Management of odontogenic tumors /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


CONTENTS
Introduction
Objectives of management
Guidelines of management
Treatment methods

Enucleation & Curettage
-Carnoys solution
-Cryosurgery
Marginal Resection
Segmental Resection
Reconstruction

INTRODUCTION
Treatment of odontogenic tumors is designed to

eradicate the lesion and restore aesthetic form and
optimal function.
Because of these needs and the benign nature of
these lesions, a variety of surgical techniques that
preserve vital structures and facial aesthetics have
been developed for the treatment of odontogenic
tumors.


Objectives of management:
Eradication of the lesion
Preservation of normal tissue to the extent possible
Restoration of significant tissue loss, form & function
Well-planned & executed resection & reconstruction

serves the patient physically & emotionally better
than repeated surgical procedure


GUIDELINES
SIZE & LOCATION OF TUMOR:
Small – Excisional biopsy
Increased size – more radical
Location – important role in post – operative
morbidity
Inaccessibility – responsible for inadequate surgical
clearance


DURATION:
When the tumor was 1st noticed
Fast growing in short duration – immediate
treatment
Prognosis depends on rate of growth of tumor
Slow growing – more elective treatment
Fast growing – indicate malignant


BENIGN Vs MALIGNANT :
Benign tumor – treat conservatively
Some benign tumors behave aggressively – radical
treatment
Benign & small – enucleation
Lesion involves full thickness – segmental resection
Lesion is extensive – radical resection


Factors governing the choice of
treatment method
Age and health of the patient
Clinical type of ameloblastoma
Site of the lesion
Size of the lesion
Chances of recurrence
Patient preference


Treatment methods
Enucleation & curettage

- Thermal cauterization
- Carnoys solution
- Cryosurgery
Resection without continuity defect
Resection with continuity defect


ENUCLEATION:
Allows the cystic cavity to be covered by a

mucoperiosteal flap & the space fills with the blood
clot which will eventually organize and form normal
bone.
INDICATIONS:
Surgical excision of tumor which tend to grow by
expansion, rather than by infiltration of surrounding
tissues.
Lesions occurring in the bone with a distinct
separation b/w the lesion & the surrounding bone.
Often there is a cortical margin of bone that
delineates the tumor from the bone.

Indicated in:
Odontoma
Ameloblastic fibroma
Ameloblastic fibroodontoma
Adenmatoid odontogenic tumor
Cementoblastoma
Squamous odontogenic tumor


Enucleation - procedure


ADVANTAGES:
Primary closure of the wound
Healing is rapid
Post operative care is reduced
DISADVANTAGES:
After primary closure, it is not possible to directly
observe the healing of the cavity
Removal of unerupted teeth with the lesion
Weakening of mandible making it prone to jaw
fracture
Damage to adjacent vital structures


Curettage
Curettage - removal of the tumour by scrapping it

from the surrounding normal tissue
Currently - least desirable form of therapy
Sehdev et al (1974) - cure rate of only 10%.
Taylor (1968) - 63% recurrence rate
Rankow and Hickey (1954) - 91% recurrence rate.
Failure - nests of tumour cells extend beyond the
clinical and radiographic margins of the lesion
Chemical and electrical cauterisation have been used
by surgeons in conjunction with curettage but they
have reported only a slight improvement in cure rate.

INDICATIONS
Unicystic ameloblastoma
 Small tumour - a child or a young adult
Patient can be followed up for 10 years or more.
Small tumour in the body of the mandible in an

elderly patient, as ameloblastoma takes several years
to recur


Operative procedure
Intra-oral approach
Mucoperiosteal flap is reflected
Mandible - buccal aspect
Lingual access - injury to lingual nerve & mandibular

neurovascular bundle
Maxilla - palatal or buccal / labial approach
Rongeur or surgical bur - remove sufficient bone expose the underlying tumor
Angular / straight curettes - convex surface of the
curette placed against the bony wall.

Ameloblastoma – Enucleation & Curettage


Adenomatoid Odontogenic tumor:


Ameloblastic fibro odontoma


Ameloblastic fibroma


Compound odontoma:


After lesion is removed - largest curette - a margin of

apparently normal bone should be removed by
aggressive scrapping.
 After thus removing 1 to 3 mm of surrounding bone,
all margins are smoothened with a rongeur or a large
round bur.
 Adjunctive treatment like cauterisation may be
employed at this stage.
Irrigation with normal saline
Small wounds - closed primarily
Large wounds - packed with gauze impregnated with
compound tincture of benzoin, balsam of Peru or
Whitehead’s varnish

Topical antibiotic - gauze pack.
The pack is removed approximately 2 to 3 inches

everyday until the surgical defect is filled with
granulation tissue.
Oral hygiene is maintained.

Complications
Numerous complications - particularly extensions to

vital structures
Curettage procedure breaks the cortical barrier, thus
paving the way for residual tumour to grow into the
soft tissues, which then becomes more difficult to
treat.

Cautery (desiccation)
Various types - primarily as an adjuvant to curettage,

but in some cases as a primary mode of therapy.
Chemical agents:
-Carnoy’s solution
-Electrocautery
-Cryotherapy
Cauterisation is basically an attempt to eradicate the
tumour that has infiltrated beyond the clinical and
radiographic margins of the tumour

Cautery is empirical :

(i)
how far the tumour in each case has extended
into
the cancellous bone
(ii) how far the caustic agent (heat / chemicals)
penetrates into the cancellous bone
(iii) how effective is the agent in eradicating the
tumour cells and
(iv) the possible harmful effects to normal tissue


Electrocoagulation (thermal
cautery)
Mehlisch et al (1972) - 50% recurrence rate
More effective therapy than curettage
Secondary ischaemia & necrosis - may destroy the

invading tumour cells.
Cautery frequently been employed as an adjuvant to
other methods of therapy to give a better result
(Gardner and Pecak – 1980)
Mehlisch et al - no recurrences


Chemical cauterisation
Carnoy’s solution - a fixing agent

absolute alcohol
chloroform
glacial acetic acid
ferric chloride (modification)
Stoelinga and Bronkhorst (1988) - unicystic
ameloblastoma and reported no recurrences
Depth of penetration - cancellous bone up to 1.5 mm after
5 minutes and up to 1.8 mm after 1 hour (Voorsmit et al –
1981)
Use of Carnoy’s solution appears to be harmless and has
the potential of reducing recurrences after curettage.

Technique:
Teeth – extracted
Enucleation and curretage
Bony cavity is examined
Carnoys solution is applied
Cotton applicator / ribbon guaze – 3 minutes
Copious irrigation with saline
BIPP inserted & wound kept open
BIPP replaced periodically
Recurrence – 10%


CRYOSURGERY:
Alternative treatment modality
Excellent results in maxillo-facial region
AIM: eliminate invasive bone lesion without

necessarily involving the problems of conventional
anatomic radical surgery
Advantage of cryotherapy is that it is possible to
devitalise the tissue with liquid nitrogen to a depth of
1.5 cm
The jaw can be frozen through its entire thickness if
necessary.

TECHNIQUE:
After curettage
Surrounding soft tissues are retracted & protected

away with gauze and flap retractors
Entire bony cavity – frozen with liquid nitrogen spray
Solid frost is observed
3 freezing cycles
Each cycle - 1 minute
Gap b/w each cycle – 5 minutes
Mucoperiosteal flap were sutured

Complications - sequestration, pathological fracture,

transient anaesthesia of mandibular nerve
More extensive the freezing, the greater the risk
Another method which has been described (Weaver
and Smith-1963, Bradley-1978) in which the affected
segment of bone is excised, frozen in liquid nitrogen
to devitalise the tissue, and then reimplanted as an
autogenous graft.


MARGINAL RESECTION / RESECTION WITHOUT CONTINUITY
DEFECT / PERIPHERAL OSTEOTOMY / EN BLOC RESECTION
Indicated in lesions which are known for recurrence
Lesions that tend to grow beyond their surgically

apparent capsule
Treatment - when the lesion does not extent closer
than 1 cm to the inferior border of the mandible.
 Margin of 1 to 2 cm - minimum acceptable margin.
Various authors - good results with en bloc resection
Lesions of the maxilla - en bloc resection is not as
successful and recommend segmental resection


INDICATIONS:
Ameloblastoma
Calcifying epithelial odontogenic tumor
Myxoma
Ameloblastic odontoma
Squamous odontogenic tumor


Procedure allows complete excision of the tumor but

at the same time a continuity f the jaw bone is
retained thus deformity, disfigurement & need for
secondary cosmetic surgery & prosthetic
rehabilitation are avoided.
ADVANTAGE:
Not violating the tumor margins during resection
which might provide the possibility of tumor seeding
in the surgical site.
DISADVANTAGE:
Does not discriminate b/w tumor tissue & vital
structures in close approximation such as inferior
alveolar nerve.

Operative procedure
Intra-oral / extra-oral approach
Intra-oral - good access and when the lesion is

anterior to third molar region
Extra-oral approach - lesion involves the ramus of the
mandible or when immediate reconstruction is
planned


Surgical approaches to maxilla:


Surgical approaches to mandible:


Intra-oral approach
Large mandibular lesions - a midline lip-splitting
incision
Connecting vertical incisions are made on the buccal
and lingual
Incisions - extend deep into buccal and lingual folds.
The teeth bordering the surgical margin should be
extracted
Horizontal incisions connecting the lower ends of
vertical incisions are made. The buccal and lingual
mucoperiosteal flaps are then developed, but not
reflected superiorly over the region of bone to be
removed.

Marginal Resection


On exposure of the mandible, the bony segment is

sectioned with an air-driven saw or bur, at least 1 to
1.5 cm from the radiographic margin of the lesion
Haemorrhage - controlled by crushing the bone over
small blood vessels with a blunt instrument or by
using bone wax
The mucoperiosteum is then undermined both
lingually and facially to relieve tension.
They are approximated with interrupted silk sutures.


Segmental (partial) mandibular
resection / hemimandibulectomy
Segmental resection - maxillectomy and

hemimandibulectomy
Least number of recurrences.
Indications:
Infiltrative lesions
Lesions – posterior/ inferior border of mandible
Lesions with high recurrence rate


Segmental resection:


Operative procedure
Depending on the size - a lip-splitting incision may or
may not be necessary
A submandibular incision - join the vertical lip
incision
Intra-orally - horizontal incision is made through the
mucoperiosteum
The facial and lingual flaps are advanced below the
horizontal incision using a periosteal elevator.
The lingual flap is raised as deep as to expose the
mylohyoid attachment.
A vertical mucoperiosteal incision is made 0.5 cm
proximal to the anticipated anterior bony cut.

Expose the mental neurovascular bundle, which is ligated

and sectioned.
Preservation of the marginal mandibular branch of the
facial nerve
Using an air-driven saw, bur or a Gigli saw, a vertical cut is
made through the mandible anterior to the lesion.
Using bone forceps, the proximal part of the mandible is
rotated laterally, exposing the inferior alveolar nerve and
vessels, at the lingula of the mandible. They are ligated
and cut adjacent to the mandibular foramen.
The capsule is cut with a scalpel and the segment of
mandible is disarticulated and removed using boneholding forceps.
Bleeding - controlled by digital pressure, coagulation or
ligation, depending on the size of the bleeding vessel.

Resection with disarticulation:


Odontogenic myxoma


The patient should be fed through a naso-gastric tube

for a week and scrupulous oral hygiene should be
maintained.
Dressings should be changed daily.
Removal of drain depends on the amount of drainage.
Alternate skin sutures are removed after 4 days and
the remaining ones, after 6 days.
After that, the naso-gastric tube may be removed and
oral feeding may be begun.


Classification of Maxillectomies
1.

Partial Maxillectomy(Alveolectomy): Removal of lower
half of the Maxilla.

2.

Subtotal Maxillectomy:: lesions which extend beyond
the confines of Antrum

3.

Medial Maxillectomy: Medial wall of antrum, inferior &
middle Turbinates, ethmoidal air cells, Lamina
papyracea (one side)

4.

Total Maxillectomy: complete removal of Maxilla.


Marginal (partial) maxillectomy
The marginal maxillectomy is the surgical procedure

most often used for tumors of maxilla when the
maxillary sinus is not involved.
Operative procedure
Intra-oral approach
Mucoperiosteal incision - 1 to 2 cm in all directions
from the underlying tumour.
It may be necessary to extract one or more teeth to
complete these incisions.

Partial Maxillectomy (Alveolectomy)


Calcifying epithelial odontogenic
tumor:


Extra oral procedure


Total maxillectomy


British Journal of Oral and Maxillofacial Surgery 45 (2007) 306–310

RECONSTRUCTION
Radical surgeries like segmental resection,

hemimandibulectomy and maxillectomy leave the
patient with a thoroughly incapacitating aesthetic and
functional deficit


Goals of mandibular reconstruction
Re-establishment of mandibular continuity and

an osseus-alveolar base
Maintenance of oral functions and proper

occlusion with maxillary arch.
To achieve minimal impairment of function
Correction of soft-tissue defects
To achieve good aesthetic results.

Goals of maxillary reconstruction

 Obliteration of the defect
 Restoration of essential function of mid face
 Provision of adequate structural support.
 Aesthetic reconstruction of external features.


Immediate Vs delayed reconstruction
IMMEDIATE
ADVANTAGES
Single stage surgery
Early retain of function
Minimal compromise of
esthetics
DISADVANTAGES
Recurrence
Time consuming
Infection

DELAYED
ADVANTAGES
Good result
Less recurrence
Good planning
DISADVATAGES
Fibrosis
Wound contraction
2nd surgery


Ideal Graft:
Restoration of ability to masticate
Acceptable esthetic appearance
Withstand physiologic forces
Non-reactive in tissues
Sterile
Readily available


CLASSIFICATION
Depending on nature of bone
Depending on donor
Depending on the preparation
Depending on the vascularity
Depending on donor site:
Depending on function


Depending on nature of bone
Cancellous bone graft
Cortical bone graft
Corticocancellous grafts

. Blocks
. Chips
. Powder
Marrow graft

Depending on donor
Autogenous bone graft – from same individual
Isogenic bone graft – from genetically related individual
Allogenic – allograft – from another individual of same

species
Xenografts from different species

Depending on the preparation allografts and xenografts
can be again divided into:
a. Freezed bone grafts
b. Freezed dried
c. Demineralised
d. Antigen extracted autolysed
Depending on the vascularity autografts can be divided
into:
Non vascularised
Vascularised bone transfer attached on soft tissue,
pedicle, microvascular free transfer.

Depending on donor site:
Iliac crest graft anterior ileum
posterior ileum
trephine grafts
Rib graft
Full thickness
Split rib graft
Calvarial graft
Full
Split
Fibula

Depending on function
Bridging graft or inlay graft
Reconstruction graft
Contour graft – onlay graft.
Bone substitutes


Maxillary reconstruction
Prosthesis
Obturator and splints
Local soft tissue flaps
Buccal and palatal advancement flaps
Cheek flaps
Buccal pad of fat


Regional flaps
Temporalis – myofascial / myo-osseous
Trapezius – muscle / myo-cutaneous / osseo-myocutaneous
Free flaps
Rectus abdominus
Radial forearm
Iliac crest
Omentum

Mandibular reconstruction
Autogenous vascularised bone by pedicled flaps
Clavicle pedicled on sternocleidomastoid
Rib pedicled on pectoralis major
Scapula pedicled on trapezius
Calvarium pedicled on temporalis
Rib pedicled on latissimus dorsi


Autogenous vascularised bone by free flaps
iliac crest based on deep circumflex iliac artery
fibula based on peroneal artery
scapula based on circumflex scapular artery
radial forearm based on radial artery
rib based on intercostal artery
second metatarsal
calvarium based on superficial temporal artery

Autogenous non-vascularised bone
calvarium
iliac crest
rib
Fibula
Allografts
Xenografts
Alloplastic materials
stainless steel reconstruction plate
hydroxyapatite


Fibula Free Flap


Mandible Reconstruction


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Management of odontogenic tumors /certified fixed orthodontic courses by Indian dental academy

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