The document discusses the anatomy and pathology of the buccal mucosa and related structures. It provides details on: - The anatomy of the buccal mucosa, muscles, nerves, blood supply, and related structures. - Common tumors that can arise in the buccal mucosa, including carcinomas which are often associated with pre-existing leukoplakia or tobacco/betel nut use. - Evaluation, staging, and treatment options for buccal mucosa tumors, which may involve surgery, radiation therapy, chemotherapy, or a combination depending on the size, extent, and staging of the cancer.

1. Dr. sumer yadav
MCh – plastic surgery

3. The buccal mucosa includes the mucosal
surfaces of the cheek and lips from the line of
contact of the opposing lips to the
pterygomandibular raphe posteriorly.
This extends to the line of attachment of the
mucosa of the upper and lower alveolar ridge
superiorly and inferiorly.

4. The muscle of the cheek is the buccinator
muscle.
The buccal fat pad is superficial to the fascia
covering the buccinator muscle and gives the
cheeks a rounded contour.
Branches of the maxillary and mandibular
nerves (cranial nerves V2 and V3) provide
sensory innervation to the skin, the cheek,
and the mucous membranes lining the
cheeks.
The facial nerve (cranial nerve VII) provides
motor innervation to the muscles of the
cheeks and lips.

6. The lips and cheeks function together as
an oral sphincter propelling food into the
oral cavity.
If the facial nerve is paralyzed, food tends
to accumulate within the cheek along the
affected side so that saliva and food
dribble out of the corner of the mouth.

7. After carcinoma of the lip, oral tongue, floor of
the mouth, and lower gum, carcinoma of the
buccal mucosa is the fifth common carcinoma
of the oral cavity.
It usually occurs in the sixth and seventh
decades of life, and is more prevalent in men
than in women.
Tobacco and betel nut chewing appear to play
an important role in the cause of these
tumors.[

8. Carcinomas of the buccal mucosa often occur
in association with pre-existing leukoplakia
and tend to have multiple primary sites and
recurrence.
Excision of the oral leukoplakia may reduce
the subsequent development of carcinoma.
These tumors usually arise in the area
adjacent to the lower molars along the
occlusal line of the teeth.

9.  Leukoplakia - A chronic white
mucosal macule which cannot
be scraped off, cannot be
given another specific
diagnostic name, and does not
disappear with removal of
potential etiologic factors
(excepting tobacco).
 4-18% progress to invasive
carcinoma

10.  Erythroplakia is the clinical
diagnostic term - A chronic
red mucosal macule which
cannot be given another
specific diagnostic name and
cannot be attributed to
traumatic, vascular or
inflammatory causes, i.e. it is
a diagnosis of exclusion.
 Higher risk of cancer
development (~ 30%)

11. 4.5 – 7.5 % progress to oral cancer

12.  Clinically, there are three distinct types: exophytic,
ulcerative, and verrucous.
 The patient may present with pain or bleeding,
trismus, or cervical lymphadenopathy.
 Posterior extension may result in involvement of the
lingual or dental nerves, which may cause ear pain.
 Extension behind the pterygomandibular raphe into
the pterygoid muscles or into the buccinator and
masseter muscles may cause trismus.
 In advanced stages, the tumor may destroy the entire
cheek and invade the adjacent bones and the neck.
Infection is common and mastication becomes
difficult. Death usually occurs as a result of poor
nutrition and general debilitation

13. Symptoms Signs Associates
Ulcer Ulceration/growth Leukoplakia
Burning sensation Induration SMF
Mild irritation Ankyloglosia eythroplakia
Pain Bleeding ulcer
Earache Trismus
Bleeding Parotid enlargement

14. Infiltrating lesions of the buccal mucosa can
invade the buccinator muscle, extend to the
buccal fat pad, and invade the subcutaneous
tissue.
Carcinomas of the buccal mucosa frequently
spread by direct invasion into the
gingivobuccal sulcus, the upper and lower
alveolar ridges, the hard palate, the maxilla,
and the mandible.

15.  Lymph node metastasis occurs in approximately
9% to 31% of the patients during the course of
the disease.
 The submandibular lymph nodes are most
frequently involved; involvement of the upper
cervical and the parotid lymph nodes is less
common. The risk of subclinical disease is 16%.
 Distant metastases are rare, as patients often
die of uncontrolled local disease before distant
metastases are manifested clinically.

16.  >90 % Squamous cell carcinomas
 Spectrum of diseases from benign
lesions like leukoplakia, lichen planus,
SMF to verrucous carcinoma to well
differentiated squamous carcinoma
 Malignant Minor salivary gland tumors
such as Adenoid cystic,
Adenocarcinoma, Mucoepidermiod
carcinoma (< 10%) are uncommon
 Malignant Melanoma, Lymphoma,
sarcoma occur rarely.

17.  History & Clinical examination , including head &
neck examination
 Clinical staging
 Assessment of performance & nutritional status
 Investigations for histological diagnosis – Punch
Biopsy

18. Investigations to determine the extent of the
disease
OPG/ Dental occlusal view
CT Scan / MRI for extent of disease
USG for N0 neck in select cases

19. Routine Investigations
CXR
Routine blood counts
Blood chemistry profile
Urinalysis

21. Stage Grouping
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T1, T2 N1 M0
T3 N0, N1 M0
Stage IV A T1, T2, T3 N2 M0
T4a N0, N1, N2 M0
Stage IV B Any T N3 M0
T4b Any N M0
Stage IV C Any T Any N M1
sumeryadav2004@gmail.com

22.  Stage I – IV A : Curative
 Stage IV B-C : Palliative
The aim of treatment:
 Cure
 Loco regional control
 Preservation of anatomy & function
 Reasonable cosmesis
 Quality of life

23. Tumor factors
 Primary site
 Size
 Proximity to bone
 Status of cervical nodes
 Tumor pathology ( histological type, grade, & depth of
invasion)
Patient factors
 Age
 General medical conditions
 Tolerance of treatment
 Acceptance of expected sequelae of therapy
 Socioeconomic considerations

25.  Primary
 Surgery : wide excision +/- marginal
mandibulectomy
 Radiotherapy : Radical external RT/
Brachytherapy
 Nodes
 N0 : Observe or
SOHD ( if cheek flap raised , USG suspicious,
thick tumor or poor follow up expected) followed
by Frozen section, if positive nodes, MND is
required.
 N+ : MND/RND
 Post op RT as per guidelines

26. Surgery + Post op RT or CT-RT
Primary
Surgery : Composite resection of the buccal
mucosa with mandible or upper alveolus or
overlying skin with reconstruction
Nodes
N0 : SOHD followed by FS, if positive nodes,
MND required.
N+ : MND/ RND

27. Management is controversial
Perceived risk that the tumor may become more
aggressive if it recurs after RT.
Many tumors that recur after treatment are
biologically more aggressive. Therefore, it is
reasonable to treat these lesions with irradiation
if surgery is not feasible.
Wang reported a series of patients with
verrucous carcinoma treated with RT; the
results were comparable to those for patients
treated for squamous cell carcinoma.

28.  Used as single modality in early disease (Stage I &
II )
 Combined with post operative adjuvant
radiotherapy in advanced disease(Stage III & IV)
 Wide excision of tumor in all dimensions with
adequate margins & appropriate neck dissection
essential for locoregional control of disease

29.  Treatment time is shorter.
 The risk of immediate and late radiation sequel
are avoided.
 Irradiation is reserved for recurrence, which
may not be resectable.
 Pathological assessment, accurate staging.
Disadvantage: functional & cosmetic
impairment, increased morbidity when bilateral
neck is addressed.

30.  Modified neck dissection is sufficient treatment
for the ipsilateral neck for patients with N1
without PNE.
 Radiation therapy is added for
 N1 with PNE/LVI
 N2,N3 stages, for control of contra lateral
subclinical disease
 For invasion through the capsule of the node,
 For multiple positive nodes

31.  RND : superficial & deep cervical fascia with its enclosed
LN (level I-V) is removed in continuity of SCM, omohyoid
muscle, internal & external jugular veins, spinal accessory
N & submandibular gland
 MND : is finding more acceptance & preference to RND in
managing N0 neck because of severe morbidity related to
RND such as, shoulder dysfunction, poor cosmesis, facial
edema (level I-V LN)
 SOHND : least morbid, provides most satisfactory
sampling of the LN at the level I, II, III which are greatest
risk
 Extended SOHND : level I-IV LN dissection

33.  Marginal mandibulectomy: partial-thickness (marginal)
mandibular resection
 Segmental Mandibulectomy
For small lesions with minimal bone invasion, a short
section of mandible is removed in continuity with the
tumor (e.g., removal of the mandible from the angle to
the mental foramen).
 Hemimandibulectomy
- Removal of the mandible symphysis to the condyle
on one side.
- Major cosmetic and functional loss
- Reconstruction is performed with a composite
osteomyocutaneous flap

34. MARGINAL MANDIBULECTOMY SEGMENTAL
MANDIBULECTOMY

35. Gross pathology
1. Morphology
2. Location & extent of the tumor / lesion
3. Tumor dimensions
4. Distance from various margins of excision
5. Nodal dissection
Microscopy
1. Histologic type
2. Grade
3. Extent of disease including depth of
infiltration
4. Perineural invasion

36. 5. Lymphovascular invasion
6. Bone / Cartilage / Skin / Soft tissue involvement
7. Margins of excision, submucosal spread, In – situ
changes
8. Nodal status – no. & size of nodes, perinodal extension
& level of nodes
9. Status of cut margins
Miscellaneous features
1. In RND/ MND status of internal jugular vein
2. Presence of predisposing factors - leukoplakia, SMF
3. Dysplasia/ in situ elements

37.  Unresectable Disease
Primary disease
 Adequate surgical clearance is not achievable
 Extensive Infra Temporal Fossa involvement
 Extensive involvement of base skull
 Extensive soft tissue disease – skin edema /
ulceration
Nodal disease
 Clinically fixed nodes
 Infiltration of Internal / Common carotid artery
 Extensive infiltration of prevertebral muscles

38.  Better functional and cosmetic outcome
 Elective irradiation of the lymph nodes can be included with
little added morbidity, whereas the surgeon must either
observe the neck or proceed with an elective neck dissection
(sometimes bilateral depending on the primary site),
 The surgical salvage of irradiation failure is probably more
likely than the salvage of a surgical failure.
 The risk of postoperative complications is avoided

39.  Accessible lesions
 Small (preferably < 3cm ) tumors
 Well defined borders
 Lesion away from bone
 Superficial lesions
 Tumors of the anterior two thirds of the buccal
mucosa without involvement of gingiva are ideally
suited for brachytherapy alone.

40. Primary:
Advanced primary – T3 or T4
Close or positive margins of excision
Depth of invasion
High grade tumor
LVI & PNI
Nodes:
Bulky nodal disease N2/N3
Extra nodal extension
Multiple level involvement

41.  T1 and T2 lesions
 Ipsilateral field arrangement that includes the
primary lesion and the level I and II lymph
nodes.
 The anterior and superior borders of the field
should be at least 2 cm from the borders of
the primary tumor. The posterior border
should be at the posterior aspect of the
spinous processes if the nodes are to be
irradiated.
 Inferior border is at the thyroid notch.

43. T3 and T4 lesions
Patients with significant tumor extension
toward the midline are treated with parallel
opposed fields weighted 3 : 2 toward the side
of the lesion.
The low neck is treated with an anterior field
with a 6-MV x-ray beam to 50 Gy in 25
fractions once daily

44.  Doses of 66 Gy in 2-Gy fractions for positive
margins.
 60 Gy in 2-Gy fractions or 59.4 to 63 Gy in 1.8-Gy
fractions to high-risk regions.
 54 Gy in 1.8-Gy fractions for low-risk regions.
 An LAN is often used, treated to either 50 Gy in 2-
Gy fractions or 50.4 Gy in 1.8-Gy fractions.

45.  Interstitial implants with iridium wires or seeds
in nylon ribbons can be considered for
treatment of early, small lesions that have not
invaded the buccogingival sulcus, the gingiva,
or bone.
 Usually a minimum tumor dose of 60 to
70 Gy in 5 to 8 days is delivered through a
single-plane or double-plane implant on the
thickness of the lesion.

46. The buccal mucosa tolerates high-dose RT
with a low risk of late complications.
Trismus may develop if the muscles of
mastication receive high doses of
irradiation.

47. Cisplatin
- Used in NACT (T4b and N3 cases)
- Used in CTRT

49. The FOM is a horseshoe-shaped area that
is confined peripherally by the inner aspect
(lingual surface) of the mandible.

 sublingual/ranine veins are visible.
The frenulum is a mucosal fold that
extends along the midline between the
openings of the submandibular ducts .

50.  Sublingual gland
and its duct.
 The deep part of
the submandibular
gland and its duct.
 Lingual frenum
 Deep lingual
artery and veins.
 Lingual nerve.

51.  The inferior surface of the tongue is covered with a thin
transparent mucous membrane through which one can see the
underlying veins
 A sublingual caruncle (papilla) - opening of the submandibular
duct
1- frenulum,
2- lingual vein,
dashed-circle- sublingual
gland.
Arrow- Wharton's duct opening,

52.  Superior and
inferior genial
tubercles.
 Mylohyoid line.
 Sublingual fossa.
 Submandibular
fossa.

62. Description :
The lesion usually presents as a smooth,
movable, solitary , asymptomatic, round,
or as a circumscribed intramuscular
mass.
DD: granular cell tumor(S-100 positivity ) - salivary gland
tumors, namely, acinic cell carcinoma or oncocytoma-
rhabdomyosarcoma.
Treatment: The treatment of
choice for rhabdomyoma is
surgical excision.

63. Description :
Cavernous hemangiomas are composed of large,
irregular, deep dermal and subcutaneous blood-
filled channels that impart a purplish discoloration
to the overlying skin. readily blanch with
compression, giving them a characteristic "bag of
worms" feel. The lesion may expand and darken
with crying, when agitated, or when placed in a
dependent position.
Occlusal Radiographs – Computed Tomography.
Etiology :
The causes of vasoformative tumors are unknown. One hypothesis postulates that
placental cells, such as the trophoblast, may be the cell of origin for hemangiomas.
DD:The diagnosis of hemangiomas is straightforward from the history
and the clinical examination, and the differential diagnosis is limited.
For intraosseous lesions, the differential diagnosis can be more
challenging, with the radiographic appearance being similar to that of a
giant cell lesion or an ameloblastoma.
Treatment: Treatment
COMPLETE SURGICAL
EXCISON OF THE LESION

64. Description :
Cystic hygromas are abnormal growths
that usually appear on a baby’s neck or
head. They consist of one or more cysts
and tend to grow larger over time. The
main symptom of a cystic hygroma is the
presence of a soft, spongy lump. This
lump most commonly appears on the
neck.
Radiography : CT Scan
DD: Branchial cleft cyst -Thyroglossal duct cyst -
Ranula -Goiter -Soft tissue tumors -Neck abscess
Treatment: The first step
of treatment is surgery.

65. Description :
A lipoma can usually be diagnosed by its
appearance alone. They present as slow growing
asymptomatic lesions with yellowish color and
soft, doughy feel, generally with no gender
predilection.
X-Ray: No X-ray Picture
DD: Other connective tissue lesions such as granular cell
tumor, neurofibroma, traumatic fibroma, and salivary gland
lesions (mucocele and mixed tumor).- Normal Fat – Well-
differentiated Liposarcoma
Treatment: Lipomas usually
are not treated, because most
of them don't hurt or cause
problems.
It might remove the lipoma if
it is painful, gets infected, or
bothers the patient.

66. Description :
Neurofibroma is an uncommon benign tumor of the oral
cavity derived from the cells that constitute the nerve
sheath. Neurofibroma is seen either as a solitary lesion
or as part of the generalized syndrome of
neurofibromatosis (usually neurofibromatosis type 1
[NF-1], also called von Recklinghausen disease of the
skin). Patients usually present with an uninflamed,
slowly enlarging, asymptomatic lesion that varies
greatly in size from tiny nodules to large pendulous
masses. Oral neurofibromas usually present as
submucosal, nontender, discrete masses that range in
size from a few millimeters to several centimeters. The
lesions are typically pedunculated or sessile, usually
painless, but occasionally pain or paresthesia is
reported due to nerve compression.
DD: Granular cell tumor -Fibroma -Scar tissue -
Neurilemmoma (schwannoma) -Leiomyoma –Rhabdomyoma.
Treatment:
Solitary oral neurofibromas
are usually treated by surgical
excision, depending on the
extent and the site.

67. Description :
Pleomorphic adenoma is a benign salivary gland tumor
that exhibits wide cytomorphologic and architectural
diversity. Pleomorphic adenoma usually presents as a
slow-growing, painless mass, which may be present for
many years. On gross examination, a pleomorphic
adenoma is a single firm, mobile, well-circumscribed
mass. Its color may vary from whitish-tan to gray to
bluish, and its size may range from a few millimeters to
quite large or even giant. Pleomorphic adenomas are
irregularly shaped and have a bosselated surface.
Computed-tomography (CT) images showed a distinct
radiolucent, homogeneous lesion extending anteriorly in the
area where the left sublingual gland (sublingual sulcus)
normally lies
DD: other salivary gland tumors of submandibular/minor salivary
glands.- lymphomas, non-neoplastic entities of salivary glands such as
ranulas, retention cysts, sialolithiasis, sialadenitis, and cystic lesions of
the floor of the mouth such as dermoid cysts.
Treatment: Early total surgical
resection of the sublingual gland
and its neoplastic mass in normal
margins for benign tumors is the
treatment of choice to avoid
recurrences.

68. Neurilemmoma
Description :
Schwannomas are usually solitary
lesions; however, some are seen as
multiple lesions as part of
Neurofibromatosis type I. The solitary
neurilemoma is a slow growing,
encapsulated tumor that typically arises
in association with a nerve trunk. As it
grows it pushes the nerve aside. Usually
the mass is asymptomatic, although
tenderness or pain may occur in some
instances.
DD: Lipoma – Fibroma –Neurofibroma - Rhabdomyoma -
Leiomyoma

70. Description :
The clinical course is characterized by an initial period of slow
and indolent growth that is usually asymptomatic. In most
cases the tumor goes unnoticed until it has invaded local
nerves and structures causing varying symptoms depending
on location. Thus, most patients will present with locally
invasive disease.
The tumor is typically a firm, poorly circumscribed, and
unencapsulated mass. Tumor size typically averages from 1
to 8 cm in maximum dimension. Tumor size greater than 3 cm
has been associated with increased rates of distant
metastasis. The cut surface is white to gray-white with a solid
appearance. Hemorrhage and necrosis are rare features and
should raise the suspicion of high-grade transformation into
dedifferentiated ACC.
Computed Tomography
DD: benign mixed tumor, mucoepidermoid carcinoma and
polymorphous low-grade adenocarcinoma (PLGA).
Treatment: Surgery

71. Description :
ES is a poorly differentiated neuroectodermal tumor with
small, round and blue cells. Swelling, pain, increased CRP,
leukocytosis, and elevated temperature may be the first signs
of oral ES, occurring also in odontogenic infections . Also
there is apical osteolysis, loss of sensibility and loosening of
teeth.
Axial MRI scan revealing a bone destroying mass of approximately 7 × 8 × 6
cm 3 surrounding the mandible and massively infiltrating the soft tissue of the floor
of the mouth and the tongue.
Etiology :More than 90% of cases show a characteristic
translocation t(11;22)(q24;q12) resulting in the fusion of the EWS and
FLI-1 genes. This gene rearrangement causes a fusion product which
functions as an oncogenic aberrant transcription factor with structural
variability and potentially prognostic impact . Immunoreactivity against
FLI-1 and CD 99 can help to confirm the diagnosis
Treatment:
Treatment of ES should
include wide surgical
resection and (neo-)adjuvant
chemotherapy .

72. Description :
Oral melanomas arise silently, with few symptoms until progression has
occurred. Most people do not inspect their oral cavity closely, and
melanomas are allowed to progress until significant swelling, tooth
mobility, or bleeding causes them to seek care. Pigmented lesions 1.0
mm to 1.0 cm or larger are found.
On physical examination, the pigmentation of these lesions varies from
dark brown to blue-black ; however, mucosa-colored and white lesions
are occasionally noted, and erythema is observed when the lesions are
inflamed.
Etiology :
The cause of oral melanoma or melanoma of any mucosal
surface remains unknown. In contrast, cutaneous lesions are
linked directly to fair-skinned and blue-eyed persons with a
history of blistering sunburns, and the incidence has
increased dramatically (approximately 4-6% per year) over the
same period. However, mucosal exposure to sunlight is
unlikely, and, therefore, cutaneous melanoma and mucosal
melanoma are different diseases.
DD : Haemangioma -Melanotic macule-Oral mucosal nevi-
Amalgam tattoo-Kaposi Sarcoma

73. Description :
The most common presentation of cancer of the floor of the mouth is a
painless inflamed superficial ulcer with poorly defined margins.
Preexistent or coincident leukoplakia can be observed in adjacent
tissues in approximately 20% of cases. The presence of erythroplasia
strongly suggests an invasive tumor. A small ulceration or nodular
lesion may remain asymptomatic for long periods, so the patient may
not seek medical attention. Vague symptoms of soreness in the
regional mucosa could be attributed to an aphthous ulcer. In fewer than
50% of cases, the ulcer is localized only to the floor of the mouth on
initial presentation.
Etiology :
Tobacco and alcohol have additive effects on oral cancer. Tobacco
includes smokeless tobacco derivatives, such as snuff and betel nut.
Some people seem to be more vulnerable than others to the effect of
these irritants. The nature of the increased vulnerability may be
genetic, familial, or acquired (eg, immunosuppression, syphilis,
Plummer-Vinson syndrome, chronic candidiasis). These risk factors
and the underlying pathogenesis do not disappear following surgical
excision or radiation therapy for the cancer. The organs remain
susceptible.
DD: Lymphoma – Adenoid cystic carcinoma – Adenocarcinoma –
Mucoepidermoid Carcinoma – Liposarcoma –Rabdomyosarcoma –
Ranula - Infected Teeth – Radionecrosis of mandibular soft tissues.
Treatment : Various therapeutic
measures are available for managing
localized carcinomas of the oral cavity,
including surgical excision, radiation
therapy, electrodesiccation, cryotherapy,
laser-beam excision, chemotherapy,
and a combination of these methods.