Follicular Ameloblastoma of the Mandible in a Young Adult Patient: Case Report

Introduction: Ameloblastoma is a locally invasive tumor that grows slowly and attacks the maxillofacial area. There are various histological variants of ameloblastoma. The most common is follicular ameloblastoma. They are characterized by slow growth and are relatively aggressive locally, with the primary site of origin being the mandible. Late recurrence after surgical management is relatively common and is related to the histologic type, site of origin, and initial treatment modality. The mandibular bone is also a relatively common location for this tumor. Optimal surgical treatment of ameloblastoma should minimize recurrence, restore function and aesthetics, and minimize morbidity at the donor site. Segmental mandibular resection surgery is tumour surgery by removing part of the mandible. Case report: A 15-year-old female patient came with complaints of a mass in the mandible area. The mass infiltrated the right mandible. The surgical intervention performed on this patient was a segmental resection operation. From the results of the Anatomic Pathology (AP) examination, follicular ameloblastoma was found in the right mandibular region. Conclusion: The patient's age and histopathological pattern of the tumor influence the treatment plan.


Introduction
Ameloblastoma is the most common odontogenic tumor, based on research by Nalabolu et al. in 2016  showed that ameloblastoma occurred in 49% of odontogenic tumor cases.Ameloblastoma was first introduced under the name Adamantinoma by a French doctor named Louis-Charles Malassez in 1885, but had previously been discovered by Cusack in 1827.It was finally given the modern name, namely ameloblastoma, in 1933 by Ivey and Churchill.Most ameloblastomas are unilateral (95%) and occur in the posterior region of the jaw (85%).Pinborg and Clausen classified odontogenic tumors based on their clinical and histological features into benign, malignant, and intermediate (borderline) tumors.][3][4] Based on its nature, ameloblastoma is an intermediate (borderline) tumor because ameloblastoma is benign but locally invasive with a high recurrence rate if excision is not complete.This tumor theoretically originates from the remaining cells of the enamel organ, from the development of the epithelium of odontogenic cysts, and the basal cells of the oral mucosa.The trigger or stimulus for the neoplastic transformation of the epithelial structure has yet to be discovered with certainty.Radiologically, it can be monocytic or polycystic, and histopathologically, it shows different images, with the highest incidence being the follicular type.6] Lu et al. studied a Chinese population and showed a mean age of 31.4 years with a 1.5:1 male: female ratio, and 90.8% of tumors were in the mandible.A study by Hatada et Al. on the Japanese population showed a mean age of 34.7 years with a ratio of 1.6:1 male: female and 92.6% located in the mandible.2.4 Ruslin et al. researching in Eastern Indonesia, of 84 patients diagnosed with ameloblastoma, it was found that 14 patients were diagnosed with unicystic ameloblastoma (25%), 60 patients with follicular ameloblastoma (57%) and 10 patients with multicystic ameloblastoma (18%).
Lu et al. studied a Chinese population and showed a mean age of 31.4 years with a 1.5:1 male: female ratio, and 90.8% of tumors were in the mandible.A study by Hatada et Al. on the Japanese population showed a mean age of 34.7 years with a ratio of 1.6:1 male: female and 92.6% located in the mandible.2.4 Ruslin et al. researching in Eastern Indonesia, of 84 patients diagnosed with ameloblastoma, it was found that 14 patients were diagnosed with unicystic ameloblastoma (25%), 60 patients with follicular ameloblastoma (57%) and 10 patients with multicystic ameloblastoma (18%).Reichart and Philipsen stated that the recurrence rate of the follicular type (29.5%) was higher than that of the plexiform type (16.7%) and also that of the acantomatous type (4.5%). 4e principle of therapy for follicular-type ameloblastoma of the jaw is to remove the entire tumor.Many clinicians prefer radical therapy because of its relapsing nature.Treatment with radical methods can reduce the recurrence rate.The recurrence rate with this method is around 15% compared to conservative treatment methods, which have a recurrence rate of more than 50%.3

Case Report
A 15-year-old female patient came with complaints of a lump in the right lower jaw.Since 3 years ago, the patient felt that he had canker sores on his lower front jaw.The patient went to a private clinic and was given diclofenac potassium and amoxicillin.Two years later, the patient went to the Sukabumi District Hospital and had the left side of the tissue removed by an oral surgeon and was diagnosed with unicystic ameloblastoma of the mandible.Then, 3 months ago, the patient's lump got bigger, and the patient was referred to the RSUD in the Cibadak area, and no action was taken; then, the patient was referred to RSHS for further action.Then, the patient undergoes an EKG, blood lab, and chest x-ray to prepare for segmental resection surgery.Systemic history (-), Drug and food allergies (-).Weight loss (+) 13 kg over 3 months.
On extra oral examination, a lump was found on the right lower jaw measuring 3x3x2 cm (figure 1).On intra-oral examination, a lump was found on the gingiva of teeth 33-47 with a size of 7x4x3 cm, did not bleed easily, was the same color as the surrounding tissue, and had a hard consistency (figure 2).The treatment plan, in this case, is mandibular segmental resection.The incision is carried out intraorally; then, the corpus bone is removed along with the attached mass tissue.After the tumor tissue and jaw bone are separated from the soft tissue and muscles attached to it, the entire tumor tissue and jaw bone are removed together with the teeth involved.The two separated bone fragments can be connected with a plate (Figure 4).Evaluation 2 weeks after the procedure, the patient is followed up for control (figures 5 and 6)

Discussion
Ameloblastoma is the most common odontogenic epithelial neoplasm.Ameloblastoma growth is slow but locally invasive.It does not cause pain, so it is usually found at an advanced stage, and there has been swelling and bone destruction. 1,2,7 Tliterature reveals that follicular ameloblastoma is the most common histological variant (64.9%), followed by plexiform (13.0%), desmoplastic (5.2%) and acanthomatous (3.9%) types.The histological picture of the follicular type shows small islands, at the edges of which are composed of cuboidal or columnar cells whose core is arranged like a fence (palisading).The central part of the island consists of stellate cells similar to the stellate reticulum.Cystic degeneration of epithelial cells often occurs, resulting in cyst cavities appearing in the tumor mass.The follicular type has a histopathological picture that is almost the same as the acantomatous type.In addition, recurrent tumors of this type are more aggressive and anaplastic than primary tumors. 4om the literature review, there are various cases where ameloblastoma did not receive early surgical intervention due to reasons including financial conditions, fear of surgery, lack of information, and undetected lesions.Several factors influence growth and prognosis, namely the solid multicystic histological type, young age, and previous therapy. 8 general, ameloblastoma shows a lump with a hard or soft consistency depending on the type, namely the solid type or cystic type; it can cause loose teeth, malocclusion, and facial deformity.In certain conditions, the histopathological picture of the ameloblastoma variant is also found, as in this case, it shows the characteristics of the follicular type.Judging from the histopathological picture of the follicular type, it shows small islands, at the edges of which are composed of cuboidal or columnar cells whose core is arranged like a fence.In this case, the central part of the island consists of stellate cells similar to the stellate reticulum.This occurs due to cystic degeneration of the epithelial cells so that cyst cavities arise in the tumor mass. 2,6,9 Bsed on WHO provisions, it is recommended to apply the same treatment modality as for solid ameloblastoma, namely surgical resection therapy, because recurrence is quite high in enucleation or curettage.However, small lesions can be treated with enucleation.Treatment with radical methods can reduce the recurrence rate.According to Muller 1985, the recurrence rate with this method is around 15% compared to treatment with conservative methods, which has a recurrence rate of more than 50%.Treatment in this case was carried out using a radical method, namely segmental resection for ameloblastoma in the right mandible, with the hope that recurrence would not occur in this patient, considering the patient's young age. 2,3,8 Oof the complications of ameloblastoma treatment is a defect in the area where tissue is removed, either soft tissue or hard tissue, which can cause a decrease in speech function, mastication and facial asymmetry.However, postoperative care plays an important role in determining the success of surgical therapy, especially in avoiding the recurrence of ameloblastoma cases in these patients. 10Conclusion acantomatous type.In addition, recurrent tumors of this type are more aggressive and anaplastic than primary tumors. 4From the literature review, there are various cases where ameloblastoma did not receive early surgical intervention due to reasons including financial conditions, fear of surgery, lack of information, and undetected lesions.Several factors influence growth and prognosis, namely the solid multicystic histological type, young age, and previous therapy. 8 general, ameloblastoma shows a lump with a hard or soft consistency depending on the type, namely the solid type or cystic type; it can cause loose teeth, malocclusion, and facial deformity.In certain conditions, the histopathological picture of the ameloblastoma variant is also found, as in this case, it shows the characteristics of the follicular type.Judging from the histopathological picture of the follicular type, it shows small islands, at the edges of which are composed of cuboidal or columnar cells whose core is arranged like a fence.In this case, the central part of the island consists of stellate cells similar to the stellate reticulum.This occurs due to cystic degeneration of the epithelial cells so that cyst cavities arise in the tumor mass. 2,6,9 Bsed on WHO provisions, it is recommended to apply the same treatment modality as for solid ameloblastoma, namely surgical resection therapy, because recurrence is quite high in enucleation or curettage.However, small lesions can be treated with enucleation.Treatment with radical methods can reduce the recurrence rate.According to Muller 1985, the recurrence rate with this method is around 15% compared to treatment with conservative methods, which has a recurrence rate of more than 50%.Treatment in this case was carried out using a radical method, namely segmental resection for ameloblastoma in the right mandible, with the hope that recurrence would not occur in this patient, considering the patient's young age. 2,3,8 Oof the complications of ameloblastoma treatment is a defect in the area where tissue is removed, either soft tissue or hard tissue, which can cause a decrease in speech function, mastication and facial asymmetry.However, postoperative care plays an important role in determining the success of surgical therapy, especially in avoiding the recurrence of ameloblastoma cases in these patients. 10