Category Archives: SurgicalManagement of Oral Pathologic Lesions

TREATMENT OF MAXilLARY SINUSITIS

TREATMENT OF MAXILLARY SINUSITIS

Early treatment of maxillary sinusitis consists of humidification of inspired air to loosen and aid in the removal of dried secretions from the nasal passage and the sinus ostium. Also required are antibiotics, systemic decongestants, And topically applied congestants to decrease mucosal edema and inflammation and to promote drainage of the sinus through \ts natural opening. On occasion, surgical drainage of the sinus is indicated. The cause of the sinusitis should be diagnosed, treated, and eliminated. Treatment ir directed at relief of pain, and narcotic analgesics are usually required. A nasal spray containing vasoconstrictors, such as 2% ephedrine or 0.25% phenylephrine, is prescribed, as are orally administered antihistamines, such as pseudoephedrine (Sudafed). Antibiotics, selected empirically as-described previously, . are rescribed for a period of 10 to 14 days. Purulent material is submitted for C&S testing, using both aerobic and anaerobic echniques.If the patient fails to respond to this initial treatment regimen within 72 hours, it is .necessary to reassess the treatment and the antibiotic. If the cause of the problem has not been identified and eliminated, this should be accomplished. The results of the C&S testing, using both aerobic and anaerobic techniques. removal of foreign-body free segments and debulking of overly extended grafts. These procedures are usually accomplished through a Caldwell-Luc lateral sinus wall surgical approach or,  arely, with nasal access endoscopic sinus surgery. Patients having sinus disease suspected to be caused by or, secondary to sinus lift procedures should be referred to an oral and maxillofacial surgeon’ for evaluation and treatment. Antibiotic therapy alone may temporarily improve the acute problem, but the ultimate treatment will require sinus exploration and debridement by a surgeon. Midface orthognathic surgical procedures, to include maxillary osteotomies are common operations performed by oral and maxillofacial surgeons to correct facial deformities and maxillomandibular jaw size discrepancies. Most of these procedures include osteotomies to mobilize the maxilla so that it can be rhoved and stabilized in a more advantageous position. The bone cuts needed to perform this operation are made through the lateral and , medial walls of the maxillary sinus and the lateral osseous nasal walls. Separation of the nasal septum from the ‘rnax- , illa at the nasal floor is also required. Once mobilized the ‘maxilla may be advanced, retruded, down grafted or impacted with bone removal at appropriate locations. Once repositioned, the maxilla is stabilized to more superior osseous structures by applying bone plates and screws of titanium, titanium alloy, or bioresorbable materials.In ,most instances midfacial osteotomies actually improve the patency and capacity of the nasal airway, even if the maxilla is yertlcally impacted because, of dilatation of the liminal valve in the anterior portion of the nasal passage. Often, maxillary osteotomies also include .perforrnance of partial inferior nasal’ turbinectomies to reduce the size of the inferior nasal turbinates that may be hypertrophied by recurrent allergic or infectious rhinitis. Usually these procedures improve and do not impede maxillary sinus dramage. However, during maxillary osteotomy procedures, initial significant disruption of the sinus membrane and displacement or disruption or both of the nasal mucosa takes place. The sinus cavities Initially fill with blood  uring

Panoramic radiograph showing mucous-retention phenomenon in right maxiliary sinus

Panoramic radiograph showing mucous-retention phenomenon in right maxiliary sinus

val or dome shaped. The base of its attachment may be oad or narrow. The cyst has a smooth, uniform outline. J!t mucosal cysts arise from the floor of the stnus. They v-ry in size from a few millimeters to occupying the i,ajority of the sinus cavity. Mucosal cysts are rarely symptomatic in the maxillary StIlUS and .generally require no treatment beyond obser- , “,tiO!’I. Radiographs taken several months after diagnosis ~-n”’Ilomy show resolution of the lesion. If, however, , me symptoms of sin IS disease cannot be attributed to. .her factors, thi>o;.:patients should be referred to a speslist for further treatment. Mucosal. cysts should be differentiated from other con- ;:itioris that produce a similar radiographic picture, These oncrdons include cysts of odontogenic origi~ antral olyps, and benign or malignant neoplasms. On rare ccasions secondary infection may produce a pyocele-a mptomatic lesion that may Invade.associated structures • ‘ith symptoms of -acute maxillary sinusitis. These atlents should also be referred to an oral-maxillofacial , ,Jrgeon for medical and surgical management. ‘

SURGERICAL MANAGEMENT OF BENEFITLESIONS IN ORL SOFT TISSUSE

SURGERICAL MANAGEMENT OF BENEFITLESIONS IN ORL SOFT TISSUSE 

Superficial soft tissue lesions of the oral mucosa arc Usually benign and in niost instances lend themselves tu simple surgical removal using biopsy techniques (see Chapter 21), They include fibromas, pyogenic granulomas.
papillomas, peripheral giant cell granulomas, verruca vulgaris; rnucocclcs (i.e .. mucous extravasation phenomena), and epulis Iissuratum, All of these lesions are overgrowths (If the normally present histologic clements i.11the oral “Iucosa and submucosa. The principles of rem ova I are
,’t’ same as those outlined previously and include the use , elliptic, wedge type of incisions during removal. In the of lesions that appear associated with the dentition I i.e., pyogenic granuloma), the associated tooth or teeth should be thoroughly curetted and polished to remove . plaque, calculus, or foreign material that may have played a role in the lesion’s development and that  may cause a recurrence if not removed.

When the patient has lost a portion of the maxilla, the maxillary sinuses or nasal cavity may be continuous with the oral cavity, which presents great difficulties for the patient in speaking and eating. Defects of the maxilla can
be managed in one of two ways: The first is with surgery. Defects that are not excessive may be closed with available soft tissues of the buccal mucosa and palate. Bone grafts may also be used to provide the patient with a’ functional alveolar process. Very large defects or defects
in patients who are poor surgical risks may, require prosthetic obliteration in which a partial- or complete denture extends into the maxillary sinus or nasal cavities and effectively partitions the mouth from these structures
(Fig. 22-12).

Several urgcom’ also delay reconstruction of defects caused by removal of benign tumors.The  surgerical of  the presence of a simultaneous intraoral and cxtraoral defect, which frequently is necessary to remove the

FIG 22-1 I Local excision of lip carcinoma. A to E, Full-thickness V excision of lip.

FIG 22-1 I Local excision of lip carcinoma. A to E, Full-thickness V excision of lip.

tumor, cont raindicates all immediate reconstruction of the mandible. Instead, a -pacc-mnintaimng device is placu at till time of resection, and a secondary recon-tnu ton h prortected weeks to months later.

When delayed reconstruction is decided upon. consld cration should be given to ‘maintaining the rcxidua: mandibular tragments ill their normal anatomic relationship with intermaxillary fixation, external pin lixat ion

FIG 32-12

FIG 23-12

splints, internal fixation, or a combination of these modalities. This technique prevents cicatricial and muscular  eformation and displacement of the segments and simplifies secondary reconstructive efforts.

Clinical results have shown that immediate reconstruction is a viable option and has the advantages of requiring a single surgical procedure and having an early return to function with a minimal compromise to facial
esthetics.” A possible disadvantage is loss of the graftfrom infection. The risk of infection may be higher when a graft is placed transorally or in an extraoral wound that was orally contaminated during the extirpative surgery. Because· the recurrence rate is substantial in some. tumors,  prudent planning and meticulous surgery are mandi\tory before reconstruction is attempted. These measures minimize the risk of failure as a result of recurrence. Three choices for immediate reconstruction are
possible.

FIG 22-12

FIG 22-12

 

 FIG 22-12

FIG 22-12

 

1. The entire surgical procedure is performed intraorally by first removing the. tumor and then grafting the defect.
2. The tumor is removed by a combined intraoral and extraoral route. A watertight oral closure is obtained, which is followed Immediately by grafting the defect through the extraoral incision.
3..When the tumor has not destroyed the alveolar crestal bone and when no extension of the tumor into oral soft tissues has occurred, the involved
teeth are extracted. A wait ng period of 6 to Rweeks is allowed for healing of the gingival tissues. “J he tumor is then removed and the defect grafted
through an exrraoral inci ion, with care taken to avoid perforation of the oral soft tissues. This procedure is the only type of immediate reconstruction with which oral contamination can be avoided.

 

 

 

 

 

 

 

 

MALIGNANT TUMORS OF THE ORAL CAVITY

MALIGNANT TUMORS OF THE ORAL CAVITY

Management of the oral cavity may arise from a variety ot tissues, such as salivary gland, muscle, and blood vessels, or may even present as metastases from distant sites, I( sl common, however, are epidermoid carcinomas ot
he oral mucosa.

Treatment Modalities for Malignancies
Malignancies of the oral cavity are treated with surgery, radiation, chemotherapy, or a combination of these modalities, The treatment forany given case depends on several factors, including the histopathologic diagnosis, the 10Ciltion of the tumor, the presence and degree of metastasis, the radio sensitivity or chemosensitivity of the tumor, the age and genera) physical condition of the patient. ‘the cxperience of the treating clinicians, and the wishes of the

FiG. 22:10-cont'd C, Ld:on after sectioning. 0, Template same size as removed specimen used to harvest similarly sized and shaped bone graft. E, Intraoral appearance of patient-l year postoperatively. F, Radioqraphic appearance' year postoperatively

FiG. 22:10-cont’d C, Ld:on after sectioning. 0, Template same size as removed specimen used to harvest similarly sized and shaped bone graft. E, Intraoral appearance of patient-l year postoperatively. F, Radioqraphic appearance’ year postoperatively

patient. In general, if a lesion can be completely excised without rnutilatmg Hie patient.ithis is the preferred modality. If spread to regional lymph nodes is suspected, radiation , may be used before or after surgery to help eliminate small foci of malignant cells in the adjacent areas: If widespread
svstcmic metas asis is detected or if a tumor, such as a Iyrnphorria, is especially chemosensitive, chemotherapv is used with or without surgery and radiation.

Fractionation of the delivery of radiation means that instead of giving the maximal amount of radiation a r,’rson can withstand at one time; smaller increments 01 radiation (i.e., fractions), are given over several week r
which allows the healthier normal tissues ti me to recover between closes, The tumor cells, however, arc less able: to recover between doses, The other delivery method uses multiple ports for radiation exposure. Instead of delivering the entire -dose through one beam (i.e., port), multiple
beams are used. All beams are focused on the tumor but from different angles. Thus the tumor is exposed to the entire dose of radiation. However, because different beams are used, the normal tissues in the path of the
x-ray beams arc spared maximal exposure and instead receive only a fractiorrof -the tumor dose.

Malignancies of the oral cavity that have either suspected or proven lymph node involvement are candidates for composite resection in which the lesion, sur- .rounding tissues, and lymph nodes of the neck’ are totally
removed. This procedure may produce large defects of the jaws and extensive loss of soft tissues, which make functional and esthetic rehabilitation a long, involved process.

 

 

PRINCIPLES OF SURGICAL MANAGEMENT OF JAW TUMORS

PRINCIPLES OF SURGICAL MANAGEMENT OF JAW TUMORS
A discussion of the surgical management of jaw tumors is made easier by the fact that many tumors behave similarly and therefore can be treated in a similar manner. The three main modalities of surgical excision of jaw
tumors are (1) enucleation (with or without curettage), (2) marginal (i.e., segmental) or partial resection, and (3) composite resection (Box 22-1). Many benign tumors  ehave nonaggressively and are therefore treated conservatively with enucleation, curettage, or both (Table 22-1).

BOX 22-1

BOX 22-1

Note: These are generalities. Treatment is individualized for each patient and each lesion, "These lesions are malignancies and may be treated variably. For lesions totally within the jaw, partial resection may be 'performed without adjacent soft tissue and lymph node dissections. Radiotherapy and chemotherapy may also playa role in the overall therapy.

Note: These are generalities. Treatment is individualized for each patient and each lesion,
“These lesions are malignancies and may be treated variably. For lesions totally within the jaw, partial resection may be ‘performed without
adjacent soft tissue and lymph node dissections. Radiotherapy and chemotherapy may also playa role in the overall therapy.

Aggressiveness of Lesion
Surgical therapy of oral lesions ranges from enucleatioh or curettage to composite resection. Histologic diagnosis positively identifies and therefore directs the’ treatment of the lesion. Because of the wide range in behavior of oral lesions, the prognosis is related more to the histologic
diagnosis, which indicates the biologic behavior of the lesion, than to any other single factor.

Anatomic Location of Lesion
The location of a lesion within the mouth or perioral areas may severely complicate surgical excision and therefore jeopardize the prognosis. A non aggressive, benign lesion in an inaccessible area, such as the pterygomaxillary fissure, presents an obvious surgical problem.
Conversely, a more aggressive lesion in an easily accessible and resectable area, such as the anterior mandible, often offers a better prognosis.

Proxiutitv to Adjacent vital . The proximitv of benign lesions to adjacent neurovascular structures and teeth is an important consideration. because’ pW;ervation of these structures should be attempted. Frequently

FiG. 22-8 Common types of mandibular resection. A, Marginal or segmental resection, which doesnot disrupt mandibular continuity. Band C, Partial mandibular resections, which disrupt mandibular continuity. At~E'mp.t~ to leave mandibular condyle to facilitate reconstruction are demonstrated.

FIG. 22-8 Common types of mandibular resection. A, Marginal or segmental resection, which doesnot disrupt mandibular continuity. Band C, Partial mandibular resections, which disrupt mandibular
continuity. At~E’mp.t~ to leave mandibular condyle to facilitate reconstruction are demonstrated.

the apices of”adjacent tooth roots are completely uncovered during a surgical procedure. The dental pulps are stripped of their blood supply. These teeth should be considered for endodontic treatment to prevent an odontogenic infection, which would complicate healing and [copardize
the success of bone grafts placed in an adjacent area.

Intraosseous versus  extraosseous location  . An aggressive oral lesion confined to the interior of the jaW, without perforation of the cortical plates, offers a better prognosis than one that has invaded surrounding soft tissues. invavion of soft tissues indicates a more aggressive tumor, which, because of its presence in soft tissues, makes complete removal more difficult and sacrifices more normal tissues. Inthe latter case the soft tissue in the area of the perforation should be locally excised. A supra eriosteal should he undertaken II til thinned to the point 01 wthout obvious perforation,

Duration of lesion
Several oral tumors exhibit 510wgrowth and may ,become static in size, The odontomas, for example, may be discovered in the second decade of life, and their size may remain unchanged for many years. The slower-growing lesions, seem to’ follow a more benign course, and treatment
should be individually tailored to each case.

Reconstructive Efforts
previously noted, the goal of any surgical procedure to remove a pathologic lesion should not ‘only be the eradication of disease but also the facilitation of the patient’s functional well-belng. Thus reconstructive procedures should be planned and anticipated befor« initial surgeryicalpl ri()rtlll\ll. I rl’ljul’lltl! the ,I!{),d, of rcconvtruction dictate a ‘lngical technique that 1\ just as effective as another technique in the removal of the disease but more optimr , for facilitating future reconstructive efforts.

Jaw Tumors Treated with Enucleation,Curettage, or Both
Most jaw, tumors with a low rate of recurrenc can be treated with enucleation or curettage; for example, most of the odontogenic tumors, including odontomas, arneloblastic fibromas, ameloblastic fibroodontomas, keratinizing and calcifying odontogenic cysts, adenornatoid odontogenic tumors, cerhentoblastomas, and central
cernentifying (i.e. ossifying) fibromas, Table 22-1 lists other lesions that are treated in this manner.

FIG 22-9

FIG 22-9

Jaw ‘Tumors Treated with Marginal or Partial Resection
When the lesion is known to be aggrl’s n ther hv histopathologic determination or by its clinical behavior, or it is of such a consistency that total removal by enucleation, curettage, or both would. be difficult, removal may be facilitated by resecting the lesion with adequate
bony margins. Odontogenic lesions treated in this manner are the ameloblastoma, the odontogenic myxoma (i.e., fibromyxomas}, till’ calcifying epithelial odontogenic tumo~ (i.e., Pindborgj, the squamous odontogenictumor  amelohlasuc odontoma. Table 22-1  other treated in this manner.

FIG. 22-9-cont'd D, Extraoral exposure and placement of bone graft to reconstruct mandibular ~Iveolus. E, Radiographic appearance immediately after graft placement.

FIG. 22-9-cont’d D, Extraoral exposure and placement of bone graft to reconstruct mandibular
~Iveolus. E, Radiographic appearance immediately after graft placement.

FIG, 22- 10 Partial mandibular resection of myxoma, A, Radiographic appearance on initial presentstion. 6, Photograph of intraoral resection of tumor (surgical resection similar to that shown in Fig, 22-8, 8), (6 from Ellis E, Fonseca RJ: Therapy of cysts and odontogenic tumors, In Thawley SE et al, editors: , Comprehensive monaqement of head and neck tumors, ed 2, Philadelphia, 1999, WB Saunders.

FIG, 22- 10 Partial mandibular resection of myxoma, A, Radiographic appearance on initial presentstion.
6, Photograph of intraoral resection of tumor (surgical resection similar to that shown in Fig, 22-8,
8), (6 from Ellis E, Fonseca RJ: Therapy of cysts and odontogenic tumors, In Thawley SE et al, editors:
, Comprehensive monaqement of head and neck tumors, ed 2, Philadelphia, 1999, WB Saunders.

If the clinician is concerned about the adequacy of the soft tissue surgical margins around a lesion when surgery is being performed in a hospital setting, specimens along, the margins can be removed and sent immediately to the pathologist for histopathologic examination, -This
process is performed in approximately 2Q minutes by freezing the tissue in liquid carbon dioxide or nitrogen and then sectioning and staining the tissue for immediate examination, The accuracy of “frozen ection”examination is good when used for detecting adequacy of , However, it is less accurate when trying to lesion histopathologically for the first time,

 

 

 

 

SURGICAL MANAGEMENT OF CYSTS AND CYSTLIKE LESIONS OF THE JAWS

SURGICAL MANAGEMENT OF CYSTS AND CYSTLIKE  LESIONS OF THE JAWS

Surgical management of oral pathologic lesions can best be discussed by broadly dassifying pathologic lesionsinto the following major categories cysts and cysrlike  lesions of the jaws, benign tumors of the jaws, malignant tumors, and benign lesions of oral soft tissues.

If the cyst has not expanded or thinned the cortical plate, normal contour and firmness are noted. Palpation with firm pressure may. indent the surface of an expanded jaw with characteristic rebound resiliency. If the cyst
has eroded through the cortical plate, fluctuance may be .noted on palpation.

FIG. 22-1 Mandibular third molar is displaced by cyst.

FIG. 22-1 Mandibular third molar is displaced by cyst.

Cysts of the jaws are treated in one of the following four basic methods: (1) enucleation, (2) marsupialization, (3) a staged combination of the two procedures, and (4) enucleation with curettage.

Enucleation
Enucleation is the process by which the total removal of a cystic lesion is achieved. By definition, it means a shellingout of the entire cystic lesion ‘without rupture. A cyst lends itself to the technique of enucleation because of the layer of fibrous connective tissue between the epithelial componen t
(which lines the interior aspect of the cyst) and the bony wall of the cystic cavity. This layer allows a cleavage plane for stripping the cyst from the bony cavity and makes enucleation similar to stripping periosteum from bone.

Advantages. The main advantage to enucleation is that pathologic’ examination of the entire cyst can be undertaken: Another advantage is that the initial excisional biopsy (i.e., enucleation) has also appropriately
treated the lesion. The patient does not have to care for a marsupial cavity with cons.tant irrigations. Once the mucoperiosteal access flap has healed, the patient is no longer bothered by the cystic cavity.
Disudvuntuges, If any of the conditions outlined under the section on indications for marsupialization exist, enucleation may be  isadvantageous. For example, normal tissue may be jeopardized, fracture of the jaw could occur, devitalization of teeth could result, or associated impacted teeth that the clinician may wish to savecould be removed. Thus. each (;.:~tmust be addressed individually, and the clinician must weigh the pros and
cons of enucleation versus marsupializatiofl (with or without enucleation) (see discussion of Lnucleatlon after Marsupialization) .

‘In large cysts or cysts proximal to neurovascular structures, nerves and vessels are usually found pushed to one side of the cavlty by the slowly expanding cyst and should be avoided or handled as atraumatically and as little as possible. Once the cyst has been removed, the bony
cavity should be inspected for remnants of tissue. Irrigating and drying the cavity with gauze will aid in visualizing the entire bony cavity. Residual tissue is removed with curettes. The bony edges o.f the defect should be
smoothed with a file before closure.

Cysts that surround tooth roots or are in inaccessible areas of the jaws require aggressive curettage, which.Is necessary to remove fragments of cystic lining that could not. be removed with the bulk of the cystic wall. Should obvious devitalization of teeth occur during a cystectomy,

FIG. 22-2 A, Typical radiographic appearance of cyst. Radiolucent center is-surrounded by zone of reactive bone. B, Expansion of buccal bone caused by underlying cyst. The proximity to mental neurovascular bundle (on distal and inferior aspect of cystic expansron) is demonstrated. C, Cystic cavity after removal of cyst is visualized. Mental nerve is left Intact. The amount of osseous tissue is destroyed by cyst.

FIG. 22-2 A, Typical radiographic appearance of cyst. Radiolucent center is-surrounded
by zone of reactive bone. B, Expansion of buccal bone caused by underlying cyst. The
proximity to mental neurovascular bundle (on distal and inferior aspect of cystic expansron)
is demonstrated. C, Cystic cavity after removal of cyst is visualized. Mental nerve is
left Intact. The amount of osseous tissue is destroyed by cyst.

FIG. 22-2-cont'd D, Cyst with buccal bone still attached, E, Mucosal closure is demonstrated.

FIG. 22-2-cont’d D, Cyst with buccal bone still attached, E, Mucosal closure is demonstrated.

endodontic treatment of the teeth may be necessary in the near future, which may help to prevent Odontogenic infection of the cystic cavity from the necrotic dental pulp.

Marsupialization
Marsuplallzatton, decompression, and the Partsch operation all refer to creating a surgical window in the wall of’ the cyst, evacuating the contents of the cyst, and maintaining continuity between the cyst and the oral cavity, maxillary sinus, or nasal cavity (Fig. 22-5). The only portion
of the cyst that is removed is th, piece removed toproduce the window. The remaining cystic lining is left in situ, This process decreases intracystic pressure and promotes shrinkage of the cyst and bone fill. Marsupialization
can be used either as the sole therapy for a cyst oras a preliminary step in management, with enucleation deferred until later.

FIG. 22·3 Multilocular appearance of cyst. This lesion was diagnosed histologically as odontogenic keratocyst.

FIG. 22·3 Multilocular appearance of cyst. This lesion was diagnosed
histologically as odontogenic keratocyst.

the inferior alveolar nerve) or devitalization of healthy
teeth, marsupialization should be considered.
2. Surgical access. If access. to all portions of the cyst is difficult,
portions of the cystic wall may be left behind,
which could result in recurrence. Marsupialization
should therefore be considered.
3. Assistance ill eruption of teeth. If an unerupted tooth
that is needed in the dental arch is involved with the
cyst (i.e., a dentigerous cyst), marsupialization may
allow its continued eruption into the oral cavity (Fig.
22-6).
4. Extent of surgery. In an unhealthy or debilitated
patient, marsupialization is a reasonable alternative to
enucleation, because it is simple and may be less stressful
for the patient .
. S. Size of cyst. In very -large cysts, a risk of jaw fracture
during enucleation is possible. It may be better to marsupialize
the cyst and defer enucleation until after
considerable bone fill has occurred.
Advaut aec», The main advantage of marsupialization
is that it is a simple procedure to perform. It may also
spare vital structures from damage should immediate
enucleation be attempted.

FIG. 22·4 Apical cystectomy performed at time of tooth removal. A to C, Removal with curette via tooth. socket is visualized. A apical cystectomy must be performed with care because of proximity of apices of teetn to other structures, such a5 maxillary sinus and inferior alveolar canal.

FIG. 22·4 Apical cystectomy performed at time of tooth removal. A to C, Removal with curette via
tooth. socket is visualized. A apical cystectomy must be performed with care because of proximity of
apices of teetn to other structures, such a5 maxillary sinus and inferior alveolar canal.

al times every day with 11 syringe. This may continue for several months, depending on the size of the cystic cavity and. the rate of bone fill.

FIG. 22-4-cont'd Dto" Removal of apical cyst by flap reflection and creation of osseous window is demonstrated -at the time of tootlt removal

FIG. 22-4-cont’d Dto” Removal of apical cyst by flap reflection and creation of osseous window
is demonstrated -at the time of tootlt removal

the area, the cyst is aspirated as discussed in Chapter 20. If the aspirate confirm’s the presumptive diagnosis of a cyst, the marsupialization procedure may proceed (Fig. 22-7). The initial incision j.s usually circular or elliptic and creates a large (1 em or larger) window into the cystic cavity. If the bone has been expanded and thinned by the cyst, the initial incision may extend

FIG. 22-5 Marsupialization technique. A, Cyst within maxilla. B, Incision through oral mucosa and cystic wall into center of cyst. C, Scissors used to complete excision of window of mucosa and cystic wall. D, Oral mucosa and mucosa of cystic wall sutured together around periphery of opening.

FIG. 22-5 Marsupialization technique. A, Cyst within maxilla. B, Incision through oral mucosa and
cystic wall into center of cyst. C, Scissors used to complete excision of window of mucosa and cystic
wall. D, Oral mucosa and mucosa of cystic wall sutured together around periphery of opening.

case the tissue contents of the window are submitted for pathologic examinatlon. If the overlying bone is thick, an osseous’ window is removed carefully with burs and rongeurs. The cyst is then incised to remove a
window of the lining, which is submitted for pathologic examination. The contents of the cyst are evacuated, and, if possible. visual examination of the residual Iining of the cyst is undertaken. Irrigation of the cyst
removes any residual fragments of debris. Areas or ulceration or thickening of the cystic wall should alert the clintcia I to tile possibility of dysplastic or neoplastic changes ill tile wall of tile cyst. In this instance enucleation of the entire cxst or incisional biopsy of the suspicious area or.
areas should be undertaken. If the cystic lining is thick enough and if access permits, the perimeter of the cystIC  wall around the window ‘can be sutured to the oral. Otherwise the cavity should be packed with
strip gauze il.ll’regnated with tincture of benzoin or an antibiotic ointment. This packing must be left in place for 10 to 14 days to prevent the oral mucosa from healing healing over the cystic window. By 2 weeks the lining of the cyst should be healed to the oral mucosa around the periphery of the window.

FIG. 22-6 Marsupialization of multiple dentigerous cysts. A, Radiographic appearance before marsupialization. Marsupialization was carried out along crest of alveolar process on both sides. 8, One year later, the uprighting and sruptlon.of teeth are demonstrated. C, Three years later. No orthodontic assistance was. required. (From Ellis E, Fonseca RJ: Therapy of cysts and odontogenic tumors. In Thawley SE et al, editors: Comprehensive management of head and neck tumors, ed 2, Philadelphia, 1999, WB Saunders; courtesy qr. TImothy Pickens, Ypsilanti, MI.)

FIG. 22-6 Marsupialization of multiple dentigerous cysts. A, Radiographic appearance before marsupialization.
Marsupialization was carried out along crest of alveolar process on both sides. 8, One
year later, the uprighting and sruptlon.of teeth are demonstrated. C, Three years later. No orthodontic
assistance was. required. (From Ellis E, Fonseca RJ: Therapy of cysts and odontogenic tumors. In
Thawley SE et al, editors: Comprehensive management of head and neck tumors, ed 2, Philadelphia,
1999, WB Saunders; courtesy qr. TImothy Pickens, Ypsilanti, MI.)

FIG. 22-7 This case combined marsupialization with subsequent enucleation. A, Radiographic appearance of lesion and displaced tooth on initial examination. 8, Mucosa reflected from anterior border of ascending ramus. Osseous window created by use of round bur; bone w~s gently removed, exposing underlying fibrous cystic wall (white membrane). Circular. piece of this cystic wall was removed, exposing cystic lumen. Cystic mucosa was then sutured to oral mucosa around periphery of osseous window. Osseous window and cystic specimen were submitted for pathologic examination

FIG. 22-7 This case combined marsupialization with subsequent enucleation. A, Radiographic
appearance of lesion and displaced tooth on initial examination. 8, Mucosa reflected from
anterior border of ascending ramus. Osseous window created by use of round bur; bone w~s
gently removed, exposing underlying fibrous cystic wall (white membrane). Circular. piece of
this cystic wall was removed, exposing cystic lumen. Cystic mucosa was then sutured to oral
mucosa around periphery of osseous window. Osseous window and cystic specimen were submitted
for pathologic examination

Marsupialization is rarely used as the sole form of treatment for cysts. In most instances enucleation is done after marsuplalization. In the case of a dentigerous cyst, however, there may not be any residual cyst to remove
once the tooth has erupted into the dental arch. In addition, if furthercontraindicated because of concornltant medical problems. marsupialization may be performed without tuture enucleation. The cavity mayor may not obliterate totally with time. If it is kept clean,
the cavity should not problem.

Enucleation after Marsupialization
Enucleation is frequently done (at a later date) after marsupialization. Initial healing is rapid after marsupiaization, but the size of the cavity may not decrease appreciably past a certain point. The objectives of the marsupialization procedure have been accomplished at this time
and a secondary enucleation may be undertaken without injury to adjacent structures. The combined approach reduces morbidity and accelerates complete healing 0 the defect.

'FIG~ 22-7-cont'd C, Appearance at 13 months of opening created into cyst, The patient had irrigated lumen twice a day, 0, Radiographic appearance at -13 months, The extent of bone regeneration (compared with Fig, 21-7, A) is visualized,-Now ample osseous tissue surrounds inferior alveolar neurovascular bundle to prevent damage during enucleation,

‘FIG~ 22-7-cont’d C, Appearance at 13 months of opening created into cyst, The patient
had irrigated lumen twice a day, 0, Radiographic appearance at -13 months, The extent of bone
regeneration (compared with Fig, 21-7, A) is visualized,-Now ample osseous tissue surrounds
inferior alveolar neurovascular bundle to prevent damage during enucleation,

Advantages, The advantages of combined marsupialization and enucleation are the same as those listed for marsupialization and enucleation. In the marsupialization phase, the advantage is that this is a simple procedurethat
spares adjacent vital structures. In the enucleation phase, the entire lesion becomes available for histologic examination, Another advantage is tile development of a thickened cystic lining, which makes the secondary enucleation an easier procedure.

Technique, The cyst is first marsupialized, and  osseous healing is allowed to progress. Once the cyst, has decreased to a size that makes it amenable to complete surgical removal, enucleation is performed as the definitive treatment. The appropriate time for enucleation is when bone is covering adjacent vital structures, which prevents their injury during enucleation, and when adequate bone fill has provided enough strength to the jaw to prevent fracture during enucleation (se Fig. 22-7).

FIG. 22-7-cont'd E, Cystectomy easily performed .13 months after initial marsupialization. Tooth being removed with cystic 'rail. The thickness 01cystic wall is demonstrated. F, Specimen after removal.

FIG. 22-7-cont’d E, Cystectomy easily performed .13 months after initial marsupialization.
Tooth being removed with cystic ‘rail. The thickness 01cystic wall is demonstrated. F, Specimen
after removal.

Once the cyst has been enucleated, the oral soft tissues must be closed over the defect, if possible, which may require the development and mobilization of soft tissue flaps that can be advanced and sutured in a watertight manner over the osseous window. If complete closure of’
the wound cannot be achieved, packing the cavity with strip gauze impregnated with an antibiotic ointment is acceptable. This packing must be changed repeatedly with cleansing of the cavity until granulation tissue has obliterated the opening and epithelium has closed over the wound.

Encleation with Curettage
Enucleation with curettage means that after enucleation a curette or bur is used to remove 1 to 2 mm of bone around the entire periphery of the cystic cavity. This is done to • remove any remaining epithelial cells that may be present in the periphery of the cystic wall or bony cavity. These
cells could proliferate into a recurrence of the cyst.

Tcctmique. After the cyst has been enucleated and removed, the bony cavity is inspected for proximity to adjacent structures. A sharp curette or a bone bur with sterile irrigation can be used to remove a 1- to 2-mm layer
of bone around the complete periphery of the cystic cavity. This should be done with extreme care when workingproximal to important anatomic structures. The cavity is then cleansed and closed.

 

 

 

 

 

 

 

 

 

 

BASIC SURGICAL GOALS

Eradication of Pathologic Condition

The therapeutic goal of any extirpative surgical procedure is to remove the entire lesion and leave no cells that. could proliferate and cause a recurrence of the lesion. The methods used to achieve this goal vary tremendously and
depend on the nature of the pathologic condition of the lesion. Excision of an oral carcinoma necessitates an aggressive approach that must sacrifice adjacent structures in an attempt to thoroughly remove the lesion.
Using this approach on a simple cyst would be a tragedy. It is therefore imperative to identify the lesion histologically with a biopsy before undertaking any major surgical extirpative procedure. Only then can the appropriate surgical procedure be chosen to eradicate the lesion with as
little destruction of adjacent normal tissue as is feasible.

Functional Rehabilitation of Patient 
As just noted the primary goal of surgery to’ remove a pathologic condition is total removal of the lesion. Although eradication of disease may be the most important goal of treatment, by itself it is frequently inadequate in the
comprehensive treatment of patients. The second goal of any treatment used for eradication of disease is an allowance for the functional rehabilitation Of the patient. After the primary objective of eradicating a lesion has been achieved, the most important consideration is dealing with
the residual defects resulting from ,he extirpative surgery. These defects can range from a mild obliteration of the labial sulcus secondary to the elimination of an area of denture epulis to a defect in the alveolus after removal of a benign odontogenic tumor or to a hemimandibulectomy defect resulting from carcinoma resection. The best results are
obtained when future reconstructive procedures are considered
before excision of lesions. 1 ‘cthods of grafting, fixation principles, soft tissue deficits, dental rehabilitation, and patient preparation must be thoroughly evaluated and . adequately handled preoperatively.

CHAPTER OUTLINE

CHAPTER OUTLINE

BASIC SURGICAL GOALS
Eradication of Pathologic Condition
Functional Rehabilitation of Patient
SURGICAL MANAGEMENT OF CYSTS AND CYSTLIKE
lESIONS OF THE JAWS
Enucleation
Indications
Advantages
Disadvantages
Technique
Marsupialization
Indications
Advantages
Disadvantages
Technique
Enucleation after Marsupialization
Indications
Advantages
Disadvantages
Technique
Enucleation with Curettage
Indications
Advantages
Disadvantages
Technique

PRINCIPLES OF SURGICAL MANAGEMENT OF JAW.
TUMORS
Aggressiveness of lesion
Anatomic location of lesion
Maxilla versus Mandible
Proximity to Adjacent Vital Structures
Size of Tumor
lntraosseous versu~ .£xtraoss~ous location
D~rationorlesiorr
Reconstructive Efforts
Jaw Tumors Treated with Enucleation, Curettage, or
Both
Technique
Jaw Tumors Treated with Marginal or Partial
Resection
Technique
MALIGNANT TUMORS OF THE ORAL CAVITY
Treatment Modalities for Malignancies
Radiotherapy
Chemotherapy
Surgery
SURGICAL MANAGEMENT OF BENIGN lESIO~S IN
ORAL SOFT TISSUES
RECONSTRUCTION OF JAWS AFTER REMOVAL OF ORAL
TUMORS

The specific surgical techniques. for treatment of oral pathologic lesions can be as varied as those for surgical management of any other entity.
Each clinician surgically treats patients using techniques based on previous training, biases, experience, personal skill, intuition, and ingenuity. The purpose of this chapter is not to describe the specifics of surgical techniques for management of individual oral pathologic lesions but
to present basic principles that can be applied to a variety of techniques to satisfactorily treat patients. Discussion of this topic is made easier by the fact that many different lesions can be treated in much the same manner, as is outlined later.