Management of jaw tumors


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modalities for management of tumor in head and neck region

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Management of jaw tumors

  1. 1. Department of Oral and Maxillofacial Surgery, CODS, BPKIHS Management of Jaw Tumors Presented by Ujwal Gautam Roll no 431 BDS 2009
  2. 2. Contents • Diagnosis • Treatment Planning • Principles of Surgical excision • Radiotherapy: indications • Reconstruction • Complications • Survival and Prognosis
  3. 3. Diagnosis  History and Examination  Biopsy  Imaging
  4. 4. History & Examination History of the lesion Duration Mode of onset and progress Exact site and shape Change in character of the lesion Associate symptoms Similar swelling elsewhere Loss of body weight Recurrence Habit
  5. 5. History & Examination Inspection Number Size Site or anatomical location Shape and size Colour Surface Pedunculated/sessile Overlying skin Clinical Examination of the Lesion Palpation Consistency of lesion Presence of pulsation Fixity Lymph node examination
  6. 6. History & Examination  Bleeding  Duration >2 wks  Erythroplasia  Fixidity  Rapid growth  Induration  Ulceration Characteristics of malignant Lesion:
  7. 7. Biopsy Indications; • Any persistent pathologic condition that cannot be clinically diagnosed • Lesions with no identifiable cause that persists for greater than 2 weeks despite local therapy • Enlarging intrabony lesions • Visible/ palpable submucosal swelling beneath clinically normal mucosa • Any lesion with malignant/ premalignant characteristics • Confirmation of clinical diagnosis • Lesions not responding to routine clinical management over 2 weeks • Any lesion that is of extreme concern for patient
  8. 8. Biopsy • Cytologic techniques • Incisional biopsy • Excisional biopsy • Aspiration biopsy
  9. 9. Incision Biopsy Indications:  Large lesion > 1 cm diameter  Location in risky or hazardous regions Principles  Site is carefully chosen after thorough clinical and radiological examination  Aspiration is always tried before  Incision in wedge shaped fashion  Normal tissue should be included  Tissue specimen should not be crushed  Deeper biopsies over superficial ones  Proper hemostasis before closure  Specimen should be well oriented and marked  Tissue is immediately placed in formalin
  10. 10. Intraosseous Biopsy ı Performed after thorough Neck examination as cervical lymphadenitis is inevitable after the procedure rendering clinical neck examination to produce false positive results ı Necessary because diagnosis from frozen section not possible ı Site: Extraction socket or flap reflection ı Full thickness mucoperiosteal flap of adequate extention is made. ı Flap should rest entirely on sound bone for closure. Eroded area of cortical bone should be approached from the lesion margins over sound bone. ı Major neurovascular structures should be avoided. ı Precautionary aspiration performed before biopsy to prevent inadverant excision into vascular lesion. ı Osseous window created on the cortical plate either with bur of rongeurs. ı Specimen can be curetted from the surrounding bone.
  11. 11. Imaging  OPG  CT  MRI  PET
  12. 12. Tumors of odontogenic epithelium o Ameloblastoma • Malignant ameloblastoma • Ameloblastic carcinoma o Calcifying epithelial odontogenic tumor o Squamous odontogenic tumor o Clear cell odontogenic carcinoma o Primary intraosseous carcinoma 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 o Adenomatoid odontogenic tumor Tumors of odontogenic ectomesenchyme ± included odontogenic epithelium o Odontogenic fibroma o Granular cell odontogenic tumor o Odontogenic myxoma o Cementoblastoma Benign Odontogenic tumors
  13. 13. 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
  14. 14. 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
  15. 15. Non Odontogenic malignancies o Osteosarcoma o Fibrosarcoma and chondrosarcoma o Squamous cell carcinoma o Secondary (metastatic) bone tumours
  16. 16. Peak age Adults, about 40 years old. Frequency Rare, but still the most common odontogenic tumour; 1% of all oral tumors, 18% of all odontogenic tumors Site Posterior body/angle/ramus of mandible, very occasionally involves the maxilla. Clinical Feature asymptomatic, slow growing, hard, non tender, ovoid swelling; may be associated with mobile teeth, exfoliation of teeth, ill fitting dentures, malocclusion, paraesthesia or ulcerations; large lesion may present with egg shell crackling Ameloblastoma
  17. 17. Shape — Multilocular, distinct septa dividing the lesion into compartments with large, apparently discrete areas centrally and with smaller areas on the periphery; Occasionally monolocular in early stages — Honeycomb or soap-bubble appearance or multicystic — shape varies with different histological subtypes. Outline — Smooth and scalloped; Well defined, Well corticated. Radiodensity Radiolucent with internal radiopaque septa. Effects — Adjacent teeth displaced, loosened, often resorbed — Extensive expansion in all dimensions; Buccolongual cortical expansion prominent Thin “eggshell” cortical bone — Maxillary lesions can extend into the paranasal sinuses, orbit or base of the skull
  18. 18. Odontomes Age 1st and 2nd decades Site commonly seen in; posterior mandible, anterior maxilla esp in third molar region Clinical Features asymptomatic, no obvious bony or facial asymmetry; may be associated with unerupted teeth
  19. 19. Compound odontome It is made up of several small toothlike denticles. The miniature tooth shapes are of dental tissue radiodensity, with a surrounding radiolucent line, and are easily identified radiographically. Complex odontome This odontome is made up of an irregular, confused mass of dental tissues bearing no resemblance in shape to a tooth. The enamel content provides the dense radiopacity, suggestive of dental tissue and again the mass is surrounded by a radiolucent line
  20. 20. Fibrous dysplasia Age 10-20 year-old adolescents. Site Maxilla — usually posteriorly, more commonly than the mandible. Maxillary lesions may spread to involve adjacent bones such as the zygoma, sphenoid, occiput and base of skull. Size Variable and difficult to define. Shape Round.
  21. 21. Outline — Poorly defined with the margins merging imperceptibly with adjacent normal bone — Not corticated. Radiodensity — Initially radiolucent (but rarely seen clinically at this stage) — Gradually becomes opaque to produce the typical ground glass, orange peel and finger print appearances resulting from superimposition of many fine, poorly-calcified bone trabeculae arranged in a disorganized fashion. — Continuing to become more opaque with age. Effects — Adjacent teeth — sometimes displaced but rarely resorbed — loss of associated lamina dura — Buccal and lingual alveolar expansion — Encroachment on, or obliteration of, the antrum — Involvement of adjacent bones including the base of the skull.
  22. 22. Age Younger adults lesser than 30 years old. Frequency Rare, but the most common primary malignant bone tumour. Site Usually the mandible. Size Shape Outline Radiodensity From a radiological viewpoint, there are three main types: Osteolytic — no neoplastic bone formation Osteosclerotic — neoplastic osteoid and bone formed Mixed lytic and sclerotic — patches of neoplastic bone formed. All very variable depending on the type of lesion (lytic or sclerotic) and how long it has been present. Osteosarcoma
  23. 23. Effects Early features: Non-specific, poorly defined radiolucent area around one or more teeth. Widening of the periodontal ligament space. Later features: • Osteolytic lesion: — Monolocular, ragged area of radiolucency — Poorly defined, moth-eaten outline. — Cumulous cloud densities — So-called spiking resorption and/or loosening of associated teeth. • Osteosclerotic and mixed lesions: — Poorly defined radiolucent area — Variable internal radiopacity with obliteration of the normal trabecular pattern — Perforation and expansion of the cortical margins by stretching the periosteum, producing the classical, but rare sun ray or sunburst appearance — Spiking resorption and/or loosening of associated teeth — Distortion of the alveolar ridge
  24. 24. Squamous cell carcinomas of the oral mucosadirectly overlying bone, in their latter stages, often invade the underlying bone to produce a destructive radiolucency. Age Adults over 50 years old. Frequency Rare, but the most common oral malignant tumour. Site Mandible, or maxilla if originating in the antrum. Size Variable. Squamous cell carcinoma
  25. 25. Shape Irregular area of bone destruction often initially saucer-shaped. Outline — Irregular and moth-eaten — Poorly defined — Not corticated. Radiodensity Radiolucent, radiodensity dependent on degree of destruction. Effects — Adjacent teeth may be displaced, loosened and/or resorbed or left floating in space — Destruction of surrounding bone may lead to pathological fracture.
  26. 26. Treatment Planning  Diagnosis confirmed by biopsy  Imaging for assessment of extension  For malignant lesions; • Evaluation for staging; Neck assessment • Approach for primaries: surgery/chemotherapy/radiotherapy • Approach for secondaries • Palliative approach  For benign lesions; • Surgical approach  Reconstruction
  27. 27. General principles Factors influencing treatment planning;  Site of disease  Stage  Histology  Age  Previous radiotherapy  Field change
  28. 28. Primary Tumors (T) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor <=2 cm in greatest dimension T2 Tumor >2 cm but <=4 cm in greatest dimension T3 Tumor >4 cm in greatest dimension T4a Tumor invades adjacent structures (eg, through cortical bone, into deep [extrinsic] muscle of the tongue, maxillary sinus, skin of face) (resectable) T4b Tumor invades masticator space, pterygoid plates, or skull base or encases internal carotid artery (unresectable) Nodal Involvement (N) NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node, <=3 cm in greatest dimension N2 Metastasis in a single ipsilateral lymph node, >3 cm but <=6 cm in greatest dimension; or in multiple ipsilateral lymph nodes, <=6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, <=6 cm in greatest dimension N2a Metastasis in a single ipsilateral lymph node >3 cm but <=6 cm in greatest dimension N2b Metastasis in multiple ipsilateral lymph nodes, <=6 cm in greatest dimension N2c Metastasis in bilateral or contralateral lymph nodes, <=6 cm in greatest dimension N3 Metastasis in a lymph node >6 cm in greatest dimension
  29. 29. Early Stage Locally advanced, operable Locally advanced, inoperable/ metastatic 0 4 4
  30. 30. Principles of Surgical excision of jaw tumors
  31. 31. Factors deciding Surgical modality Aggressiveness of Lesions Depends on biologic behavior of lesion depicted by histologic diagnosis. Most Benign lesions treated conservatively without much destruction of adjacent structures.
  32. 32. Factors deciding Surgical modality Anatomic Location of Lesion Lesion in easily accessible and resectable areas offer better prognosis.
  33. 33. Factors deciding Surgical modality Anatomic Location of Lesion 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.
  34. 34. Factors deciding Surgical modality Anatomic Location of Lesion 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.
  35. 35. Factors deciding Surgical modality Anatomic Location of Lesion 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.
  36. 36. Factors deciding Surgical modality Anatomic Location of Lesion Intraosseous vs Extraosseous location An aggressive oral lesion confined to the interior of jaw provides better prognosis than a lesion invading surrounding soft tissues.
  37. 37. Factors deciding Surgical modality Duration of Lesion Slow growing lesions follow a benign course and hence treated accordingly.
  38. 38. Factors deciding Surgical modality Reconstructive efforts Reconstructive procedures should be planned and anticipated before surgery.
  39. 39. Modalities of Surgical excision  Enucleation (with or without curettage)  Resection  Marginal Resection  Partial Resection  Total Resection  Composite Resection
  40. 40. Modalities of Surgical excision  Enucleation (with or without curettage) Indications: • Tumors with expansile growth rather than by infiltration • Well defined lesion with distinct separation from surrounding tissue • Tumor with corticated lining
  41. 41. Modalities of Surgical excision  Marginal/En bloc Resection (Resection without continuity defect) Indications: • Recurrent lesion previously treated by enucleation alone • Incompletely encapsulated or tendency to grow beyond surgically apparent capsule
  42. 42. Modalities of Surgical excision  Marginal/En bloc Resection (Resection without continuity defect) Indications(for malignancy): • Horizontal mandibulectomy for Gingivobuccal cancer reaching close to mandible but not grossly involving mandible • Lingual plate excision for lesions of floor of mouth or tongue • Buccal plate excision for lesions of gingivobuccal complex with minimal paramandibular spread • Minimal cortical erosion
  43. 43. Modalities of Surgical excision  Segmental Resection (Resection with continuity defect) Indications: • Lesions with infiltrative tendency • Extension closer to inferior or posterior border of mandible, maxillary sinus or nasal cavity • High recurrence • Lesions with chances of post operative fracture
  44. 44. Modalities of Surgical excision Segmental Resection of Mandible: – Hemimandibulectomy – segmental mandibulectomy – posterior segmental – middle segmental – Disarticulation
  45. 45. 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
  46. 46. Modalities of Surgical excision  Total Resection Resection of tumor with removal of involved bone Involves: Mandibulectomy Maxillectomy
  47. 47. Modalities of Surgical excision 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
  48. 48. Modalities of Surgical excision Modifications for Total Maxillectomy 1. When the tumor extends up to the roof of the maxillary sinus (but does not invade) the orbital floor should be included in the resection 2. When the tumor invades the roof of the maxillary sinus, the orbit or the ethmoidal sinuses, orbital exenteration is mandatory 3. Tumors confined to the posterior aspect of the maxillary sinus is managed with conservative resection sparing maxilla
  49. 49. Modalities of Surgical excision  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
  50. 50. Modalities of Surgical excision  Composite Resection Neck dissection; 1. Radical Neck dissection 2. Modified Radical Neck dissection 3. Selective neck dissection 4. Extensive radical neck dissection
  51. 51. Radical Neck Dissection removal of all ipsilateral cervical lymph node groups extending from the inferior border of the mandible to the clavicle, from the lateral border of the sternohyoid muscle, hyoid bone, and contralateral anterior belly of the digastric muscle medially, to the anterior border of the trapezius. Included are levels I through V. This entails the removal of three important nonlymphatic structures—the internal jugular vein, the sternocleidomastoid muscle, and the spinal accessory nerve.
  52. 52. Modified Radical Neck Dissection removal of the same lymph node levels (I through V) as the radical neck dissection, but with preservation of the spinal accessory nerve, the internal jugular vein, or the sternocleidomastoid muscle.
  53. 53. Selective Neck Dissection preservation of one or more lymph node groups normally removed in a radical neck dissection. Extended Neck Dissection removal of one or more additional lymph node groups, nonlymphatic structures, or both, not encompassed by a radical neck dissection
  54. 54. Enucleation Marginal or Partial resection Composite resection Odontogenic tumors Odontoma Ameloblastoma Malignant ameloblastoma Ameloblastic fibroma Calcifying epithelial odontogenic tumor Ameloblastic fibrosarcoma Ameloblastic fibroodontoma Myxoma Ameloblastic odontosarcoma Adenomatoid odonogenic tumor Ameloblastic odontoma Primary intraosseous carcinoma Calcifying odontogenic cyst Squamous odontogenic tumor cementoblastoma Central cementifying fibroma Fibroosseous lesions Central ossifying fibroma Benign chondroblastoma Fibrosarcoma Fibrous dysplasia, Cherubism Osteosarcoma Central giant cell granuloma Ewing’s sarcoma Aneurysmal bone cyst Chondrosarcoma Osteoma Osteoid osteoma osteoblastoma Other lesions Hemangioma hemangioma Lymphoma Eosinophilic granuloma Carcinoma, adeno carcinoma, melanoma Neurilemmoma, Neurofibroma neurofibrosarcoma
  55. 55. Criteria for inoperability  Fixed neck nodal adenopathy  Recent onset of trismus (gross infratemporal fossa invasion)  Base skull involvement  Extensive soft tissue involvement  Distant metastasis
  56. 56. Radiotherapy  Indications  Multiple positive lymph nodes in the neck confirmatory of metastasis  Extracapsular extension by metastatic disease  Perivascular or Perineural invasion  Gross residual disease following surgery; positive surgical resection margins  Cranial nerve involvement or extension to skull base
  57. 57. Preradiotherapy • Avoid radiation therapy for tumours involving the mandible • Extract poor-prognosis teeth prior to starting treatment • Remove cysts and odontomes Postradiotherapy • Stress on maintenance of oral and dental hygiene through and after radiation therapy • Avoid dental extraction, especially of multiple teeth after radiation therapy • Removal of caries and extirpation of pulps • Root canal therapy • Prevent tooth loss • Fluoride gel and mouthwashes • Chlorhexidine mouthwashes • Limit radiation caries with dental splint coverage Considerations for patients undergoing radiotherapy
  58. 58. Chemotherapy Radiotherapy plus Cetuximab for Squamous-Cell Carcinoma of the Head and Neck James A. Bonner, M.D., Paul M. Harari, M.D., Jordi Giralt, M.D., Nozar Azarnia, Ph.D., Dong M. Shin, M.D., Roger B. Cohen, M.D., Christopher U. Jones, M.D., Ranjan Sur, M.D., Ph.D., David Raben, M.D., Jacek Jassem, M.D., Ph.D., Roger Ove, M.D., Ph.D., Merrill S. Kies, M.D., Jose Baselga, M.D., Hagop Youssoufian, M.D., Nadia Amellal, M.D., Eric K. Rowinsky, M.D., and K. Kian Ang, M.D., Ph.D.N Engl J Med 2006; 354:567-578February 9, 2006DOI: 10.1056/NEJMoa053422 BACKGROUND We conducted a multinational, randomized study to compare radiotherapy alone with radiotherapy plus cetuximab, a monoclonal antibody against the epidermal growth factor receptor, in the treatment of locoregionally advanced squamous-cell carcinoma of the head and neck METHODS Patients with locoregionally advanced head and neck cancer were randomly assigned to treatment with high-dose radiotherapy alone (213 patients) or high-dose radiotherapy plus weekly cetuximab (211 patients) at an initial dose of 400 mg per square meter of body- surface area, followed by 250 mg per square meter weekly for the duration of radiotherapy. The primary end point was the duration of control of locoregional disease; secondary end points were overall survival, progression-free survival, the response rate, and safety. RESULTS The median duration of locoregional control was 24.4 months among patients treated with cetuximab plus radiotherapy and 14.9 months among those given radiotherapy alone (hazard ratio for locoregional progression or death, 0.68; P=0.005). With a median follow-up of 54.0 months, the median duration of overall survival was 49.0 months among patients treated with combined therapy and 29.3 months among those treated with radiotherapy alone (hazard ratio for death, 0.74; P=0.03). Radiotherapy plus cetuximab significantly prolonged progression-free survival (hazard ratio for disease progression or death, 0.70; P=0.006). With the exception of acneiform rash and infusion reactions, the incidence of grade 3 or greater toxic effects, including mucositis, did not differ significantly between the two groups. CONCLUSIONS Treatment of locoregionally advanced head and neck cancer with concomitant high-dose radiotherapy plus cetuximab improves locoregional control and reduces mortality without increasing the common toxic effects associated with radiotherapy to the head and neck
  59. 59. Reconstruction  Objectives  Achieve primary healing  Maintain oral competence  Facilitate swallowing  Prevent aspiration  Preserve speech  Restore continuity, bone height and bone bulk of jaw
  60. 60. Immediate reconstruction Advatages 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 later Reconstruction of Osseous Defect
  61. 61. Delayed reconstruction • usually performed after 6 months of waiting period to observe for recurrence • Preferred in malignancies • If rediotheray is anticiopated as it may jeopardise 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
  62. 62. Modalities for repair of defect  Primary closure  Split thickness graft  Pedicled flap  Free composite graft with microvascular reconstruction
  63. 63. Modalities for repair of defect Flap: bailey
  64. 64. Modalities for repair of defect
  65. 65. Modalities for repair of defect Anatomical site Microvascular free flap Alternative flaps Floor of mouth Forearm Nasolabial flap(b/l) Lateral tongue Forearm Platysma skin flap Total tongue/glossectomy Rectus abdominus Pectoralis major Buccal mucosa Forearm Temporalis muscle Mandible Dentate Iliac crest Fibula Edentate Fibula Reconstruction plate, pectoralis Maxilla Low level/hard palate Temporalis muscle Forearm High Iliac crest Fibula Soft palate/tonsil Forearm Temporalis, pectoralis muscle Tongue base forearm Pectoralis major
  66. 66. Complications  Surgery  Accessory nerve palsy: shoulder dysfunction and pain  Soft tissue oedema  Phrenic nerve injury  Thoracic duct injury  Cranial nerve injury  Rupture of carotid artery
  67. 67. Complications  Radiotherapy  Osteoradionecrosis of mandible  Hypothyroidism  Atherosclerosis of carotid artery  Neck and Shoulder dysfunction  Trismus  Xerostomia  Dental caries  Visual Impairment  Radiation neuritis
  68. 68. Complications  Chemotherapy  Nausea and Vomiting  Diarrhoea  Stomatitis  Gastrointestinal upset  Renal Toxicity  Leukopenia and thrombocytopenia
  69. 69. Survival & Prognosis Prognostic factors  Advanced stage has poor survival rate  Carcinoma has poor prognosis than benign lesions  Depends on site of lesion. Eg Lesions in posterior 1/3 of tongue has worst prognosis  Perineural invasion and angioinvasion has poor prognosis  Tumor thickness >6 mm has poor prognosis  Histologically positive lymph nodes carry poor prognosis
  70. 70. Survival & Prognosis Stage of presentation (for malignant lesions) 5 year Survival rate % I 80 – 90 II 65 – 75 III 40 – 50 IV 30
  71. 71. References Hupp, Ellis III, Tucker; Contemporary Oral and Maxillofacial Surgery; 5/e; Elsevier Inc; 2008 Laskin DM; Oral and Maxillofacial surgery Vol. 2; Mosby Co.;1996 Malik NA; Textbook of Oral and Maxillofacial Surgery; 2/ed; Jaypee; 2008 Fonseca RJ; Oral and Maxillofacial Surgery Vol. 5; WB Saunders; 2000 Booth PW, Schendel SA, Hausamen JE; Maxillofacial Surgery Vol. 2; Harcourt Brace and Co., 1999