When reconstruction isn't the end: Late-occurring ameloblastoma in a fibula-grafted mandible.

backgroundAmeloblastomas are rare odontogenic tumors with a high tendency for local recurrence, particularly in previously operated or reconstructed jaws. Late manifestations decades after initial therapy are extremely uncommon and pose diagnostic as well as surgical challenges. CASE PRESENTATION: We present the case of a 90-year-old woman with a history of squamous cell carcinoma of the mandible, treated decades earlier by segmental resection and microvascular fibula graft reconstruction. After nearly three decades of clinical stability, the patient developed bilateral mandibular masses with progressive symptoms including submental swelling and lip paresthesia. Imaging revealed two osteolytic lesions adjacent to, but not involving, the fibula graft. Histopathological examination confirmed a conventional follicular ameloblastoma without cytological atypia. Molecular profiling showed a BRAF-wildtype genotype. Surgical resection was performed bilaterally, preserving the structurally intact fibula flap on the left side. The postoperative course was uneventful with functional recovery and no signs of recurrence at three-month follow-up.

conclusionThis case illustrates the potential for extremely late-onset ameloblastomas in reconstructed mandibles and emphasizes the importance of lifelong follow-up in patients with a history of mandibular malignancy. It also highlights the value of molecular diagnostics in therapy planning and demonstrates that preserving existing grafts during revision surgery can offer oncologically sound and functionally superior outcomes in selected elderly patients.