Surgical Management of Oral Pathological Lesions

Surgical Management of Oral
Pathological Lesions
Overview
• Odontogenic cysts & tumors arise from the
odontogenic apparatus.
• The odontogenic apparatus consists of:
– Epithelium:
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Remnants of dental lamina
Reduced enamel epithelium
Odontogenic rests
Lining of odontogenic cysts
Basal cell layer of oral mucosa
– Ectomesenchyme:
• Dental papilla
What is a cyst?
Definition:
• A cyst is a pathological cavity with fluid,
semi-fluid or gaseous contents, which is not
created by accumulation of pus. It is
frequently lined by epithelium.
• Typical features:
a) Cysts grow slowly and expansively
b) Form sharply-defined radiolucencies with
smooth borders
c) Frequently they are found as an incidental
radiographic finding.
Classification
• Odontogenic cysts:
– Inflammatory:
• Periapical (radicular) cyst
• Residual periapical
(radicular) cyst
– Developmental:
• Dentigerous cyst
• Odontogenic keratocyst
(OKC)
• Gingival (alveolar) cyst of the
newborn
• Gingival cyst of the adult
• Lateral periodontal cyst
• Calcifying odontogenic
(Gorlin) cyst
• Eruption cyst
• Non Odontogenic cysts that
are not really cysts:
– Nasopalatine duct cyst,
– Nasolabial cyst,
– Dermoid cyst,
• Cysts without epithelial
lining:
– Simple bone cyst
– Aneurysmal bone cyst
Diagnostic modalities
• Panoramic Radiograph, CBCT are most
valuable diagnostic tools for detection
• Histopathology Confirms diagnosis.
Clinical Features
• Noticeable swelling:
– Initially smooth bony hard swelling with normal overlying
mucosa
– As bone thins through resorption, cyst may show through
as bluish fluctuant swelling (may be compressible in
nature)
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Discharge into mouth
Pain due to secondary infection
Fluid may be aspirated
Thin-walled cysts may be trans illuminated
Basic Goals
• Eradication of Pathological condition
• Functional rehabilitation
• Broad Classification
– Cysts
– Cystlike lesions of the jaws
– Benign tumors of the jaws
– Benign tumors of the soft tissues
– Malignant tumors
Cysts Surgical Management
• Four methods
– Enucleation
– Marsupialization
– A staged combination of two procedures
– Enucleation with curettage
Enucleation
• Definition : Shelling out of the entire lesion without rupture
• Indications
– Any cyst that can be removed without sacrificing any adjacent vital
structures.
• Advantages
– Cyst is removed entirely
– Complete Histopathology
• Disadvantages
– Devitalization of teeth
– Jaw fracture
– w/o curettage OKC may
be left behind
Marsupialization
• Definition
– Decompression
– Referred to as Partsch procedure
– Surgical window is created and contents of the
cyst are evacuated
– Continuity b/w cyst and OC, or Maxillary Sinus is
maintained
Marsupialization - Indications
• Amount of tissue injury
– Proximity to vital structures ( OA Fistula, Damage to IAN,
devitalization of teeth)
• Surgical access
– Difficulty in accessing the areas
• Assistance in eruption of teeth
– Unerupted tooth in the arch
• Extent of surgery
– Patients Medical status
• Size
– Large cyst (Jaw#)
Marsupialization
• Advantages
– Simple
– Spares vital structures
• Disadvantages
– Pathologic tissue left in
situ
– Recurrence
– Post operative
maintainence
– Longer time to heal
Marsupialization - Technique
• Initial Incision circular, extending into cystic
cavity
• Osseous window-Bur, Rongeurs
• Removal of window of cyst lining
• Evacuate contents
• Irrigation
• Perimeter of the cystic lining is sutured to oral
mucosa/ Pack the cavity with strip of gauze
Post operative care
• Pack-Changed after 10-14 days ( prevents the
mucosa from healing over the window)
• Frequent irrigation
• Enucleation is performed after
marsupialization
• Residual cavity may not obliterate
Enucleation after Marsupialization
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Combined approach reduces morbidity
Accelerates healing pocess
Indications: Same as marsupialization
Advantages/Disadvantages
Rationale :
– Osseous healing is allowed to practice
– Once cyst has reduced in size, enucleation is more
amenable
Technique
• Marsupialization
• Wait for cyst to decrease in size
• Check if sufficient bone has formed over the vital structure
• Enucleation
• Intravenous tubing
fashioned into a drain
by heating
and flattening the ends.
Enucleation with curettage
• 1-2mm of bone is removed around the entire
cystic cavity
• Indications
– OKC ( recurrence is between 20% to 60%)
– Recurrence of cyst
• Advantages/Disadvantages
• Technique
Ameloblastoma
• Epithelial Origin
• Pathogenesis
– Originates from epithelium involved in formation of teeth
– Trigger for neoplastic transformation of theses epithelial
residues are unknown
• Clinical Features
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Benign aggressive tumor
Invasive and persistent
Age- mean age 40 years
Mandibular ramus area
Radiolucent
Unilocular/multilocular
Slow growing
Technique- Marginal or Partial Resection
• Indication:
– Aggressive lesion (confirmed by histopathology)
– Removal by curettage/enucleation difficult
• General Rule :
– Resected specimen should include
LESION + 1 cm of bony margins around radiographic
boundaries
Overview of treatment
• Benign/Malignant
• Aggressiveness of the lesion
• Anatomic location of lesion
– Proximity to adjacent vital structures
– Size of the tumor
– Intraosseous versus extra osseous location
Overview of treatment
• Duration of the lesion
• Reconstructive efforts
• Treatment method
– Treated with Curettage, enucleation or both
– Treated with Marginal or Partial resection
Jaw tumors treated with Enucleation,
curettage or both
• Indications:
– Tumors with low recurrence rate
• Technique
– Similar to procedure described with cysts
– Additional sectioning might be necessary for
sectioning large osseous masses
Technique- Marginal or Partial Resection
• Indication:
– Aggressive lesion (confirmed by histopathology)
– Removal by curettage/enucleation difficult
• General Rule :
– Resected specimen should include
LESION + 1 cm of bony margins around radiographic
boundaries
Malignant Tumors of the Oral cavity
• Origin
• Most common tumor
• Treatment
– Surgical
– Radiotherapy
– Chemotherapy
– Combination of any one of the above
• Factors affecting treatment planning
Staging- TNM System
• T = the size of the primary Tumor
• N = the status of the cervical lymph Nodes
• M = the presence or absence cancer in sites
other than the primary tumor (Metastasis)
• Staging is defined through physical
examination, diagnostic tests, and biopsies.
What Does Each Stage Mean?
• T- Tumor
• N-Lymph node involvement
• M-Metastasis
Codes Describing the Tumor (T)
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TX primary tumor cannot be assessed
T0 no evidence of primary tumor
Tis carcinoma in situ
T1 tumor less than 2 centimeters (cm) in greatest
dimension
– T2 tumor more than 2 cm but not more than 4 cm in
greatest dimension
– T3 tumor more than 4 cm in greatest dimension
– T4 tumor invades adjacent structures (mandible, tongue
musculature, maxillary sinus, skin)
Codes Describing Nodal Involvement (N)
– NX regional lymph nodes cannot be assessed
– N0 no regional lymph node metastasis
– N1 metastasis in a single ipsilateral lymph node, less than 3
cm in greatest dimension
– N2a metastasis in a single ipsilateral lymph node, more
than 3 cm but not more than 6 cm in greatest dimension
– N2b metastasis in multiple ipsilateral lymph nodes, none
more than 6 cm in greatest dimension
– N2c metastasis in bilateral or contralateral lymph nodes,
none more than 6 cm in greatest dimension
– N3 metastasis in a lymph node, more than 6 cm in greatest
dimension
Codes Describing Metastasis (M)
– Mx – Metastasis cannot be assessed
– M0 - No distant metastasis
– M1 - Distant metastasis
Stage Grouping
Stage Grouping
• Stage I- T1N0M0
• Stage II- T2N0M0
• Stage III-T3N0M0
– T1 or T2 or T3N1M0
• Stage IV-T4N0 or N1M0
– Any T, N2, or N3M0
– Any T, any N, M1
Oral Cancer –
The Patient’s Journey
• Cancer Diagnosis
• Pre-treatment Dental
Management
• During Treatment
Management
• Post Treatment Dental
Management
Pre Treatment Dental Management
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Restorations / Extractions
Oral Hygiene Programme
Debridement
Diet Advice
Use of Fluoride Trays
Smoking Cessation
“Prevention is better than cure”
Radiotherapy
• Mechanism of Action
– Actively growing tumor cells are more susceptible to
radiation
– Interferes with nuclear material
• 3Hs
• Types– Low dose brachytherapy
• Needles, cesium, irridium wires
– External Radiation sources
• Fractionation
• Multiple beams (portals)
How does radiation kill cells?
H
H•
O•
High energy
particle (b, g)
H
O
H
H
H•
Free radicals
O•
O2
HOO•
Secondary reactions with DNA
(and other macromolecules)
Mutations
Guidelines for management of a patient
for a surgical Procedure Before
radiotherapy
• All mandibular carious teeth in field of radiation
(>6000 cGy)should be extracted
• Full bony impaction should be left in place
• Optimal time of procedure-3weeks prior to radiation
• Radical alveolectomy with primary closure
• Less optimally- Extractions can be done within 4
months of completion of therapy
Guidelines for management of a patient
for a surgical Procedure During
radiotherapy
• Palliative treatment only
– Pulpectomy
– Pulpotomy
– Incision and drainage
– Extractions should be avoided or delayed until after
radiotherapy
Guidelines for management of a patient
for a surgical Procedure After
radiotherapy
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Careful management to prevent ORN
Recall every 3 month for prophylaxis
Daily flouride application
Restorative dentistry procedure may be performed as needed
If mucositis has cleared prosthetic appliances may be
fabricated
• Avoid invasive procedures
• Within 4 months of completion of radiotherapy minor OS
procedures
Radiotherapy / Chemotherapy
Side Effects
• Mucositis
• Dry Mouth
• Radiation Caries
• Osteoradionecrosis
Mucositis
• 83% of HNC patients
develop mucositis
• 29% developed severe
mucositis
• Short term effects
• Long term effects
Vera – Lionch M, et Al Oral mucositis in patients undergoing radiation treatment for
head and neck carcinoma
Cancer. 2006 Jan 15;106(2):329-36
Management of irradiation Mucositis
and Xerostomia
• Keep the mouth , teeth moist and plaque free
• NO Spicy food, carbonated drinks, commercial
mouth washes, peroxide rinses, Alcohol,tobacco
use
• Encourage sugarless candy and gum chewing
• Liquid or semisolid diet
• Salivary substitutes• No dentures to be worn on areas with mucositis
• Baking soda if toothpaste irritates
Trismus - Limited Opening
• 5% - 38%
prevalence
• Site of Cancer
• Surgery
• Radiation of TMJ
or Medial
Pterygoid Muscle
• Plast Reconstr Surg. 2006 Jul;118(1):102-7
Exercise/ Physiotherapy
Dry Mouth
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Reduced Flow
Thick / Stringy
Loss of taste
Difficulty swallowing
Speech
Recovery depends on
site and dose of Rx
Use of Fluoride
Fluoride /
Chlorhexidine
Regime
each alternate
day for 10-15
minutes in
dental trays
Osteoradionecrosis
• Disease of irradiated bone that may lead to
marked pain, bone loss and functional or
cosmetic disability
• Site: Mandible > Maxilla (Why?)
• Radiation in excess of 6000 rad causes death
of bone cell and in progressive obliterative
arteritis
Sequence of Events
• Radiation----HHH---- Breakdown of tissue ----Non healing wound
• Clinical features
– Pain
– Evidence of exposed bone (gray/yellowish color)
– Trismus
– Fetid odor
– Usually associated with intra/extra oral fistula
ORN- Clinical features
• Little or no radiographic changes in early
disease
• Formation of sequestra or involucrum is seen
late or NOT AT ALL in osteoradionecrosis
Osteoradionecrosis
• Superficial
Debridement
• Oral Saline Irrigation
• Antibiotics for
secondary infection
• HBO
Chemotherapy
• Drugs systemically administered
• Treatment rounds or courses
– Administration over several weeks or months in a
sequence
• Cytotoxic effects
• Myelosuppression
– Oral manifestations are due to myelosuppression
Chemotherapy-Oral Manifestations
• Bleeding
– Reduction of platelets
• Xerostomia
• Neurotoxicity
– Odontalgia
• Infection- Myelosuppression
– Opportunistic infections
• Pain
– Oropharyngeal pain
• Mucositis and Ulceration
– GI mucosa has high cellular turnover
Management during
Chemotherapy
• Maintain Excellent oral hygiene
• Tooth brushing– with care, avoid during periods of
thrombocytopenia(<50000 cubic mm or neutropenia (
ANC<1000 cubic mm)
– Good, gentle oral lavage with soda-saline rinses
– Cotton tips
• Flossing/ Toothpicks • Denture Care-Not to wear at night or when
mucosa is irritated
• Mouth rinses-NO alcohol mouth rinses
Surgical treatment
• Surgical Excision
– Extent
• Small lesions
– Accessible-simple Excision
– Un accessible- Extensive surgery
• Large lesions
– Composite Resections
– Functional/esthetic rehabilitation
• Lymph node involvement
Role of a general dentist
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Immediate reconstruction
Future reconstruction
Grafts
Defects of Maxilla
– Surgery
– Grafts
– Prosthetic obliteration
• Partial or complete dentures extend maxillary
sinus/nasal cavity
Surgery
Role of a general dentist
• Defects of Mandible
– Immediate reconstruction
• Benign tumors
– Delayed reconstruction
• Malignant tumors
Reasons of reconstruction
 Recurrence needs to be evaluated
Role of a general dentist
• Defects of Mandible-Delayed reconstruction
– Maintain residual mandibular fragments in normal
anatomic relationship
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IMF
Internal pin and external pin fixation
Splints internal fixation
Combination of the above
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