GORDON B.

WONG

179
Report of nine cases and review of the literature. Oral Surg 40:631, 1975 Perzin KH, Gullane P, Clairmont AG: Adenoid cystic carcinomas arising in salivary glands : A correlation of histologic features and clinical course. Cancer 42:265, 1978 Simpson JR, Thawley SE , Matsuba HM: Adenoid cystic carcinoma: Treatment with irradiation and surgery. Radiology 151:509, 1984 Antonio G, Ana LP, Lygia AF, et al: Adenoid cystic carcinoma of salivary glands : A study of 61 cases with clinicopathologic correlation. Cancer 57:312, 1986 Matsba HM, Gershon J, Stanley E, et al: Adenoid cystic salivary gland carcinoma: A histopathologic review of treatment failure patterns. Cancer 57:519, 1986 Rentschler R, Burgess MA, Byers R: Chemotherapy of malignant major salivary gland neoplasms. Cancer 40:619, 1977 Vermeer RJ, Pinedo HM: Partial remission of advanced adenoid cystic carcinoma obtained with adriamycin. Cancer 43:1604, 1979 Belson TP, Toohill RJ, Lehman RH , et al: Adenoid cystic carcinoma of the submaxillary gland. Laryngoscope 92:497, 1982 Gates GA: Current concepts in otolaryngology: Malignant neoplasms of the minor salivary glands. N Engl J Med 306:718, 1982

References
I. Bumsted WD: Cylindroma of the mandible. Oral Surg 8:546, 1955 2. Bradley JC: A case of cylindroma ofthe mandible. Br J Oral Surg 5:186,1%8 3. Dhawan IK, Bhargava S, Nayak NG, et al: Central salivary gland tumors of jaws. Cancer 26:211, 1970 4. Slavin G, Mitchell RM: Adenoid cystic carcinoma of the mandible. Br J Surg 58:546, 1971 5. Yoshimura Y, Hasega K, Wada T, et al: Metastasis of adenoid cystic carcinoma of the mandible to the gasserian ganglion. J Am Dent Assoc 94:469, 1978 6. Mushimoto K, Hashimoto Y, Tabuchi M, et al: Central adenoid cystic carcinoma of the mandible: Report of a case. Jpn J Oral Surg 24:973, 1978 7. Kaneda T, Mizuno N, Takeuchi M, et al: Primary central adenoid cystic carcinoma of the mandible. J Oral Maxillofac Surg 40:741, 1982 8. Bhaskar SN, Bernier JL: Mucoepidermoid tumors of major. and minor salivary glands (144 cases). Cancer 15:801, 1%2 9. Alexander RW: Central mucoepidermoid tumor of the mandible. J Oral Surg 32:541,1974 10. Browand BC: Central mucoepid ermoid tumors of the jaws: I I. 12.
13.

14. 15. 16. 17. 18.

J Oral Maxillofac Surg 47:179-182.1989

Surgical Management of a Large, Complex Mandibular Odontoma by Unilateral Sagittal Split Osteotomy
GORDON B. WONG, MSc, DDS*
Introduction

Odontomas are the most common odontogenic tumors when the classification has been restricted to only those mixed lesions containing fully formed dental tissues of both epithelial and mesenchymal origin. t The complex odontoma consists of a mass of irregularly arranged enamel, dentine, cementum, and connective tissue. The compound odontoma consists of a collection of small, morphologically recognizable teeth in the tissue mass. Although they possess limited growth potential, quite large dimen-

In private practice, Oral and Maxillofacial Surgery, Sault Ste Marie , Ontario, Canada. Addre ss correspondence and reprint reque sts to Dr Wong: 350 Queen St E, Sault Ste Marie, Ontario P6A IZI, Canada.
1989 American Association of Oral and Maxillofacial Sur-

sions can be attained during the active growth period. Rittersma and Van Goof initially described the use of sagittal splitting of the mandible to gain access for enucleation of a large, multinucleated keratocyst, thereby avoiding the increased morbidity associated with resection and bone grafting of a nonmalignant lesion. A similar approach has recently been described by Petti et al 3 for the resection of a mandibular myxoma with good results. When large complex odontomas have occurred in the mandibular angle and ramus region, two recent successful cases of removal after sagittal splitting of the mandible have been reported.Y This report describes a similar case of a large, complex odontoma of the mandible treated by a complete splitting of the ramus through the inferior border.
Report of a Case
A healthy 13-year-old white boy was referred by his family dentist in December 1986for evaluation regarding

geons 02782391/8914702-0012$3.00/0

180

SAGITIAL SPLIT OSTEOTOMY FOR ODONTOMA

FIGURE 1. Panoramic radiograph demonstrating a large, radiopaque lesion of the right mandibular ramus and angle area, with an inferiorly displaced, unerupted lower second molar.

an unerupted lower-right second molar. The patient was asymptomatic and was not aware of any swelling or discomfort in his jaw. Clinical examination did not reveal any extraoral facial swelling or asymmetry, and there was normal sensation in the distribution of the right mental nerve. He had a full complement of permanent teeth except for the absence of the lower-right second molar. There was only minimal evidence of buccal or lingual cortical expansion of the mandible. A panoramic radiograph revealed a 2.5-cm diameter radiopaque mass in the right mandibular ramus and angle region with an unerupted lower-right second molar displaced anteriorly and inferiorly at the lower border of the mandible (Fig I). The lesion was surrounded by a thin radiolucent zone. The lower-right third molar was missing, and the mandibular nerve canal was displaced inferiorly. Submental vertex and postero-anterior mandible views showed minimal bony expansion of the buccal and lingual cortices (Fig 2). The density of the mass and the uniform soft tissue capsule were compatible with a diagnosis of a complex odontoma. It was elected to excise the tumor by a sagittal split osteotomy because this would not only provide adequate surgical access to the lesion, but would also preserve the buccal and lingual cortices. In March 1987, under hypotensive general anesthesia administered via nasoendotracheal intubation, Ivy loops were placed on the premolar teeth in each quadrant. A standard intraoral buccal vestibular incision was made along the external oblique ridge from the right mandibular ramus to the mesial of the first molar. A subperiosteal dissection exposed the anterior border of the ramus, the coronoid process, and the medial aspect of the ramus above the lingula. The usual horizontal osteotomy was made through the medial cortical plate of the ramus, extended along the anterior border of the ramus, and passed vertically through the buccal cortex of the mandibular body at the distal aspect of the first molar. The mass was noted to have expanded both the buccal and lingual cortices, and the osteotomy incision along the anterior border of the ramus passed directly through the superior aspect of the tumor. The mass

was bony-hard, of uniform density, and yellowish in color. Using fine burs and osteotomes, the sagittal split was completed, deep through the tumor mass to the inferior border of the mandible. A satisfactory split was achieved. The inferior alveolar nerve was not visualized. The lateral

FIGURE 2. Submental vertex radiograph of the mandible showing some minimal buccal and lingual cortical expansion.

GORDON B. WONG

181

FIGURE 3. Panoramic radiograph immediately postoperatively, showing excision of the tumor mass along with the unerupted lower second molar. Note the superior border wire fixation .

portion of the mass was enucleated from the inner aspect of the proximal segment, and the greater majority of the mass within the distal tooth-bearing segment was removed in multiple fragments by sectioning. All specimens were submitted for histologic examination. The unerupted lower-right second molar was visualized and removed in the usual fashion. A 2S-gauge stainless steel wire was passed through the superior borders of the proximal and distal segments. The wound was then thoroughly irrigated with bacitracin solution and maxillomandibular fixation was applied using 25-gauge stainless steel wires ligated to the Ivy loops. Gelfoamv (Upiohn, Kalamazoo, MI) was placed into the remaining bony cavity and the intraosseous wire was tightened while the proximal segment was positioned posteriorly and superiorly in the glenoid fossa. The wound was closed in one layer using Vicryl (Ethicon, Peterborough, Ontario) sutures. The patient had an uneventful postoperative course and was discharged two days later. There was evidence of mild right ment al nerve paresthesia postsurgically. A postoperative panoramic radiograph showed excellent bony alignment (Fig 3). Fixation was released at 6 weeks. The histologic examination showed a haphazard arrangement of enamel,

enamel organ, dentine, cementum, and dental pulp, consistent with a diagnosis of complex odontoma. At the 12month follow-up visit, there was evidence of good bony regeneration in the area of the excised tumor (Fig 4), along with a stable occlusion. There was mild residual paresthesia localized to the right vermilion border of the lower lip.

Discussion
The advantages of a sagittal split osteotomy to gain access for the removal of a large benign lesion of the mandible in a young person outweigh those of the conventional block resection technique. It avoids the formation of a large defect in the cortical bone with its associated increased risk of fracture. It prevents the need for autogenous bone grafting of a nonmalignant lesion in a young patient, along with its associated morbidity. Excellent access to the lesion is achieved, especially when the lesion lies entirely within the cortical plates, and the continuity

FIGURE 4. Panoramic radiograph 12 months postoperatively, showing excellent bony regeneration in the area of the excised odontoma and second molar.

182
of the mandible is preserved after fixation of the proximal and distal fragments. The ability to dissect and preserve the neurovascular bundle, especially when it has been displaced by a lesion, is a decided advantage over other resection techniques where the nerve would most likely have to be sacrificed. The major potential complication of this approach would be fracture of the buccal, cortical bone as alluded to by Frame." However, his case involved an older patient with extreme thinning of the buccal cortex. He performed a modification of the sagittal split osteotomy as suggested by Barnard," in which a buccal, instead of a lingual, horizontal osteotomy was made in order to preserve the bony continuity of the mandible. Barnard" did not perform a complete separation of the proximal and distal segments, but did mention a greenstick fracture of the buccal cortical bone. In the present case, the surgical management of a similar large,

SAGITTAL SPLIT OSTEOTOMY FOR ODONTOMA

complex odontoma of the mandible was accomplished by performing a complete sagittal split through the inferior border. The possible complications of buccal cortical fracture by torquing of segments to gain access through the superior aspect of the split were thus avoided.
References
I. Lucas RB: Pathology of Tumours of the Oral Tissues (ed 3).

Edinburgh, Churchill, Livingston, 1976 2. Rittersma J, Van Gool AV: Surgical access to multicystic lesions by sagittal splitting of the lower jaw. J Maxillofac Surg 7:246, 1979 3. Petti NA, Weber FL, Miller MC: Resection of a mandibular myxoma via a sagittal ramus osteotomy. J Oral Maxillofac Surg 45:793, 1987 4. Barnard D: Surgical access to a complex composite odontome by sagittal splitting of the mandible. Br J Oral Surg 21:44,1983 5. Frame JW: Surgical excision of a large complex composite odontome of the mandible. Br J Oral Maxillofac Surg 24:47, 1986