CARCINOMA OF

THE LOWER
ALVEOLAR RIDGE
& RETROMOLAR
TRIGONE
DR. RAHILA AZIZ
PGR-1ST YEAR
OMFS-PIMS
THIS PRESENTATION WILL
COVER
 Anatomy
 Incidence & Etiology
 Clinical Presentation
 Approach to the patient
 Cancer treatment modalities
 Reconstruction options after surgical Rx of CA LAR/RMT
 Take home message
CANCER OF LOWER
ALVEOLAR RIDGE
 ANATOMY OF LAR
 Part of the mandibular bone that harbors the tooth roots
 Bounded,

- Anterolaterally by labial & buccal vestibule

- Posteriorly by the FOM
- Bilaterally extending up to RMT area
 INCIDENCE & ETIOLOGY OF
LAR CANCER
 2nd least common site for oral cancer
 Accounts for about 5.2% of all the oral cavity cancers as
registered in NCDB
 OSCC is the most prevalent histological type & makes
up almost 89% of all the LAR cancers
 Tobacco, alcohol consumption, HPV, excessive sun
exposure, chronic irritation, genetics,
immunosuppression play a huge role in etiology
CLINICAL PRESENTATION
 Early lesions are often asymptomatic and can be
detected by routine oral exam
 As lesions progress, the patient may complain of
pain, ulceration, bleeding, loose teeth, ill-fitting
dentures, numbness of the teeth or lips and trismus
 Some patients may also present after
transformation of premalignant lesions e.g. oral
leukoplakia
 APPROACH TO PATIENT
WITH CA OF LAR
Presenting complaint & a detailed history of presenting complaint
PAIN, ULCERATION, BLEEDING, TRISMUS, LOOSE TEETH – ONSET, DURATION, INTENSITY, AGGRAVATING & RELIEVING
FACTORS, PREVIOUS H/O MALIGNANCY, TOBACCO & ALCOHOL CONSUMPTION

Performing site specific clinical examination

EXTRAORAL EXAMINATION (muscle tone, neurosensory testing, lymph nodes exam), INTRAORAL EXAMINATION (detailed examination of
the mass)

Ordering Specific Investigations

PLAIN RADIOGRAPH, CT SCAN, MRI, BIOPSY

Definitive Diagnosis
DEPENDING ON RADIOGRAPHS & BIOPSY RESULTS

Treatment Modalities
MDT APPROACH REGARDING SURGERY, RADIOTHERAPY, CHEMOTHERAPY, SURGERY FOLLOWED BY RADIOTHERAPY,
RECONSTRUCTION
 MANDIBULAR BONE INVASION

LAR/RMT cancer can invade the underlying cortical bone via foramina (mental, mandibular)

Radiographically, Invasion can be

Erosive

Invasive (poor prognosis as the W&DOI is greater)


Pre-treatment mandibular invasion can be assessed via

Clinical exam
Plain radiography
Bone scintigraphy
SPECT
CT scan
MRI
USG
Out of all the above, CT shows highest degree of specificity in the detection of mandibular
invasion.
SURGICAL TREATMENT OPTIONS FOR CA
OF LAR
SURGICAL
Rx
OPTIONS

MARGINAL SEGMENTAL
MANDIBULECTOM MANDIBULECTOM
Y Y

ANTERIOR POSTERIOR
MARGINAL MARGINAL
MANDIBULECTOM MANDIBULECTOM
Y Y
ANTERIOR MARGINAL
MANDIBULECTOMY
Is indicated for the mandibular tumors with extensions into FOM or the lingual
gingiva. A circumferential mucosal incision is given which is extended into the
periosteum of the alveolar ridge around the lesion. The dental extractions can be
performed prior to executing the osteotomies. At least 1 cm of mandible must
be left intact to preserve the mandibular stability.
POSTERIOR MARGINAL
MANDIBULECTOMY
 Marginal mandibulectomy of the posterior LAR usually requires resection of
the posterior mandibular alveolar ridge as well as the coronoid process in order
to ensure a completely tumor free margin
 SEGMENTAL
MANDIBULECTOMY
 Segmental mandibulectomy involves the complete
resection of a mandibular segment followed by
reconstruction
 Indicated in cases of

- Gross bony invasion/erosion (advanced T stage)

- Inadequate bony remnant ( less than 1cm height)
 TYPES

Anterior
Lateral
Posterior
CANCER OF RETROMOLAR
TRIGONE
 ANATOMY OF RMT
 Triangular area bounded by
temporal crest/ATP medially
ramus/buccal mucosa laterally
base posterior to 3rd molar
 Lateral border gives attachment to superficial fibers while
medial border gives attachment to deeper fibers of
temporalis M
 Lingual nerve, buccal nerve and artery runs close to the
medial border
 PMR lies below the RMT which gives attachment to
superior constrictor & buccinator
 The lymphatic drainage is important in the early spread of
carcinoma of the oral cavity. The main lymphatic drainage
of the retromolar trigone is into the superior-deep jugular
lymph nodes (level II)
INCIDENCE & ETIOLOGY OF
CA OF RMT
 4th most common site for oral cancers with an incidence rate of 8% of
all oral cancers
 Etiology is multifactorial. Cigarette smoking and alcohol
consumption remains the most important risk factors. Regular
alcohol consumption is associated with the increased risk of oral
cancer including retromolar subsite of oral cavity.
 Betel nut chewing is one of key factors causing the increase in the
incidence of retromolar cancers in Southeast Asia. About 600 million
people are exposed to the habit of betel nut chewing making it the 4 th
most-consumed drug after nicotine, ethanol, and caffeine
 CLINICAL PRESENTATION OF
CA OF RMT
Isolated ulcerative or endophytic lesions or may present with
involvement of adjacent structures (buccal mucosa/anterior
tonsillar fossa)

Patients often presents with advanced stage disease

presenting with trismus as an initial presenting symptom
Due to it’s proximity to the maxilla, mandible, and
pterygomandibular raphe, the cancer of RMT has a
significant tendency for local invasion of these sites
One or more adjacent subsites are involved in 73 to 84% of
cases reported in literature. The most common sites of local
involvement are reported to be the

- Anterior tonsillar pillar (80%)

- soft palate (59%)
- lower gingiva (37%). 
 DIAGNOSIS
 Tumors that involve RMT can extend to nearby muscles, adipose spaces, soft palate,
tonsillar fossa, parapharyngeal space, and floor of the mouth.
 (CECT) has high accuracy for the detection of mandibular cortical and marrow invasion as
well as inferior alveolar canal invasion in RMT carcinoma.
 CT is readily accessible and offers faster image acquisition; it provides a better assessment
of cortical bone involvement
 MRI has the advantage of better soft tissue resolution, characterization of tumor, local
tumor extent, masticator space or infratemporal fossa invasion, bone marrow involvement,
and detection of perineural spread
TREATMENT OF RMT CANCER
 Retromolar trigone tumors are rare and aggressive malignancies, which often
require an aggressive surgical approach.
 Resections depend on the extent of the tumor,spread and infiltrative depth.
 Surgical resection can be performed by intraoral or extraoral approaches.
 Generally, a 1.5- to 2-cm superficial resection margin is adequate.
 For retromolar trigone and buccal cancers penetrating through the cheek skin,
a generous 2- to 3-cm skin surface margin is mandatory.
 SURGICAL APPROACHES TO RMT CANCER
APPROACH DESCRIPTION
Per Oral Reserved for smaller T1 or T2 lesions, which are easily accessible.
Upper & lower cheek The cheek flap approach may be upper or lower depending on the precise location of the tumor. It is particularly
flap useful for posteriorly located tumors.

Lower lip splitting & More suitable for posterior retromolar trigone tumors in patients who also present with trismus.
marginal
mandibulectomy
Paramedian Provides good exposure of the retromolar trigone, floor of mouth, and soft palate.
Mandibulotomy &
marginal
mandibulectomy
Upper lip splitting Upper lip splitting can involve only an upper lip split or can extend to a full Weber Ferguson incision.

Segmental Indicated in patients with gross cortical invasion or evidence of bone marrow infiltration of the mandible.
Mandibulotomy
RADIATION THERAPY TECHNIQUES FOR LAR & RMT
CANCER
 EBRT is the most common radiotherapy technique used for OC cancers nowadays

3D-Conformal • Several radiation beams are aimed at the tumor from

RT different directions

• Is a form of 3D-CRT

Intensity • It uses a computer driven machine that moves around the

patient and delivers radiation

modulated RT • Along with shaping the beam and aiming them at the
tumor, the intensity/strength of the beams can be adjusted
to limit the dose reaching to normal tissues

Proton beam • Proton beam is used for radiation instead of the x-rays
RT
DIFFERENT TREATMENT SCHEDULES
FOR EBRT
 Standard EBRT for cancers of oral cavity is usually given in daily doses that is
5 days a week for about 7 weeks. Other schedules are :

• Slightly lower than standard radiation dose

HYPERFRACTIONATION
• Given twice a day for 7 weeks

ACCELERATED • Standard dose radiation but for a shorter time

FRACTIONATION • Given 6 days a week for 5 weeks

• Slightly higher than standard radiation dose to lessen

HYPOFRACTIONATION the number of treatments
• Given each day for 6 weeks
DIFFERENT RX MODALITIES FOR RMT CANCER

• SCC of RMT has a poor prognosis even if it is

SURGERY detected early therefore an adequate surgical margin
can improve the survival

• Good outcome in patients with locally advanced RMT

SURGERY + tumors can be achieved by an aggressive surgical
RADIOTHERAPY approach with a post-op RT

• RT can be used for small RMT carcinomas (T1-T2

RADIOTHERAPY lesions)
 RADIOTHERAPY VERSUS
RADIOTHERAPY COMBINED
WITH SURGICAL RESECTION
 Surgery with or without adjuvant RT is the standard of care for oral cavity cancer. Studies
have been done to compare different Rx modalities. Their main conclusions were:
 Radiation therapy can be used with curative intent for small RMT cancers (T1-T2 lesions). For
advanced stages without bone invasion, concurrent chemotherapy and radiation therapy may
improve prognosis and survival rates (Ayad et al)
 Patients treated with surgery and radiotherapy had a better chance of cure than those treated
with radiotherapy alone (Hitchcock et al)
 In the treatment of locally advanced tumors, good outcomes can be achieved by combining an
aggressive surgical approach with postop RT, with 3-year disease-free and overall survival rates
close to 70% (Deo et al)
 RMT SCC are aggressive tumors and the maxilla is more prone to be involved in RMT cancer
than the mandible. Deep infiltration of the masticator space and invasion of the maxilla and
mandible worsen the prognosis (Hao et al)
NECK DISSECTION : PROPHYLAXIS
VS THERAPEUTIC
 Decision regarding elective neck dissection is
based upon the risk of presence of occult
metastasis
 The best predictor of metastatic disease for OSCC
is the DOI
 Tumors with DOI greater than 4 mm, elective
dissection should be strongly considered
 For DOI less than 2 mm, elective dissection
should only be performed in very selective
situations.
 For DOI between 2 and 4 mm, careful clinical
judgement should determine the decision of
elective dissection.
RECONSTRUCTION
 Reconstruction of OC defects is a challenge because of the critical role of this area both
aesthetically and functionally.
 A wide variety of reconstructive options are available for OMF region post surgery. Smaller
defects can be repaired via grafts such as split grafts whereas bigger defects can be recon. by
local and regional flaps such as BFP, FAMM flap, temporalis flap, PMMC flap, etc.
 The RFA free flap is frequently used as 1st choice for intraoral reconstruction due to its
thinness and pliability, making it adaptable to different intraoral sites
 A comparative study was conducted between the performance of ALT and RFA flaps for
intraoral reconstruction after RMT surgery. ALT free flap provided better results in terms of
appearance and scarring than the RFA flap
 The ability of the propeller lingual flap to rotate upto 180 allows it to reconstruct small-to-
medium sized defects of the floor of the mouth, soft palate and RMT
TYPES OF PEDICLED FLAPS
TYPES OF FREE FLAPS
Exemplificative clinical patient. (A) Squamous cell carcinoma of the right retromolar trigone just behind the third
maxillary molar. (B) Tumor excision and partial maxillectomy were performed through a Weber-Ferguson approach.
(C) Planning of a deep lingual artery propeller flap marked as a mucosal island along the lateral border of the
tongue. (D) The flap was raised and isolated on the deep lingual artery. (E) The flap was rotated as a propeller; the
longer blade covered the defect, while the shorter blade was used to partial cover the donor site and protect the
pedicle, avoiding compression caused by direct closure. (F) Result at the end of the operation; the shape and
mobility of the tongue were preserved
TAKE HOME MESSAGE
General public awareness & education regarding oral cancer and its etiology
6-monthly screening of conditions with pre-malignant or malignant potential
Ordering Specific investigations & formulation of definitive diagnosis as early
as possible
Early meeting with the MDT for finalizing the treatment plan
Patient’s wishes and concerns should be prioritized while planning
reconstruction
Regular follow-ups
THANK
YOU