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Management of jaw tumors

Management of jaw tumors

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Management of jaw tumors

  1. 1. Management of Jaw Tumors Dr. Saleh Bakry Assistant Professor of Oral and Maxillofacial Surgery
  2. 2. Diagnosis  History and Examination  Biopsy  Imaging  Laboratory investigation
  3. 3. I. History & Examination 1. Duration 2. Mode of onset and progress 3. Exact site and shape 4. Change in character of the lesion 5. Associate symptoms 6. Similar swelling elsewhere 7. Loss of body weight 8. Recurrence 9. Habit
  4. 4. 1. The anatomic location of the mass: Lesions may arise from any tissue within the oral cavity, including epithelium, subcutaneous and submucosal connective tissue, muscle, tendon, nerve, bone, blood vessels and salivary glands. 2. Physical character of the lesion. II. Clinical Examination of the Lesion
  5. 5. 3. Size and shape of the lesion 4. The surface of the lesion: It may be smooth, lobulated, irregular or ulcerated. 5. The color of the lesion: e.g., bluish mass blanches on pressure may indicate hemangioma. 6. The consistency of the lesion: It may be soft (lipoma), firm (fibroma), hard (pleomorphic adenoma) or bony hard (osteoma) II. Clinical Examination of the Lesion
  6. 6. 7. Presence of fluctuation: It is felt on palpation. It indicates fluid within the mass. 8. Presence of pulsation: Palpation of a mass may reveal a palsatile quality which indicates a large vascular component. II. Clinical Examination of the Lesion
  7. 7. 9. Single Vs multiple lesions: • Presence of multiple lesions is an important diagnostic sign. • When multiple areas of ulceration are found within the mouth then you can eliminate a carcinoma in the mouth. • While vesicobullous lesions commonly present such a clinical picture. 10. The sharpness of its boundaries: • In an ulcer, the margins could be flat, rolled, raised or everted. II. Clinical Examination of the Lesion
  8. 8. 11. Lymph node examination: Five characters of the nodes should be recorded: 1. Location 2. Size. 3. Tenderness (painful versus non painful). 4. Degree of fixation (movable, matted, fixed) 5. Consistency (hard or firm). II. Clinical Examination of the Lesion
  9. 9. III. Radiographic Examination For lesion within or adjacent to the bone we may use: 1. Plain radiograph: Indicate intra-bony lesions. 2. C.T.: Indicate intra-bony lesions. 3. M.R.I.: Indicate intra-bony lesions. 4. Ultrasound 5. Scintegraphy: denote distant metastasis. 6. Sialography: assess S.G. tumors.
  10. 10. IV. Laboratory investigations  CBC.  Liver and renal function tests.  Albumin/globulin ratio.  Serum Ca, Ph., alkaline phosphatase.  Tumor markers e.g. alpha feto protein in hepatocellular carcinoma.  Bence johns protein in multiple myeloma.
  11. 11. V. Biopsy Biopsy is the removal of tissue from a living individual for microscopic diagnostic examination. Value of biopsy: 1. Proper and correct diagnosis. 2. Determination of the degree of malignancy e.g., by percentage of undifferentiated cells. 3. Determination of the prognosis.
  12. 12. Indications: 1. Lesion not responds to ttt within 14 days. 2. No apparent cause. 3. If suspect malignancy.
  14. 14. Feature of the lesion  Direct biopsy: when the lesion is located on the oral mucosa and can be easily accessed with a scalpel from the mucosal surface  Indirect biopsy: when the lesion is covered by an apparently normal oral mucosa
  15. 15. Area of surgical removal:  Incisional biopsy.  Excisional biopsy.  Etc.………
  16. 16. Timing of the biopsy:  Pre-operative.  Intra-operative.  Post-operative: when aimed at checking the efficiency of a treatment
  18. 18. 1. INCISION BIOPSY It is the removal of a portion or sample from the edge of the lesion with some normal tissue for identification of the lesion. INDICATIONS: • Large lesion > 1 cm diameter  Location in risky or hazardous regions  If the lesion nature is uncertain. CONTRAINDICATIONS: • Hemangioma. • Malignant melanoma.
  19. 19. A) INCISION BIOPSY PRINCIPLES 1. The sample is cut in a wedge shape. It is much better to take a deep narrow biopsy rather than a broad shallow one. 2. The biopsy should be taken from the edges of the lesion to include some normal tissue. 3. Avoid injection of local anesthetic directly into the tumor tissue which may cause distortion of the tissues. Ring block or regional nerve block is recommended. 4. Also avoid cauterization, areas of necrosis and/or impaction of foreign bodies. 5. The lesion should not be wiped with an antiseptic having staining properties (iodine) because this will change the staining character of the tissues. 6. The sample should be placed in 10% formalin solution in a wide
  20. 20. B) EXCISION BIOPSY • It is the complete excision or removal of the lesion. • A margin of 2-3 mm of the surrounding normal tissues should be excised with the lesion to ensure its total removal. INDICATIONS: 1. Small superficial lesion (1-2 cm in diameter). 2. Well encapsulated tumors.
  21. 21. B) EXCISION BIOPSY CONTRAINDICATIONS: • Large lesions involving important structures. • Tumors are planned to other line of treatment e.g. radiotherapy or chemotherapy.
  22. 22. C) Drill biopsy (intra-osseous biopsy) 1. For obtaining samples from deeply seated lesions. 2. Indication: intra osseous lesion
  23. 23. D. Punch biopsy 1.This is performed with a punch type forceps which punches or bites out a portion of tissue. 2.It is indicated in inaccessible areas (larynx and oropharynx).
  24. 24. E. Frozen section biopsy This is performed during surgery to attain immediate information.
  25. 25. F. Curettage biopsy • In this type, tissues removed from the depth of tooth socket after extraction or from maxillary sinus using bone curette. • Indication: intra-osseous lesion or inside extraction socket. • Disadvantage: not accurate as it damages the specimen.
  26. 26. G) Aspiration biopsy 1.It is the most valuable investigation for cystic and fluctuant lesions. 2.A wide bore needle (18 gauge) attached to a 10 ml syringe is used. The needle is inserted deeply into the lesion for
  27. 27. H) Exfoliative oral cytology 1. It is performed by scraping the lesion's surface repeatedly and firmly by a spatula or tongue depressor. 2. The cells obtained are smeared on a glass slide, fixed and stained, and microscopically examined. 3. It is useful in poor surgical risk patients & in
  28. 28. I) Fine needle aspiration cytology (FNAC):1. A fine disposable needle of gauge 18-23 is used with 3-10 lcc disposable plastic syringes. 2. The needle is inserted into the lesion and moved in and out and laterally in three dimensional planes without being removed outside the lesion. 3. Cells from the lesion will be collected inside the lumen of the needle. Then the needle is withdrawn and the aspirate containing the cells is disposed on a glass slides. It is then spread, fixed, stained and examined microscopically. 4. Indications: S.G & L.N. 5. Adv.: simple, atraumatic & cheap. 6. Disadv: insufficient sample.
  29. 29. I) Fine needle aspiration cytology (FNAC):
  31. 31. Handling the Biopsy 1. Do not wash the specimen or paint it with a colored antiseptic solution. 2. Gently blot excess blood off the specimen with a gauze sponge. 3. Place specimen into formalin without delay. 4. Make sure the bottle contains 10% formalin in at least 10 times the volume of the specimen.
  32. 32. Container Specimen should be placed in a wide-mouthed glass bottle. Bottle should contain a preservative (10°formalin). 1. Personal history: Age, sex, etc. 2. History of chief complaint. 3. Description of the lesion (size, number ,site, shape,...etc) 4. Description of associated clinical findings e.g. L.N metastasis. 5. Radiographic findings (R.L, R.0, well or ill defined,... etc). BIOPSY DATA SHEET
  33. 33. Biopsy results 1. Another biopsy is needed if results does not corroborate with the clinical findings. 2. Complete treatment. 3. Referred to specialist if malignant.
  34. 34. Tumors of odontogenic epithelium o Ameloblastoma • Malignant ameloblastoma • Ameloblastic carcinoma o Calcifying epithelial odontogenic tumor o Squamous odontogenic tumor o Clear cell odontogenic Tumors of odontogenic epithelium With odontogenic ectomesenchyme ± dental hard tissue formation o Ameloblastic fibroma o Ameloblastic fibro-odontoma o Ameloblastic fibrosarcoma o Odontoameloblastoma o Odontoma • Compound composite • Complex composite Tumors of odontogenic ectomesenchyme ± included odontogenic epithelium o Odontogenic fibroma o Granular cell odontogenic tumor o Odontogenic myxoma o Cementoblastoma Benign Odontogenic tumors
  35. 35. Benign Non-odontogenic tumors Osteogenic neoplasm o Ossifying fibroma o Osteoma Non neoplastic bone lesions o Fibrous Dysplasia o Cementoosseous dysplasia • Periapical cementoosseous dysplasia • Focal cementoosseous dysplasia • Florid cementoosseous dysplasia Other cementoosseous dysplasia o Cherubism o Central Giant Cell Granuloma
  36. 36. Odontogenic Carcinomas o Malignant (metastasizing) ameloblastoma o Ameloblastic carcinoma • Primary • Dedifferentiated • Peripheral o Primary intraosseous squamous cell carcinoma • Solid • Cystogenic  Nonkeratinizing cyst  Odontogenic keratocyst o Clear cell odontogenic carcinoma o Malignant epithelial odontogenic ghost cell tumor Odontogenic Sarcoma o Ameloblastic fibrosarcoma Odontogenic malignancies
  37. 37. Non Odontogenic malignancies o Osteosarcoma o Fibrosarcoma and chondrosarcoma o Squamous cell carcinoma o Secondary (metastatic) bone tumours
  38. 38. Treatment Planning  Diagnosis confirmed by biopsy  Imaging for assessment of extension  For benign lesions; • Surgical approach  Reconstruction
  39. 39. Principles of Surgical excision of jaw tumors
  40. 40. Factors deciding Surgical modality 1. Aggressiveness of Lesions  Non-aggressive benign lesions (e.g. central fibroma, CGCG)  Enucleation/ curettage  Cauterization in case of CGCG.  Locally aggressive benign lesions (e.g.ameloblastoma, Myxoma and CEOT)  Marginal resection (in mandible).  Segmental resection.
  41. 41. Factors deciding Surgical modality 2. Anatomic Location of Lesion  The location of the lesion in the oral or perioral areas may complicate the choice of treatment.  Nonaggressive, benign lesion is an inaccessible area (e.g. pterygomaxillary fissure) make surgical problem.  Which a more aggressive lesion in an accessible and resectable area (e.g. anterior
  42. 42. Factors deciding Surgical modality 3. Maxilla vs mandible  Tumors in mandible are confined largely due to the thick cortical plates but maxillary tumors tend to enlarge into the sinuses, orbit, skull base and nasopharynx.  They present a poorer prognosis.
  43. 43. Factors deciding Surgical modality 4. Proximity to Adjacent Vital Structures  Benign lesions may cause damage to neurovascular structures and teeth.  Neurologic deficit and vascular compromise might occur.  Tumors can also be associated with root resorption.
  44. 44. Factors deciding Surgical modality 5. Size of tumor  Larger tumor requires a larger segment of bone resection.  Continuity of mandible can be compromised leading to a more difficult reconstruction process.
  45. 45. Factors deciding Surgical modality 6. Intraosseous vs Extraosseous location  Intra-osseous lesions that does not perforate bone:  Enculation and curettage.  Marginal resection.  Total resection.  Intra-osseous lesions that perforate the cortical bone:
  46. 46. Factors deciding Surgical modality 7. Duration of Lesion  Slowly growing lesion (benign): enucleation or block excision.  Rapidly growing lesion (malignant): Composite resection.
  47. 47. Factors deciding Surgical modality 8. Reconstructive efforts  The goal of any surgical procedure is the removal of the tumor as well as restoration of function.  The goals of reconstruction could dictate a certain surgical technique than another since it is more optimal for facilitating future reconstructive procedures.
  48. 48. Modalities of Surgical excision  Enucleation (with or without curettage)  Resection  Marginal Resection  Segmental Resection  Total resection  Composite Resection
  49. 49. THE GOAL OF TREATMENT 1. Complete eradication of the lesion. 2. Preservation of normal tissues. 3. Excision with least morbidity. 4. Restoration of tissues loss, form and function. 5. Long term follow up for recurrence.
  50. 50. Enucleation (with or without curettage) Indications:  Accessible tumors.  Small to moderate sized tumors that do not endanger vital structures.  Tumors that do not involve soft tissues.  Curettage and Cauterization (Electerical or chemical) is necessary to avoid recurrence with some lesions e.g. Central giant cell granuloma.
  51. 51. Enucleation (with or without curettage) Advantages: 1. The whole tumor mass can undergo pathological examination. 2. Removal of the entire pathologic tissue. 3. Decreases the need for post operative care and irrigation.
  52. 52. Marginal/Enbloc Resection (Resection without continuity defect) Technique  This is a surgical procedure in which the entire tumor is removed intact with a rim (1 cm) of the surrounding uninvolved bone without disruption of the continuity of the jaw.
  53. 53. Marginal/Enbloc Resection (Resection without continuity defect) Uses 1. It is for the treatment of aggressive odontogenic tumors with tendency for recurrence as:  Ameloblastoma when there is at least 1 cm of uninvolved bone closer to the inferior border of the mandible.  Odontogenic myxoma. 2. It is either done through inraoral or extraoral approaches.
  54. 54. Marginal/Enbloc Resection (Resection without continuity defect)
  55. 55. Segmental Resection (Resection with continuity defect) Technique In this technique, the lesion is removed with 1-2 cm of uninvolved bone distal and proximal to it with continuity defect or disruption of the jaw including inferior border of the mandible.
  56. 56. Segmental Resection (Resection with continuity defect) Uses 1. It is indicated in large aggressive tumor with tendency for recurrence & less than 1 cm of uninvolved bone at the inferior border, for example ameloblastoma and myxoma. 2. Either partial (hemimandiblelloectomy) or total
  57. 57. Segmental Resection (Resection with continuity defect)
  58. 58. Modalities of Surgical excision Segmental Resection of Mandible: – Hemimandibulectomy – segmental mandibulectomy – posterior segmental – middle segmental – Disarticulation
  59. 59. Modalities of Surgical excision Disarticulation Whenever condylar head is included in the resection part of the mandible, the procedure is known as hemi- mandibulectomy with disarticulation and whereas the condylar head is retained for rehabilitation procedure, then the procedure is known as hemi-mandibulectomy without disarticulation
  60. 60. Total Resection Resection of tumor with removal of involved bone Involves: Mandibulectomy Maxillectomy
  61. 61. Maxillectomy  Total: it refers to surgical resection of the entire maxilla. Resection includes the floor and medial wall of the orbit and the ethmoid sinuses.  Sub total inferior: on alveolar ridge, palate, antral floor  Sub total anterior: for lesions anterior to maxillary 1st premolar
  62. 62. Composite Resection Most common ablative procedure for locally advanced malignant lesions INVOLVES: • removal of involved mucosa, skin, mandible with a margin of at least 2-2.5 cm • Removal of neck nodes
  63. 63. Reconstruction  Objectives  Achieve primary healing  Maintain oral competence  Facilitate swallowing  Prevent aspiration  Preserve speech  Restore continuity, bone height and bone bulk of jaw
  64. 64. Immediate reconstruction Advantages o Single stage surgery o Early return of function o Minimal compromise of esthetics Disadvantages o Recurrence in grafted bone o Loss of graft from infection Techniques: 1. Performing surgical excision and grafting, both via intraoral approach 2. Surgical excision utilizing both intraoral and extraoral approach; first obtaining water tight oral closure and grafting done extraorally 3. Earlier extraction of involved teeth and waiting for 6-8 wks for oral healing and surgery via extraoral approach Reconstruction of Osseous Defect
  65. 65. Delayed reconstruction • usually performed after 6 months of waiting period to observe for recurrence • Preferred in malignancies • If radiotherapy is anticipated as it may jeopardies the graft • Residual mandibular fragments are maintained with their normal anatomic relationship (IMF/ Reconstruction plate) in order to avoid muscular deformation and displacement of segments Reconstruction of Osseous Defect
  66. 66. Delayed reconstruction Advantages o Follow up for 6 m clinically and radiographically to ensure absence of recurrence. Disadvantages o need 2nd surgery Techniques: 1. First stage: Resection and Reconstruction plate to preserve bone continuity. 2. Second stage: after 6- - 9 months bone reconstruction is done Reconstruction of Osseous Defect
  67. 67. THANK YOU

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