PRINCIPLES OF SURGICAL MANAGEMENT OF JAW TUMORS Medical Assignment Help

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,

 

 

 

 

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