Ameloblastoma of the jaw

A tumor odontogenic process - ameloblastoma - is of epithelial nature and has a tendency to aggressive growth. The tumor is not malignant, but it can cause bone destruction and, in rare cases, metastasize. Surgical treatment: the scale of the operation depends mainly on the stage of the pathology. [1]

Epidemiology

Ameloblastoma occurs with approximately the same frequency in both men and women. It accounts for about 1% of all tumors of the oral cavity and about 9-11% of odontogenic tumors. It is usually a slow-growing but locally invasive tumor. [2]The average age of patients is from twenty to fifty years. The appearance of a tumor in childhood and adolescence is also possible, although this happens much less often - in only 6.5% of patients with any benign neoplasms of the jaw location.

In the vast majority of cases, ameloblastoma affects the lower jaw (80-85%), and much less often - the upper (15-20%):

• the most common lesion is the mandibular angle and ramus;
• in 20% of cases, the body is affected by the large molars;
• in 10% the chin is affected.

In women, ameloblastoma of the sinusonasal system is more common, which is formed from the proliferating odontogenic epithelium. Pathology is poly and monocystic, which requires the most accurate differential diagnosis with cysts.

The incidence of odontogenic neoplasms is from 0.8 to 3.7% among all tumor processes affecting the maxillofacial region. Among them, odontomas (over 34%), ameloblastomas (about 24%), myxomas (about 18%) prevail. [3]

Ameloblastoma is benign in almost 96-99% of cases. Malignancy is observed only in 1.5-4% of patients. [4]

Other names for ameloblastoma are adamantoblastoma, adamantinoma (from the word  enamel  - substantia adamantina). 

Causes of the ameloblastomas

There is no consensus among experts about the causes of the development of ameloblastoma. Some scientists associate the pathology with a violation of the formation of the tooth rudiment, while others - with odontogenic epithelial residues. However, there is still no clear answer to the question of the origin of the tumor process, and the risk factors are unknown.

The name of the neoplasm comes from a combination of English and Greek words: "amel" enamel, and "blastos" rudiment. Pathology develops from the epithelium of the dental plate, is characterized by local aggressive growth and a high risk of recurrence. [5]

The first tumor was described by Dr. Cusack, and it happened in 1827. Almost 60 years later, another scientist Malassez described a disease that he called adamantinoma. Today, this term refers to a rare primary malignant bone tumor. But the name ameloblastoma was first introduced into medical use only in 1930, and it is still used today.

Ameloblastoma is a true formation of a benign nature, consisting of a proliferating odontogenic epithelium that lies in the fibrous stroma.

Pathogenesis

The etiology of the development of ameloblastoma is not fully understood. Experts believe that the growth of the neoplasm begins with the cellular structures of the oral cavity, or with the epithelial islets of Malasse, the rudiments of supernumerary teeth or scattered cellular complexes of the dental plate and dental sacs.

In the context of ameloblastoma, it is distinguished by a pinkish-grayish tint and a spongy structure. The basic structure is represented by fibrous connective tissue enriched with fusiform cells and branches of strands of odontogenic epithelium. Near each of the strands, cells of the columnar epithelium are localized, and on the inside, polygonal structures are adjacent to them, turning into stellate ones.

In addition, cellular structures of irregular configuration are noted: it is in them that the main difference between ameloblastoma and the enamel organ lies. Cystic intratumoral formations damage epithelial cells, therefore, during microscopic examination, only cylindrical peripheral cells are observed.

The sizes of destructive zones in ameloblastoma range from three millimeters to several centimeters. In severe cases, the swelling spreads throughout the jaw body. [6]

At the moment, experts talk about several pathogenetic theories of the appearance of ameloblastoma. Of these, only two have the greatest validity:

1. A. Abrikosov's theory suggests that the development of the tumor process starts during the formation of the tooth at the stage of the enamel organ. Normally, after dental eruption, the enamel organ undergoes a reverse development. But with violations, it persists and proliferates: this becomes the cause of the formation of ameloblastoma.
2. The theory of V. Braitsev and N. Astakhov indicates the involvement of the remains of epithelial tissue in the bone and periodontium (islets of Malyasse). This assumption is plausible, first of all, because ameloblastoma is distinguished by a large histological diversity. In addition, in many patients, in the course of diagnostics, similar enamel structures were found in tumors.

Other theories are also known that have not been sufficiently studied at the moment. For example, the hypothesis of connective tissue metaplasia and the hypothesis of epithelial proliferation of the maxillary sinus are under consideration.

Symptoms of the ameloblastomas

The main symptom in ameloblastoma, with which patients turn to doctors, is asymmetry and violation of the shape of the jaw, with varying degrees of such manifestations. Most often, a kind of protrusion, swelling appears in the jaw region. When the tumor is located along the mandibular body and branches, deformation of the entire lower lateral part of the face is noted.

Feeling the neoplasm makes it possible to detect a seal with a smoothed or bumpy surface. In the later stages, against the background of thinning of the bone tissue, its bending is noted when pressed with fingers. The skin over the ameloblastoma has a normal appearance, the color and density do not change, they are easily formed into a fold and displaced. Examination of the oral cavity allows you to notice a violation of the configuration of the alveolar process. [7]

If we are talking about maxillary ameloblastoma, then the appearance may suffer only slightly, since the tumor grows into the sinus. However, deformation of the hard palate is noted, and there is also a considerable share of the probability of the process spreading into the orbital and nasal cavities. [8]

In general, the clinical picture can be represented by the following symptoms:

• pain sensations that increase with the onset of damage to bone tissue;
• deterioration of jaw mobility;
• unsteadiness of teeth, violation of the dentition;
• difficulty swallowing, chewing, yawning;
• unpleasant sounds during movement of the lower jaw, which is due to the thinning of the cortical plate;
• ulceration, bleeding of mucous tissues in the area of the neoplasm;
• lack of reaction from the submandibular lymph nodes.

If a complication develops in the form of a purulent inflammatory reaction, then there are signs characteristic of phlegmon or an acute form of osteomyelitis. [9]

At the initial stage of the formation of ameloblastoma, a person usually does not feel anything unpleasant. The tumor progresses rather slowly, since its growth is directed into the cavity of the maxillary sinus. After about six months of such a gradual development, it is already possible to detect a violation of the jaw configuration. The appearance is impaired, and the function suffers. In the area of localization of ameloblastoma, a smoothed or tuberous fusiform protrusion is noted, causing a change in the shape of the alveolar process and subsequent loosening of the chewing teeth.

Due to pathological processes, the patient feels pain and unpleasant clicks during movement of the lower jaw in the area of the temporal bones. This leads to problems with chewing and swallowing food. [10]

With the further growth of tumor formation, a purulent inflammatory reaction develops with the possible formation of fistulas leading into the oral cavity. If by this time the patient has not been provided with qualified surgical care, the risk of the subsequent spread of the painful process to the orbital and nasal cavities increases.

In some cases, fistulas with purulent contents may appear on the mucous tissues of the oral cavity. Wounds left after tooth extraction are difficult to heal. During the puncture of the tumor focus, a light turbid colloidal substance or a yellowish substance is found, which may contain cholesterol crystals.

Ameloblastoma is prone to suppuration, so you should see a doctor as early as possible. [11]

Ameloblastoma in children

In childhood, ameloblastoma occurs in 6-7% of all benign jaw tumors. Pathology is more often diagnosed at the age of 7 to 16 years, with a predominant localization in the zone of the mandibular branch and angle. The reasons for the appearance of a neoplasm have not yet been studied.

At an early stage of development, the child does not voice any complaints. Less often, pains are noted, which are regarded as toothaches. At a later date, there is difficulty in nasal breathing, visual impairment, lacrimation, a change in the sensitivity of the skin from the side of the tumor. A visit to a doctor follows, mainly, after the detection of deformities in the face and jaws.

In children, malignancy of ameloblastoma is observed in extremely rare cases - for example, with prolonged improper therapy. Treatment is exclusively surgical: the neoplasm is removed within healthy tissues (10-15 mm from the tumor). [12]

Forms

Experts subdivide ameloblastoma into the following varieties:

1. Solid ameloblastoma.
2. Cystic ameloblastoma:
   • single-cystic;
   • polycystic.

Ameloblastoma of the lower jaw is most often represented by a polycystic variant of a tumor that grows from particles of odontogenic epithelium.

A solid tumor on macroscopic examination has the appearance of a loose pinkish-grayish formation, in some places with a brownish tinge. During microscopic examination, cysts can be found. [13]

Cystic ameloblastoma has one or more interconnected cavities - smooth-walled or slightly tuberous, divided by soft tissue layers, filled with light brown or colloidal contents. In the course of histology, in most cases, zones are found, arranged by analogy with a solid tumor.

Therefore, both dense and cystic zones can be found in the structure of ameloblastoma. Some experts believe that different types of disease represent just different stages of tumor formation. [14]

In the cystic variant, there are more parenchymal areas and less stroma. There are a number of cystic cavities of various sizes and configurations, as well as bone septa. Inside the cysts, a stretching fluid is found, sometimes containing cholesterol crystals.

A solid form of pathology is represented by the stroma and parenchyma, has a capsule. The stroma is a connective tissue with vascular and cellular inclusions. The parenchyma consists of strands of epithelial tissue prone to overgrowth. [15]

Ameloblastoma of the upper jaw is quite rare and almost never manifests itself as a defect in the jaw wall, which is associated with the growth of a neoplasm into the cavity of the maxillary sinus. However, if germination occurs in the nasal cavity or orbit, there is a violation of the configuration of the hard palate and alveolar process, displacement of the eyeball.

Depending on the microscopic characteristics, the mandibular ameloblastoma is subdivided into the following subspecies:

• follicular ameloblastoma - in the stroma contains peculiar follicles, or epithelial islets;
• pleomorphic - contains a network of epithelial strands;
• acantomatous - differs in the formation of keratin in the area of tumor cells;
• basal cell - has signs characteristic of basal cell carcinoma;
• granular cell - contains acidophilic granules in the epithelium.

In practice, the first two types of neoplasm are more often found: follicular and pleomorphic forms. Many patients have a combination of several histological variants in one tumor.

Complications and consequences

Ameloblastoma is prone to re-development even several years after its removal. In about 1.5-4% of cases, malignancy is possible, which is manifested by accelerated growth and germination of the formation into nearby tissues.

Of the immediate postoperative consequences, one can name pain and swelling, which go away on their own for several days. The pain can spread to the jaw, teeth, head, neck. If during the week the discomfort does not disappear, but worsens, then you should definitely visit a doctor. [16]

Other possible postoperative complications:

• inflammatory processes;
• neuritis;
• paresthesia (numbness, loss of sensitivity of the cheeks, tongue, jaws);
• hematomas, soft tissue abscesses.

Inflammatory processes can develop with insufficient adherence to antiseptics, with improper postoperative care (for example, when food gets into the wound).

An urgent need to consult a doctor if:

• within a few days, the edema does not disappear, but increases;
• the pain becomes more intense, and pain medications are ineffective;
• body temperature rises for several days;
• against the background of loss of appetite, general weakness and nausea appear.

During growth, the tumor formation distorts the dentition and jaw. It happens that ameloblastoma suppurates, swelling of soft tissues is formed, which can be complicated by the laying of fistulas. [17]

The repeated development of ameloblastoma in the form of a relapse is noted in 60% of cases after conservative curettage, in 5% of cases after radical surgical removal.

Preoperative complications

Pathological fracture of the jaw. Inflammatory process. Malignancy.

Early postoperative complications

Bleeding. Inflammatory process. Lack of engraftment of the autograft. Blockage of the vascular pedicle of the revascularized graft.

Late complications

Re-development of a neoplasm, requiring a repeat of the surgical intervention and having a more unfavorable prognosis. Violation of the jaw configuration. Skin and mucous deformities caused by cicatricial changes.

Diagnostics of the ameloblastomas

Ameloblastoma is diagnosed through a dental examination and X-ray, which can detect characteristic changes in the bone structure. To confirm the diagnosis, a cytological examination is prescribed. [18]

Analyzes are nonspecific and can be prescribed as part of a general clinical diagnosis:

• a general blood test is taken three times (before surgery, after surgery and before discharge);
• urine analysis is also submitted three times;
• a biochemical blood test is taken once every 14 days during the entire period of treatment (the level of total protein, cholesterol, urea, bilirubin, creatinine, ALT, AST);
• coagulogram;
• SCC tumor markers;
• a blood test for glucose levels.

In addition, a cytological examination of a smear from the tumor surface is performed.

To recognize ameloblastoma, the following instrumental diagnostics are used:

• X-ray (provides information about the size of the tumor, its boundaries and structure);
• CT, computed tomography (a method that is more accurate and detailed than radiography);
• MRI, magnetic resonance imaging of the jaws;
• biopsy (with difficulties with the final diagnosis);
• cytology, histology (to study the composition of the neoplasm, confirm the diagnosis).

Histological examination reveals that ameloblastoma has a similarity to the structure of the enamel organ. On the periphery of epithelial outgrowths, tall columnar or cubic cells are localized, containing large hyperchromic nuclei, with a transition to polyhedral and cubic, and further to the central part - to stellar cellular structures. Between loosely distributed cells there are cysts of different sizes, filled with granular or homogeneous contents. [19]

Cystic cavities can be covered inside by stratified squamous epithelial tissue. In such situations, the doctor prescribes an excisional biopsy to examine the tissues of the entire neoplasm.

Tumor parenchyma may include mainly combinations or cords of squamous epithelial cells, or outgrowths of polyhedral and columnar cells. Sometimes the structure contains cells of the basal epithelium, as well as glandular tissue covered with columnar epithelium. In rare cases, the angiomatous structure of the neoplasm is observed. The tumor stroma is well developed; hyalinosis with focal calcification may be present.

The X-ray picture of ameloblastoma is quite specific. A distinctive X-ray criterion is the transparency of cavity shadows of different degrees. Cavities can have different levels of transparency, from low to high. The central part of the cyst is always very transparent. With a cystic variant of ameloblastoma, one large cyst, localized in the area of the mandibular angle and branches, or polycystoma, can be found. A large cyst is radiographically characterized by clear boundaries of formation, often homogeneous bone rarefaction. In some cases, an impacted tooth is projected onto the cystic cavity, but its crown is located outside with a different dental arrangement. X-ray of polycystoma demonstrates the presence of several cysts of different diameters, mutually adjacent (like "soap bubbles"). The formations have a clear rounded configuration, sometimes with uneven contours. May contain an impacted tooth. [20]

Solid ameloblastoma on the roentgenogram is determined by uneven bone rarefaction with relatively clear boundaries. In some patients, against the background of rarefaction, barely distinguishable cystic cavities are found, which often indicate a transition period of a neoplasm from a solid ameloblastoma to a cystic one.

Differential diagnosis

Ameloblastoma should be differentiated with the following pathologies:

• osteoblastoclastoma;
• odontogenic cysts;
• fibrous osteodysplasia;
• sarcoma ;
• chronic osteomyelitis (with a suppurating tumor).

If the tumor formation is located in the mandibular angle, then additionally it should be distinguished from odontoma, hemangioma, cholesteatoma, fibroma, eosinophilic granuloma.

Treatment of the ameloblastomas

Ameloblastoma can be cured only by surgery, namely by removing the tissues of the jaw damaged by the tumor. The extent of the intervention is determined by the location and stage of the pathological process. The earlier the operation is performed, the fewer structures have to be removed. If the neoplasm has reached a large size and has spread to the predominant part of the bone, it may be necessary to remove part of the jaw and even the entire dentition. Since the operation is performed in the area of the face, where the aesthetic factor is especially important, the intervention is completed with reconstructive correction of the removed tissues and organs - that is, the elimination of a visible cosmetic defect. [21]

After resection of the tumor focus, drug therapy is started, aimed at preventing postoperative complications and re-development of pathology.

Antibiotics after the operation are prescribed by the surgeon. Often, Amoxiclav becomes the drug of choice, which is associated with its effectiveness, the minimum number of contraindications and side effects. Medications are taken, strictly adhering to the scheme described by the doctor.

When pain occurs, analgesics and anti-inflammatory drugs (for example, Nimesulide) are taken, as well as vitamin agents to support immunity.

Chlorhexidine, furacilin solution, Miramistin are usually used to rinse the mouth.

During the rehabilitation phase, it is important to adhere to a special diet. Food should be soft (optimally liquid), with a comfortable temperature. Spicy seasonings, salt and sugar, soda, alcoholic beverages, raw plant foods should be excluded from the diet. [22]

Medicines

When choosing medicines, contraindications, the degree of toxicity of the drugs, possible side effects, the rate of penetration into soft tissues and the term of excretion from the body must be taken into account. [23]Prescription of the following medications is possible:

• Ibuprofen - take one tablet three times a day for three days. Longer use can negatively affect the state of the digestive system.
• Ketanov - taken orally once or repeatedly, depending on the severity of pain, 10 mg per dose, up to 3-4 times a day. The duration of treatment is no more than five days, which avoids erosive and ulcerative lesions of the gastrointestinal tract.
• Solpadein - used to eliminate severe pain, 1-2 tablets three times a day, maintaining an interval between doses of at least 4 hours. Do not take the drug for more than five days. With prolonged use, abdominal pain, anemia, sleep disturbances, tachycardia are possible.
• Tsetrin - to relieve puffiness, take 1 tablet daily with water. The drug is usually well tolerated, only sometimes it can cause digestive discomfort, headache, drowsiness, dry mouth.
• Amoxiclav - in the postoperative period, appoint 500 mg 2-3 times a day, for up to 10 days. Possible side effects: dyspepsia, headache, convulsions, allergic reactions.
• Cifran (ciprofloxacin) is prescribed as part of antibiotic therapy in individual dosages. Possible side effects include nausea, diarrhea, allergic reactions.
• Lincomycin is an antibiotic-lincosamide, which is taken 500 mg three times a day. Treatment may be accompanied by nausea, abdominal pain, reversible leukopenia, and tinnitus. At the end of the treatment course, such side effects go away on their own.

Physiotherapy treatment

Physiotherapy can be used after surgical resection of ameloblastoma to speed up tissue repair. A good effect is provided by:

• electrical exposure to ultra-high frequencies in an oligothermal or athermal dose, lasting 10 minutes, six procedures per treatment course;
• Fluctuorization with a duration of 10 minutes, in the amount of six procedures (three - daily, and the rest - once every two days);
• infrared laser with a treatment duration of 15-20 minutes, daily, in the amount of 4 procedures;
• magnetic laser treatment at a wavelength of 0.88 microns, a total power of 10 mW, magnetic induction from 25 to 40 mT, with a duration of 4 minutes and a course of eight sessions.

If seals and cicatricial changes remain in the area of the operation, then ultrasound treatment is indicated in a continuous mode, with a session duration of up to 8 minutes and a head area of 1 cm². The treatment course consists of 8-10 sessions.

Herbal treatment

How can herbs help with ameloblastoma? Certain plants are able to relieve pain and stimulate the immune system, thereby speeding up tissue repair. Other advantages of herbal medicine are known:

• herbs can have anticancer effects;
• many plants maintain acid-base balance;
• herbal preparations are well absorbed even by a weakened body at any stage of pathology;
• herbs improve the adaptation of the body to new conditions of existence, facilitate the course of the postoperative stage.

Medicinal plants can be used both dried and freshly harvested. Infusions, decoctions are prepared from them. With ameloblastoma, the following types of herbs will be relevant:

• Katarantus is a shrub with antitumor activity. To prepare the tincture, take 2 tbsp. L. Twigs and leaves of the plant, pour 250 ml of vodka, keep in a dark place for 10 days, filter. Take 5 drops half an hour before meals, increasing the dosage daily, bringing to 10 drops a day. The duration of treatment is 3 months. Caution: the plant is poisonous!
• Marshmallow is a well-known expectorant and anti-inflammatory plant, which is no less effective in various tumor processes. One tablespoon of crushed rhizomes is poured into a thermos with 200 ml of boiling water, kept for 15 minutes, poured into a cup and cooled at room temperature for 45 minutes, then filtered. It is taken orally three times a day after meals, 50-100 ml, for 2-3 weeks.
• Marsh calamus - a terpenoid is present in the rhizome of this plant, which has an analgesic and restorative effect. An infusion is prepared at the rate of 1 tbsp. L. Chopped root in 200 ml of boiling water. Take 50 ml per day (divided into two doses).
• Barberry - contains an alkaloid that is successfully used to treat even malignant tumors. The roots and young shoots of barberry (20 g) are poured with 400 ml of boiling water, boiled for 15 minutes, then infused for about 3-4 hours. Filter and bring the volume with boiled water to 500 ml. Drink 50 ml 4 times a day.
• Immortelle - excellently relieves spasms and eliminates pain after surgery. To prepare the infusion, take 3 tbsp. L. Crushed plant, pour 200 ml of boiling water, insist for 40 minutes, filter. The volume is brought up to 200 ml with boiled water. Take 50 ml three times a day half an hour before meals, for a month.
• Burdock root - has an antitumor effect. It is taken orally in the form of a decoction (10 g per 200 ml of water), 100 ml twice a day, for a month.
• Sedum - a decoction and infusion of this herb improves metabolism, tones, eliminates pain and stops the inflammatory process. An infusion is prepared from 200 ml of boiling water and 50 g of dry crushed leaves of the plant. They drink 50-60 ml daily.
• Tatarnik - prevents the development of tumor recurrence. The infusion is prepared at the rate of 1 tbsp. L. Leaves in 200 ml of boiling water. Take 100 ml 3 times a day.
• Calendula - promotes resorption of pathological foci, blood purification, wound healing. Pharmacy tincture is taken 20 drops 15 minutes before meals (with water) three times a day, within a month.

The use of medicinal plants must be approved by the attending physician. In no case should they be used instead of traditional treatment. [24]

Surgery

Treatment consists of prompt removal of the ameloblastoma. With a purulent inflammatory process, the surgeon performs oral cavity sanitation. The neoplasm is exfoliated, the walls are washed with phenol: this is necessary to start necrotic processes in tumor elements and slow down their development. If the operation is performed in the mandibular region, then bone grafting and dental prosthetics are additionally performed with the constant wearing of an orthopedic apparatus. At the end of the operation, the cavity is not sutured to reduce the risk of tumor recurrence. Instead of suturing, tamponade is used, which promotes epithelialization of the cavity walls. [25]

In complex old cases, partial jaw disarticulation is performed (operative twisting of the jaw along the border of the joint space, which does not require bone cutting). Instead of the removed part of the jaw, a bone plate is implanted using a special orthopedic apparatus.

If removal of ameloblastoma is impossible for any reason, or if the neoplasm is malignant, radiation therapy is prescribed. [26]

After surgery, the operated patients are prescribed a course of antibiotics, explain the main points of postoperative nutrition. For several weeks, the patient should not eat hard and rough foods, and after each meal it is necessary to rinse the mouth with a special solution. [27]

Removal of ameloblastoma is carried out as follows:

• If the neoplasm is localized in the bone mass, then a partial mandibular resection is performed.
• If the ameloblastoma is large and extends to the edge of the lower jaw, then a through mandibular resection is performed. If the branch has severe damage, and the condylar process is affected, this is an indication for disarticulation of the lower jaw and neoplasms to the boundaries of healthy tissue.
• To exclude recurrent tumor growth, the surgeon must be familiar with and follow the principles of ablastic and antiblastic surgery.

The patient is inpatient treatment for about 2 weeks, after which he is transferred to outpatient observation with a mandatory visit to the doctor:

• during the first year after surgery - every three months;
• within the next three years - once every six months;
• further - annually.

Prevention

In order to prevent complications in the form of inflammatory processes, pathological fractures and malignancy at the preoperative stage, the earliest possible detection of ameloblastoma is required. For all patients without exception, a complex treatment with the use of symptomatic drugs and antibiotic therapy is recommended.

To prevent bleeding at the stage of postoperative recovery, the quality of blood coagulation and blood pressure indicators should be monitored.

Prevention of late adverse effects is closely related to qualified diagnostics, preliminary stereolithographic modeling. The optimal is a radical intervention with subsequent plastic surgery of the bone, with the setting of endoprostheses and zebra implants, contour plastic, transplant microvascular measures.

Forecast

Ameloblastoma is often diagnosed already in the late stages of growth, which is associated with insufficiently expressed symptoms of the disease and its low spread. The main option for treating a tumor is its immediate removal with further reconstruction (if possible).

The basic factor for a favorable prognosis is early diagnosis of the disease and timely qualified treatment, including surgical removal, chemical or electrical coagulation, radiation therapy, or a combination of surgery with radiation.

The further outcome of postoperative recovery depends on the volume and nature of the treatment, including surgery. For example, radical removal of the lower jaw entails the appearance of significant cosmetic defects, as well as impaired speech and chewing function. [28]

The main point in the rehabilitation of patients who have undergone radical interventions is the correction of jaw function. For this, primary or delayed bone grafting is performed, followed by dental prosthetics. The scope of such an operation is determined by the maxillofacial surgeon.

At this time, the methods of individual dentoprosthetics have not been sufficiently developed after the patient has been removed from the ameloblastoma, despite the fact that the restoration of the face configuration and the functionality of the jaws is an important point of social and medical rehabilitation.