Ent and head neck surgery

1. SWELLING OF JAWS AND
SURGERY OF MANDIBLE
Dr. Prakash Khanal
MS ORL-HNS
1st Year Resident
GMSMA of ENT-Head and Neck Studies
MMC-TUTH, IOM

2. ROAD MAP
• WHO classification of Jaw tumours and cysts
• Cysts of jaw
• Benign tumours of jaw
• Malignant tumours of jaw
• Surgery of mandible
• Reconstruction of mandible

3. HISTOLOGICAL CLASSIFICATION
OF JAW TUMOUR
WHO , 1992

4. NEOPLASMS AND OTHER TUMOURS
RELATED TO ODONTOGENIC APPARATUS
Benign
• Odontogenic epithelium without odontogenic ectomesenchyme
• Ameloblastoma
• Squamous odontogenic tumour
• Calcifying epithelial odontogenic tumour (Pindborg tumour)
• Clear cell odontogenic tumour
• Odontogenic epithelium with odontogenic ectomesenchyme with or
without dental hard tissue formation
• Ameloblastic fibroma
• Ameloblastic fibrodentinoma (dentinoma) and ameloblastic fibro-odontoma
• Odontoameloblastoma
• Adenomatoid odontogenic tumour
• Calcifying odontogenic cyst
• Complex odontoma
• Compound odontoma

5. NEOPLASMS AND OTHER TUMOURS
RELATED TO ODONTOGENIC APPARATUS
Benign
• Odontogenic ectomesenchyme with or without included
odontogenic epithelium
• Odontogenic fibroma
• Myxoma (odontogenic myxoma,myxofibroma)
• Benign cementoblastoma (cementoblastoma, true cementoma)

6. NEOPLASMS AND OTHER TUMOURS
RELATED TO ODONTOGENIC APPARATUS
Malignant
• Odontogenic carcinomas
• Malignant ameloblastoma
• Primary intraosseous carcinoma
• Malignant variants of other odontogenic epithelial tumours
• Malignant changes in odontogenicc ysts
• Odontogenic sarcomas
• Ameloblastic fibrosarcoma(ameloblastic sarcoma)
• Ameloblastic fibrodentinosarcoma and ameloblastic fibro-odonto
sarcoma
• Odontogenic carcinosarcoma

7. NEOPLASMS AND OTHER LESIONS
RELATED TO BONE
• Osteogenic neoplasms
• Cemento-ossifying fibroma (cementifying fibroma, ossifying fibroma)
• Non-neoplastic bone lesions
• Fibrous dysplasia of the jaws
• Cemento-osseous dysplasias
• Periapical cemental dysplasia (periapical fibrous dysplasia)
• Florid cemento-osseous dysplasia ( gigantiform cementoma, familial multiple
cementomas)
• Other cemento-osseous dysplasias
• Cherubism (familial multilocular cystic disease of the jaws) .
• Central giant cell granuloma
• Aneurysmal bone cyst
• Solitary bone cyst (traumatic, simple, haemorrhagic bone cyst)
• Other tumours
• Melanotic neuroectodermal tumour of infancy (melanotic progonoma)

8. EPITHELIAL CYSTS
Developmental
• Odontogenic
• "Gingival cysts" of infants
(Epstein pearls)
• Odontogenic keratocyst(
primordial cyst)
• Dentigerous (follicular) cyst
• Eruption cyst
• Lateral periodontal cyst
• Gingival cyst of adults
• Glandular odontogenic cysts;
sialo-odontogenic cyst
• Non-odontogenic
• Nasopalatine duct (incisive canal)
cyst
• Nasolabial (naso alveolar) cyst
Inflammatory
• Radicular cyst
• Apical and lateral
• Residual
• Paradental
• ( inflammatory collateral,
mandibular infected buccal) cvst

9. CYSTS OF JAW
• Odontogenic epithelium :
responsible for cysts and
tumors
• 3 epithelial structures
• Remnants of dental lamina
(rests of Serres ) –Adult
gingival cysts, Odontogenic
keratocysts
• Reduced enamel epithelium –
Dentigerous cysts
• Cell rests of Malassez –
Radicular cysts

10. DEVELOPMENTAL CYSTS

11. GINGIVAL CYSTS OF NEWBORN
• occur on alveolar ridge of newborns.
• seen only in first few months of life.
• up to 50% of all newborns.
• Sessile, normal to yellow or white colour
• soft tissue cyst , does not have an intra
bony component
Treatment
• spontaneously rupture , require no
therapy.
• Simple enucleation / deroofing
• If cyst large enough to interfere with
nursing
• persist >6 months of age.

12. DENTIGEROUS CYST
• Second most commom odontogenic cyst
• a/w crown of unerupted teeth
• Cyst attached with cervical region of teeth
• Involvs
• Mandibular 3rd molar
• Maxillary 3rd molar
• Maxillary canines
• Mandibular second bicuspids
• C/F
• Arch appears to be missing teeth
• Usually asymptomatic
• May cause expansion of bone

13. DENTIGEROUS CYST
• Radiologic findings:
• well circumscribed, unilocular
radiolucency surrounding
crown of unerupted teeth
• Treatment:
• Removal of impacted tooth
along with enucleation of cyst
• Large mandibular cyst:
marsupialization f/b
enucleation

14. CALCIFYING ODONTOGENIC CYST
• Also known as a Gorlin’ s cyst
• Arise from remnents of dental lamina with in gingiva or jaws
• Peak incidence: 2nd decade
• located in anterior portion of jaw.
• little recurrence potential
• Clinical and radiological features:
• Extraosseous lesion : painless gingival expansion.
• incidental findings on routine radiographic evaluation.
• initially appear lucent.
• calcifications - well-circumscribed mixed radiolucent/radiopaque

15. CALCIFYING ODONTOGENIC CYST
Treatment and Prognosis
• Surgical enucleation :
• complete resolution.
• Extraosseous lesions
• often a/w other odontogenic
tumors
• lesion removal only - low
recurrence potential

16. GLANDULAR ODONTOGENIC CYST
• Sialo- Odontogenic Cyst
• Clinical and Radiographic Features
• Common in middle aged adults.
• Site : 75% in mandible (esp. anterior region.)
• Multilocular radiolucencies, frequently cross midline
• Treatment and Prognosis
• Most amenable to enucleation and curettage.
• Recurrence potential ( up to 30%)
• marginal resection.
• long-term follow-up .

17. RADICULAR CYST
• Most common odontogenic cyst
• Develops at apex of erupted tooth
• Response to pulpal necrosis secondary
to dental caries or trauma
• C/F:
• Most asymptomatic ,incidental
findings
• Radiologically:
• round to ovoid, well circumscribed,
contiguous with apex of tooth
• Treatment:
• Extraction of infected teeth f/b
enucleation of cyst.
• Complete bony healing with in 6
months

18. NON ODONTOGENIC CYSTS

19. NASOPALATINE DUCT CYST
• Incisive Canal Cyst
• Arise from epithelial remnants of
embryonic nasopalatine ducts
• arise in anterior maxilla near incisive
foramen
Clinical and Radiographic Features
• M:F= 2:1, 4th to 6th decades.
• Asymptomatic
• soft tissue swelling in midline of
anterior hard palate once lesion has
perforated bone.

20. NASOPALATINE DUCT CYST
• Well-circumscribed, heart-shaped, unilocular radiolucency in
midline of anterior palate.
• Treatment and Prognosis
• Surgical enucleation is usually curative
• May result in sacrificing nasopalatine nerve and vessel
• Recurrence is rare.

21. STAFNE BONE CYST
• Lingual Salivary Gland Depression,
Static Bone Cyst
• not a true cyst.
• Depression on lingual aspect of
posterior body of mandible
• well-circumscribed radiolucency below
inferior alveolar canal in 2nd /3rd molar
region
• depression filled with an accessory
lateral lobe of submandibular gland
• No treatment is required.

22. SOLITARY BONE CYST
• Traumatic bone cyst, hemorrhagic cyst
• Intraosseous cavity lined by fibrovascular membrane ,lacking
epithelium.
• Cysts arise from a traumatic, intraosseous haemorrhage with
subsequent bone resorption
• 2 % of all jaw cysts.
• Site : posterior mandible
• Cyst : solitary and often large and non expansile.
• Well -demarcated and sometimes scalloped edge.

23. SOLITARY BONE CYST:
• Presence of cavity filled with
straw-coloured fluid :
virtually diagnostic.
• Once opened, cavity normally
resolves spontaneously
• Few cases require bone
grafting

24. ANEURYSMAL BONE CYST
• rare, expansile osteolytic bone lesion.
• large blood-filled spaces without
endothelial lining
• not a true cyst
• Clinical /Radiographic Features
• age :first 3 decades of life,
• predilection for posterior part of jaws.
• firm swellings , can be diffuse.
• Radiologically
• expansile radiolucencies that can
displace teeth.
• Treatment and Prognosis
• managed by curettage

25. ODONTOGENIC TUMORS
• Arise from epithelial or mesenchymal cells, or both, associated
with tooth structures.
• Most are true neoplasms
• Some behave as hamartomatous growths.
• C/F
• asymptomatic swellings, which can eventually cause bone loss,
tooth displacement, and jaw expansion.
• Rarely cause sensory nerve dysfunction.

26. ODONTOMA
• Not true neoplasms
• Hamartomatous growths form during normal tooth development,
then reach a fixed size
• contains enamel, dentin, cementum, and pulp tissue.
• Classified as
• Compound: if resembles tooth-like structures or
• Complex: if appears as an amorphous mass.

27. ODONTOMA
• Clinical and Radiographic
Features
• First two decades, no sex
predilection
• Asymptomatic, discovered on
routine radiographic
examination.
• Can block eruption of a
permanent tooth.
• Radiographically, radiopaque
masses with well-demarcated
border.
• Treatment and Prognosis
• Enucleation and curettage -
curative
• No recurrence.

28. AMELOBLASTOMA
• Most common odontogenic tumor.
• Arises from residual epithelial elements of tooth development:
• reduced enamel epithelium
• rests of Serres
• rests of Malassez
• basal layer of the oral mucosa.
• Can also develop from within a dental follicle or a dentigerous cyst.
• Classification
• Solid or multicystic
• Unicystic
• Peripheral

29. AMELOBLASTOMA
• Clinical/Radiographic Features
• locally aggressive , slow growth
• Usually asymptomatic -does not alter
sensory nerve function.
• Common site : posterior mandible
• peak occurrence : 3rd /4th decades, no sex
predilection.
• Radiographically :
• unilocular or multilocular radiolucency,
with ill defined borders
• Buccal and lingual cortical expansion is
common, even progressing to cortical
perforation

30. AMELOBLASTOMA
• Treatment and Prognosis
• Enucleation and curettage.
• More aggressive treatment
• If grows into/through
connective tissue layer of
lesion
• If recurs
• Resection :
• 1.0- to 1.5-cm bony margin and
one uninvolved overlying
anatomic barrier margin

31. ADENOMATOID ODONTOGENIC TUMOR
• Benign hamartoma of odontogenic epithelium
• Slow , progressive growth
• Clinical and Radiographic Features
• 2-3rd tumor
• 2-3rd a/w unerupted tooth
• 2-3rd in canine, 2-3rd in maxilla; 2-3rd in young females (adolescents
and teens)
• Radiographically :
• well-circumscribed, unilocular radiolucency a/w impacted tooth.
• Treatment and Prognosis
• curettage alone is curative.
• Bony regeneration of defect usually occurs in 1 year in younger
patients.
• No Recurrence

32. PINDBORG TUMOR
• Calcifying Epithelial Odontogenic Tumor
• < 1% of all odontogenic tumors
• Arise from epithelial rests of dental
lamina or reduced enamel epithelium
• Clinical and Radiographic Features
• Slow growing, firm, painless swelling,
in posterior mandible.
• molar area :most frequent region
• does not alter nerve function.
• Peripheral variant
• soft tissue swelling in anterior aspect of
mouth

33. PINDBORG TUMOR
• Radiologically :
• Diffuse radiolucent lesions
• If large or mature : areas of faint opacities - calcifications
• Associated with crown of impacted tooth.
• Treatment and Prognosis
• Resection
• 1-cm bony margin along with any necessary soft tissue
• Recurrence reported-long-term follow-up recommended.
• Peripheral variant treatment
• local excision with 5-mm margin, including underlying
periosteum.

34. ODONTOGENIC MYXOMA
• derived from odontogenic
ectomesenchyme
• rare in non tooth-bearing portions of
jaws/ facial bones
Clinical and Radiographic Features
• Asymptomatic, slow growing
• potential to displace teeth or resorb roots,
but does not alter sensory function.
• all portions of jaws, most frequently
posterior mandible.

35. ODONTOGENIC MYXOMA
Radiographically:
• unilocular or multilocular
radiolucency
• Honeycomb appearance
Treatment and Prognosis
• Curative treatment :
• resection with a 1- to 1.5-cm
bony margin and a layer of
overlying soft tissue.
• Recurrence: if only enucleation
and curettage done

36. AMELOBLASTIC FIBROMA
• true neoplasm
• composed of odontogenic epithelium and ecto mesenchyme.
• epithelium resembles dental lamina or ameloblastoma
• mesenchyme resembles dental papilla or myxoma
• Clinical Features
• young patients
• painless swelling, usually in posterior mandible.

37. AMELOBLASTIC FIBROMA
Radiographic Features
• unilocular or multilocular
radiolucency, often over an
unerupted tooth and often
displacing the tooth
Treatment and Prognosis
• enucleation and curettage
• bony defect repair within
approximately 1 year.
• If recurrence : consider
ameloblastic fibrosarcoma

38. NON ODONTOGENIC LESIONS
OF JAWS

39. TORUS
• Developmental overgrowth
• Arise because of bone stress
• 2 sites
• Torus palatinus : if occurs on midline of palate
• Torus mandibularis or lingual tori.: When occur on lingual
aspect of mandible

40. TORUS
• Clinical /Radiographic Features
• Palatal torus :
• smooth ovoid appearance or multiple
pedunculated loculations,
• normal pink overlying mucosa.
• If grow large :
• impair speech or feeding or prohibit
fabrication of maxillary prosthesis
• require surgical excision.
• Mandibular torus :
• commonly bilateral , slow growth
• can reach sizable proportions,
affecting speech/feeding/ use of a
lower prosthesis.

41. TORUS
• Treatment and Prognosis
• Removal if interfere with normal function /fabrication and
placement of a prosthesis

42. OSTEOMA
• Hamartomas or reactive proliferations of bone
• composed of dense compact bone
• Arises on
• Surface of bone : Periosteal osteoma
• Within bone : Endosteal osteoma
• If multiple osteomas : consider Gardner syndrome

43. OSTEOMA
Clinical and Radiographic Features
• Slow-growing, exophytic bony masses
• mandibular angle : common site
• incidental finding on routine
radiographic evaluation
• well-circumscribed radiopaque mass
Treatment and Prognosis
• Asymptomatic single lesions : follow up
clinically and radiographically
• Surgical excision :
• for lesion requiring biopsy
• little chance for recurrence.

44. OSTEOCHONDROMA
• benign hamartomas
• occur in mandibular condyle or coronoid
process
• proliferation of epiphyseal cartilage into
surrounding tissues.
Clinical and Radiographic Features
• 2nd and 3rd decade, M:F = 2:1
• slow growing lesion
• swelling and pain , deviation of teeth
and chin pointing toward the unaffected
side.
• Radiographically,
• irregular popcorn like radiopaque mass
on medial side of the condyle or
replacing coronoid

45. OSTEOCHONDROMA
Treatment and Prognosis
• Lesions affecting coronoid process
• coronoidectomy with minimal removal of attached temporalis
muscle tendon.
• Lesions of condyle
• condylectomy
• Immediate reconstruction
• costochondral graft or an alloplastic condyle.
• Recurrence is rare.

46. OSSIFYING FIBROMA
• Cemento-Ossifying Fibroma
• True benign tumors of
mesenchymal origin
• strong predilection for tooth-
bearing portion of jaws
• slow-growing, expansile lesion
• can grow large resulting in
profound facial disfigurement.

47. OSSIFYING FIBROMA
• Clinical and Radiographic
Features
• woman in 3rd to 4th decade
• Immature lesion
• initially radiolucency, eventually
radiopaque.
• Aggressive lesions
• expand cortices of jaws ,
frequently displace adjacent
structures.
• In mandible
• midbody growth at inferior border ,
enlarging outward and downward as
if hanging off lower lateral border.

48. OSSIFYING FIBROMA
Treatment and Prognosis
• Enucleation and curettage if detected early
• Resection for larger lesions.
• 5-mm margin is appropriate
• Recurrence is rare.
Juvenile ossifying fibroma
• a rare variant
• more aggressive lesion
• appearing at a younger age
• predilection for the maxilla.

49. FIBROUS DYSPLASIA
• Not a true neoplasm
• Tumor like condition
• Normal medullary bone is replaced with fibrous connective tissue
mixed with irregular bony trabeculae.
• commonly occurs in one bone : monostotic
• rarely multiple bones : polyostotic
• Polyostotic fibrous dysplasia
• component of McCune - Albright syndrome
• café -au-lait skin macules
• multiple endocrinopathies : hyperthyroidism or precocious
puberty

50. FIBROUS DYSPLASIA
Clinical and Radiographic Features
• slow-growing asymptomatic process, self-
limiting
• bony hard swelling
• tooth displacement , malocclusion
• Lesions of midface, calavarium, or skull
base
• progressive facial distortion
• cranial nerve dysfunction via
compression.
• Starts in 1st decade and ceases when bone
reaches maximal growth /maturation.
• Early lesions radiolucent, become opaque
as lesion matures.
• ground-glass appearance on radiographs.

51. FIBROUS DYSPLASIA
Treatment and Prognosis
• Surgery :
• indicated in
• disfiguring lesion
• cranial nerve dysfunction
• patient choice
• delayed until affected bone reaches maturity
• Recurrence : if treated during an active growth period.
• Sarcomatous transformation : rare

52. VASCULAR MALFORMATIONS
• Developmental lesions, affect soft tissue or bone.
• Not present at birth
• Classified as
• arterial (high-flow)
• venous (low-flow) malformations.
• Arteriovenous fistulas : high-flow lesions.

53. VASCULAR MALFORMATIONS
• Clinical features
• Slow growing, asymptomatic, expansile lesions
• Mobile teeth and can even appear elevated.
• Thrills or bruits on physical examination.
• Radiologically
• well circumscribed radiolucencies or
• mixed radiolucent/radiopaque.
• CT or MRI
• to ascertain extent of lesion
• Angiography
• To determine primary vascular inflow
• Presence of any contralateral vascular contributions.

54. VASCULAR MALFORMATIONS
• Treatment and Prognosis
• Preoperative selective embolization followed by resection
• Hypotensive anesthesia
• reduce intraoperative bleeding.
• Venous malformations
• intralesional injections with coils or sclerosing agents.
• If adequate thrombosis , can be curettaged

55. MALIGNANT TUMOURS
ARISING IN AND
AROUND THE JAWS

56. HEAD AND NECK SARCOMAS
• Rare , about 10% of all sarcomas.
• Two clinical groups – arising in bone and soft tissue
• Biphasic age distribution, 80–90 % in adult life.
• Rhabdomyosarcoma : approx. 4–5 % of all childhood malignancy.
• Common primary bone tumors in head and neck
• Osteosarcoma
• Chondrosarcoma
• Fibrosarcoma
• Malignant fibrous histiocytoma
• Ewing’s sarcoma

57. RHABDOMYOSARCOMA
• Third most common neoplasm in childhood
• Most common soft tissue sarcoma of childhood
• Approx. 35% of children have disease in head and neck
• Approx. 50 % tumours occur in age <5 years
• Sites of involvement
• Orbital tumours :10 %
• Parameningeal (nasopharynx, nasal cavity, paranasal sinuses, middle
ear, mastoid, pterygoid fossa) :20 %
• Other head and neck sites: 10 %
• Parameningeal site : risk of intracranial spread and cerebrospinal
fluid (CSF) involvement.

58. RHABDOMYOSARCOMA
Presentation and Evaluation
• pain and swelling
• Paranasal Rhabdomyosarcoma
• nasal obstruction , bloody nasal discharge.
• Tumors within ear
• bloody discharge , persistent otalgia despite treatment
• Lymph node involvement
• 3 to 36 percent
• Metastases
• haematogenous
• lymphatic spread
• Common sites : lungs, bone and bone marrow.

59. RHABDOMYOSARCOMA
• Subtypes
• Embryonal : most common , 60% of tumors.
• botryoid ( subtype of embryonal) ; 5% of cases
• Alveolar : 20% of affected children
• Pleomorphic : features of both embryonal and alveolar subtypes
• Investigation:
• Complete blood count, electrolyte panel
• Liver and renal function tests, coagulation studies
• CT scan of the chest
• 99mTc diphosphonate bone scan
• Bilateral aspiration and biopsy of iliac bone marrow.

61. RHABDOMYOSARCOMA
Treatment
• Multimodality approach
• Role of surgery
• to evaluate extent of lesion
• biopsy of tumour.
• Wide surgical removal
• If easily accessible polypoid lesion
Chemotherapy
• Combination of cisplatin, etoposide, and dacarbazine
• Other agents
• Ifosfamide
• Etoposide or doxorubicin for new and recurrent rhabdomyosarcoma

62. RHABDOMYOSARCOMA
• Radiotherapy
• to eradicate residual tumor cells at primary site
• to treat gross persistent disease
• Overt parenchymal, meningeal, or cerebrospinal fluid involvement
• whole-brain irradiation
• intrathecal chemotherapy
Prognosis
• Excellent with early tumours (>80 % survival).
• Relatively poor in advanced tumours
• Meningeal involvement :
• five-year survival < 10 %

63. EWING’S SARCOMA
• Arise primarily in bone, soft tissue presentation may be seen.
• 10–15 % of primary bone tumours
• Peak age : 10 to 20 years.
• Presentation
• pain and swelling of affected area.
• <2 % arise in skull bones
• Systemic symptoms: fatigue, weight loss , fever
• Lymphatic spread - unusual.
• 20 % : metastases at time of diagnosis, usually lungs, but bone and
bone marrow.

64. EWING’S SARCOMA
Principles of management
• Multi agent chemotherapy: 4 to 6 cycles
• Followed by Reimaging and Local therapy
• Surgery, radiotherapy or both
• Radiotherapy
• if surgery is mutilating
• surgical margins are positive
• Poor response to chemotherapy
• Adjuvant chemotherapy
• 12–14 cycles, with reduced intensity regimens
• ifosphamide and or cyclophosphamide + either actinomycin and
doxorubicin.

65. OSTEOSARCOMA
• Osteosarcoma in craniofacial region : 5 % of all osteosarcomas
• Presentation
• median age : 4th decade
• higher proportion : low-grade tumours
• Most subtypes can occur in head and neck.
• Osteoblastic not otherwise specified (NOS) : most common (75 %)
• chondroblastic (16 %).
• Fibroblastic, juxtacortical and telangictatic subtypes : uncommon.
• Majority arise in mandible and maxilla.

66. OSTEOSARCOMA
Management of head and neck osteosarcoma
• Surgical treatment for a low-grade osteosarcoma
• total excision of tumor
• segmental mandibulectomy / Maxillectomy
• Effects Chemotherapy
• Unclear due to higher proportion of lower grade tumours in head and
neck
• Radiotherapy or chemothepary
• for low grade tumor: controversial as neither has proven to be beneficial
• Improved survival over last 20 years
• current survival : approx. 60 %

67. CHONDROSARCOMA
• Group of tumours of varying behaviour.
• Peak age: 5th to 7th decade.
• Central types
• conventional
• dedifferentiated
• mesenchymal
• clear cell types
• Extraskeletal types
• myxoid
• Arising in osteochondromas
• associated with a multiple exostosis syndrome.

68. CHONDROSARCOMA
• majority in adults and children are low grade.
• Surgery
• treatment of choice, usually without adjuvant therapies.
• Chemotherapy and radiotherapy
• Chondrosarcoma (except mesenchymal and dedifferentiated
subtypes)
• resistant to both these therapies

69. MALIGNANT ODONTOGENIC
TUMOURS
• represent 0–6.1 % of all odontogenic tumour
• Includes
• Malignant ameloblastoma.
• Ameloblastic carcinoma

70. MALIGNANT AMELOBLASTOMA
• Metastasizing ameloblastoma
• Histologically resemble ameloblastoma
• Interval between diagnosis of tumour and manifestation of
metastases : about 12 years
• Metastases
• lung (88 %)
• lymph nodes (27 %).
• Distant metastases
• bone, brain, kidney, small intestine and liver

71. AMELOBLASTIC CARCINOMA
• Very rare tumour
• found primarily in mandible
• wide age range, no sex or race predilection.
• Variable presentation:
• predominantly cystic lesion with benign clinical features or
• large tissue mass with ulceration, bone resorption and tooth mobility.
• Clinical course is aggressive
• extensive local destruction.
• Direct extension of the tumour
• lymph node involvement
• metastasis to various sites

72. TREATMENT
• Surgical resection with 2–3 cm margins and neck dissection.
• Postoperative radiation therapy also must be considered.
• Prognosis is guarded with 5-year survival rates less than 40 %.
• Distant metastasis
• associated with poor prognosis
• palliative chemoradiotherapy may be indicated.
• Recurrence rate >60 %.

73. METASTATIC TUMOURS OF THE JAW
• Includes
• Carcinoma of lung
• Adenocarcinoma of breast
• Prostate
• Kidney
• Thyroid
• Liver
• Most common site within jaws : posterior mandible.
• Presentation
• Loosening of teeth
• Unilateral numbness of the chin
• Eventually ulceration of the soft tissues.
• Treatment : palliative chemotherapy and/or radiotherapy.

74. SURGERY OF
MANDIBLE

75. • Mandibular resections
• Segmental : whole height of the mandible:
• leading to mandibular discontinuity
• Marginal :only alveolar bone is resected
• Marginal defects reconstruction
• to improve dental rehabilitation
• placement of dental implants.
• Segmental defects reconstruction
• to provide mandibular continuity.

76. • Loss of mandibular continuity
laterally (posterior to mental
foramen
• deviation of mandible towards
resected side
• dental occlusion affected.
• Loss of mandibular continuity
anteriorly (anterior to mental
foramen)
• functional problems
• Andy Gump deformity

77. CLASSIFICATION OF MANDIBULAR
DEFECT
Boyd et al., 1993
• Mandibular defect classified as
H, C, L:
• H – lateral defects of any length
including condyle
• L – as above but condyle not
included
• C – entire central segment from
lower canine to canine.

78. CLASSIFICATION OF MANDIBULAR
DEFECT
• A combination of letters is possible
• e.g. a defect from angle to angle of mandible is LCL.
• For a soft tissue defect:
• o – neither skin or mucosa affected
• s – skin
• m – mucosa.
• sm -through and through defect

79. CLASSIFICATION OF MANDIBULAR
DEFECT
Urken et al., 1991
• anatomic designations,
including separate components
• condyle (C)
• ramus (R)
• body (B)
• total symphysis (S)
• hemisymphysis (SH)
• palate (P).
• Includes detailed description of
soft tissue and neurologic
deficits.

80. AIMS OF MANDIBULAR
RECONSTRUCTION
• Restore facial dimensions (facial height, width and projection).
• Ideal reconstruction for a segmental mandibulectomy
• restores oral competency
• maintains occlusal relationships with remaining teeth
• allows for prosthetic dental restoration
• restores bone continuity
• restores facial symmetry and contour to lower third of face

81. MANDIBULAR RECONSTRUCTIVE
LADDER
• No bony reconstruction
• Direct soft tissue closure
• Local flaps
• Soft tissue interposition
• Alloplastic materials
• Bony reconstruction
• Non-vascularized bone with or without soft tissue flap:
• free bone graft, costochondral graft
• Vascularized bone:
• pedicled flap, free flap
• Distraction osteogenesis
• TMJ reconstruction
• Dental implants

82. ALLOPLASTIC MATERIALS
• Must be
• biocompatible
• able to withstand the forces
sustained by mandible in
mastication.
• Materials
• medical polymers
• ceramics
• metals
• Titanium reconstruction plates
• THORP (titanium hollow
osseointegrated reconstruction
plate)
• Use
• mandibular reconstruction for
advanced cancers will die of their
disease within two years

83. FREE BONE GRAFTS
• Non vascularized bone grafts
• Defects < 5 cm in length in healthy surrounding soft tissue
• not to be treated with postoperative radiotherapy
• Bony free flap
• longer defects
• patients with poor surrounding soft tissues that has been/may
be irradiated
• Types of non-vascularized bone grafts
• autologous
• allogenic
• xenografts
• Best site for autologous bone : anterior or posterior iliac crests.

84. NON -VASCULARIZED BONY
RECONSTRUCTION
• Advantages
• quick and easy technique
• no viable neck vessels required
• no risk of microvascular
failure.
• Disadvantages
• healthy bed of surrounding
tissue required
• high risk of bone resorption
• high risk of infection
• increased complications with
radiotherapy

85. COSTOCHONDRAL RIB GRAFTS
• Main role
• Reconstruction of temporomandibular joint.
• Similar in size to native condyle
• Prevention of ankylosis at skull base.
• Aims of condylar reconstruction
• Restore ramus length and thus vertical face height
• Restore occlusion
• Ensure new TMJ movements allow normal mastication ,speech and
growth in children.

86. VASCULARIZED BONY
RECONSTRUCTION OF MANDIBLE
• Vascularized bone may be transferred as:
• Pedicled osseous flaps
• Microvascular bone transfer.
• Bony free flaps routinely used for mandibular reconstruction:
• Fibula flap
• Deep circumflex iliac artery (DCIA) flap
• Scapula flap
• Composite radial flap.

87. FIBULA FLAP
• Advantages
• length of bone available – upto 26
cm available for transfer
• only single flap that can be used
for total mandibular
reconstruction
• good bone quality and reasonable
quantity
• pedicle length, consistent anatomy
• two team operating possible.
• Disadvantages
• high incidence of atherosclerosis
in lower limb vessels
• lack of height of bone.

88. DEEP CIRCUMFLEX ILIAC ARTERY
FLAP
• Advantages
• Best quality and quantity of
bone
• Ideal for dental implants and
rehabilitation;
• Reduces osteotomies required
• Predictable anatomy
• Two team operating possible
• Disadvantages
• Poor pedicle length
• High risk of hernia formation

89. COMPOSITE SCAPULA FLAP
• Advantages
• good donor scar, minimal donor
site morbidity
• reasonable bone quality and
quantity
• best flap for complex defects.
• Disadvantages
• two team operating is not
possible
• increasing operating time
• bone quality and quantity not
as good as fibula or DCIA flaps.

90. COMPOSITE RADIAL FLAP
• Advantages
• thin pliable skin
• consistent anatomy
• good pedicle length
• two team operating possible.
• Disadvantages
• poor bone quality and quantity
• poor healing , may lead to tendon
exposure
• poor cosmetic result
• risk of fracture of residual radius
• altered sensation to the thumb
• decreased function of the hand.

91. DISTRACTION OSTEOGENESIS
• Technique of growing new bone by distraction of pre-existing
bone.
• Four main stages:
• Osteotomy – cuts through bony cortex.
• Latency
• time between osteotomy and start of distraction.
• allows formation of a primitive callus
• Distraction
• optimum rate of 1.0mm per day : four movements of 0.25 mm per day.
• Consolidation – new bone is stabilized for up to 4 weeks.