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INDIAN DENTAL ACADEMY

Leader in continuing dental education


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CONTENTS
Introduction
Objectives of management
Guidelines of management
Treatment methods
Enucleation & Curettage
-Carnoys solution
-Cryosurgery
Marginal Resection
Segmental Resection
Reconstruction


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INTRODUCTION
Treatment of odontogenic tumors is designed to
eradicate the lesion and restore aesthetic form and
optimal function.
Because of these needs and the benign nature of these
lesions, a variety of surgical techniques that preserve
vital structures and facial aesthetics have been
developed for the treatment of odontogenic tumors.
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Objectives of management:
Eradication of the lesion
Preservation of normal tissue to the extent possible
Restoration of significant tissue loss, form & function
Well-planned & executed resection & reconstruction
serves the patient physically & emotionally better than
repeated surgical procedure

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GUIDELINES
SIZE & LOCATION OF TUMOR:
Small Excisional biopsy
Increased size more radical
Location important role in post operative
morbidity
Inaccessibility responsible for inadequate surgical
clearance
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DURATION:
When the tumor was 1
st
noticed
Fast growing in short duration immediate treatment
Prognosis depends on rate of growth of tumor
Slow growing more elective treatment
Fast growing indicate malignant
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BENIGN Vs MALIGNANT :
Benign tumor treat conservatively
Some benign tumors behave aggressively radical
treatment
Benign & small enucleation
Lesion involves full thickness segmental resection
Lesion is extensive radical resection

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Factors governing the choice of
treatment method
Age and health of the patient
Clinical type of ameloblastoma
Site of the lesion
Size of the lesion
Chances of recurrence
Patient preference




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Treatment methods
Enucleation & curettage
- Thermal cauterization
- Carnoys solution
- Cryosurgery
Resection without continuity defect
Resection with continuity defect
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ENUCLEATION:
Allows the cystic cavity to be covered by a
mucoperiosteal flap & the space fills with the blood
clot which will eventually organize and form normal
bone.
INDICATIONS:
Surgical excision of tumor which tend to grow by
expansion, rather than by infiltration of surrounding
tissues.
Lesions occurring in the bone with a distinct
separation b/w the lesion & the surrounding bone.
Often there is a cortical margin of bone that delineates
the tumor from the bone.
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Indicated in:
Odontoma
Ameloblastic fibroma
Ameloblastic fibroodontoma
Adenmatoid odontogenic tumor
Cementoblastoma
Squamous odontogenic tumor
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Enucleation - procedure

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Enucleation - procedure
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ADVANTAGES:
Primary closure of the wound
Healing is rapid
Post operative care is reduced
DISADVANTAGES:
After primary closure, it is not possible to directly
observe the healing of the cavity
Removal of unerupted teeth with the lesion
Weakening of mandible making it prone to jaw
fracture
Damage to adjacent vital structures
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Curettage

Curettage - removal of the tumour by scrapping it
from the surrounding normal tissue
Currently - least desirable form of therapy
Sehdev et al (1974) - cure rate of only 10%.
Taylor (1968) - 63% recurrence rate
Rankow and Hickey (1954) - 91% recurrence rate.
Failure - nests of tumour cells extend beyond the
clinical and radiographic margins of the lesion
Chemical and electrical cauterisation have been used
by surgeons in conjunction with curettage but they
have reported only a slight improvement in cure rate.




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INDICATIONS
Unicystic ameloblastoma
Small tumour - a child or a young adult
Patient can be followed up for 10 years or more.
Small tumour in the body of the mandible in an elderly
patient, as ameloblastoma takes several years to recur
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Operative procedure

Intra-oral approach
Mucoperiosteal flap is reflected
Mandible - buccal aspect
Lingual access - injury to lingual nerve & mandibular
neurovascular bundle
Maxilla - palatal or buccal / labial approach
Rongeur or surgical bur - remove sufficient bone -
expose the underlying tumor
Angular / straight curettes - convex surface of the
curette placed against the bony wall.


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Ameloblastoma Enucleation & Curettage
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Adenomatoid Odontogenic tumor:
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Ameloblastic fibro odontoma
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Ameloblastic fibroma
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Compound odontoma:
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After lesion is removed - largest curette - a margin of
apparently normal bone should be removed by
aggressive scrapping.
After thus removing 1 to 3 mm of surrounding bone,
all margins are smoothened with a rongeur or a large
round bur.
Adjunctive treatment like cauterisation may be
employed at this stage.
Irrigation with normal saline
Small wounds - closed primarily
Large wounds - packed with gauze impregnated with
compound tincture of benzoin, balsam of Peru or
Whiteheads varnish


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Topical antibiotic - gauze pack.
The pack is removed approximately 2 to 3 inches
everyday until the surgical defect is filled with
granulation tissue.
Oral hygiene is maintained.
Complications
Numerous complications - particularly extensions to
vital structures
Curettage procedure breaks the cortical barrier, thus
paving the way for residual tumour to grow into the
soft tissues, which then becomes more difficult to
treat.



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Cautery (desiccation)
Various types - primarily as an adjuvant to curettage,
but in some cases as a primary mode of therapy.
Chemical agents:
-Carnoys solution
-Electrocautery
-Cryotherapy
Cauterisation is basically an attempt to eradicate the
tumour that has infiltrated beyond the clinical and
radiographic margins of the tumour
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Cautery is empirical :
(i) how far the tumour in each case has extended into
the cancellous bone
(ii) how far the caustic agent (heat / chemicals)
penetrates into the cancellous bone
(iii) how effective is the agent in eradicating the
tumour cells and
(iv) the possible harmful effects to normal tissue

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Electrocoagulation (thermal
cautery)
Mehlisch et al (1972) - 50% recurrence rate
More effective therapy than curettage
Secondary ischaemia & necrosis - may destroy the
invading tumour cells.
Cautery frequently been employed as an adjuvant to
other methods of therapy to give a better result
(Gardner and Pecak 1980)
Mehlisch et al - no recurrences

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Chemical cauterisation
Carnoys solution - a fixing agent
absolute alcohol
chloroform
glacial acetic acid
ferric chloride (modification)
Stoelinga and Bronkhorst (1988) - unicystic ameloblastoma
and reported no recurrences
Depth of penetration - cancellous bone up to 1.5 mm after 5
minutes and up to 1.8 mm after 1 hour (Voorsmit et al
1981)
Use of Carnoys solution appears to be harmless and has
the potential of reducing recurrences after curettage.

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Technique:
Teeth extracted
Enucleation and curretage
Bony cavity is examined
Carnoys solution is applied
Cotton applicator / ribbon guaze 3 minutes
Copious irrigation with saline
BIPP inserted & wound kept open
BIPP replaced periodically
Recurrence 10%

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CRYOSURGERY:
Alternative treatment modality
Excellent results in maxillo-facial region
AIM: eliminate invasive bone lesion without
necessarily involving the problems of conventional
anatomic radical surgery
Advantage of cryotherapy is that it is possible to
devitalise the tissue with liquid nitrogen to a depth of
1.5 cm
The jaw can be frozen through its entire thickness if
necessary.
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TECHNIQUE:
After curettage
Surrounding soft tissues are retracted & protected
away with gauze and flap retractors
Entire bony cavity frozen with liquid nitrogen spray
Solid frost is observed
3 freezing cycles
Each cycle - 1 minute
Gap b/w each cycle 5 minutes
Mucoperiosteal flap were sutured

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Complications - sequestration, pathological fracture,
transient anaesthesia of mandibular nerve
More extensive the freezing, the greater the risk
Another method which has been described (Weaver
and Smith-1963, Bradley-1978) in which the affected
segment of bone is excised, frozen in liquid nitrogen to
devitalise the tissue, and then reimplanted as an
autogenous graft.
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MARGINAL RESECTION / RESECTION WITHOUT CONTINUITY
DEFECT / PERIPHERAL OSTEOTOMY / EN BLOC RESECTION
Indicated in lesions which are known for recurrence
Lesions that tend to grow beyond their surgically
apparent capsule
Treatment - when the lesion does not extent closer
than 1 cm to the inferior border of the mandible.
Margin of 1 to 2 cm - minimum acceptable margin.
Various authors - good results with en bloc resection
Lesions of the maxilla - en bloc resection is not as
successful and recommend segmental resection

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INDICATIONS:
Ameloblastoma
Calcifying epithelial odontogenic tumor
Myxoma
Ameloblastic odontoma
Squamous odontogenic tumor

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Procedure allows complete excision of the tumor but at
the same time a continuity f the jaw bone is retained
thus deformity, disfigurement & need for secondary
cosmetic surgery & prosthetic rehabilitation are
avoided.
ADVANTAGE:
Not violating the tumor margins during resection
which might provide the possibility of tumor seeding
in the surgical site.
DISADVANTAGE:
Does not discriminate b/w tumor tissue & vital
structures in close approximation such as inferior
alveolar nerve.
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Operative procedure

Intra-oral / extra-oral approach
Intra-oral - good access and when the lesion is anterior
to third molar region
Extra-oral approach - lesion involves the ramus of the
mandible or when immediate reconstruction is
planned
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Surgical approaches to maxilla:
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Surgical approaches to mandible:
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Intra-oral approach
Large mandibular lesions - a midline lip-splitting
incision
Connecting vertical incisions are made on the buccal
and lingual
Incisions - extend deep into buccal and lingual folds.
The teeth bordering the surgical margin should be
extracted
Horizontal incisions connecting the lower ends of
vertical incisions are made. The buccal and lingual
mucoperiosteal flaps are then developed, but not
reflected superiorly over the region of bone to be
removed.
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Marginal Resection
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On exposure of the mandible, the bony segment is
sectioned with an air-driven saw or bur, at least 1 to 1.5
cm from the radiographic margin of the lesion
Haemorrhage - controlled by crushing the bone over
small blood vessels with a blunt instrument or by
using bone wax
The mucoperiosteum is then undermined both
lingually and facially to relieve tension.
They are approximated with interrupted silk sutures.

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Segmental (partial) mandibular
resection / hemimandibulectomy
Segmental resection - maxillectomy and
hemimandibulectomy
Least number of recurrences.
Indications:
Infiltrative lesions
Lesions posterior/ inferior border of mandible
Lesions with high recurrence rate


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Segmental resection:
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Operative procedure
Depending on the size - a lip-splitting incision may or
may not be necessary
A submandibular incision - join the vertical lip
incision
Intra-orally - horizontal incision is made through the
mucoperiosteum
The facial and lingual flaps are advanced below the
horizontal incision using a periosteal elevator.
The lingual flap is raised as deep as to expose the
mylohyoid attachment.
A vertical mucoperiosteal incision is made 0.5 cm
proximal to the anticipated anterior bony cut.


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Expose the mental neurovascular bundle, which is ligated
and sectioned.
Preservation of the marginal mandibular branch of the
facial nerve
Using an air-driven saw, bur or a Gigli saw, a vertical cut is
made through the mandible anterior to the lesion.
Using bone forceps, the proximal part of the mandible is
rotated laterally, exposing the inferior alveolar nerve and
vessels, at the lingula of the mandible. They are ligated and
cut adjacent to the mandibular foramen.
The capsule is cut with a scalpel and the segment of
mandible is disarticulated and removed using bone-
holding forceps.
Bleeding - controlled by digital pressure, coagulation or
ligation, depending on the size of the bleeding vessel.

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Resection with disarticulation:
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Odontogenic myxoma
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The patient should be fed through a naso-gastric tube
for a week and scrupulous oral hygiene should be
maintained.
Dressings should be changed daily.
Removal of drain depends on the amount of drainage.
Alternate skin sutures are removed after 4 days and the
remaining ones, after 6 days.
After that, the naso-gastric tube may be removed and
oral feeding may be begun.

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Classification of Maxillectomies
1. Partial Maxillectomy(Alveolectomy): Removal of lower
half of the Maxilla.

2. Subtotal Maxillectomy:: lesions which extend beyond
the confines of Antrum

3. Medial Maxillectomy: Medial wall of antrum, inferior &
middle Turbinates, ethmoidal air cells, Lamina
papyracea (one side)

4. Total Maxillectomy: complete removal of Maxilla.
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Marginal (partial) maxillectomy
The marginal maxillectomy is the surgical procedure
most often used for tumors of maxilla when the
maxillary sinus is not involved.
Operative procedure
Intra-oral approach
Mucoperiosteal incision - 1 to 2 cm in all directions
from the underlying tumour.
It may be necessary to extract one or more teeth to
complete these incisions.
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Partial Maxillectomy (Alveolectomy)
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Calcifying epithelial odontogenic
tumor:
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Extra oral procedure

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Total maxillectomy
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British Journal of Oral and Maxillofacial Surgery 45 (2007) 306310 www.indiandentalacademy.com
RECONSTRUCTION
Radical surgeries like segmental resection,
hemimandibulectomy and maxillectomy leave the
patient with a thoroughly incapacitating aesthetic and
functional deficit
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Goals of mandibular reconstruction
Re-establishment of mandibular continuity and an
osseus-alveolar base
Maintenance of oral functions and proper
occlusion with maxillary arch.
To achieve minimal impairment of function
Correction of soft-tissue defects
To achieve good aesthetic results.

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Goals of maxillary reconstruction

Obliteration of the defect
Restoration of essential function of mid face
Provision of adequate structural support.
Aesthetic reconstruction of external features.

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Immediate Vs delayed reconstruction
IMMEDIATE
ADVANTAGES
Single stage surgery
Early retain of function
Minimal compromise of
esthetics
DISADVANTAGES
Recurrence
Time consuming
Infection
DELAYED
ADVANTAGES
Good result
Less recurrence
Good planning

DISADVATAGES
Fibrosis
Wound contraction
2
nd
surgery
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Ideal Graft:
Restoration of ability to masticate
Acceptable esthetic appearance
Withstand physiologic forces
Non-reactive in tissues
Sterile
Readily available
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CLASSIFICATION
Depending on nature of bone
Depending on donor
Depending on the preparation
Depending on the vascularity
Depending on donor site:
Depending on function

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Depending on nature of bone
Cancellous bone graft
Cortical bone graft
Corticocancellous grafts
. Blocks
. Chips
. Powder
Marrow graft
Depending on donor
Autogenous bone graft from same individual
Isogenic bone graft from genetically related individual
Allogenic allograft from another individual of same
species
Xenografts from different species


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Depending on the preparation allografts and xenografts
can be again divided into:
a. Freezed bone grafts
b. Freezed dried
c. Demineralised
d. Antigen extracted autolysed

Depending on the vascularity autografts can be divided
into:
Non vascularised
Vascularised bone transfer attached on soft tissue,
pedicle, microvascular free transfer.

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Depending on donor site:
Iliac crest graft -
anterior ileum
posterior ileum
trephine grafts
Rib graft
Full thickness
Split rib graft
Calvarial graft
Full
Split
Fibula


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Depending on function
Bridging graft or inlay graft
Reconstruction graft
Contour graft onlay graft.
Bone substitutes
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Maxillary reconstruction

Prosthesis
Obturator and splints
Local soft tissue flaps
Buccal and palatal advancement flaps
Cheek flaps
Buccal pad of fat

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Regional flaps
Temporalis myofascial / myo-osseous
Trapezius muscle / myo-cutaneous / osseo-myo-
cutaneous
Free flaps
Rectus abdominus
Radial forearm
Iliac crest
Omentum
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Mandibular reconstruction

Autogenous vascularised bone by pedicled flaps
Clavicle pedicled on sternocleidomastoid
Rib pedicled on pectoralis major
Scapula pedicled on trapezius
Calvarium pedicled on temporalis
Rib pedicled on latissimus dorsi

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Autogenous vascularised bone by free flaps
iliac crest based on deep circumflex iliac artery
fibula based on peroneal artery
scapula based on circumflex scapular artery
radial forearm based on radial artery
rib based on intercostal artery
second metatarsal
calvarium based on superficial temporal artery

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Autogenous non-vascularised bone
calvarium
iliac crest
rib
Fibula
Allografts
Xenografts
Alloplastic materials
stainless steel reconstruction plate
hydroxyapatite

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Fibula Free Flap

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Fibula Free Flap

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Mandible Reconstruction
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