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Table of Contents
CASE REPORT
Year : 2013  |  Volume : 3  |  Issue : 1  |  Page : 25-28

Surgical enucleation of Pindborg tumor and immediate prosthetic rehabilitation


1 Department of Prosthodontics Including Crown and Bridge, Maxillofacial Prosthodontics and Oral Implantology, Bhojia Dental College, Baddi-Solan, Himachal Pradesh, India
2 Department of Prosthodontics Including Crown and Bridge, Maxillofacial Prosthodontics and Oral Implantology, I.T.S. Center for Dental Studies and Research, Muradnagar, Ghaziabad, Uttar Pradesh, India
3 Department of Oral and Maxillofacial Pathology and Microbiology, Bhojia Dental College, Baddi-Solan, Himachal Pradesh, India

Date of Web Publication25-Oct-2013

Correspondence Address:
Sharad Vaidya
Department of Prosthodontics Including Crown and Bridge, Maxillofacial Prosthodontics and Oral Implantology, Bhojia Dental College, Baddi-Solan, Himachal Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5194.120523

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   Abstract 

Rehabilitating patients with maxillofacial defects is one of the most challenging therapies of the stomatognathic system. Maxillomandibular defects being the most common of these defects need to be rehabilitated to restore the lost form, function and speech. Prosthetic reconstruction of these defects may be achieved with the help of varied prosthesis, removable and fixed. The present case report describes a case of CEOT (Calcifying Epithelial Odontogenic Tumor) managed with a treatment obturator which allowed closure of the defect by secondary healing through granulation tissue maturation and associated bone fill. A 19 gauge wire was used for creating the substructure treatment obturator. Wire was adapted to stabilize the appliance, and provide retentive properties. The obturator allowed decrease in size of defect and enhanced comfort and overall well-being of the patient.
Clinical Relevance to Interdisciplinary Dentistry

  1. Team work involving oral surgeon, oral radiologist and rehabilitation by a prosthodontist lead to the success of the procedure.

Keywords: Enucleation, Pindborg tumor, prosthetic rehabilitation, treatment obturator


How to cite this article:
Vaidya S, Gupta S, Bhargava A, Kapoor C. Surgical enucleation of Pindborg tumor and immediate prosthetic rehabilitation. J Interdiscip Dentistry 2013;3:25-8

How to cite this URL:
Vaidya S, Gupta S, Bhargava A, Kapoor C. Surgical enucleation of Pindborg tumor and immediate prosthetic rehabilitation. J Interdiscip Dentistry [serial online] 2013 [cited 2019 Dec 6];3:25-8. Available from: http://www.jidonline.com/text.asp?2013/3/1/25/120523


   Introduction Top


Maxillomandibular defects may be the result of congenital malformations, trauma or surgical resection of tumors. The primary objective of rehabilitating these defects is to eliminate the disease by surgical resection and improve the quality-of-life for these individuals. [1]

Calcifying epithelial odontogenic tumor (CEOT) is a rare benign odontogenic neoplasm, forming 0.4-3.0% of all intraosseous tumors. [2],[3] CEOT was first described by Dr. Jens J. Pindborg, 1955, henceforth called as Pindberg tumor. [4],[5] It is an uncommon, benign, odontogenic neoplasm that is exclusively derived from epithelial tissue. There is no consensus on the originating cells. Some Pathologists suggests that it is derived from the stratum intermedium layer of the enamel organ in the tooth development stage, others favor a different hypothesis in which, this tumor may arise from remnants of the primitive dental lamina found in the initial stage of odontogenesis. The tumor is similar in behavior to ameloblastoma but has a slightly lesser recurrence rate after surgery. [6] The treatment of CEOT ranges from simple enucleation [7] or curettage to radical and extensive resection, such as, hemimandibulectomy or hemimaxillectomy. The prognosis of CEOT is good with infrequent recurrence with the recurrence rate of 14% and recurrent lesion may not be manifested for many years. [8]

Management of such mandibular defects warrants all facets of patient care from diagnosis and treatment planning to rehabilitation and using obturator prosthesis is one of them. Obturator is derived from the Latin verb "obturare" which means to close or to shut off. [9] With the aim of preventing the defective area from contamination and provide an uneventful healing.

We report a case of CEOT which was surgically enucleated and was prosthodontically managed with treatment obturator.


   Case Report Top


A 26-year-old female patient reported to the out-patient department, with the chief complaint of swelling on the left side of face past 9 months with no associated pain. The swelling was insidious in onset, asymptomatic and gradually increased in size.

On extra-oral examination, the patient was moderately built with all the vital signs within the normal limits. Facial asymmetry with a hard palpable mass was felt with respect to the lower left mandibular region of the face. There was no tenderness or lymphadenopathy noted. On inspection, a solitary swelling extending from the lower left border of the mandible up to the straight line extending from the angle of the mouth posteriorly and anteroposteriorly 2 cm from the left corner of mouth to about 3 cm in front of the angle of mandible. The swelling was approximately 3.5 cm × 3 cm in size, ovoid in shape, endophytic in nature and hard in consistency. The color was similar to that of normal skin, with a smooth texture and well-defined borders. No visible secondary changes were seen. On inspection, the swelling was non-compressible, non-tender.

Intra-oral examination revealed a solid swelling on the lower left mandibular buccal vestibule extending from 31 to 37. The swelling was fusiform in shape extending approximately 4 cm anteroposteriorly and 2 cm supero-inferiorly. It was reddish pink in color, bosselated in appearance with well distinct margins. No visible secondary changes were seen [Figure 1]a and b.
Figure 1: (a and b) Intra-oral examination revealed a solid swelling on the lower left mandibular buccal vestibule opposite extending from 31 to 37

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Radiographic investigations as: Intra-oral periapical [Figure 2] and magnetic resonance imaging (MRI) [Figure 3] was performed to define the extent of lesion and amount of bone loss.
Figure 2: Intra-oral periapical showed radiolucency with expansion with respect to the lingual and buccal cortical plates

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Figure 3: Magnetic resonance imaging showing a well-defined expansile lesion with respect to the lower left mandibular area extending from 31 to 37

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MRI revealed a well-defined expansile radiolucent osteolytic lesion crossing the midline, extending from mesial aspect of 44 across up to the medial aspect of 37. The lesion showed well-defined and corticated margins with expansion and thinning of adjacent buccal lingual cortices.

The case was posted for surgical enucleation under local analgesia [Figure 4].
Figure 4: Lesion removed via enucleation

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Histopathologically, the tumor composed of polyhedral epithelial cells packed closely in large sheets in bland fibrous connective tissue stroma. Multinucleated giant cells with frequent pleomorphic nuclei and prominent inter-cellular bridges were also evident. Characteristic homogeneous acellular material admixed with the tumor epithelium identified as amyloid was also seen. A definitive diagnosis of CEOT was given [Figure 5].
Figure 5: H and E, ×10 showing epithelial islands associated with multiple areas of calcification (inset, ×40): Shows pleomorphc and hyperchromatic epithelial cells with prominent desmosomal and amyloid like material

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Treatment consisted of surgical enucleation of the defect followed by the closure with treatment obturator [Figure 6]. This led to healthy granulation tissue formation and bone healing. The obturator also prevented food accumulation and contamination of the defect.
Figure 6: Treatment obturator constructed to close the defect and allow uneventful healing

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Treatment obturator (interim) construction

After a thorough diagnostic evaluation, a surgical procedure was planned with the particular attention to the nature of the disease, patient's condition, size and extension of the cyst, tissue loss and the possibilities of prosthetic management of a mandibular bone defect with partial post-resection dental prosthesis.

Fabrication of the treatment obturator was done using a 19 gauge wire. Wire adaptation was done from the lingual side and it was adapted around 1 st premolar and was readapted over the buccal surface of the defect. Adams clasp was prepared over the molar that provided the retention to the treatment obturator. Wax up was done and treatment obturator was fabricated with a clear heat cure resin. The buccal surface of the obturator was relined with soft liner Ufi Gel P VOCO GmbH (Cuxhaven, Germany) to close the defect.

Patient was instructed about maintenance of oral hygiene and was advised to report once every month (for a period of 6 month). On every visit, the relining material was changed and the defect was inspected to check for reoccurrence and healing. The defect showed a gradual decrease in size in each follow-up and led to effective bone tissue regeneration (osteogenesis).


   Discussion Top


Treatment of mandibular defect may arise from surgical resection of mandible, tongue, floor of mouth and associated structures. Disabilities resulting from such resection include impaired speech articulation, difficulty in swallowing, trismus, deviation of mandible during functional movement, [10],[11] poor control of salivary secretions and severe cosmetic disfigurement.

Based on the amount of resection or extent of bone loss, mandibular defects can be classified as continuity and discontinuity defects. Mandibular discontinuity can be managed by immediate or delayed surgical reconstruction to re-establish continuity. Loss of mandibular continuity alters the symmetry of mandible, due to the rotation and deviation of the residual mandible toward the affected side. [11],[12]

Most patients who require maxillofacial prosthesis have an extensive amount of surgical and dental treatment. The prosthetic rehabilitation of patients with resection generally requires an immediate post-surgical prosthesis, an interim prosthesis and a permanent prosthesis. However, most of patients with acquired surgical defects can be restored close to normal function and appearance. [13],[14] The success and the failure of the prostheses may be influenced by the degree of malignancy; the propensity of recurrence; the level of resection; and other associated complications. [15]

The terms obturator is defined as prosthesis used to close a congenital or an acquired tissue opening, primarily of the hard palate and or contiguous alveolar structures. Obturators classified on the basis of prosthetic rehabilitation of acquired defects.

  • Surgical obturator
  • Interim obturator
  • Definitive obturator.


After a thorough diagnostic evaluation, an interim obturator was made with the particular attention to the nature of the disease, patient's condition, size and extension of the cyst, tissue loss, rare rate of reoccurrence, for the closer of the cystic opening after enucleation.

Interim/treatment obturator

The treatment/interim obturator sometimes can be modified to compensate for tissue changes or surgical defect, which is different from the pre-surgical obturator. Usually it is constructed from the post-surgical impression to accurately reflect the defect. It replaces the surgical obturator and is worn in the post-operative healing period. The interim prosthesis in addition to clasps for retention can have anterior teeth for esthetics and a flange for lip and cheek support, which contributes to the patient's well-being and social integration. Use of molar teeth is avoided to minimize occlusal pressure on the defect. The obturator is relined periodically for better adaptation as the healing progress. [16],[17]

Primary concern of the treatment is to assure that the oral cavity is prepared to reduce the potential untoward effects of cancer treatment. [17] Patient was trained in oral hygiene methods and therapeutics for oral health preservation and rehabilitate the post-surgical defect utilizing prosthesis. [14],[16] Long-term follow-up and evaluation with an eye to the possibility of lesion recurrence is a part of the crucial contribution by the Prosthodontist (Khan et al., 2006). [13]


   Conclusion Top


Rehabilitation of patients with tumorous growths has always been a challenge due to the unpredictable nature of the defects and the uncertainty of recurrence. Henceforth, it is of utmost importance to carry out early surgical intervention before such lesions show wide spread involvement. The effectiveness and acceptance of the prosthesis should be the primary factor that the Prosthodontist should bear in mind. The treatment stresses mainly upon the need for multidisciplinary approach and psychosocial consideration. An integrated effort, sound knowledge and practical implication are all required in rehabilitating these defects.

 
   References Top

1.Lethaus B, Lie N, de Beer F, Kessler P, de Baat C, Verdonck HW. Surgical and prosthetic reconsiderations in patients with maxillectomy. J Oral Rehabil 2010;37:138-42.  Back to cited text no. 1
    
2.Basu MK, Matthews JB, Sear AJ, Browne RM. Calcifying epithelial odontogenic tumour: A case showing features of malignancy. J Oral Pathol 1984;13:310-9.  Back to cited text no. 2
    
3.Goode RK. Calcifying epithelial odontogenic tumor. Oral Maxillofac Surg Clin North Am 2004;16:323-31.  Back to cited text no. 3
    
4.Nestal Zibo H, Miller E. Endoscopically assisted enucleation of a large mandibular periapical cyst. Stomatologija 2011;13:128-31.  Back to cited text no. 4
    
5.Dabir A, Padhye M. Calcifying epithelial odontogenic tumor-A case report. (Pindborg's tumor). Sci J 2008;2:1-4.   Back to cited text no. 5
    
6. Thota KK, Tella S, Anulekha CKA, Ravuri R. A Prosthodontic Rehabilitation of a Partial Maxillectomy Patient with Hollow Bulb Obturator. Ind J Dent Adv 2010;2:383-5.  Back to cited text no. 6
    
7.Bonanno A, Choi JY. Mapping out the social experience of cancer patients with facial disfigurement. Health 2010;2:18-24.  Back to cited text no. 7
    
8.Brown KE. Clinical considerations improving obturator treatment. J Prosthet Dent 1970;24:461-6.  Back to cited text no. 8
    
9.Davenport J. Managing the prosthetic rehabilitation of patient with head and neck cancer. Dent News 1996;3:7-11.  Back to cited text no. 9
    
10.Desjardins RP. Obturator prosthesis design for acquired maxillary defects. J Prosthet Dent 1978;39:424-35.  Back to cited text no. 10
    
11.Gibbons P, Bloomber H. A supportive type prosthetic speech aid. J Prosthet Dent 1958;8:362-74.  Back to cited text no. 11
    
12.Khan Z, Gettleman L, Jacobson CS. Conference report: Materials research in maxillofacial prosthetics. J Dent Res 1992;71:1541-2.  Back to cited text no. 12
    
13.Khan Z, Farman AG. The prosthodontist role in head and neck cancer and introduction - Oncologic dentistry. J Indian Prosthodont Soc 2006;6:4-9.  Back to cited text no. 13
  Medknow Journal  
14.Rozen RD, Ordway DE, Curtis TA, Cantor R. Psychosocial aspects of maxillofacial rehabilitation. I. The effect of primary cancer treatment. J Prosthet Dent 1972;28:423-8.  Back to cited text no. 14
    
15.Sykes BE, Curtis TA, Cantor R. Psychosocial aspects of maxillofacial rehabilitation. II. A long-range evaluation. J Prosthet Dent 1972;28:540-5.  Back to cited text no. 15
    
16.Rilo B, Dasilva JL, Ferros I, Mora MJ, Santana U. A hollow-bulb interim obturator for maxillary resection: A case report. J Oral Rehabil 2005;32:234-6.  Back to cited text no. 16
    
17.Medford HM. Repair of hollow-bulb maxillary obturator. J Prosthet Dent 1981;45:111-2.  Back to cited text no. 17
    


    Figures

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



 

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