the depth of penetration of Nd: YAG laser light tissue is optimal for cutting and for simultaneous coagulation.
Nd: YAG wavelength is mainly absorbed by hemoglobin, melanin and other organic compounds. It acting on the tissue through photo thermal effect. When enough energy is applied, the tissue is dry and it is removed with ablation.

The size of the surface exposed to the laser depends on the diameter of the optical fiber of delivering unit of fiber optic beam, distance of the delivering unit of fiber-optic beam from the tissue and the speed of movement of the delivering unit of fiber-optic beam. Much smaller diameter, the greater its intensity per unit area.

The farther from the fiber tissue, the greater is the diameter of the beam and lower on unit area. How faster movement of the delivery of the beam is, the less energy is transferred to the exposed surface, resulting with less effect on removal.

Purpose of paper:

Our goal was to show successful treatment with Nd: YAG laser as a modern solution for the treatment of vascular malformations of the lower lip.

Material and methods:

In the Clinic of Oral Surgery in Skopje we treated patient aged 14 years with vascular malformation of the lower lip, which has appeared on 11 months of age after blow (traumatic etiology). From history we learned that over time the change increases so make the patient comfortable aesthetic and also
unconsciously traumatize, which appears bleeding.

We used the Nd: YAG laser treatment of vascular malformations of the lower lip and we used a fiber optic tip diameter of 300 μm and the following parameters: 5 W and 100 Hz. During the entire procedure, the tip of the fiber was in direct or close contact with the surface of the tissue. Treatment was in one session and lasted 3 min, i.e. until the whitening of the treated surface appeared.

Results and discussion:

Vascular lesions of head and neck, including haemangiomas and vascular malformations are frequent, and quite different modes of therapy are used for their removal. In literature for treatment of these changes are used: local and systematic use of corticosteroids, embolization, excision , electrolysis, thermo cauterization, immunomodulation therapy with IN-alpa 2-a , and methods of observation and giving time for spontaneous involution of the change (which occurs exclusively in haemangiomas). In the last decade with the introduction of Nd: YAG laser have emerged new ways of managing vascular lesions.

Figure 1.Clinical review, diagnosed vascular malformation of the lower lip Figure 2.Treatment of the lesion with Nd; Yag laser (the change whitens
Figure 1.Clinical review, diagnosed vascular malformation of the lower lip Figure 2.Treatment of the lesion with Nd; Yag laser (the change whitens)
Figure 3.control after 3 days (edema present without pain) Figure 4.control after 2 weeks (started reepithelization on the edges of the
wound) Figure 5.control after 4 weeks, completely absence of vascular changes
Figure 3.control after 3 days (edema present without pain) Figure Figure 4.control after 2 weeks (started reepithelization on the edges of the wound) Figure 5.control after 4 weeks, completely absence of vascular changes

Conclusion:
Thanks to its coagulating and sterilizing effect (photocoagulation), a procedureon soft tissue is performed easily and efficiently with Nd: YAG laser than with
conventional techniques. So use of Nd: YAG laser, it is remove the negative consequences of conventional techniques and the absence of bleeding, preserve the aesthetic appearance of the patient and avoids the occurrence of scar tissue.

Authors : Dr. Alberto Benedetti, Dr. Popovski V, Iliev A., Dr. PopovicD., Dr. Fidoski Jasmin

Aim
The purpose of the study is presentation of diagnosis and operative treatment of buccal giant pleomorphic adenoma in 16 years old boy.

Introduction
Salivary gland neoplasms are relatively uncommon with an incidence between 0,4 to 13,5 cases per 100.000 and represent between 1 and 5 percent of all head and neck tumors.
Tumors of the salivary glands comprise 3% of all neoplasms (Grewal).

The majority of salivary gland neoplasms are benign with pleomorphic adenomas the most common, but the majority of minor salivary gland tumors are malignant (Spiro).
The incidence of salivary gland neoplasms in minor salivary glands varies from 9 to 22% (Magliulo, Spiro) approximately 8% of pleomorphic adenomas involve minor salivary glands(Grewal).
Tumors arising in minor salivary glands account for 22% of all salivary gland neoplasms and majority of them are malignant with only 18% benign, most frequent being pleomorphic adenoma.
Joshihara and Suzuki found that the majority of pleomorphic adenoma of minor salivary gland involve the palate followed by lip. The next common sites are the buccal mucose, tongue, tonsil, pharynx, retromolar area and nasal cavity.

Waldron et all. report 57,5% incidence of benign tumor in 426 cases of intraoral minor salivary gland tumor with most common pleomorphic adenoma. The palate was the most common site followed by the upper lip and buccal mucosa.

The majority of salivary gland neoplasms occur in the third to fifth decade slight female predominance.

Waldron-slight female to male preponderence at 1.59 to 1 and the mean age of patients is 49.8 years versus 55.2 years for patients with malignant tumors.

Lesions at these three sites (palate, upper lip, and buccal mucosa) account for 76.1% of oral minor salivary gland tumors.

Diagnosis

Symptoms
Minor salivary gland pleomorphic adenoma are usually slow-growing, firm single mobile, solitary, painless and nodular mass covered with normal appearing mucosa.

Radiographic
  • Ultrasound
  • Computerized tomography (CT)
  • Magnetic resonance imaging (MRI).
  • Aspiration (fine needle aspiration (FNA)
  • Use large bore needle
  • Biopsy
  • May consider frozen section at the time of surgery

Treatment

Operative treatment with wide and complete surgical excision is method of choice for minor salivary gland pleomorphic adenoma.

Case

A 16year-old boy sought medical attention for a large growth on the left side of the face in November 2007. The painless swelling had gradually increased in size over a period in excess of 3 years.

The last six months he felt that tumor had extremly growth in size. Examination showed the swelling to be related to the left buccal side and was oval in shape. The growth measured 6.0 × 5.5 x3.5cm in dimensions and was firm in consistency.

It was attached to the deeper structures in maxillary and nasal bone, but movable. The overlying mucosa and skin were normal in appearance.On intraoral examination there was firm painless solitary mobile mass nontender to palpation well-encapsulated and clearly demarcated from normal tissue.

The lesion was clinically diagnosed as a benign tumor arising in the parotid gland and fine needle aspiration cytology diagnosed the lesion as a pleomorphic adenoma (PA).

Computerised tomography shows benign tumor with contact of mandibular body involving sphenoidal bone and sinus maxillaris, mandibular body, pterygoid lateral and temporal muscle with subbuccal and submasseterical position. X-ray pictures with laboratory tests have been also performed.

The tumor was subsequently excised under general anaesthesia along with total extirpation with intraoral approach and preservation of nearby bone structures. One week post-operatively patient recovered fully. Very good aesthetic and functional results were achieved.

Macroscopically, the excised specimen was ovoid in shape and 6 × 5,5 × 3,5 cm in dimensions and weighed 42 g.

Microscopically, the tumor was composed of strands and islands of epithelial and myoepithelial cells with many chondrocites sometimes in a myxomatous components. Some areas showed solid sheets of epithelial cells with squamous metaplasia. There was no evidence of malignancy and the tumour was diagnosed as a PA.

Clinical features
  • Debate about pathogenesis, aggressive behavior and treatment.
  • PA - most common benign tumor of the minor salivary glands.
  • Peak incidence in the third to fifth decade
  • Most common site palate followed by the upper lip, and buccal mucosa.

Symptoms
  • Slowly growing,asymptomatic intraoral swelling in early period.
  • Pain,trismus,sensory deficits,infection, numbness,toothache,ill-fitting dentures,malocclusion,ulcerations,draining sinuses,nasal obstruction,or even epistaxis may bring the patient.
  • Pathological fracture is very unusual finding.
Radiographic
  • Ultrasound
  • Computer tomography (CT)
  • Mmagnetic resonance imaging (MRI).
  • Aspiration
  • Use large lumen needle
  • Biopsy
  • May consider frozen section at the time of surgery

Histology
  • Strands and islands of epithelial and myoepithelial cells
  • Many chondrocites sometimes in a myxomatous components -corrugated surface layer of parakeratin
  • Aareas with solid sheets of epithelial cells with squamous methaplasia.
Treatment
  • Treatment must be guided of the behavior and growth potential of the PA
  • anatomic site
  • size
  • and pathohistological analisys
  • The treatment of choice for PA is total extirpation with intraoral approach(if it is possible) and preservation of nearby structures .
  • Treatment modalites are ranged from conservative excision to wide block resection and bone grafting.
Conclusions
  • Patient was followed on an outpatient basis
  • Very successful esthetic result with intraoral approach was achieved.
  • Neither reccurens or functional disorder have been observed.
  • Future follow up is necessary.