(( Maxillofacial surgeon ))
Tikrit dentistry college
Definition of cancer
• Uncoordinated and uncontrolled growth of the
tissue, resulting from multiplication of its cells
and the condition persists even after the stimulus
or the initiating factor is removed.
Types of Intraoral Malignancies
1. Tumors originate from surface epithelium:
a. Squamous cell carcinoma. Most common type (90-95 % )
2. Tumors originate from glandular tissues (salivary glands ,
metastatic cancer from breast,prostate, lung ) :
3. Tumors originate from mesenchymal tissues :
a. Sarcoma (osteosarcoma ,chondrosarcoma .
fibrosarcoma,Ewing sarcoma )
• Tobacco ; It has been shown that those smoking 40 or more
cigarettes /day are 5 to 7 times more at risk of developing cancer
• Alcohol ; This possibly acts as irritant or solvent which facilitates
penetration of mucosa by other carcinogens like tobacco. It may
also suppress efficiency of DNA repair after exposure to
• Viruses; Human Papilloma Virus (HPV) , Herpes simplex ,HIV,
Epstein –Barr Virus (EBV)
• Poor Dental Hygiene and Constant Chronic Trauma to Mucosa Due
to Dental Cause Poor oral and dental hygiene, sharp teeth, ill fitting
dentures, sharp crown and bridges, etc…
• Radiation (x-ray ,sunlight,UV light)
• Heriditary syndroms ( basal cell nevus syndrome , xeroderma
• Premalignant conditions (lichen plannus,teriary syphilis,leukoplakia,
chronic candidiasis, Plumer –Venson syndrome)
• Malnutrition (vitamin deficiency )
Spread of Squamous Cell Carcinomas of the
A. Local infiltration
• 1. Invasion of local soft tissues.
• 2. Invasion of perineural spaces.
• 3. Invasion of bone.
B. Lymphatic Spread—Metastasis in regional lymph nodes.
C. Blood borne metastasis (Distant spread)
1.History : include ;
a.history of general health; chest pain, limited exercise tolerance
,shortness of breath, anemia…
b.history of the lesion(mass or ulcer ); onset of occurrence,duration,
a.extraoral examination ;
1.inspection of head ,face ,neck for any asymmetry or changes in
the color of the skin
2.examination of the regional lymph nodes bilaterally .
b.intraoral examination; inspection and palpation of the tumor for
checking borders, shape ,size , tenderness .
3.radiographical examination; OPG, CT scan ,MRI for evaluation of
primary site and regional lymph nodes (some times we need chest x-ray
to exclude metastasis to the lung)..
better imaging to assess bony involvement and extension are CT scan
, while Imaging to assess extent of soft tissue spread and recurrent
tumors are MRI .
4. Laboratory investigations ;blood (Hb,Blood sugar, blood urea) ,
enzymes(liver function tests) ,electrolytes
• a.Excision Biopsy ;When the lesion is small, it should be
• b. Incision Biopsy;indicated in the large lesions or when
complete excision is not possible
• c. Aspiration Biopsy;If the lesion is deep seated, cystic or
hemorrhagic aspiration biopsy should be done.In oral
cancer its mostly usful in evaluation of enlarged lymph
• d. Punch Biopsy;It is of limited value in the oral cavity. It is
useful when small tissue specimen is to be taken from
inaccessible areas e.g. the maxillary sinus, the lateral or
posterior pharyngeal walls.
• The before treatment – for larger lesions.
Clinical Features of Oral Cavity Cancer
• Classically they present either as a non healing ulcer, with varying
degrees of pain and occasional episodes of bleeding from the lesion
usually have an irregular edge and induration of the underlying soft
• exophytic growth of duration may be several weeks to a few months
before patient seeks treatment. Exophytic growth may present as a
cauliflower like irregular growth or may be flat.
• More advanced lesions can present with pain, bleeding or fixity to
• Cancers that involve the infratemporal fossa present with
recent onset of trismus. This must be distinguished from long
standing trismus, which is a sign of oral submucous fibrosis.
• Lesions can also present with metastatic disease to the regional
draining cervical nodes.
• It is important to remember that occasionally lesions of the
alveolus in and around the non healing tooth extraction sockets
can manifest with unexplained loosening of the involved teeth.
Clinical Features of Oral Cavity Cancer
• Clinical staging system designed to express the severity, or
extent, of the disease. It is meant to facilitate an estimation of
prognosis and provide useful information for treatment
• T staging : tumor size (length and width but not depth)
• T0 No evidence of primary lesion
• Tis Carcinoma in situ
• T1 Lesion 2 cm or less in the greatest diameter
• T2 Lesion > 2 cm but < 4 cm in the greatest diameter
• T3 Lesion > 4 cm in the greatest diameter
• T4 lesion invades adjacent structures (muscle ,bone, maxillary
• N Staging : assess regional lymph nodes involvement
• N0 No regional LN metastasis
• N1 Metastasis to a single ipsilateral lymph node <3 cm
in greatest dimension
• N2 Metastasis in (a) a single ipsilateral lymph node 3-6
cm or (b) multiple ipsilateral lymph nodes < 6 cm or (c)
bilateral or contralateral lymph nodes, < 6 cm
• N3 Metastasis in a lymph node more than 6 cm
• M stage
• M0 no distant metastasis
• M1 distant metastasis present
• Histological grading :
• It represent the degree of resembles of tumor cells to the
• it determine the aggressiveness of tumor
• Well differentiated (have nearly same shape of normal cells
,produce keratine ,less mitotic activity) is the least aggressive
one while undifferentiated (not resemble the original cells, high
mitotic activity, not produce keratine) is the most aggressive
Management of oral cancer
• Treatment modalities for oral cancer involve :
• 4.additional treatment modalities : immune therapy,
• Surgery is the preferred treatment of choice ,
radiotherapy is reserved for patients who are not willing
for surgery or when surgery will cause significant cosmetic
or functional defects or if patients are unfit for general
Advantages of Surgery
2. Repeated procedures possible
3. Cost effective
Disadvantage of surgery
1. Esthetic alteration
2. Inability to precisely eliminate foci of microscopical lesion
3.relatively high incidence of complications
(infection,orocutanous fistula etc….)
Advantage of Radiotherapy
1.minimal esthetic and functional alteration
2.ability to sterilize microscopical tumor cells
Disadvantages of Radiotherapy
1.Ineffective to ablate large tumor volume
2.Acute and chronic morbidity
4. Not suitable for treatment if lesion involves or is close
to the bone
• Selection the modality depends upon the stage of cancer at
diagnosis. The broad guidelines are as follows:
• Early stage oral cancer (Stage I and II) can be treated with single
modality treatment. Surgery or radiotherapy .
• advanced cancers (Stage III and IV) need to be treated with
combined modality treatment (surgery and radiotherapy).
• Some cases tumor are consided inoperable(not indicated for surgery
and should be treated palliatively (chemotherapy and /or
Criteria for considering tumor inoperable
Recent onset of trismus (gross infratemporal fossa invasion)
Base of skull involvement
Management of the Neck Lymph Nodes
• Involvement of regional lymph nodes by oral cancer is dependant
on following factors:
1. Site and location of primary lesion , tongue and floor of the
mouth lesions show more increased risk of nodal metastasis
than hard palate lesion
2. Size of primary site
3. T stage ,increasing stage will increase the risk of nodal
metastasis, irrespective to site.
4. Histomorphologic feature, poorly differentiated carcinoma have
increased risk of metastasis than well differentiated carcinoma.
1. Surgical treatment ; neck dissection (radical ND, modified ND ,
Selective ND) for surgical clearance of all involved lymph
nodes and those suscepected to be involved .
Management of the Neck Lymph Nodes
Principles of Reconstruction
Mucosal Defects can be Delt with Following Modalities :
1. Leave raw areas, allow it to heal by granulation tissue
2. Primary closure
3. Cover with skin graft
4. Coverd with flap.
Reconstruction of bony defects
• Bony defects can be reconstructed using
external materials (alloplasts like plates,
silastic implants etc.), allografts (cadaveric
bone) or autografts.
Survival and Prognosis :
• The stage of disease at presentation is the most important
factor. Stage I and II disease has better prognosis( 5 yr.
survival 31-100%) whereas advanced stages III, IV have poor
prognosis( 5 yr. survival 7-41%)
Role of Dental Practitioner in Oral Cancer
• Prevention and early detection—It is important for practicing
dentists to examine the entire oral cavity when performing
routine dental care to pick up suspicious lesions.
• Dental care prior to commencing radiation—this is very
important and involves oral prophylaxis,fluoride application,
extract hopeless teeth and restore carious teeth.
• Patient education post radiotherapy to maintain good oral
• Maxillofacial prosthesis fabrication—both intra and extra-
oral prosthesis can be fabricated to replace teeth, nose, ear
and eye, etc.