4
LETTERS TO THE EDITOR
series of 40 cases of mandibular ameloblastoma, we have found only 1 case of recurrence and that was when teeth in communication with the lesion were retained. The recurrence was a 1-cm cyst that was easily enucleated (with Carnoy’s solution) without adverse effect. It seems little is lost if a recurrence occurs and is picked up early. The appropriate selection of cases for this approach is based on radiologic appearance and not on biopsy. Incisional biopsy is frequently not representative of the main specimen.2 Large cystic lesions represent slowly pushing lesions and are ideal for enucleation and the Carnoy’s approach. Close surveillance by clinical and radiographic evaluation is mandatory for perusing this conservative approach. JAHRAD HAQ MARK MCGURK London, UK
References 1. Nkenke E, Agaimy A, von Wilmowsky C, et al: Mandibular reconstruction using intraoral microvascular anastomosis following removal of an ameloblastoma. J Oral Maxillofac Surg 15:1, 2013 2. Ackermann GL, Altini M, Shear M: The unicystic ameloblastoma: A clinicopathological study of 57 cases. J Oral Pathol 17:541, 1988
http://dx.doi.org/10.1016/j.joms.2013.09.017
LETTER TO THE EDITOR In reply:—We thank Drs Haq and McGurk for their commentary regarding our publication. Their letter reminds us that the surgical management of ameloblastoma remains a matter of debate.1,2 In the past, numerous treatment concepts have been proposed. Some of them have been referred to as being ‘‘radical,’’ whereas others have been termed ‘‘conservative.’’ Many surgeons emphasize that ameloblastomas are benign and grow slowly and therefore should be managed conservatively (eg, by enucleation). Conversely, an ameloblastoma is an aggressive neoplasm that prompts other surgeons to opt for radical surgery with curative intent (eg, by segmental mandibular resection with safety margins of up to 3 cm). We support the opinion of Haq and McGurk that the surgical treatment plan should be individualized and centered on the patient, no matter whether the plan adopts a radical or conservative approach.2 As many others do, we base the decision to opt for one or the other approach to therapy of an ameloblastoma on radiographs and biopsies.1 Definitely, Haq and MacGurk are correct that major mandibular resections in younger patients include a certain risk that employment opportunities and marriage prospects are impaired. Nevertheless, to date, microvascular reconstruction can be considered a very safe procedure with a predictable outcome. We were able to show that microvascular reconstruction of the mandible with intraoral anastomosis after the removal of an ameloblastoma can be performed even in infants without impairing their facial appearance or causing functional problems.3 When radical resection is combined with simultaneous microvascular reconstruction,
it seems that form and function can be preserved and that the risk of recurrence of an ameloblastoma is lowered to a minimum. In this context, one has to be aware that when a conservative approach is used, the term recurrence may be a misnomer and persistence would probably be the more accurate term.1 Our case report aimed at adding an additional treatment option to the therapy of ameloblastoma. It should allow complete removal of the neoplasm and at the same time minimize any decrease in the quality of life. A decreased risk for persistence or recurrence of the benign tumor may allow cessation of close surveillance of the patient at an earlier point compared with a more conservative approach. There may be a chance to limit the need for clinical and radiologic follow-up to a minimum. All in all, it seems that segmental mandibular resection combined with simultaneous microvascular reconstruction with intraoral anastomosis should be considered a concept that offers new possibilities and advantages. Therefore, it should always be taken into account as a therapeutic option when the individual treatment of a patient is planned. EMEKA NKENKE, MD, DMD, MA Erlangen, Germany
References 1. Carlson ER, Marx RE: The ameloblastoma: Primary, curative surgical management. J Oral Maxillofac Surg 64:484, 2006 2. Sachs SA: Surgical excision with peripheral ostectomy: A definitive, yet conservative, approach to the surgical management of ameloblastoma. J Oral Maxillofac Surg 64:476, 2006 3. Nkenke E, Agaimy A, St Pierre M, et al: Intraoral microvascular anastomosis for segmental mandibular reconstruction following removal of an ameloblastoma. J Craniofac Surg 24:e265, 2013
http://dx.doi.org/10.1016/j.joms.2013.09.018
THREE-DIMENSIONAL VIRTUAL MANDIBULAR RECONSTRUCTION To the Editor:—I read with great interest your recent article on virtual planning in mandibular reconstruction using a free fibular graft.1 I commend you on a well-written article and second your conclusions regarding the benefits of computer-aided surgical planning with the addition of surgical cutting templates. I would like to point out that a case report on 3-dimensional computer virtual planning was first presented by Dr Michael Stephanides et al2 at the 1999 International Congress and Exhibition on Computer Assisted Radiology and Surgery in Paris and at the 1999 meeting of the American Society of Plastic Surgeons in New Orleans and later cited in Computer Aided Surgery3 (Fig 1). This was part of the work derived from the Stanford–National Aeronautics and Space Administration National Biocomputation Center. STEPHEN A. SCHENDEL, MD, DDS Palo Alto, CA
5
LETTERS TO THE EDITOR
References 1. Coppen C, Weijs W, Berge S, et al: Oromandibular reconstruction using 3D planned triple template method. J Oral Maxillofac Surg 71: e243, 2013 2. Stephanides M, Montgomery K, Schendel S: Microsurgical reconstruction of the mandible using a new 3D surgical planning system. Presented at: 13th International Congress and Exhibition on Computer Assisted Radiology and Surgery (CARS’99); Paris, France; June 1999 3. Montgomery K, Stephanides M, Schendel S: Development and application of a virtual environment for reconstructive surgery. Comput Aided Surg 5:90, 2000
http://dx.doi.org/10.1016/j.joms.2013.09.032
FIGURE 1. Three-dimensional virtual A, mandibular resection and B, fibular reconstruction. Stephen A. Schendel. Letters to the Editor. J Oral Maxillofac Surg 2014.
LETTERS TO THE EDITOR
series of 40 cases of mandibular ameloblastoma, we have found only 1 case of recurrence and that was when teeth in communication with the lesion were retained. The recurrence was a 1-cm cyst that was easily enucleated (with Carnoy’s solution) without adverse effect. It seems little is lost if a recurrence occurs and is picked up early. The appropriate selection of cases for this approach is based on radiologic appearance and not on biopsy. Incisional biopsy is frequently not representative of the main specimen.2 Large cystic lesions represent slowly pushing lesions and are ideal for enucleation and the Carnoy’s approach. Close surveillance by clinical and radiographic evaluation is mandatory for perusing this conservative approach. JAHRAD HAQ MARK MCGURK London, UK
References 1. Nkenke E, Agaimy A, von Wilmowsky C, et al: Mandibular reconstruction using intraoral microvascular anastomosis following removal of an ameloblastoma. J Oral Maxillofac Surg 15:1, 2013 2. Ackermann GL, Altini M, Shear M: The unicystic ameloblastoma: A clinicopathological study of 57 cases. J Oral Pathol 17:541, 1988
http://dx.doi.org/10.1016/j.joms.2013.09.017
LETTER TO THE EDITOR In reply:—We thank Drs Haq and McGurk for their commentary regarding our publication. Their letter reminds us that the surgical management of ameloblastoma remains a matter of debate.1,2 In the past, numerous treatment concepts have been proposed. Some of them have been referred to as being ‘‘radical,’’ whereas others have been termed ‘‘conservative.’’ Many surgeons emphasize that ameloblastomas are benign and grow slowly and therefore should be managed conservatively (eg, by enucleation). Conversely, an ameloblastoma is an aggressive neoplasm that prompts other surgeons to opt for radical surgery with curative intent (eg, by segmental mandibular resection with safety margins of up to 3 cm). We support the opinion of Haq and McGurk that the surgical treatment plan should be individualized and centered on the patient, no matter whether the plan adopts a radical or conservative approach.2 As many others do, we base the decision to opt for one or the other approach to therapy of an ameloblastoma on radiographs and biopsies.1 Definitely, Haq and MacGurk are correct that major mandibular resections in younger patients include a certain risk that employment opportunities and marriage prospects are impaired. Nevertheless, to date, microvascular reconstruction can be considered a very safe procedure with a predictable outcome. We were able to show that microvascular reconstruction of the mandible with intraoral anastomosis after the removal of an ameloblastoma can be performed even in infants without impairing their facial appearance or causing functional problems.3 When radical resection is combined with simultaneous microvascular reconstruction,
it seems that form and function can be preserved and that the risk of recurrence of an ameloblastoma is lowered to a minimum. In this context, one has to be aware that when a conservative approach is used, the term recurrence may be a misnomer and persistence would probably be the more accurate term.1 Our case report aimed at adding an additional treatment option to the therapy of ameloblastoma. It should allow complete removal of the neoplasm and at the same time minimize any decrease in the quality of life. A decreased risk for persistence or recurrence of the benign tumor may allow cessation of close surveillance of the patient at an earlier point compared with a more conservative approach. There may be a chance to limit the need for clinical and radiologic follow-up to a minimum. All in all, it seems that segmental mandibular resection combined with simultaneous microvascular reconstruction with intraoral anastomosis should be considered a concept that offers new possibilities and advantages. Therefore, it should always be taken into account as a therapeutic option when the individual treatment of a patient is planned. EMEKA NKENKE, MD, DMD, MA Erlangen, Germany
References 1. Carlson ER, Marx RE: The ameloblastoma: Primary, curative surgical management. J Oral Maxillofac Surg 64:484, 2006 2. Sachs SA: Surgical excision with peripheral ostectomy: A definitive, yet conservative, approach to the surgical management of ameloblastoma. J Oral Maxillofac Surg 64:476, 2006 3. Nkenke E, Agaimy A, St Pierre M, et al: Intraoral microvascular anastomosis for segmental mandibular reconstruction following removal of an ameloblastoma. J Craniofac Surg 24:e265, 2013
http://dx.doi.org/10.1016/j.joms.2013.09.018
THREE-DIMENSIONAL VIRTUAL MANDIBULAR RECONSTRUCTION To the Editor:—I read with great interest your recent article on virtual planning in mandibular reconstruction using a free fibular graft.1 I commend you on a well-written article and second your conclusions regarding the benefits of computer-aided surgical planning with the addition of surgical cutting templates. I would like to point out that a case report on 3-dimensional computer virtual planning was first presented by Dr Michael Stephanides et al2 at the 1999 International Congress and Exhibition on Computer Assisted Radiology and Surgery in Paris and at the 1999 meeting of the American Society of Plastic Surgeons in New Orleans and later cited in Computer Aided Surgery3 (Fig 1). This was part of the work derived from the Stanford–National Aeronautics and Space Administration National Biocomputation Center. STEPHEN A. SCHENDEL, MD, DDS Palo Alto, CA
5
LETTERS TO THE EDITOR
References 1. Coppen C, Weijs W, Berge S, et al: Oromandibular reconstruction using 3D planned triple template method. J Oral Maxillofac Surg 71: e243, 2013 2. Stephanides M, Montgomery K, Schendel S: Microsurgical reconstruction of the mandible using a new 3D surgical planning system. Presented at: 13th International Congress and Exhibition on Computer Assisted Radiology and Surgery (CARS’99); Paris, France; June 1999 3. Montgomery K, Stephanides M, Schendel S: Development and application of a virtual environment for reconstructive surgery. Comput Aided Surg 5:90, 2000
http://dx.doi.org/10.1016/j.joms.2013.09.032
FIGURE 1. Three-dimensional virtual A, mandibular resection and B, fibular reconstruction. Stephen A. Schendel. Letters to the Editor. J Oral Maxillofac Surg 2014.
