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Paper text:
ameloblastoma is a unique neoplasm of the jaws arising from odontogenic epithelium presenting in a variety of clinico - radiological and histological forms . although histologically benign , ameloblastoma represents a locally aggressive lesion with potency to cause extensive destruction of jaws with infiltration into the surrounding soft tissues .
very rarely , they may present in temporal / infratemporal fossa , orbit , anterior skull base and with intracranial extensions .
a 32-year - old indian female reported to our institution in october 2010 with a painless swelling in the left temporal region .
she had undergone a fine needle aspiration cytology ( fnac ) which was reported elsewhere as 
she gave a history of prior surgery ( 2005 ) for the lower jaw swelling .
clinical examination showed a ~8 cm  7 cm  5 cm , soft , fluctuant , non - pulsatile , and non - tender swelling in left temporal fossa along with a 6 cm scar in the submandibular region .
oral cavity examination was normal [ figure 1a and b ] . a computed tomography ( ct ) showed a well - defined , 8 cm  6 cm , uniform , oval , cystic , homogenous lesion medial to the left zygomatic arch , infiltrating the pterygoid and temporalis muscles , abutting the deep lobe of the parotid gland , and causing erosion of the left zygomatic arch [ figure 2a and b ] .
( a and b ) frontal and worm 's eye views show swelling over the left side of face arising from temporal region .
furthermore , note the submandibular scar from the previous surgery and the cosmetic deformity due to surgery and the swelling ( a and b ) radiological appearance of the lesion in left temporal fossa on computed tomography ( detail description in text ) on fnac , amber colored , non - purulent fluid showed inflammatory infiltrate of macrophages , occasional giant cells , atypical squamous cells with enlarged nuclei and keratinous cytoplasm .
a core biopsy showed fibroadipose tissue with tiny focus of a tumor with squamoid differentiation infiltrating skeletal muscle .
squamous cell carcinoma was reported . however , clinical course and radiological features of the lesion were pointing toward a benign pathology .
after thorough work - up , patient underwent excision of left temporal mass with infratemporal fossa clearance via a combined temporal and cervical approaches under general anesthesia [ figure 3a ] .
reconstruction was carried out using the free anterolateral thigh flap to provide for oral cavity lining and bulk in the temporal area .
intraoperative exposure of the tumor and post - operative frontal view after 1 year ( a ) h and e stained sections showing ameloblastoma with solid and cystic patterns .
( a ) papanicolaou stain ( x400 ) ( b ) giemsa stain ( x400 )
it is commonly seen in adults between 30 years and 50 years without gender predilection .
it runs an indolent course and therefore remains asymptomatic for a long time and can attain massive sizes .
clinically , ameloblastomas are classified as ( 1 ) solid / multicystic ( 2 ) unicystic , ( 3 ) extraosseous / peripheral .
the follicular type is further divided into acanthomatous , desmoplastic , granular cell , basal cell , and clear cell and mixed variety .
reichart et al . , found the solid variant to be the most common ( 92% ) while the unicystic ( 6% ) and peripheral variants ( 2% ) were rare .
enucleation , cauterization or local curettage , are  conservative approaches  while segmental resection is referred to as  radical . 
due to benign histology , it is likely that a conservative surgical approach may be favored .
however , conservative treatment modalities have very high recurrence rates ( 90% for mandibular tumors , 100% for maxillary tumors ) .
time for recurrence is highly variable , ( range 1 - 30 years , average 5 years ) .
recurrence is attributed to inadequate removal ,  seeding ,  aggressive histology and spread along the muscle attachment .
treatment of recurrence often mandates extensive ablative and reconstructive surgery with inherent morbidity , even in expert hands .
we hypothesize that recurrence in the temporal region probably occurred due to retraction of temporalis muscle already infiltrated by tumor with / without a small fractured fragment of coronoid process ( weakened due to existing pathology and fracturing during the surgical manipulation ) [ figure 5 ] .
schematic representation showing large ameloblastoma ( grey shaded area ) involving ramus coronoid and condyle of mandible histopathology is the gold standard to confirm the diagnosis of recurrences at such rare sites . in this case , the histopathological diagnosis ( fnac , biopsy ) of squamous cell carcinoma was perplexing .
fnac of the lesion showed a few scattered epithelial cells resembling squamous cells with mild nuclear atypia , along with a few foamy macrophages [ figure 4 ( b and c ) ] .
it is difficult to differentiate ameloblastic epithelial cells from squamous cells in fnac due to overlapping morphological features .
small clusters of ameloblastic epithelial cells in core biopsy can resemble squamous cells . a scanty focus of ameloblastoma in core biopsy , hence can lead to suspicion of oral squamous cell carcinoma .
ameloblastoma recurrences can occur at non - conventional sites such as temporal and infratemporal fossa .
fnac or core biopsy of these recurrent lesions may be inconclusive or even misleadingly suggestive of malignancy .
recurrences are due to incomplete removal at primary surgery , rather than de novo lesions .
strict adherence to the principles of ablative surgery , which include adequate surgical exposure , en bloc removal with adequate bony ( 1 - 1.5 cm ) and soft - tissue margins , is mandatory .
the policy of including the next uninvolved anatomic structure for adequate clear margins must be followed .
extensive bone destruction of the vertical ramus , coronoid , and condylar process are high - risk features and should be evaluated using computerised tomography / magnetic resonance imaging ( preferred ) to look for infiltration of attached muscles .
similarly , maxillary ameloblastomas with erosion of bony walls are high risk tumors as they may infiltrate pterygoid muscles posteriorly or extend superiorly into orbital floor , paranasal sinuses . clinico - radiological follow - up
ameloblastoma is a unique , histologically benign but aggressive neoplasm of the jaws , arising from odontogenic epithelium with potency to cause extensive destruction of jaw bones and infiltration into the surrounding tissues . 
 recurrences are common after incomplete treatment . 
 recurrences can occur at difficult sites such as temporal and infratemporal fossa , orbit , anterior cranial base , paranasal sinuses etc . 
 fine needle aspiration cytology or core biopsy of these recurrent lesions may be misleading . 
 clinical course and radiological features help immensely in these situations . 
 good communication between surgeon , radiologist , and pathologist is of paramount importance .