Management of jaw tumors

1. Management of Jaw
Tumors
Dr. Saleh Bakry
Assistant Professor of Oral and Maxillofacial Surgery

2. Diagnosis
 History and Examination
 Biopsy
 Imaging
 Laboratory investigation

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. 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. 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. 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. 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. 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. 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. 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. 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. Indications:
1. Lesion not responds to ttt within 14
days.
2. No apparent cause.
3. If suspect malignancy.

13. CLASSIFICATION OF BIOPSY

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. Area of surgical removal:
 Incisional biopsy.
 Excisional biopsy.
 Etc.………

16. Timing of the biopsy:
 Pre-operative.
 Intra-operative.
 Post-operative: when aimed at checking the
efficiency of a treatment

17. TYPES OF BIOPSY

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. 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

22. 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.

23. B) EXCISION BIOPSY
CONTRAINDICATIONS:
• Large lesions involving important structures.
• Tumors are planned to other line of treatment e.g.
radiotherapy or chemotherapy.

25. C) Drill biopsy (intra-osseous
biopsy)
1. For obtaining samples from deeply seated lesions.
2. Indication: intra osseous lesion

26. 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).

27. E. Frozen section biopsy
This is performed during surgery to attain immediate
information.

28. 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.

29. 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

30. 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

31. 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.

32. I) Fine needle aspiration cytology
(FNAC):

33. AFTER TAKING THE BIOPSY

34. 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.

35. 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

36. 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.

37. 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

38. 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

39. 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

40. Non Odontogenic malignancies
o Osteosarcoma
o Fibrosarcoma and
chondrosarcoma
o Squamous cell carcinoma
o Secondary (metastatic) bone
tumours

41. Treatment Planning
 Diagnosis confirmed by biopsy
 Imaging for assessment of extension
 For benign lesions;
• Surgical approach
 Reconstruction

42. Principles of Surgical
excision
of jaw tumors

43. 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.

44. 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

45. 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.

46. 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.

47. 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.

48. 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:

49. Factors deciding Surgical modality
7. Duration of Lesion
 Slowly growing lesion (benign):
enucleation or block excision.
 Rapidly growing lesion (malignant):
Composite resection.

50. 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.

51. Modalities of Surgical excision
 Enucleation (with or without curettage)
 Resection
 Marginal Resection
 Segmental Resection
 Total resection
 Composite Resection

52. 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.

53. 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.

54. 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.

55. 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.

56. 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.

57. Marginal/Enbloc Resection (Resection
without continuity defect)

58. 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.

59. 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

60. Segmental Resection (Resection with
continuity defect)

61. Modalities of Surgical excision
Segmental Resection of Mandible:
– Hemimandibulectomy
– segmental mandibulectomy
– posterior segmental
– middle segmental
– Disarticulation

62. 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

63. Total Resection
Resection of tumor with removal of
involved bone
Involves:
Mandibulectomy
Maxillectomy

64. 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

65. 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

66. Reconstruction
 Objectives
 Achieve primary healing
 Maintain oral competence
 Facilitate swallowing
 Prevent aspiration
 Preserve speech
 Restore continuity, bone height and bone bulk of
jaw

67. 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

68. 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

69. 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

70. THANK YOU