Surgical

management of
oral pathological
lesions
- Surgical techniques for treating oral pathologic lesions vary widely, akin to those used for
other medical conditions.
- Clinicians employ techniques based on training, experience, personal skill, intuition, and
ingenuity.
- The chapter's objective isn't to detail specific surgical methods for managing individual
oral pathologic lesions.
- Instead, it aims to present fundamental principles applicable across various techniques
to ensure satisfactory patient treatment.
- Many lesions can be managed similarly, simplifying the discussion as numerous
treatments share common approaches.
Basic surgical goals:
1. Eradication of Pathologic Condition
2. Functional Rehabilitation of Patient
 Eradication of Pathologic Condition
- Ablative surgical procedures aim to completely remove lesions, preventing any remaining cells
from causing a recurrence.
- Methods employed vary based on the nature of the lesion's pathology.
- Aggressive excision for an oral carcinoma involves sacrificing nearby structures to ensure
thorough removal, a drastic approach unsuitable for a simple cyst.
- Histological identification of the lesion through biopsy before any major ablative surgery is
crucial.
- Identifying the lesion's nature guides the selection of the most appropriate surgical
procedure, minimizing damage to surrounding healthy tissue during eradication.
 Functional rehabilitation of patient
- Primary objective in surgical removal of a pathologic condition: total elimination of the lesion.
- However, merely eradicating the disease might not suffice for comprehensive patient
treatment.
- The second goal after disease eradication: enabling functional rehabilitation of the patient.
- Post-lesion eradication, addressing residual defects resulting from ablative surgery is crucial.
- Defects can vary, from mild changes like labial sulcus obliteration to significant ones like alveolar
defects or hemimandibulectomy defects.
- Optimal outcomes occur when reconstructive procedures are considered before lesion excision.
- Preoperative assessment must thoroughly consider grafting methods, fixation principles,
managing soft tissue deficits, dental rehabilitation, and patient readiness.
Surgical Management of Cysts and
Cystlike Lesions of the Jaws
* Surgical management of oral pathologic lesions is effectively discussed by categorizing
them broadly into major groups:
1- Cysts and cystlike lesions of the jaws
2- Benign tumors of the jaws
3- Malignant tumors
4- Benign lesions of oral soft tissues

- General definition of a cyst: an epithelium-lined sac containing fluid or soft material.

- Jaw cyst prevalence linked to abundant epithelium growth during tooth formation in bone
and along fusion lines of embryonic jaw processes.
- Jaws cysts classified into two types:
- Odontogenic cysts: arising from odontogenic epithelium.
- Fissural cysts: originating from oral epithelium trapped between merging embryonic
processes.
- Stimulus causing dormant epithelial cells to proliferate into surrounding tissue remains
undetermined.
- Residual fragments of cystic membrane can lead to recurrent cysts, necessitating
complete excision of the cyst's epithelial lining during operation.
- Certain cysts, like keratocysts, exhibit more aggressive and destructive
characteristics, resulting in higher recurrence rates.
- Cysts are capable of causing extensive jaw destruction and displacing teeth to
remote areas like the mandibular condyle, angle, or coronoid process.
- Enlargement of cysts occurs gradually, often detected through routine dental
radiographs.
- Typically, cysts are asymptomatic unless they suffer secondary infection.
- The overlying mucosa appears normal in color and consistency, and there are no
sensory deficits due to encroachment on nerves are found
- If the cyst hasn't expanded or thinned the cortical plate, the jaw maintains a
normal contour and firmness.
- Palpation with firm pressure might indent the surface of an expanded jaw,
showing characteristic rebound resiliency.
- When the cyst has breached the cortical plate, palpation may reveal fluctuance.

- Radiographically, cysts display a characteristic appearance:

- Distinct, dense periphery of reactive bone known as condensing osteitis.
- Radiolucent center, creating a noticeable contrast (see Fig. 23.2).
- Most cysts appear unilocular, although multilocular forms are common in certain
types like keratocysts and cystic ameloblastomas (refer to Fig. 23.3).
- Typically, cysts don't cause resorption of tooth roots. Therefore, the presence of
root resorption might indicate a neoplasm.
- In rare instances, the epithelial lining of cysts may undergo ameloblastic or
- All excised cystic tissue must undergo pathologic examination.
- While cysts are broadly categorized as odontogenic and fissural, this classification
isn't crucial for discussing cyst removal techniques.
- Surgical treatment of cysts is generally addressed without specific regard to cyst
type, except for those requiring special consideration.
- Principles of surgical management for cysts are also pertinent for handling benign
odontogenic tumors and other oral lesions.
- Treatment methods for jaw cysts typically encompass four basic approaches:
1. Enucleation
2. Marsupialization
3. Staged combination of enucleation and marsupialization
4. Enucleation coupled with curettage
1- enucleation
- Enucleation involves complete removal of a cystic lesion without rupture.
- This technique relies on the presence of fibrous connective tissue between the cyst's epithelial
component and the bony cavity wall, allowing for a cleavage plane.
- Enucleation resembles stripping the periosteum from bone, utilizing this fibrous layer for
cyst removal.
- Careful enucleation aims to extract the cyst in one piece to minimize recurrence chances by
ensuring total removal.
- Despite efforts, maintaining cystic architecture isn't always feasible during the procedure, and
inadvertent rupture of cyst contents might occur during manipulation.

Indications:
- Enucleation is the treatment of choice for removal of cysts of the jaws and should be used with
any cyst of the jaw that can be safely removed without unduly sacrificing adjacent structures.
1- enucleation
Advantages :
- Enucleation allows for complete examination of the entire cyst as it's removed.
- This technique serves both as an excisional biopsy and a treatment method, addressing the lesion
adequately during the initial procedure.
- Unlike marsupialization, enucleation spares the patient from managing a marsupial cavity requiring
continual irrigations.
- Once the mucoperiosteal access flap heals post-enucleation, the patient is relieved from any discomfort
associated with the cystic cavity.

Disadvantages :
- Enucleation might not be the ideal choice if conditions outlined for marsupialization exist.
- Situations where normal tissue could be at risk, jaw fracture might occur, teeth could become devitalized, or
where impacted teeth, intended for preservation, might inadvertently be removed, can make enucleation
disadvantageous.
- Each cyst case demands individual consideration, requiring the clinician to assess the advantages and
disadvantages of enucleation versus marsupialization.
- It's important to weigh the options, considering factors like performing enucleation after marsupialization,
1- enucleation
Technique:
Enucleation technique for cysts was detailed in Chapter 21, but special considerations exist.
- Antibiotics are unnecessary unless the cyst is large or the patient's health condition requires them (refer to
Chapters 1 and 2).
- The periapical (radicular) cyst is the most common jaw cyst, stemming from dental pulp inflammation or
necrosis.
- Differentiating between a periapical radiolucency being a cyst or a granuloma is challenging; removal during
tooth extraction is advisable.
- If the tooth is restorable, endodontic treatment followed by periodic radiographic checks allows assessment of
bone fill.
- Lack of bone fill or lesion expansion post-endodontic treatment suggests a likely cyst, warranting periapical
surgery for removal.
- For teeth extraction with small cysts evident in periapical radiographs, enucleation through the tooth socket can
be achieved using curettes (refer to Fig. 23.4).
- Caution is exercised when dealing with teeth whose apices are near critical anatomical structures like the inferior
alveolar neurovascular bundle or the maxillary sinus.
- Bone apical to the lesion might be extremely thin or even absent in such cases.
- For larger cysts, a mucoperiosteal flap might be reflected to access the cyst via the labial plate of bone.
1- enucleation
Technique:
- After obtaining access through an osseous window, the dentist can commence cyst enucleation.
- A thin-bladed curette proves effective for separating the connective tissue layer of the cystic wall from
the bony cavity.
- Use the largest curette suitable for the cyst's size and the access available.
- Maintain the concave surface of the curette facing the bony cavity while using the edge of the convex
surface for stripping the cyst.
- Careful maneuvering is crucial to prevent cyst tearing and escape of cystic contents, as intact cyst walls
aid in defining margins.
- Retaining intracystic pressure facilitates easier separation of the cyst from the bony cavity.
- In larger cysts or those near neurovascular structures, nerves and vessels are often displaced to one
side by the expanding cystMinimize contact with and avoid trauma to these structures during cyst
removal.
- Post-cyst removal, inspect the bony cavity for any remaining tissue remnants.
- To enhance visibility of the entire cavity, irrigation followed by drying with gauze is recommended.
- Any residual tissue should be carefully eliminated using curettes.
1- enucleation
 Technique:
- Cysts surrounding tooth roots or located in inaccessible jaw areas require aggressive curettage to eliminate
residual cystic lining fragments.
- Obvious devitalization of teeth during cyst removal may necessitate future endodontic treatment to prevent
odontogenic infection in the cystic cavity resulting from necrotic dental pulp.
- After enucleation, securing a watertight primary closure using appropriately positioned sutures is crucial.
- The bony cavity fills with a blood clot initially, which gradually organizes over time.
- Radiographic evidence of bone fill usually takes 6 to 12 months to become evident.
- Jaws that have been expanded by cysts undergo slow remodeling, gradually returning to a more normal contour.

**If primary closure breaks down and the wound opens, the bony cavity is packed open for secondary intention
healing:
- The wound is irrigated with sterile saline, and strip gauze lightly impregnated with an antibiotic ointment is gently
packed into the cavity.
- This process is repeated every 2 to 3 days, gradually reducing the packing until it's no longer necessary.
- Granulation tissue forms on the bony walls within 3 to 4 days, slowly filling the cavity and eliminating the need for
packing.
- Oral epithelium then covers the opening, and osseous healing progresses accordingly.
2- marsupialization
- Marsupialization, decompression, and the Partsch operation involve creating a
surgical window in the cyst wall.
- The purpose is to evacuate the cyst's contents and maintain a connection
between the cyst and oral, maxillary, or nasal cavities.
- Only the part of the cyst required to make the window is removed; the rest of
the cyst lining remains in place.
- This process reduces intracystic pressure, aiding in cyst shrinkage and bone fill.
- Marsupialization can serve as the primary treatment for a cyst or as an initial
step before enucleation at a later stage.
2- marsupialization
Indications :
- The following factors should be considered before deciding whether a cyst should be removed by
marsupialization:
1. Amount of tissue injury. Proximity of a cyst to vital structures can mean unnecessary sacrifice of
tissue if enucleation is used. For example, if enucleation of a cyst would create oronasal or
oroantral fistulae or cause injury to major neurovascular structures (e.g., 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 in 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. 23.7).
4. Extent of surgery. In a patient with ill health or any debilitation, marsupialization is a reasonable
alternative to enucleation because it is simple and may be less stressful for the patient.
5. Size of cyst. In very large cysts, a risk of jaw fracture during enucleation is possible. It may be
better to perform marsupialization of the cyst and defer enucleation until after considerable bone
fill has occurred.
2- marsupialization
Advantages :
- The main advantage of marsupialization is that it is a simple procedure to
perform. Marsupialization may also spare vital structures from damage should
immediate enucleation be attempted

Disadvantages :
- Marsupialization's major drawback is leaving pathological tissue without
thorough histologic examination. While the tissue from the window can be
examined pathologically, more aggressive lesions might persist in the remaining
tissue.
- Patients face inconveniences due to maintaining the cavity's cleanliness to avoid
infection, often trapping food debris.
- Daily irrigation using a syringe is usually necessary, a process that can extend for
months, depending on the cavity's size and bone fill rate.
2- marsupialization
Technique :
- Prophylactic systemic antibiotics are generally not recommended for marsupialization except in cases
where the patient's health condition demands it (refer to Chapters 1 and 2).
- After anesthetization, the cyst is aspirated to confirm the presumptive diagnosis before proceeding with
marsupialization.
- The initial incision, often circular or elliptical, creates a sizable window (1 cm or larger) into the cystic
cavity.
- If the bone is thinned by the cyst, the incision might extend through the bone into the cystic cavity;
tissue contents are then examined pathologically.
- Thicker overlying bone requires careful removal using burrs and rongeurs to create an osseous window.
- The cyst is incised to remove a lining window, submitted for pathologic examination, and its contents
evacuated.
- Visual examination of the residual cyst lining is performed, and irrigation eliminates residual debris.
- Ulceration or thickening in the cystic wall can indicate dysplastic or neoplastic changes, prompting
further action such as enucleation or biopsy.
- Suturing the perimeter of the cystic wall around the window to the oral mucosa is possible if the lining
is thick enough and access permits.
2- marsupialization
 Technique :
- Packing the cavity with strip gauze containing tincture of benzoin or antibiotic ointment is essential.
- This packing remains in place for 10 to 14 days to prevent oral mucosa from closing over the cystic window.
- Within two weeks, the cyst's lining should heal to the oral mucosa around the window's periphery.
- Detailed instructions must be given to the patient regarding proper cleansing of the cavity.
- Marsupialization of maxillary cysts offers two external options: opening into the oral cavity or into the maxillary
sinus/nasal cavity.
- If the cyst extensively damages the maxilla and encroaches on the sinus or nasal cavity, facial access via the alveolus is
preferred.
- After creating a window into the cyst, a second unroofing can be performed into the adjacent sinus or nasal cavity.
- Enucleation might be possible at this stage, allowing the cystic cavity to be lined with respiratory epithelium from the
adjoining sinus or nasal cavity.
- Subsequently, the oral opening is closed, facilitating continuity between the cystic lining and the sinus/nasal cavity lining.
** Marsupialization is seldom the primary treatment for cysts; usually, enucleation follows marsupialization in most cases:
- However, with a dentigerous cyst, once the tooth erupts into the dental arch, there might be no remaining cyst to remove.
- In situations where additional surgery is not advisable due to concurrent medical issues, marsupialization might be
performed without subsequent enucleation.
- The cavity might or might not completely close over time, but proper hygiene should prevent any issues if the cavity
remains open.
3- enucleation after marsupialization
- Enucleation often follows marsupialization at a later stage.
- Initial healing after marsupialization is quick, but the cavity might not significantly decrease in size
beyond a certain point.
- Once the objectives of marsupialization are achieved and the cavity stabilizes, secondary
enucleation can be performed safely without harming adjacent structures.
- This combined approach minimizes complications and speeds up the full healing of the defect.

Indications :
- The criteria for employing this combined surgical method align with those for using
marsupialization alone.
- Indications consider the extent of tissue damage enucleation might cause, access feasibility for
enucleation, potential benefits for impacted teeth via eruptional guidance with marsupialization,
the patient's health status, and the lesion's size.
- However, if the cyst persists after marsupialization, enucleation becomes a consideration.
- Enucleation might be warranted if the patient struggles to adequately clean the cystic cavity or if
the clinician seeks a comprehensive histological examination of the entire lesion.
3- enucleation after marsupialization
Advantages :
- The benefits of the combined marsupialization and enucleation approach mirror
those of individual marsupialization and enucleation techniques.
- During marsupialization, the advantage lies in its simplicity and its ability to spare
adjacent vital structures.
- Enucleation offers the advantage of providing the entire lesion for comprehensive
histologic examination.
- Additionally, marsupialization leads to the development of a thickened cystic lining,
simplifying the subsequent enucleation procedure.

Disadvantages
- The disadvantages of this modality of surgical intervention are the same as those for
marsupialization. The total cyst is not removed initially for pathologic examination.
However, subsequent enucleation may then detect any occult pathologic condition.
3- enucleation after marsupialization
 Technique :
- Initially, the cyst is marsupialized, allowing osseous healing to occur.
- Enucleation, the definitive treatment, is conducted once the cyst has sufficiently decreased in size for complete surgical
removal.
- The ideal timing for enucleation occurs when bone coverage safeguards adjacent vital structures, minimizing potential injury
during the procedure.
- Adequate bone fill is crucial to strengthen the jaw, preventing fractures during the enucleation process.
- Enucleation incisions differ when marsupialization precedes the procedure.
- Post-marsupialization, the cyst shares an epithelial lining with the oral cavity.
- The initial window created into the cyst contains this epithelial bridge, necessitating its complete removal along with the cystic
lining.
- An elliptical incision encircling the window down to healthy bone is crucial.
- Stripping the cyst from the window into the cystic cavity allows for easy establishment of the dissection plane, simplifying
enucleation.
- After enucleation, closing the oral soft tissues over the defect is preferred, often necessitating the creation and mobilization of
soft tissue flaps.
- These flaps are advanced and sutured in a manner that ensures a watertight closure over the osseous window.
- If complete closure isn't feasible, packing the cavity with strip gauze containing antibiotic ointment is an acceptable alternative.
- The packing needs frequent changing alongside cavity cleansing until granulation tissue fills the opening, and epithelium seals
the wound.
4- Enucleation with curettage
- Enucleation with curettage means that after enucleation a curette or burr 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.

 Indications :
- Curettage should accompany enucleation in specific cases. For instance, when dealing with an odontogenic keratocyst, a more
aggressive approach is necessary due to its known aggressive clinical behavior and high recurrence rates.
- Odontogenic keratocysts display a considerably high rate of recurrence, reported between 20% and 60%.
- The locally aggressive behavior is attributed to increased mitotic activity and epithelial cellularity within the odontogenic
keratocyst.
- Daughter cysts, located at the periphery of the main cystic lesion, might not be completely removed during treatment, leading
to increased recurrence rates.
- The thin and easily fragmented cystic lining complicates thorough enucleation, particularly in cases of suspected odontogenic
keratocysts.
- For suspected odontogenic keratocysts, initial treatment should involve careful enucleation coupled with aggressive curettage
of the bony cavity to minimize recurrence risk.
- If recurrence occurs, treatment options depend on accessibility: another attempt at enucleation if accessible or bony
resection with 1-cm margins if inaccessible.
- Continuous monitoring for recurrence is crucial as odontogenic keratocysts have been known to recur years after treatment.
- Enucleation with curettage is also warranted in cases where a cyst recurs after an initially deemed thorough removal due to
4- Enucleation with curettage
Advantages
• If enucleation leaves epithelial remnants, curettage may remove them, thereby decreasing the
likelihood of recurrences

Disadvantages
- Curettage is more destructive of adjacent bone and other tissues.
-The dental pulps may be stripped of their neurovascular supply when curettage is performed
close to the root tips.
-Adjacent neurovascular bundles can be similarly damaged.
- Curettage must always be performed with great care to avoid these hazards.
Technique
- After the cyst has been enucleated and removed, the bony cavity is inspected for proximity to
adjacent structures. A sharp curette or a bone burr 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 working proximal to important anatomic structures. The cavity is
Principles of Surgical Management
of Jaw Tumors
- Managing jaw tumors is simplified because several tumors exhibit similar behavior, allowing for similar
treatment approaches.
- Surgical excision of jaw tumors primarily involves three modalities:
1. Enucleation, with or without curettage.
2. Marginal or partial resection.
3. Composite resection (as detailed in Box 23.1).
- Benign tumors, often nonaggressive, are frequently treated conservatively using enucleation, curettage, or a
combination of both (refer to Table 23.1).
- A subset of aggressive benign oral tumors demands wider margins of unaffected tissue to reduce recurrence
risk, thus requiring marginal or partial resection for removal.
- Malignant oral tumors necessitate more aggressive intervention, often requiring wider margins of uninvolved
tissue. Surgical approaches may involve excising adjacent soft tissues and performing lymph node dissection.
- Treatment for malignant tumors may include radiotherapy, chemotherapy, or a combination of both, used
independently or in conjunction with surgery.
- Beyond cysts, inflammatory or benign neoplastic jaw lesions are commonly encountered by dentists.
- Many cysts can be removed using simple excisional biopsy methods, but some more aggressive lesions may
also be encountered, requiring careful consideration to determine the most suitable treatment.
- The primary factor influencing treatment choice is the aggressiveness of the lesion.
- Other critical factors for evaluation pre-surgery include the lesion's anatomic location, whether it's confined to
bone, the duration of the lesion, and available reconstruction methods post-surgery.
Aggressiveness of lesion
Surgical therapy of oral lesions ranges from enucleation or curettage to composite
resection. Histologic diagnosis positively identifies the lesion and thus directs the
treatment. 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 oral or perioral regions can significantly complicate surgical removal, impacting
the prognosis.
- Nonaggressive benign lesions situated in inaccessible areas, like the pterygomaxillary fissure, pose significant
surgical challenges.
- Conversely, a more aggressive lesion in easily accessible and readily resectable regions, such as the anterior
mandible, often presents a better prognosis due to easier surgical intervention.
1- maxilla versus mandible :
An essential consideration for aggressive oral lesions like odontogenic tumors and carcinomas is their location
within the mandible or the maxilla.
Tumors in the maxilla can grow without symptoms to larger sizes due to the adjacent maxillary sinuses and
nasopharynx, leading to delayed symptom onset. Consequently, maxillary tumors tend to have a poorer prognosis
compared to those within the mandible.

2- proximity to adjacent vital structures :

- Preservation of adjacent neurovascular structures and teeth is crucial when dealing with benign lesions.
- Often, surgical procedures might leave adjacent tooth root apices exposed, compromising dental pulps' blood
supply.
- Teeth in such situations should be evaluated for potential endodontic treatment to prevent odontogenic
Anatomic location of lesion
3- size of tumor :
- The extent of involvement in specific sites like the mandible's body dictates the required surgical
procedure for aggressive lesions.
- Preserving the inferior border of the mandible is preferred for continuity whenever feasible.
This might involve marginal resection of the affected region.
- However, when the tumor spans the entire thickness of the affected jaw, partial resection
becomes imperative for treatment.

4- intraosseous vs extraosseous location :

- An aggressive oral lesion contained within the jaw, without breaching the cortical plates, yields a
better prognosis compared to one invading surrounding soft tissues.
- Soft tissue invasion signifies a more aggressive tumor, complicating complete removal and
necessitating sacrifice of more normal tissues.
- In cases of soft tissue perforation, localized excision of the affected area is recommended.
- A supraperiosteal excision of the involved jaw is advised when the cortical plate is significantly
Duration of lesion
Several oral tumors exhibit slow growth and may become static. An odontoma, for
example, may be discovered in the second decade of the patient’s life, and its size
may remain unchanged for many years. Slower-growing lesions seem to follow a
more benign course, and treatment should be individually tailored to each case.

Reconstructive efforts
- Surgical procedures aimed at removing pathological lesions should not only focus on
eradicating the disease but also consider enhancing the patient's functional well-being.
- Anticipating and planning reconstructive procedures before the initial surgery is crucial.
- Reconstruction goals often influence the choice of surgical technique, sometimes favoring a
method equally effective in disease removal but more suitable for future reconstructive efforts.
 Jaw Tumors Treated With Enucleation,
Curettage, or Both

- Jaw tumors with a low recurrence rate often find treatment through enucleation
or curettage.
- Examples include various odontogenic tumors like odontomas, ameloblastic
fibromas, ameloblastic fibro-odontomas, keratinizing and calcifying odontogenic
cysts, adenomatoid odontogenic tumors, cementoblastomas, and central
cementifying fibromas.
- Other lesions treated similarly are detailed in Table 23.1.

technique
The technique for enucleation or curettage of jaw tumors is not unlike that
described for cysts. However, additional procedures, such as sectioning large
calcified masses with burrs in odontomas and cementomas, may be required. In
these instances, the principles discussed in Chapter 9 for the removal of impacted
teeth are used.
 Jaw Tumors Treated With Marginal or Partial
Resection
- In cases where a lesion is identified as aggressive via histopathologic assessment or its clinical behavior, or
if its consistency impedes total removal through enucleation or curettage, removal may require resecting
the lesion with adequate bony margins.
- Odontogenic lesions treated using this approach include the ameloblastoma, odontogenic myxoma
(fibromyxomas), calcifying epithelial odontogenic tumor (Pindborg tumor), squamous odontogenic tumor,
and ameloblastic odontoma.
- Other lesions treated similarly are outlined in Table 23.1.

Technique :
- The resected specimen ideally contains the lesion and approximately 1-cm bony margins surrounding its
radiographic boundaries.
- Marginal resection, preserving the inferior border of the mandible if possible, is the preferred method.
Reconstruction then focuses on replacing the lost osseous structure, including the alveolus (refer to Fig.
23.10).
- When the lesion is near the inferior border, the full thickness of the mandible must be part of the
specimen, which disrupts mandibular continuity (as shown in Fig. 23.11).
- Reconstruction becomes notably more challenging in such cases as the remaining mandibular fragments
must be carefully secured in their proper relationship for functional restoration and symmetry.
 Jaw Tumors Treated With Marginal or Partial
Resection
Technique :
- The technique for marginal (segmental) resection involves creating a full-thickness mucoperiosteal
flap, which is then separated from the bone intended for removal.
- Air-driven surgical saws or burrs are utilized to cut the bone along planned locations, facilitating the
removal of the segment.
- In cases where marginal or partial resection is chosen, assessing whether the tumor has breached
cortical plates and invaded adjacent soft tissues is crucial. If so, sacrificing a layer of soft tissue is
necessary to eliminate the tumor, often accompanied by a supraperiosteal dissection of the involved
bone.
- Immediate reconstruction becomes more challenging when minimal soft tissue remains available to
cover bone grafts due to the necessary sacrifice during the tumor removal process.
-The concern over soft tissue surgical margins during hospital surgery prompts the removal of
specimens along these margins for immediate histopathologic examination.
-This rapid process, taking about 20 minutes, involves freezing the tissue using liquid carbon dioxide
or nitrogen, followed by sectioning and staining for immediate assessment.
- Frozen-section examination is reliable for evaluating surgical margin adequacy but exhibits reduced
accuracy when attempting the initial histopathological diagnosis of a lesion.
Malignant Tumors of the Oral
Cavity
- Malignancies of the oral cavity may arise from a variety of tissues including the salivary gland,
muscle, and blood vessels or may even present as metastases from distant sites.
- However, the most common form of oral cancer discovered during thorough oral examinations
by dentists are epidermoid carcinomas of the oral mucosa.
- The seriousness of an oral malignancy varies, ranging from a simple excisional biopsy to
composite jaw resection with neck dissection required for a cure.
- To formulate a treatment plan, clinical staging is usually undertaken due to the variation in
clinical presentation.

- Clinical staging aims to assess the disease's extent before treatment and serves two purposes:
selecting the best treatment and enabling meaningful comparison of results across different
sources.
- Various oral malignancies, such as epidermoid carcinomas and oral lymphomas, undergo clinical
staging, each with a distinct staging process.
- Staging involves diverse diagnostic tests like radiography, blood tests, and surgical exploration of
other body areas to determine potential tumor metastasis.
- Once the tumor is staged, a treatment plan is devised based on well-defined treatment
protocols established by surgeons and oncologists to meticulously study treatment effectiveness.
 Treatment Modalities for Malignancies
- Surgery, radiation, chemotherapy, or a combination thereof are employed in treating oral cavity
malignancies.
- Determining the treatment approach relies on various factors: histopathologic diagnosis, tumor
location, metastasis presence and extent, tumor's sensitivity to radiation or chemotherapy, patient's age
and overall health, clinician expertise, and patient preferences.
- Ideally, complete excision without causing extensive damage to the patient is the preferred treatment
method.
- In cases where lymph node involvement is suspected, radiation may precede or follow surgery to
eradicate potential malignant cells in adjacent areas.
- For widespread systemic metastasis or highly chemosensitive tumors like lymphomas, chemotherapy
becomes a primary treatment, either alone or alongside surgery and radiation.

- Malignancy treatments commonly occur in specialized institutions where a team of experts reviews
each case and deliberates on treatment plans.
- These interdisciplinary "tumor boards" consist of essential specialists: a surgeon, a chemotherapist, and
a radiotherapist.
- Head and neck tumor boards typically comprise additional experts such as a general dentist, a
Radiotherapy
- Radiotherapy targets malignant neoplasms by exploiting the increased susceptibility of
actively growing tumor cells to ionizing radiation compared to mature tissue.
- Effectiveness of radiation correlates with the rapidity of cell multiplication or the degree
of undifferentiation in tumor cells.
- Radiation's efficacy lies in its interference with the nuclear material of cells, hindering
their multiplication.
- While targeting tumor cells, radiotherapy also impacts normal host cells, necessitating
protection of healthy cells during treatment.

- Radiation administration methods vary, such as implanting radioactive material directly

into the tumor or more commonly, using external x-ray generators.
- Radiation dosage remains within safe limits, avoiding surpassing the body's tolerable
levels, and safeguarding unaffected neighboring areas through protective shielding.
- Employing fractionation and multiple ports as delivery mechanisms helps protect the
patient's surrounding healthy tissues near the tumor site.
Radiotherapy

- Fractionation in radiation delivery involves administering smaller, incremental

doses of radiation over several weeks rather than the maximum tolerable dose at
once. This allows healthy tissues time to recuperate between doses while hindering
the ability of tumor cells to recover.
- Another method employs multiple ports for radiation exposure, using various
beams focused on the tumor from different angles. While the tumor receives the
full radiation dose, normal tissues in the path of these beams receive only a
fraction of the dose due to the use of different angles, sparing them from maximal
exposure.
Chemotherapy
- Chemical treatments targeting rapidly growing tumor cells are utilized for various
malignancies, though they affect normal cells to some degree, akin to radiation's
impact on normal tissues.
- Typically administered intravenously, these agents have seen recent use in arterial
injections directed at the tumor's blood supply.
- Systemic delivery of these agents leads to adverse effects on multiple body
systems, notably impacting the rapidly regenerating hematopoietic system, often
causing anemia, neutropenia, and thrombocytopenia.
- Chemotherapy necessitates a fine balance between eliminating tumor cells and
managing complications like infections and bleeding, common in these patients.
- To mitigate the toxicity of a single agent administered in high doses, multiple-
agent therapy is commonly employed, often involving three to five agents
simultaneously. Each agent targets different phases of the tumor cell's life cycle,
enhancing efficacy while reducing host toxicity.
Surgery
- Surgical procedures for excision of oral malignancies vary based on the type and
extent of the lesion.
- Small epidermoid carcinomas in accessible locations, such as the lower lip and not
associated with palpable lymph nodes, can be excised.
- Extensive surgery may be necessary for larger lesions related to palpable lymph
nodes or those in areas like the tonsillar pillar to ensure adequate removal along
with local metastases.
- Oral malignancies with suspected or confirmed lymph node involvement often
require composite resection, involving the complete removal of the lesion,
surrounding tissues, and neck lymph nodes.
- However, this procedure may result in significant jaw defects and extensive loss of
soft tissues, making the process of functional and esthetic rehabilitation lengthy
and complex.
Surgical Management of Benign
Lesions in Oral Soft Tissues
- Superficial soft tissue lesions in the oral
mucosa are typically benign and often can be
easily removed through biopsy techniques.
- Examples of such lesions include fibromas,
pyogenic granulomas, papillomas, peripheral
giant cell granulomas, verruca vulgaris,
mucoceles (mucous extravasation
phenomena), and epulis fissurata.
- These lesions result from overgrowths of
normal histologic elements in the oral mucosa
and submucosa.
- Removal principles remain consistent with
earlier outlined methods, involving elliptical or
wedge-type incisions during extraction.
- Lesions associated with teeth, like pyogenic
granulomas, require thorough curettage and
polishing of the related tooth or teeth to
eliminate plaque, calculus, or foreign material
that might contribute to lesion development
or recurrence if left untreated.
Reconstruction of Jaw After
Removal of Oral Tumors
- Removal of oral tumors can lead to osseous defects, varying from alveolar bone loss to
substantial jaw portions being affected.
- These defects might raise functional or cosmetic concerns for the patient.
- Effective treatment for oral pathologic conditions should incorporate reconstruction plans,
either immediately or for the future.
- These reconstruction plans should be established before the surgical removal of the lesion,
ensuring optimal reconstructive outcomes for the patient.

- The general dentist's role is pivotal in the functional and cosmetic recovery of patients who
have had teeth surgically removed.
- Prior to dental rehabilitation, any necessary reconstruction of the jaw skeleton should be
addressed.
- Surgical removal of a lesion might entail removing part of the alveolus, posing a challenge for
dental solutions: bridges or dentures would lack an osseous base for support.
- In such cases, ridge augmentation becomes crucial before dental restorative procedures to
provide a base for dental replacements.
- Augmentation methods include bone grafts, synthetic bone grafts, or a combination thereof to
- Reconstruction of mandibular defects resulting from resection can occur immediately during the
surgical lesion removal or at a later stage.
- Some surgeons opt to delay reconstruction for defects caused by benign tumor removal. They
suggest that the simultaneous presence of intraoral and extraoral defects, often a reason for
tumor removal, makes immediate mandibular reconstruction unsuitable.
- Instead of immediate reconstruction, a space-maintaining device is inserted during resection,
and a secondary reconstruction is performed weeks to months later.
Of course, here it is reordered into bullet points without changing any words:

- When opting for delayed reconstruction, it's crucial to maintain the residual mandibular
fragments in their natural anatomical position. This can be achieved through intermaxillary
fixation, external pin fixation, splints, internal fixation, or a combination of these methods.
- This technique serves to prevent scarring, muscular deformities, and displacement of segments,
thereby simplifying subsequent reconstructive efforts.
- Immediate reconstruction, as supported by clinical outcomes, stands as a viable choice. It offers
the benefits of a single surgical procedure and enables an early return to function with minimal
compromise to facial aesthetics.
- However, a potential drawback of immediate reconstruction is the risk of graft loss due to
- Infection risk increases when grafts are placed transorally or in an orally
contaminated extraoral wound after ablative surgery.
- Due to substantial recurrence rates in some tumors, meticulous surgery and careful
planning are essential prerequisites before reconstruction attempts to minimize the
risk of failure due to recurrence.
- Three immediate reconstruction choices are available:
1. Entire surgical procedure conducted intraorally: Tumor removal followed by
grafting the defect within the oral cavity.
2. Combination approach: Tumor removed using both intraoral and extraoral
routes, ensuring a sealed oral closure, followed by grafting the defect through the
extraoral incision.
3. Preservation approach: If the tumor hasn't destroyed alveolar crestal bone or
extended into oral soft tissues, involved teeth are extracted. A waiting period of 6 to
8 weeks for gingival tissue healing precedes tumor removal and defect grafting
through an extraoral incision, carefully avoiding oral soft tissue perforation. This
method remains the only immediate reconstruction type to circumvent oral