BUCCAL CARCINOMA AND ITS COMPLICATIONS PPT

1. BUCCAL CARCINOMA

2. • The buccal mucosa is the mucosal lining of the inner
surface of the cheek. The area extends from the oral
commissure anteriorly to the retromolar trigone
posteriorly.
• The junction between the buccal mucosa and
retromolar trigone is an arbitrary line drawn from the
maxillary tuberosity to the distobuccal aspect of the
mandibular third molar.
• The inferior and superior boundaries of the area are
delineated by the mandibular and maxillary gingiva-
buccal sulci respectively.
• The buccal mucosa is not exposed to masticatory loads
and so is covered by a lining mucosa with non-
keratinizing stratified squamous epithelium. The
mucosa is firmly attached to the underlying buccinator
muscle.

3. • Sensory innervation to the area is via the
buccal branch of the mandibular division of
the trigeminal nerve.
• Lymphatic drainage of the site is via the
ipsilateral facial and submandibular nodes to
the deep cervical chain.
• The thickness of the cheek, from mucosal
lining to external skin, is 1-3 cm.

4. CLINICAL PRESENTATION
• After carcinoma of the lip, oral tongue, floor of
the mouth, and lower gum, carcinoma of the
buccal mucosa is the fifth common carcinoma of
the oral cavity.
• It usually occurs in the sixth and seventh decades
of life, and is more prevalent in men than in
women.
• Tobacco and betel nut chewing appear to play an
important role in the cause of these tumors.

5. • Clinically, there are three distinct types:
1) EXOPHYTIC,
2) ULCERATIVE
3) VERRUCOUS
• The patient may present with pain or bleeding, trismus, or
cervical lymphadenopathy.
• Posterior extension may result in involvement of the lingual or
dental nerves, which may cause ear pain.
• Extension behind the pterygomandibular raphe into the
pterygoid muscles or into the buccinator and masseter
muscles may cause trismus.
• In advanced stages, the tumor may destroy the entire cheek
and invade the adjacent bones and the neck. Infection is
common and mastication becomes difficult. Death usually
occurs as a result of poor nutrition and general debilitation

6. • SYMPTOMS:
a) ULCER
b) BURNING SENSATION
c) PAIN
d) EAR ACHE
e) BLEEDING
• SIGNS:
a) ULCERATION/GROWTH
b) INDURATION
c) ANKYLOGLOSIA
d) BLEEDING ULCER
e) TRISMUS
f) PAROTID ENLARGEMENT
• ASSOCIATED: LEUKOPLAKIA, ERYTHROPLAKIA, SUBMUCOUS FIBROSIS

7. TNM STAGING
• TNM 7th edition incorporated tumour thickness
into staging criteria as previous data had
demonstrated that tumour thickness has
prognostic value.
• TNM 8th Edition tumour thickness has been
replaced by an assessment or measurement of
tumour depth of invasion (DOI) as this has been
shown to be a better prognosticator that tumour
thickness. Three DOI groups have been defined:
<5 mm, > 5 mm but < 10 mm and > 10 mm. Each
incremental increase in DOI results in an increase
in clinical T stage (cT) and pathological T stage
(pT) levels.

8. • DOI relies on clinical examination and
measured radiological evidence whilst pT is
measured by a perpendicular dropped from
a line drawn at the level of the basement
membrane These modifications have led to
the following revised T stages:
• T1: < 2 cm, <5 mm DOIb.
• T2: ≤2 cm, DOI > 5 mm and < 10 mm or
• > 2 cm but <4 cm, and < 10 mm DOI
• T3: >4 cm or any tumour > 10 mm DOI

10. • N stage
• 1. Extra-nodal extension (ENE) has been added as a
prognostic variable in addition to the number and size
of metastatic lymph nodes.
• 2. Radiological evidence alone is insufficient to
determine ENE and must be associated with overt
clinical evidence of invasion of adjacent anatomical
structures (e.g. overlying skin or adjacent nerve)
• 3. Pathological determination of ENE is subdivided into
minor ENE, when ENE <2mm beyond the lymph node
capsule and major ENE when extension is >2mm
beyond the capsule +/- soft tissue metastatic deposits

13. STAGE GROUPING
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T1, T2 N1 M0
T3 N0, N1 M0
Stage IV A T1, T2, T3 N2 M0
T4a N0, N1, N2 M0
Stage IV B Any T N3 M0
T4b Any N M0
Stage IV C Any T Any N M1

14. TREATMENT:

15. NECK DISSECTION
• RND : superficial & deep cervical fascia with its
enclosed LN (level I-V) is removed in continuity of SCM,
omohyoid muscle, internal & external jugular veins,
spinal accessory N & submandibular gland
• MND : is finding more acceptance & preference to RND
in managing N0 neck because of severe morbidity
related to RND such as, shoulder dysfunction, poor
cosmesis, facial edema (level I-V LN)
• SOHND : least morbid, provides most satisfactory
sampling of the LN at the level I, II, III which are
greatest risk
• Extended SOHND : level I-IV LN dissection

17. MANDIBULECTOMY

18. Classification of mandibulectomy:
• 1. Total mandibulectomy
• 2. Partial mandibulectomy
• 3.Marginal mandibulectomy

19. THE CURRENT INDICATIONS FOR A
SEGMENTAL MANDIBULECTOMY
(1) gross invasion by oral cancer
(2) invasion of inferior alveolar nerve or canal
by the tumor
(3) massive soft-tissue disease adjacent to the
mandible
(4) a primary malignant tumor of the
Mandible
(5) a tumor that has metastasized to the
mandible.

20. INDICATIONS FOR MARGINAL
MANDIBULECTOMY
• Primary tumor abutting against the mandible
• Minimal involvement of the alveolar process
• Minimal cortical erosion

21. 1. Total mandibulectomy: Removal of the whole
mandible including bilateral disarticulation .
2. Partial mandibulectomy: Resection of any part
of the mandible, leaving the unaffected part
intact e.g. segmental mandibulectomy and
marginal mandibulectomy.
a. Segmental mandibulectomy: Resection
of a potion of the mandible (i.e. a segment of
the mandible is resected)
b. Marginal mandibulectomy: Resection of
a portion of the mandible without a continuity
defect

22. • Segmental mandibulectomy:
i. Hemimandibulectomy
ii. Subtotal mandibulectomy
iii. Unilateral free end mandibulectomy
iv. Unilateral bounded segmental
mandibulectomy
v. Bilateral bounded segmental mandibulectomy

23. • I. Hemimandibulectomy: Mandibulectomy
involving the resection of one half of the
mandible starting from the midline.
• II. Subtotal segmental mandibulectomy:
Mandibulectomy involving one half of the
mandible, crossing the midline to involve a
portion of the other half of the mandible. It is
further divided into five classes:

24. a) Parasymphyseal subtotal mandibulectomy at X (Right or
left): A subtotal segmental andibulectomy with the
resection of a segment from the Parasymphysis (x=2 or 3)
on one side with disarticulation on the other.
b) Body subtotal mandibulectomy at X (Right or left): It is a
subtotal segmental mandibulectomy with the resection of
a segment from the body region (x=3, 4, 5, 6 or 7) on one
side with disarticulation on the other side.
c) Angle subtotal mandibulectomy (Right or left): It is a
subtotal segmental mandibulectomy with the resection of
asegment from the Angle on one side with disarticulation on
the other side.

25. d) Ramus subtotal mandibulectomy (Right or left): It is a subtotal
segmental mandibulectomy with the resection of a segment
from the ramus on one side with disarticulation on the other
side.
e) Condylar subtotal mandibulectomy (Right or left): It is a
subtotal segmental mandibulectomy with the resection of a
segment leaving the condyle on one side intact and
disarticulation on the other side.

26. • Unilateral Free End Mandibulectomy: This is a
form of segmental mandibulectomy of half of the
mandible that does not get to the midline but
limited to area posterior to symphysis. It is
further divided into five classes descriptively as
follows.
a) Parasymphyseal
b) Body unilateral free end mandibulectomy
c) Angle unilateral free end mandibulectomy
d) Ramus unilateral free end mandibulectomy
e) Condylectomy

27. • Unilateral Bounded Mandibulectomy: Resection
of the portion of half of the mandible anterior to
the condyle. It is further divided into nine classes
descriptively as follows
– Unilateral Ramus-Body mandibulectomy
– Unilateral Ramus-Parasymphyseal mandibulectomy
– Unilateral Ramus-Symphyseal mandibulectomy
– Unilateral Angle-Body mandibulectomy
– Unilateral Angle-Parasymphyseal mandibulectomy
– Unilateral Angle-Symphyseal mandibulectomy
– Unilateral Body-Body mandibulectom
– Unilateral Body-Parasymphyseal mandibulectomy
– Unilateral Body -Symphyseal mandibulectomy

28. • Bilateral Bounded Mandibulectomy: Resection
of the anterior aspect of the mandible
crossing the midline with intact posterior
mandibular segment bilaterally

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