Oral cavity 6

and oropharynx

INTRODUCTION

The oral cavity is that part of the tipper acrodigestivc tract which
begins at the lips and ends at the anterior surface of the faucial
arch. It is lined by squamous epithelium with interspersed minor
salivary glands. The oral cavity also contains the dentoalveolar
structures with the upper and lower dentition. Primary tumors of
the oral cavity, therefore, may arise from the surface epithelium,
minor salivary glands or submucous soft tissues. On the other
hand, tumors of dental origin and bone tumors, as well as tumors
of neurovascular origin, may also arise within the oral cavity. The
various anatomic sites within the oral cavity as described by
the American Joint Committee for Cancer Staging are shown in
Fig. 6.1
The oral cavity is by far the most predominant location in the
head and neck region for primary malignant tumors. The
worldwide incidence rates of cancers of the tongue, mouth and
oropharynx are depicted in Figs 6.2, 6.3 a n d 6.4. In the USA, the
American Cancer Society estimates approximately 20 M)0 new
patients diagnosed with cancers in the oral cavity and 5:500 deaths
from oral cancer in 2002, in the USA (Fig. 6.5).
The tongue and floor of the mouth are the most common sites
of origin for primary squamous cell carcinomas in the oral cavity F i g . 6.2 W o r l d w i d e incidence of cancer of t h e t o n g u e : age-standardized
in the Western world. Ketromolar trigone and buccal mucosa are, rates ( w o r l d p o p u l a t i o n per 100,000 in males. Data Source: Cancer
Incidence in 5 C o n t i n e n t s Vol. VII, 1997.)
however, the most frequently encountered primary sites in those
parts of the world where tobacco chewing and chewing of betel
nuts are most prevalent. The site distribution of various primary
cancers in the oral cavity and the oropharynx in the USA is shown
in Fig. 6.6.

Fig. 6.J Worldwide incidence of cancer of the mouth: age-standardized

rates (world population per 100,000 in males. Data Source: Cancer
Fig. 6.1 Anatomic sites within the oral cavity. Incidence in 5 Continents Vol. VII, 1997.)

173
Fig. 6.4 Worldwide incidence of cancer of the oropharynx: age-
standardized rates (world population per 100,000 in males. Data Source:
Cancer Incidence in 5 Continents Vol. VII, 1997.)

Fig. 6.6 The site distribution of primary cancers in the oral cavity and
the oropharynx.

Fig. 6.5 Estimate of new cases and deaths for cancer of the oral cavity in
the USA in 2002.

The oropharynx begins at the anterior aspect of the faucial arch

and extends posteriorly. It includes the soft palate, tonsillar fossae
on each side, as well as the posterior pharyngeal wall and the pos-
terior one-third of the base of tongue. These anatomic sites within
the oropharynx are shown from anterior and posterior views in
Fig. 6.7. Although squamous cell carcinomas are the most fre-
quently encountered primary tumors of epithelial origin in the
oropharynx, lymphomas are often seen due to the abundance of
lymphoid (issue in the oropharynx, a significant component of
Waldeyer's ring. A primary lymphoma of the tonsil, pharyngeal
wall or base of the tongue can therefore present as a surface lesion
following ulceration due to rapid proliferation. The frequency of
each histologic variant of primary malignant tumors of the oral Fig. 6.7 Anterior and posterior views of anatomic sites within the
cavity and oropharynx is shown in Fig. 6.8. oropharynx.

174
Fig. 6.8 The f r e q u e n c y of histologic variants of p r i m a r y m a l i g n a n t
tumors of t h e oral cavity a n d o r o p h a r y n x . Fig. 6 . 1 0 T h e rising incidence of t o n g u e cancer in females.

The staging of primary tumors of t h e oral cavity and oro-

pharynx, as agreed upon by the American Joint Committee and
the UICC, has been widely accepted. The surface dimensions of
the tumor are the most important parameters for primary tumor
staging in the oral cavity and oropharynx. One glaring deficiency
of this staging system, however, is the omission of the depth of
infiltration of the tumor as a parameter for staging of the primary
tumor. Deeply infiltrating but early staged primary tumors have
an increased risk of regional metastases and death due to disease
compared to superficial tumors of the same T-Stage. Thus a more
aggressive therapeutic approach, including elective treatment of
regional lymph nodes, should be considered for patients with
early T-Staged but deeply infiltrating tumors. On the other hand,
advanced T-staged but relatively superficial lesions have a better
prognosis. The stage distribution of patients presenting with
squamous carcinoma of the oral cavity and oropharynx at the
Memorial Sloan-Kcttering Cancer O u t e r in New York is shown in
Fig. 6.9.

The majority of patients with cancer in (he oral cavity are males
although the incidence of tongue cancer in females in the United
States has progressively increased to 47% (1988-1997) from 15%
Fig. 6.9 Stage d i s t r i b u t i o n f o r squamous carcinomas of t h e oral cavity
(1927-1934) as shown in Fig. 6.10.
and o r o p h a r y n x .

CLINICAL CHARACTERISTICS AND DIAGNOSIS

The clinical features of the primary tumors arising in the mucosal

surface of the oral cavity are variable. The tumor may be ulcerative,
exophytic or endophytic, or it may be a superficial proliferative
lesion. The clinical characteristics of the lesion are usually sufficient
to raise the index of suspicion regarding the need for a biopsy to
establish the tissue diagnosis. Ulcerative lesions are usually accom-
panied by an irregular edge and induration of the underlying soft
tissues (Fig. 6.11). (In the other hand, exophytic lesions may
present either as a cauliflower-like irregular growth, or they may be
Hat, pink to pinkish-while proliferative lesions (Figs 6.12 and 6.13|.

175
Fig. 6.11 Ulcerative squamous carcinoma ol the under surface ol the Fig. 6.14 A red to pink velvety flat in situ carcinoma of the floor of the
oral tongue. mouth.

Fig. 6.1 S Hyperkeratosis of the under surface of the tongue with

squamous carcinoma.

Occasionally, a red (o p i n k velvety flat lesion is the o n l y mani-

Fig. 6.12 Deeply infiltrating exophytic carcinoma ol the floor of the
mouth.
festation of superficially invasive or in situ carcinoma (Pig. 6.14).
Squamous carcinomas w i t h excessive keratin p r o d u c t i o n and
verrucous carcinomas present as w h i t e heaped-up keralotic lesions
with v a r y i n g degrees of keratin debris on the surface (Figs
6 . 1 S - 6 . 1 7 ) . Papillary projections are often seen in lesions w h i c h
are a c c o m p a n i e d or preceded by a squamous p a p i l l o m a ( F i g .
6 . 1 8 | . Bleeding f r o m i h e surface of Ihe lesion is a characteristic for
m a l i g n a n c y a n d s h o u l d i m m e d i a t e l y raise the suspicion for a
neoplastic process. E n d o p h y t i c lesions have a very small surface
c o m p o n e n t but have a substantial a m o u n t of soft tissue involve-
ment beneath the surface ( F i g . 6 . 1 9 ) . l e u k o p l a k i a a n d crythro-
plakia have a varying incidence of malignancy (Figs 6.2(1 and 6.21).
Speckled leukoplakia has a particularly h i g h incidence of malig-
n a n l t r a n s f o r m a t i o n ( F i g . 6 . 2 2 ) . M u l t i p l e p r i m a r y cancers occur
s y n c h r o n o u s l y i n a p p r o x i m a t e l y 4 % o f patients w i t h oral cancers
(Figs 6 . 2 3 a m i 6 . 2 4 ) . Therefore, a t h o r o u g h e x a m i n a t i o n of the
oral c a v i t y s h o u l d be p e r f o r m e d in every case. Tumors of m i n o r
salivary o r i g i n present as submucosal masses (Figs 6 . 2 S - 6 . 2 9 ) .
Metastatic t u m o r s m a y also present as submucosal masses ( F i g .
6.31). Mucosal m e l a n o m a is a very characteristic pigmented
lesion ( F i g . 6 . 3 1 ) .
Tissue diagnosis is usually c o n f i r m e d by a wedge or punch
biopsy o b t a i n e d f r o m the p e r i p h e r y of the lesion or from Ihe
center of the lesion w i t h adequate v o l u m e of viable tissue retrieved

176
Fig. 6.16 Exophytic squamous carcinoma of cheek mucosa with white
keratin debris.
Fig. 6.17 Verrucous carcinoma of the oral tongue.
in the specimen. H i g h l y keratinizing squamous carcinomas a n d
verrucous carcinomas m a y often n o t provide satisfactory rep-
resentative tissue f r o m the surface of the lesion a n d the diagnosis
of invasive carcinoma can he missed from a superficial biopsy,
rherefore, in situations where excessive keratin deposit is seen on
Fig. 6.21 Erythroplakia of the left floor of the mouth.
the surface of an e x o p h y t i c lesion, the biopsy should he obtained
f r o m the adjacent invasive /.one or f r o m the d e p t h ol the lesion,
rather than from Ihc surface. If a biopsy does not show carcinoma
in a lesion w h i c h is c l i n i c a l l y suspicious of being malignant, then
it s h o u l d be repeated u n t i l the tissue diagnosis is confirmed.
177
Fig. 6.22 Speckled leukoplakia of the oral tongue Fig. 6.2S Synchronous primary carcinomas of the upper and lower
alveolar ridges.

Fig. 6.2J Two separate foci of squamous carcinoma of the oral tongue. Fig. 6.26 Mucoepidermoid carcinoma of the hard palate.

Fig. 6.24 Synchronous squamous carcinomas of the tongue and cheek Fig. 6.27 Ulcerated adenoid cystic carcinoma of the hard palate.
mucosa.

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Fig. 6.28 Mucoepidermoid carcinoma of the hard palate.
Fig. 6.29 Adenocarcinoma of the hard palate.
Fig. 6.J0 Metastatic lung carcinoma in the oral tongue.
FACTORS AFFECTING CHOICE OF TREATMENT
The factors that influence Choice Of initial treatment are those
related to the characteristics of the primary tumor (Tumor factors),
those related to the patienl (Patient factors), and those that are
related to the treatment team (Physician factors). In selecting
optimal treatment, therefore, one should consider these three sets
of factors for treatment planning. The ultimate goals in the
Fig. 6.31 Mucosal melanoma of the upper gum.
treatment of cancer of the oral cavity are: (1) cure of the cancer;
(2) the preservation or restoration of form and function; (3) to
minimize the sequelae of treatment; and (4) the prevention of
second primary tumors.
In order to achieve these goals, t h e currently available
therapeutic modalities include:
• Surgery
• Radiotherapy
• Chemotherapy
• Combined modality treatments
• Primary and secondary prevention strategies including life-
style changes and chemoprevention.
TUMOR FACTORS
TUmor factors which influence choice of treatment are:
• Site
• Size (T-stage)
• Location (anterior versus posterior)
• Proximity to hone (mandible or maxilla)
• Status of cervical lymph nodes
• Previous treatment
• Histology (type, grade, and depth of invasion).
The site of origin of the primary tumor does affect prognosis.
Primary cancer of the lip has a biological behavior similar to skin
cancer with an excellent potential for cure and thus a very
favorable prognosis. Similarly, squamous carcinomas of the hard
palate and upper gum have a relatively indolent behavior with a
low risk of regional lymph node metastases. On the other hand,
cancers of the oral tongue, floor of the mouth and lower gum have
a high risk of regional lymph node metastases with an adverse
impact on prognosis.
The size of the primary tumor clearly impacts heavily on the
decision regarding choice of initial treatment. Small and
superficial primary tumors of the oral cavity are easily accessible
for surgical resection through the open mouth. On the other hand,
larger tumors will require more extensive surgical approaches for
exposure and excision. Certain primary sites in the oral cavity are
easily amenable to initial treatment by radiotherapy, such as primary
tumors of the tongue in contrast to those which are situated in
179
p r o x i m i t y to bone, such as a lesion of the g u m . Similarly, w i t h
increasing size of the p r i m a r y lesion, the risk of regional lymph
node metastasis increases, b r i n g i n g i n t o consideration the need
for elective treatment of the neck for larger p r i m a r y lesions. A l o n g
the same lines, certain p r i m a r y sites have a higher risk (or nodal
metastasis compared to other sites in the oral cavity. Tor example,
primary tumors of t h e oral t o n g u e a n d f l o o r of t h e m o u t h have an
increased risk of l y m p h node metastasis compared w i t h similar
staged lesions of the hard palate or upper g u m . Primary t u m o r s
located anteriorly in the oral cavity have a lesser risk for dis-
semination to regional l y m p h nodes compared to similar staged
lesions in t h e posterior part of t h e oral c a v i t y a n d o r o p h a r y n x ; for
example, primary t u m o r s of the oral tongue versus base of the
tongue. Thus, more posteriorly located lesions w i l l require c o n -
sideration of elective treatment of the c l i n i c a l l y negative neck in
initial treatment p l a n n i n g .
The presence of clinically palpable cervical lymph node
metastasis requires the need for neck dissection as an integral part Fig. 6.32 The incidence ot lymph node metastasis and survival in
relation to the thickness of the primary lesions for Tl and T2 squamous
of surgical treatment p l a n n i n g . The extent of neck dissection,
carcinomas ot the oral tongue and floor of mouth.
however, w i l l vary upon the extent of nodal metastasis a n d the
location of palpable l y m p h nodes. For a discussion regarding the
PATIENT FACTORS
management of cervical l y m p h node metastases a n d selection of
the type of neck dissection for p r i m a r y t u m o r s of the oral cavity
see Chapter 9. Several factors related to patient characteristics are i m p o r t a n t in
The histology of the p r i m a r y t u m o r is an i m p o r t a n t parameter the selection of i n i t i a l treatment of oral cancer:
w h i c h w i l l influence the selection of i n i t i a l t r e a t m e n t . W h i l e
• Age
squamous cell carcinomas are radio-responsive, p r i m a r y carci-
• General medical c o n d i t i o n
nomas of m i n o r salivary g l a n d o r i g i n a n d malignant lesions of t h e
• Tolerance
somatic soft tissues are best treated by surgical resection. Most
• Occupation
lesions of squamous cell o r i g i n have a v a r y i n g degree of histologic
• Acceptance and c o m p l i a n c e
progression from in situ to invasive carcinoma. The histologic
• Life style ( s m o k i n g / d r i n k i n g )
grade of the lesion generally reflects the aggressiveness of the
• Six'io-economic considerations.
tumor. Poorly differentiated carcinomas a n d undifferentiated
carcinomas are predictably m o r e aggressive in c o m p a r i s o n to In general, older age is not considered to be a c o n t r a i n d i c a t i o n
moderately well-differentiated a n d well-differentiated carcinomas. for i m p l e m e n t a t i o n of adequate i n i t i a l surgical treatment for oral
However, the most i m p o r t a n t histologic feature of the p r i m a r y carcinoma. However, a d v a n c i n g age, intercurrent disease, and
t u m o r w h i c h impacts on selection of treatment a n d eventual d e b i l i t y due to associated c a r d i o p u l m o n a r y c o n d i t i o n s increases
prognosis is its d e p t h of i n f i l t r a t i o n . T h i n a n d superficially the risk of the i m p l e m e n t a t i o n of extensive surgical i n t e r v e n t i o n ,
invasive lesions have a lower risk of regional lymph node T h e a b i l i t y of the patient to tolerate an o p t i m a l therapeutic
metastasis, are h i g h l y curable, a n d offer an excellent prognosis. program is s i m i l a r l y an i m p o r t a n t facet w h i c h can influence the
On the other h a n d , thicker lesions w h i c h are deeply i n f i l t r a t i n g choice of i n i t i a l treatment. T h e patient's o c c u p a t i o n , acceptance,
the underlying soft tissues have a s i g n i f i c a n t l y increased incidence a n d c o m p l i a n c e for the proposed treatment arc similarly impor-
of regional l y m p h node metastasis w i t h its adverse impact on tant considerations in designing an o p t i m a l treatment program
prognosis. The risk of l y m p h node metastasis and survival in for the t u m o r . The patient's life style, w i t h particular reference to
relation to the thickness of the p r i m a r y lesion for II a n d T2 s m o k i n g and d r i n k i n g , impacts heavily on the selection and
squamous carcinomas of the oral tongue and floor of m o u t h is tolerance of treatment offered. U n w i l l i n g n e s s on the part of the
shown in Fig. 6 . 3 2 . W h i l e it w o u l d be ideal to k n o w the exact patient to give up s m o k i n g a n d d r i n k i n g causes further c o m p l i -
thickness of the lesion prior to surgical i n t e r v e n t i o n , it is c l i n i c a l l y cations of therapy a n d increased risk of m u l t i p l e p r i m a r y tumors.
impractical to be able to have that i n f o r m a t i o n available prior to Finally, socio-economic considerations have started p l a y i n g an
surgical excision of the p r i m a r y t u m o r in m a n y instances. In increasing role in the selection of t r e a t m e n t . A l l o c a t i o n of
general, however, thickness of the lesion as appreciated by pal- resources clearly has to be judged based on outcomes analysis of a
pation is a reasonably good i n d i c a t o r of deeply invasive lesions particular treatment p r o g r a m . Previous treatment for other lesions
versus superficial lesions to estimate the extent of soft tissue in the same area w i l l also influence the decision regarding selec-
and/or bone resection for t h e p r i m a r y lesion, a n d t o decide u p o n t i o n o f t r e a t m e n t , e.g. radiation t h e r a p y previously delivered t o
the need for elective dissection of the regional l y m p h nodes at risk the same area for a different lesion m a y not be available to treat a
in the clinically negative neck. second t u m o r in the same area.
Patients w i t h advanced stage of disease, i.e. those presenting
with spread to regional cervical l y m p h nodes or w i t l i large primary
PHYSICIAN FACTORS
tumors, i.e. T3 a n d T 4 , are candidates for c o n s i d e r a t i o n of c o m -
bined modality treatment. Currently, surgical resection followed
by postoperative radiation therapy is considered standard treat- Several physician-related factors also play an i m p o r t a n t role in the
ment for patients w i t h Stage III and Stage IV disease. selection of i n i t i a l treatment for oral cancer:

180
• Surgical
• Radiotherapy
• Chemotherapy
• Rehabilitation services
• Dental
• Prosthetics
• Support services.
Management of cancer of the head and neck is a multi-
disciplinary team effort and technical capabilities and support
services from various disciplines arc essential for a successful out-
come. A comprehensive head a n d neck surgery team would
consist of a head and neck surgeon, with other surgical specialties
including microsurgery, neurosurgery, vascular surgery, plastic
and reconstructive surgery, and dental surgery arid prosthetics.
Similarly, expertise in radiation oncology including brachy-
therapy, and integration of combined treatment programs of
chemoradiothcrapy are essential. A well-qualified team of medical
oncologists with expertise in administration of chemotherapeutic
drugs and the management of chemotherapy-related complica-
tions is essential in the management of patients with advanced
disease and recurrent tumors. In addition, physical and psycho-
social rehabilitation services are vitally important for long-term
restoration of the quality of life of the patient. Implicit in the
organization of such a team are the services of a psychologist,
social worker, and family support groups to provide the patient
with all essential services.
SELECTION OF INITIAL TREATMENT
Both surgical resection and radiotherapy are applicable either
singly or in combination in the treatment of cancer of the oral
cavity. Presently, the role of chemotherapy in the management of
oral cancer remains investigational. Small and superficial tumors
of the oral cavity are equally amenable for cure by surgical
resection or radiotherapy. Therefore, single modality is preferred
as the definitive treatment in early staged tumors (Tl and T2
lesions) of the oral cavity. When the end-point of treatment, i.e.
cure of cancer, is comparable, other factors must play a role in the
selection of initial treatment. These include complications, cost,
convenience, compliance and long-term sequelae of treatment
(Fig. 6.33).
Patients with advanced stage tumors clearly require combined
modality treatment for a successful outcome. Radiotherapy in
combination with surgery can be employed either preoperative^
or postoperatively. There are obvious advantages and dis-
advantages of preoperative radiotherapy versus postoperative
radiation therapy.
Preoperative radiotherapy produces a delay in the imple-
mentation of the surgical treatment by several weeks. However,
this time can be gainfully employed in improvement of nutrition
of the patient either by nasogastric tube feedings or supplemental
nutrition through a gastrostomy tube. The employment of pre-
operative radiotherapy has been claimed to 'enhance rcsectability'.
However, it must be borne in mind that tumor response with
shrinkage of the primary tumor should not influence the extent of
surgical resection. It is a well-known fact that tumors do not shrink
concentrically, and viable islands of tumor cells may still be
present in grossly normal appearing tissues adjacent to the residual
tumor following preoperative radiotherapy. Therefore, t h e extent
and the margins of surgical resection should be essentially the
Fig. 6.J3 Factors which play a role in the selection of initial treatment.
same as those in the absence of preoperative radiotherapy. In
those patients who will require multiple staged reconstruction,
preoperative radiotherapy offers an advantage in posing no con-
flict with such staged reconstructive procedures. However, now-
adays, one stage primary reconstruction is considered the state of
the art and therefore preoperative radiotherapy is not considered
advantageous anymore. On the other hand, irradiated tissues may
pose a problem with healing of tissue and increase the risk of local
wound complications. In addition, an important disadvantage of
preoperative radiotherapy is dose limitation. It is well known that
with increasing dosage of preoperative radiotherapy, the wound
complications of surgery increase.
Postoperative radiotherapy, on the other band, offers significant
advantages over preoperative radiotherapy and offers better or
comparable local and regional control rates of cancer. There is no
delay in implementation of surgical resection and there are no
dose limitations with postoperative radiotherapy. At present, doses
in the range of 6000 c(iy to the primary site and neck are recom-
mended with a boost to areas at increased risk for local recurrence.
Postoperative radiotherapy dex's not influence the extent of surgical
resection and healing and wound complications are not a factor
since radiotherapy is given following surgery.
Tor patients with advanced disease (Stage III and Stage IV), the
current preferred sequence for combined treatment programs
consists of surgical resection with immediate appropriate recon-
struction followed by postoperative radiation therapy.
The factors that influence t h e choice of surgical approach for a
primary tumor of the oral cavity or oropharynx are the size of the
primary, its depth of infiltration, the site of the primary, i.e.
anterior versus posterior location, and proximity of the tumor to
the mandible or maxilla. Therefore, thorough clinical assessment
of t h e primary tumor is mandatory to select the appropriate
surgical procedure. Examination under anesthesia is often
indicated lo accomplish this goal. The proximity of the tumor to
the maxilla or mandible mandates the need for adequate clinical
and radiographic assessment to rule out the possibility of bone
involvement. In addition, radiographic evaluation may provide
information regarding the extent of soft tissue involvement.
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RADIOGRAPHIC EVALUATION

Direct extension of a p r i m a r y t u m o r of the oral cavity to the

mandible or its p r o x i m i t y to the m a n d i b l e requires appropriate
radiologic studies to establish the extent of bone i n v o l v e m e n t .
W h i l e the absence of radiographic findings does not rule out bone
invasion, bone destruction as seen on the radiograph c o n f i r m s
t u m o r invasion. Radionuclide bone scans are often positive prior
to radiographic appearance of b o n e destruction but they seldom
provide accurate information regarding the extent of b o n e
invasion. Bone scans may also be positive in non-ncoplastic c o n -
ditions, e.g. i n f l a m m a t o r y lesions.
Plain radiographs of the m a n d i b l e in anteroposterior a n d oblique
views are not satisfactory as a routine screening procedure to establish
or rule out bone destruction. However a panoramic v i e w of the
mandible ( o r t h o p a n t o m o g r a m ) is, perhaps, the most i m p o r t a n t
radiographic study to assess the general architecture of the
mandible in relation to the dentoalveolar structures a n d invasion Fig. 6.35 Computerized tomogram of the mandible showing an
by t u m o r (Fig. 6.34). It must, however, be appreciated that due to intraosseus cystic lesion.
technical reasons the m i d l i n e of the m a n d i b l e near the symphysis
is not adequately evaluated by a panoramic view. Early invasion of Fig. 6.J6 A Dentascan.
the lingual cortex of the m a n d i b l e is also not seen on a panoramic
view. Occlusal films of the body of the m a n d i b l e a n d intraoral
dental films are often most accurate in d e m o n s t r a t i n g early
invasion by tumor.

Fig. 6.J7 Three-

dimensional
Fig. 6 3 4 Panoramic radiograph of the mandible showing bone invasion. reconstruction of the
CT scan in a lateral
view showing the
Computerized tomograms of the m a n d i b l e are generally not expansile lesion of the
Optimal for routine screening but may be considered in certain body of the mandible.
circumstances, such as p r i m a r y t u m o r s of t h e m a n d i b l e a n d those
lesions where soft tissue extension f r o m t u m o r s i n v o l v i n g the
ascending ramus of the m a n d i b l e is suspected ( F i g . 6 . 3 5 ) .
A sophisticated software program for the CT scan called
'Dentascan' provides more accurate details of the m a n d i b l e a n d
may be considered in appropriate circumstances w h e n dental details
are required (Fig. 6.36). In a d d i t i o n to these, three-dimensional
reconstructions of CT images provide an excellent overview of
the mandible or maxilla from any desired angle. Three-dimensional
reconstructions of the m a n d i b l e of a patient w i t h an ossifying
fibroma of the body of the m a n d i b l e on the left-hand side causing
expansion and i n v o l v i n g the lingual cortex are s h o w n in Figs i m p o r t a n t to o b t a i n coronal cuts of the computerized scans w i t h
6.37 and 6.38. A three-dimensional CT scan a n d a one-to-one soft tissue a n d h o n e w i n d o w s to adequately assess the extent of
reproduction of the CT are of great value to the surgeon for t u m o r i n v o l v i n g the hard palate and alveolus. Magnetic resonance
mandible reconstruction w i t h a microvascular free flap. These i m a g i n g (MKI) is superior in d e f i n i n g soft (issue details. A sagittal
images are essential to fabricate a n d shape the graft to m a t c h the MRI of a patient w i t h an e n d o p h y t i c tongue carcinoma v i v i d l y
resected p o r t i o n of the mandible. Invasion of the maxilla by- demonstrates its i n t r a m u r a l extent as seen in the bisected
primary tumors of the oral cavity, such as those arising f r o m the specimen (Figs 6 . 3 9 - 6 . 4 1 ) . Also, in situations w h e n extensive
palate or upper alveolus, is best assessed by a CT scan. II is soil tissue invasion in the parapharyngeal space is suspected, an

182

Fig. 6.38 Three-
dimensional
reconstruction of an
oblique caudal view of
the body of the
mandible showing an
expansile lesion
involving the lingual
cortex.
T ? * Fig. 6.J9 Sagittal view
of an MRI scan of the
oral cavity showing a
large endophytic
tumor of the tongue.
Fig. 6.40 Surgical
specimen of total
glossectomy shows
minimal surface
ulceration.
MRI scan is desirable. Bony details are, however, not very clear on
MRI and a CT scan is preferred here. Regardless of the presence or
absence of invasion of the mandible or maxilla by tumor, if any
bone resection or osteotomy is to be undertaken for surgical
treatment of a p r i m a r y t u m o r of the oral cavity or o r o p h a r y n x ,
appropriate radiographic studies of t h e b o n e under consideration
must be obtained prior to the surgical procedure in order to avoid
any 'surprises' on the operating table.
XJ \jnnl. i_ M v I I I MINU UKUI'HAKYNX
Fig. 6.41 Bisected
specimen of the
tongue shows a large
endophytic tumor.
PREOPERATIVE DENTAL ASSESSMENT
M a n y patients w i t h p r i m a r y carcinomas of the oral cavity have
poor oral hygiene. T h e i r d e n t i t i o n is in poor repair and often
harbors gross sepsis. It is very i m p o r t a n t that preoperative dental
evaluation and appropriate dental care are provided to obtain an
o p t i m a l status of hygiene in the oral cavity prior to a surgical
procedure. All grossly septic teeth should be adequately assessed
for consideration of extraction, either preoperatively or intra-
operatively if indicated. It is, however, important to stress that
teeth, w h e t h e r loose o r i m m o b i l e w i t h i n the t u m o r o r i n its
vicinity, should not be extracted prior to the definitive surgical
resection.
Extraction of teeth near a t u m o r opens up dental sockets which
are vulnerable to i m p l a n t a t i o n of tumor. The efficacy of a satis-
factory surgical procedure m a y be seriously jeopardized under
these circumstances. Deposits of tartar need to be removed and
appropriate scaling of the d e n t i t i o n undertaken to avoid dental
complications and prevent sepsis in the oral cavity following
surgery. A n y restorative dental w o r k , however, should be post-
poned until adequate surgical treatment of the primary oral cancer
is completed.
If the contemplated surgical procedure requires resection of any
part of the mandible or maxilla, appropriate dental consultation
Should be o b t a i n e d for consideration of fabrication of either a
palatal obturator or a mandibular splint if necessary. If any post-
operative splint, obturators or dental prostheses are desired then it
is imperative that dental impressions are obtained before surgery.
If the patient has received radiation therapy or will receive
postoperative radiotherapy, adequate dental consultation becomes
even more imperative. It is i m p o r t a n t that the patient has dental
prophylaxis for radiation therapy in terms of extraction and/or
treatment of septic teeth, restoration of salvageable teeth and
advice regarding fluoride treatment for prevention of caries of
remaining viable teeth.
ANESTHESIA AND POSITION
A l t h o u g h excision of small p r i m a r y lesions in the oral cavity can
be accomplished under local anesthesia, most surgical procedures
183
for primary cancers of the oral cavity require satisfactory general
endotracheal anesthesia w i t h adequate relaxation. A nasotracheal
intubation is desirable for ease of access to the oral cavity a n d
instrumentation d u r i n g surgery. II is, however, essential that the
skin incisions be marked out prior to endotracheal i n t u b a t i o n a n d
taping of the tube to avoid d i s t o r t i o n of facial skin lines leading to
improperly placed incisions. Patients w i t h b u l k y t u m o r s of the
oropharynx w i t h potential obstruction to airway s h o u l d have a
preliminary tracheostomy performed under local anesthesia before
i n d u c t i o n of general anesthesia.
The patient is placed in a supine position w i t h the upper half
of the body elevated at 30°. Appropriate d r a p i n g of the head a n d
neck area is undertaken d e p e n d i n g u p o n w h e t h e r the operative
procedure w i l l be intraoral or w i l l require external incision either
on the face or the neck. A transparent plastic drape isolates the
anesthetic t u b i n g a n d makes t h e patient's eyes, nose a n d
endotracheal tube clearly visible to b o t h the surgeon and the
anesthesiologist.

SURGICAL APPROACHES TO THE ORAL CAVITY

A variety of surgical approaches arc available for resection of

primary tumors of the oral cavity. T h e choice of a particular
approach w i l l depend on the factors m e n t i o n e d earlier such as the
size and site of the p r i m a r y t u m o r as w e l l as its d e p t h of i n f i l -
tration and p r o x i m i t y to m a n d i b l e or maxilla. The various surgical
approaches such as peroral, m a n d i b u l o t o m y , lower cheek flap
approach, visor flap approach and upper cheek flap approach are
shown in F i g . 6.42.

PERORAL LASER EXCISION OF LEUKOPLAKIA Fig. 6.42 Various surgical approaches: (a) peroral; (b) mandibulotomy;
(c) lower cheek flap; (d) visor flap; (e) upper cheek flap.

Piemalignant lesions of the mucosa of the oral cavity such as

hyperkeratosis, keratosis w i t h dysplasia a n d even carcinoma in
situ can be treated by a relatively conservative peroral excision.
Surgical excision of these lesions is advisable if the lesions are focal
and limited in surface extent. However, if (he lesions are diffuse or
multifocal and involve a large surface area, t h e n surgical excision
is impractical. Laser vaporization appears to be an effective
method of treatment of such lesions. A patient w i t h leukoplakia
involving a large area of the soft palate w i t h punctate changes is
shown in F i g . 6.43. In order to encompass the entire area involved,
a large surface of the mucosa of the soft a n d hard palate needs to
be treated.
t h e patient is placed under general anesthesia w i t h naso-
Fig. 6.43 Patient with leukoplakia of a large area of the soft palate
tracheal i n t u b a t i o n a n d adequate relaxation is o b t a i n e d w i t h the
use of muscle relaxants. A D i n g m a n self-retaining oral retractor
is now employed to expose the lesion and the area to be treated cavity w i t h saline s o l u t i o n . The smoke generated by tissue destruc-
( F i g . 6 . 4 4 i . The skin of the face in the field is shielded w i t h wet t i o n is suctioned out w i t h a c o n t i n u o u s suction t i p held adjacent
towels to protect against accidental i n j u r y by the laser beam. The to the laser beam.
posterior pharyngeal w a l l is similarly protected using a wet roll of In F i g . 6.46 the area of laser vaporization is s h o w n at the
gauze as a packing w h i c h also covers a n d protects the nasotracheal conclusion of the procedure. Complete hemostasis is obtained by
tube in the o r o p h a r y n x . c o n t r o l l i n g focal bleeding points by defocusing the laser beam. To
The carbon d i o x i d e laser w i t h a hand-held piece is now brought control hemorrhage the hand-held piece is brought away from
into the field a n d the laser beam is focused over the area of desired the target area to diffuse the focus w h i c h provides m a x i m u m
tissue destruction ( F i g . 6 . 4 5 ) . The desired d e p t h of tissue destruc- hemostasis. The surgical field at this stage shows adequate tissue
tion for leukoplakia is a p p r o x i m a t e l y 1-2 mm in thickness. This destruction in the desired area w i t h complete hemostasis. The
level of tissue destruction is safely obtained at a p p r o x i m a t e l y patient is allowed to take liquids by m o u t h the same day and
15 watts of c o n t i n u o u s current laser beam. Tissue destruction is instructions arc given for maintenance of o p t i m a l oral hygiene In-
performed in segments w i t h i n t e r m i t t e n t irrigation of the oral frequent oral irrigations and rinses using a solution of w a r m water

184
Fig. 6.44 The oral cavity is exposed with a Dingman self-retaining oral
retractor.
Fig. 6.46 The area of laser vaporization.
w i t h baking soda and salt. O n e quart of w a r m water w i t h a
teaspoon of salt a n d a teaspoon of b a k i n g soda is recommended
for oral rinses and irrigations.
The postoperative v i e w of t h e oral c a v i t y at a p p r o x i m a t e l y o n e
week following laser vaporization is s h o w n in Fig. 6 . 4 7 . Super-
Fig. 6.47 Appearance of the oral cavity approximately one week later.
Fig. 6.48 Appearance of the oral cavity one month later.
ficial g r a n u l a t i o n tissue is seen in focal areas at the site of tissue
destruction. Note that there is m i n i m a l i n f l a m m a t o r y reaction
and there is g r o w t h of n o r m a l appearing mucosa in some areas.
Appearance of the oral c a v i t y one m o n t h f o l l o w i n g laser vapor-
ization for leukoplakia is s h o w n in Fig. 6.48. Complete resto-
ration of the n o r m a l e p i t h e l i u m is n o w seen. Palpation of this area
shows completely n o r m a l soft tissues w i t h no scar formation or
fibrosis beneath.
Superficial in situ carcinomas of the oral cavity and diffuse areas
of leukoplakia (hyperkeratosis, dysplasia, etc.) are suitable for
treatment by laser vaporization. Laser vaporization as definitive
treatment, however, is inadequate f o r i n f i l t r a t i n g carcinomas of
the mucosa of the oral cavity.
PERORAL SURGICAL APPROACH
Surgical treatment for t u m o r s of the oral cavity can safely be
e m p l o y e d via the open m o u t h provided the t u m o r is small and
easily accessible. Thus, small p r i m a r y t u m o r s of the oral tongue,
floor of m o u t h , g u m , cheek mucosa a n d hard or soft palate are
suitable for peroral excision ( F i g . 6 . 4 9 ) . However, there are some
patients in w h o m the m o u t h does not open wide enough, even
under anesthesia, to provide adequate access to the tumor.
185

Fig. 6.49 Small primary tumors of the oral cavity, are suitable for peroral
excision.
PARTIAL GLOSSECTOMY
All Tl and most T2 lesions of the oral tongue, i.e. anterior two-
thirds of the tongue, are suitable for a partial glossectomy which
can be safely performed through the open mouth. The patient
shown in Fig. 6.SO has an ulcerated, endophytic 2.S cm carci-
noma involving the lateral border of the anterior and middle one-
third of the tongue on the right hand side. Mobility of the tongue
is not restricted and the tumor does not extend to involve the
adjacent floor of the mouth. The tumor also does not extend
across the midline to involve the opposite side of the tongue.
The patient is placed under general anesthesia with nasotracheal
intubation and the oral cavity is isolated, lor bulky tumors
involving the lateral aspect of the oral tongue, it is preferable to
perform a wedge excision oriented in a transverse fashion rather
than longitudinal fashion. A longitudinally oriented excision of a
large tumor will result in an elongated narrow tongue which often
impairs speech and interferes with mastication. On the other
hand, transversely oriented wedge excisions foreshorten the
length of the tongue and result in a functionally better and
186
Fig. 6.50 An ulcerated, endophytic carcinoma of the oral tongue.
Fig. 6.51 The area of
excision is outlined.
Fig. 6.S2 The surgical
defect.
visually normal-appearing tongue. The area of excision is marked
out as shown in Fig. 6.SI with a generous portion of the mucosa
adjacent to the tumor with full complement of the thickness of
the musculature of the tongue surrounding the palpable tumor.
Surgical excision is preferably performed with an electrocautery
using the cutting current to incise the mucosa of the tongue both
on its superior and inferior aspects. Following mucosal incision,
resection of the underlying musculature of the tongue is per-
formed using coagulating current. Minor bleeding points in the
musculature of the tongue are electrocoagulated while major
branches of the lingual artery are ligated with chromic catgut. The
surgical defect shows satisfactory excision of the primary tumor of
the oral tongue (Fig. 6.52). Frozen sections are now obtained
from the mucosal margins, as well as the depth of the surgical
defect, to ensure that an adequate excision of the primary tumor
is accomplished.
Following confirmation of negative margins by frozen section,
and after securing hemostasis, repair of the surgical defect begins.
A two-layered repair is performed using 3-0 chromic catgut
interrupted sutures, to approximate the musculature and the same
suture material for approximation of the mucosa on the superior,
as well as the inferior aspect of the tongue. Note a skin hook

Fig. 6.54 The appearance of the tongue three months after partial
glossectomy.
retracting the apex of the wedge-shaped surgical defect for
transverse o r i e n t a t i o n of the closure. Interrupted chromic catgut
sutures are taken t h r o u g h o u t . Blood loss d u r i n g the procedure is
negligible.
The patient can lake clear liquids by m o u t h in 24 to 48 hours
and is allowed a pureed diet on the t h i r d postoperative day. Most
patients w i l l be able lo tolerate a soil diet by the end of t h e week.
There is usually some degree of speech impairment w h i c h improves
as healing progresses and m o b i l i t y of the tongue improves.
The surgical specimen s h o w n in F i g . 6 . 5 3 demonstrates f u l l -
thickness, three-dimensional resection of the t u m o r of the oral
tongue w i t h adequate mucosal and soft tissue margins. The post-
operative appearance of the t o n g u e a p p r o x i m a t e l y three m o n t h s
after partial glossectomy is s h o w n in F i g . 6.S4. Note the trans-
verse scar at the suture line, g i v i n g a n o r m a l c o n f i g u r a t i o n of the
oral tongue. The patient now has no speech i m p a i r m e n t a n d is
able to tolerate all types of food by m o u t h .
EXCISION OF THE FLOOR OF THE MOUTH AND
FULL THICKNESS SKIN GRAFT
Peroral excision lor superficial lesions of the floor of the m o u t h ,
cheek mucosa or soft palate can be performed w i t h the surgical
deled safely left open to granulate and heal by secondary i n t e n -
tion. However, w h e n such an excision is in certain critical areas
where m o b i l i t y is essential, or w h e n the depth of excision includes
the underlying musculature, then secondary healing leads to fibrosis
and contracture leading to i m p a i r m e n t of f u n c t i o n . I m m e d i a t e
coverage of such surgical defects by skin graft is desirable. A primary
carcinoma of the floor of the m o u t h i n v o l v i n g f r e n u l u m , as w e l l
as openings of the Wharton's ducts on b o t h sides w i t h involvement
of the adjacent mucosa is s h o w n in F i g . 6.55. The lesion does not
involve the lingual gingiva and does not infiltrate deeply to involve
Fig. 6.55 Carcinoma ot the floor of the mouth involving the frenulum
and openings of Wharton's ducts.
Fig. 6.56 The proposed area oi surgical excision is outlined by mucosa]
incision.
the underlying muscular d i a p h r a g m of the f l o o r of the m o u t h .
The patient is placed under general anesthesia w i t h naso-
tracheal i n t u b a t i o n and the oral cavily is isolated and exposed
w i t h self-retaining m o u t h retractors. Using an electrocautery, the
proposed area of surgical excision w i t h satisfactory mucosal
margins is marked out ( F i g . 6 . 5 6 ) . Note that the line of excision
goes t h r o u g h the lingual gingiva anteriorly a n d through the under-
surface of the tongue posteriorly.
A three-dimensional resection of the p r i m a r y t u m o r is under-
t a k e n , using the electrocautery. As the u n d e r l y i n g soft tissues are
mobilized and d i v i d e d , the W h a r t o n ' s ducts become visible as
shown in Fig. 6 . 5 7 . Portions of sublingual salivary glands form
the deep margin of the surgical specimen. The Wharton's d u d s are
transected a n d their stumps are held by 4-0 chromic catgut
sutures.
T h e openings of the transected Wharton's ducts are transposed
posteriorly. T h e ducts are transected o b l i q u e l y to provide a larger
circumference at its opening. The posterior half of its circum-
ference is a p p r o x i m a t e d to the mucosa of the floor of the m o u t h
w i t h interrupted 4-0 c h r o m i c catgut sutures as shown in Fig.
6.58. The r e m a i n i n g surgical defect reveals the musculature of the
undersurface of the tongue a n d the floor of the m o u t h .
A full-thickness skin graft is harvested f r o m the supraclavicular
area of the neck. The skin graft is appropriately t r i m m e d and
sutured to the mucosal edges of the surgical defect using 3-0
c h r o m i c catgut i n t e r r u p t e d sutures ( F i g . 6 . 5 9 ) . T h e anterior half
of the circumference of the stump of Wharton's duct is approxi-
mated to the edge of the skin graft w i t h interrupted 4-0 chromic
187

Fig. 6.57 The Wharton's ducts are dissected.
Fig. 6.58 The stumps of the Wharton's ducts are transposed to the
posterior mucosal edge.
Fig. 6.59 The skin graft is trimmed and sutured to the mucosal edges of
the surgical defect.
catgut sutures. After the graft is sutured in place several stab
incisions are made in the skin graft to permit drainage of b l o o d
and/or serum that may accumulate beneath the graft.
A Xeroform gauze holster is made to lit the area of the skin graft
and is anchored in position w i t h 2-0 silk tie-over sutures as s h o w n
in Fig. 6.60. A nasogastric feeding tube is inserted to m a i n t a i n
nutritional intake in the postoperative period. T h e patient is not
allowed to take a n y t h i n g by m o u t h for a p p r o x i m a t e l y one week
and intense oral irrigations a n d rinses are encouraged to m a i n t a i n
optimal oral hygiene. At the e n d of one week the bolster dressing
is removed and the patient is asked to c o n t i n u e oral irrigations
until the graft has satisfactorily healed. The patient can n o w take
clear liquids a n d pureed foods by m o u t h .
188
Fig. 6.60 The Xeroform gauze bolster is anchored in position.
Fig. 6.61 The appearance of the skin graft eight weeks following
surgery.
The postoperative appearance of the skin graft at approximately
eight weeks f o l l o w i n g surgery is s h o w n in F i g . 6 . 6 1 . I he graft has
healed w e l l , retaining normal m o b i l i t y of the tongue, and the func-
t i o n of mastication a n d speech is also practically n o r m a l . On m a n y
occasions skin grafts in the oral cavity do not take completely.
a l t h o u g h in those instances they do serve an i m p o r t a n t f u n c t i o n
of p r o v i d i n g a biological dressing on the surgical defect in the
i m m e d i a t e postoperative period. Even t h o u g h the skin graft may
not take totally, a n d some parts of it slough o u t , the o t h e r areas do
take a n d eventually good e p i t h e l i a l i z a t i o n takes place. Split- or
full-thickness skin grafts p r o v i d e excellent coverage of inter-
mediate d e p t h defects in the oral cavity.
EXCISION OF BENIGN MIXED TUMOR OF MINOR
SALIVARY GLANDS OF THE SOFT PALATE
t u m o r s of m i n o r salivary g l a n d o r i g i n arise anywhere in the
mucosa of the upper aerodigestive tract: in the nasal cavity, naso-
pharynx, oral cavity, o r o p h a r y n x , h y p o p h a r y n x , larynx, esophagus
or trachea. A m a j o r i t y of t u m o r s of m i n o r salivary g l a n d o r i g i n are
m a l i g n a n t in nature; however, benign t u m o r s do arise occasion-
ally. Most benign t u m o r s of m i n o r salivary o r i g i n occur in the
hard or soft palate. T h e patient s h o w n in Fig. 6 . 6 2 was unaware
of the presence of a t u m o r in his oral cavity u n t i l his dentist
indicated a bulge on the right side of his soft palate.
Fig. 6.62 Benign mixed tumor ol the soft palate.
Fig. 6.64 The patient is placed under general anesthesia with
nasotracheal intubation. A Dingman retractor is used to expose the oral
cavity.
A C T scan t h r o u g h the area o f the t u m o r s h o w n i n H g . 6 . 6 3
demonstrates a well-encapsulated t u m o r mass i n v o l v i n g the soft
palate but not e x t e n d i n g to involve the pterygoid musculature or
in the parapharyngeal space. The patient h a i l an o p e n biopsy of
this t u m o r performed elsewhere a n d the diagnosis of a benign
mixed t u m o r was established.
Fig. 6.66 Dissection around the pseudocapsule of the tumor continues.
As s h o w n in F i g . 6 . 6 4 t h e patient is placed tinder general
anesthesia w i t h nasotracheal i n t u b a t i o n a n d adequate relaxation
is obtained w i t h the use of muscle relaxants. The oral cavity is
exposed using a D i n g m a n sell-retaining retractor. The entire
surface of the t u m o r is n o w exposed and on palpation the tumor
is felt to be mobile over the deeper soft tissues. Using an electro-
cautery, an incision is made in t h e intact mucosa of the anterior
aspect of the soft palate. The incision is deepened through the
submucous soft tissues u n t i l the pseudocapsule of the tumor is
reached [tig. 6 . 6 5 1 .
Dissection around the pseudocapsule Of the t u m o r continues,
w i t h gentle traction on the tumor, w h i c h is extracted, by retract-
ing the edges of the surgical defect ( F i g . 6 . 6 6 1 . Circumferential
m o b i l i z a t i o n of the t u m o r proceeds in this way w i t h occasional
b l u n t a n d sharp dissection. M o b i l i z a t i o n of the t u m o r around its
entire circumference is n o w complete as s h o w n in F i g . 6.67.
Deeper attachments c o n t a i n i n g b l o o d supply to the tumor are
clamped a n d d i v i d e d a n d t h e t u m o r is delivered in a monobloc
fashion.
The surgical defect resulting from excision of the tumor is
s h o w n in F i g . 6 . 6 8 . Note the superficial aspects of the surgical
defect w h i c h show m i n o r salivary gland tissue w h i l e the depth of
the defect shows musculature of the soft palate. Complete
hemostasis is ascertained. No a t t e m p t is made to close this surgical
defect w h i c h w i l l be allowed to heal by secondary i n t e n t i o n . Any
attempt at closure w o u l d result in d i s t o r t i o n of the faucial arch
189
 Fig. 6.69 The surgical
specimen.

Fig. 6.70 The

bisected specimen.

Fig. 6.68 The surgical defect.

with impairment of velopharyngeal competence leading to distor-

tion of the quality of voice and nasal regurgitation during
swallowing. A nasogastric feeding tube is inserted a n d the patient
is not permitted to eat by m o u t h for a p p r o x i m a t e l y o n e week.
During this t i m e o p t i m a l oral hygiene is m a i n t a i n e d by frequent
oral irrigations a n d rinses as w e l l as power sprays of the surgical
defect, using half-strength peroxide s o l u t i o n to provide m e c h a n -
ical cleaning of the defect.
The surgical specimen ( F i g . 6 . 6 9 ) shows the t u m o r measuring
approximately 4 cm in diameter. Note the a t t a c h m e n t of adjacent
soft tissues on the pseudocapsulc of the t u m o r e n s u r i n g its c o m -
plete removal. On bisecting the specimen, the rubbery consistency
of the benign mixed t u m o r becomes apparent w i t h n o d u l a r fleshy,
firm and t i g h t l y packed t u m o r as seen in F i g . 6.7(1.
The postoperative appearance of the surgical site, a p p r o x i m a t e l y
one m o n t h f o l l o w i n g excision of the t u m o r , shows complete
Fig. 6.71 The surgical site one month following excision of the tumor.
healing of the large surgical defect w h i c h has tilled in w i t h cicatrix
and has e p i t h e l i a l i / e d spontaneously ( F i g . 6 . 7 1 ) . Note that the
Faucial arch is o n l y m i n i m a l l y distorted. The p a t i e n t has no
impairment of voice or s w a l l o w i n g a n d is able to o p e n his m o u t h t h e soft palate are not accessible t h r o u g h the open m o u t h and
normally. resection s h o u l d not be a t t e m p t e d in this way. Such an under-
The excision of benign m i n o r salivary g l a n d t u m o r s arising in t a k i n g w o u l d not o n l y be hazardous but due to inadequate
the soft palate can therefore be safely accomplished t h r o u g h the exposure w o u l d result in piecemeal removal of the t u m o r w i t h
open m o u t h . However, it must be realized that b e n i g n m i x e d occasional u n c o n t r o l l e d hemorrhage a n d significant risk of injury
tumors of the deep lobe of the p a r o t i d g l a n d p r o d u c i n g a bulge of to facial nerve.

190
RESECTION OF TUMOR OF THE UPPER ALVEOLUS Further m o b i l i z a t i o n of the soft tissues over the anterolateral
aspect of the m a x i l l a is accomplished using electrocautery and
periosteal elevators ( F i g . 6.751. Prolapse of the buccal fat pad is
Small tumors of dentoalveolar o r i g i n or p r i m a r y t u m o r s of the
seen adjacent to the lower Richardson's retractor due to elevation
mucosa of the upper alveolus can be considered for excision via a
of soft tissues f r o m the lateral aspect of the maxilla. Using a high-
peroral alveolectomy. It is, however, i m p o r t a n t to remember that
speed d r i l l the area of bone transection is marked out prior to
adequate radiographic assessment of the t u m o r is m a n d a t o r y prior
fracture of the alveolar process using osteotomes. Alternatively,
to embarking on a surgical approach.
one m a y use o n l y osteotomes to fracture the maxillary tubercle
The patient s h o w n i n F i g . 6 . 7 2 has a n ameloblastoma arising
f r o m the rest of the maxilla a n d the hard palate. It is, however,
in the region of the socket of the last upper molar t o o t h on the
preferable to use a high-speed drill w i t h a fine burr to demarcate
left-hand side adjacent to the m a x i l l a r y tubercle. T h e t u m o r has
the lines of bone transection as m u c h as possible, and then use
minimal submucosal c o m p o n e n t . A coronal t o m o g r a m of the hard
osteotomes to make the final fractures to mobilize the specimen in
palate in the region of the t u m o r shows i n v o l v e m e n t of the
a m o n o b l o c fashion.
alveolar process a n d reactive changes in the floor of the m a x i l l a r y
T h e surgical specimen ( F i g . 6.76) shows the last molar tooth
antrum on the left-hand side ( F i g . 6 . 7 3 ) . T h e t u m o r , however,
a n d t h e m a x i l l a r y tubercle, a l o n g w i t h the t u m o r w i t h adjacent
docs not extend i n t o the nasal cavity or the a n t r u m of the maxilla
n o r m a l bone a n d a cuff of soft tissues s u r r o u n d i n g the resected
and can, therefore, be resected t h r o u g h the open m o u t h .
tumor. The surgical defect is s h o w n in F i g . 6 . 7 7 w i t h a portion of
The patient is placed under general anesthesia w i t h nasotracheal
the medial pterygoid muscle in its d e p t h . The opening in the
intubation a n d the oral cavity is exposed w i t h a self-retaining
a n t r u m of the left maxilla is also seen as a result of resection of the
retractor. Using Richardson's retractors the commissure of the
floor of the a n t r u m in the surgical specimen. The surgical defect is
mouth is retracted to expose the area of the m a x i l l a r y tubercle a n d
irrigated w i t h Bacitracin s o l u t i o n . T h e interior of the maxillary
retromolar trigone on t h e left side. As s h o w n in F'ig. 6 . 7 4 , a
a n t r u m is inspected for any pathology. If the mucosa of the antrum
circular incision in the mucosa a r o u n d the palpable t u m o r is
appears edematous t h e n it is curetted out as m u c h as possible.
marked out using an electrocautery w i t h a needle t i p .

Fig. 6.72 An ameloblastoma of the upper alveolus adjacent to the last Fig. 6.74 A circular incision in the mucosa around the palpable tumor is
molar tooth. made.

Fig. 6.73 Coronal tomogram of the hard palate. Fig. 6.7S Further mobilization of the soft tissues over the anterolateral
aspect of the maxilla.

191
Fig. 6.76 The surgical specimen. Fig. 6.78 The split-thickness skin graft is sutured to the edges of the
mucosa.

Fig. 6.77 The surgical defect. Fig. 6.79 The surgical dental obturator is wired to the remaining teeth
to hold the Xeroform gauze packing in place.

Alternatively, if the mucosa appears n o r m a l a n d there is no

other pathology w i t h i n the m a x i l l a r y a n t r u m , t h e n it is best left
alone. The remaining surgical defect w i l l require coverage w i t h a
split-thickness skin graft due to a large area of exposed soft tissues
and hone.
A split-thickness skin graft is harvested f r o m a suitable d o n o r
site and is sutured to the edges of the mucosa as s h o w n in F i g .
6.78, using 3-0 c h r o m i c catgut sutures. T h e superior aspect of the
edge of the skin graft is allowed to enter the m a x i l l a r y a n t r u m ,
which is snugly packed w i t h X e r o f o r m gauze to retain it in
position.
Xeroform gauze is used to m o l d the graft in the surgical defect,
completely obliterating any potential spaces for collection of
hematoma. This packing is retained in p o s i t i o n u s i n g a surgical
dental obturator w h i c h is wired to the r e m a i n i n g teeth as s h o w n
in F i g . 6.79. The packing is left in position for a p p r o x i m a t e l y one
Fig. 6.80 The view of the oral cavity three months after the surgical
week, although the patient can take liquids a n d pureed food by
procedure, showing a healed skin graft.
m o u t h from the first postoperative day. W h i l e the packing is left
i n , optimal oral hygiene is m a i n t a i n e d by frequent oral irrigations
and sprays in the oral cavity w i t h half-strength peroxide s o l u t i o n . m o n t h s alter the surgical procedure shows a well-healed skin graft
After one week the surgical dental obturator a n d the packing are w i t h the apex of the surgical defect leading to Ihe maxillary
removed. In most cases the skin graft heals very w e l l . A n y excess a n t r u m [ F i g . 6 . 8 0 1 . The permanent dental obturator is now made
shreds of skin graft are t r i m m e d off a n d an i n t e r i m dental a n d w i l l provide a plug to obliterate the o p e n i n g of the maxillary
obturator is fabricated w h i c h the patient uses u n t i l soft tissue a n t r u m in the oral cavity. T h e patient is able to tolerate regular
healing is complete. diet b y m o u t h a n d has n o f u n c t i o n a l i m p a i r m e n t w i t h
The postoperative view of the oral cavity a p p r o x i m a t e l y three mastication or speech.

192
MANAGEMENT OF THE MANDIBLE
Adequate assessment of the m a n d i b l e for invasion by t u m o r is
essential for appropriate surgical treatment p l a n n i n g . The man-
dible is considered at risk w h e n the p r i m a r y t u m o r overlies the
mandible, is adherent to the mandible, or is in p r o x i m i t y to
the mandible. In addition to careful examination under anesthesia
by bimanual palpation, radiographic evaluation of the mandible
should be available lor satisfactory treatment p l a n n i n g .
MECHANISM OF TUMOR INVASION
In order to assess the need for m a n d i b l e resection necessary to
encompass the tumor, it is essential to understand the mechanism
of spread of the t u m o r to invade the mandible. Primary carci-
nomas of the oral cavity extend along the surface mucosa and the
submucosal soft tissues to approach the attached l i n g u a l , buccal or
labial gingiva. Prom this p o i n t , the t u m o r does n o t extend directly
through intact p e r i o s t e u m a n d c o r t i c a l b o n e t o w a r d t h e
cancellous part of I h e m a n d i b l e since the periosteum acts as a
significant protective barrier. Instead, the t u m o r advances f r o m
the attached gingiva toward the alveolus. In patients w i t h teeth,
the tumor extends t h r o u g h the dental socket i n t o the cancellous
part of the bone a n d invades the mandible in that fashion (Fig.
6.81). In edentulous patients, the t u m o r extends up to the alveolar
process and then infiltrates Ihe dental pores in the alveolar process
and extends to the cancellous part of the mandible ( F i g . 6 . 8 2 ) .
Thus, in patients even w i t h early invasion of the m a n d i b l e , mar-
ginal m a n d i b u l e c t o m y is feasible since the cortical part of the
mandible inferior to the roots of the teeth remains u n i n v o l v e d
and can be safely spared.
elderly patients. The a b i l i t y to perform a satisfactory marginal
m a n d i b u l e c t o m y in such patients is almost impossible since the
p r o b a b i l i t y of iatrogenic fracture or postsurgical spontaneous
fracture of the r e m a i n i n g p o r t i o n of the mandible is very high.
Similarly, in patients w h o have received previous radiotherapy,
marginal m a n d i b u l e c t o m y s h o u l d he performed w i t h extreme
c a u t i o n . The probability of pathologic fracture at the site of
marginal m a n d i b u l e c t o m y in a previously irradiated edentulous
mandible is very h i g h .
W h e n there is extension of t u m o r to involve the cancellous part
of the m a n d i b l e , a segmental m a n d i b u l e c t o m y must be per-
formed. Segmental m a n d i b u l e c t o m y may also be required in
patients whose 'massive p r i m a r y t u m o r s ' are in the proximity of
the m a n d i b l e w i t h significant soft tissue disease adjacent to the
mandible. However, segmental m a n d i b u l e c t o m y should never be
considered s i m p l y to gain access to p r i m a r y cancers of the oral
cavity w h i c h are not in Ihe v i c i n i t y of the mandible. The concept
of the ' c o m m a n d o o p e r a t i o n ' needs to be revised since there are
no l y m p h a t i c channels passing t h r o u g h the mandible warranting
the need for an in c o n t i n u i t y 'composite resection' of the un-
i n v o l v e d m a n d i b l e . Therefore, sacrifice of the normal uninvolved

In edentulous patients, however, the feasibility of marginal

mandibulectomy depends on the vertical height of the body of
the mandible. W i t h aging, the alveolar process recedes a n d the
mandibular canal conies closer and closer to the surface of
the alveolar process. As s h o w n in Fig. 6 . 8 3 , the resorption of the
alveolar process eventually leads to a 'pipestem' m a n d i b l e in very

Fig. 6.82 Tumor invasion ot the edentulous mandible occurs through

the dental pores on the alveolar process to the cancellous bone and
then to the alveolar canal.

Fig. 6.81 Tumor invasion of the dentate mandible occurs through the Fig. 6.8J Vertical height and location of the alveolar canal in dentate
dental socket to the cancellous bone and then to the alveolar canal. and edentulous mandibles.

193
mandible to gain access lo the primary tumors of the oral cavity
or to accomplish an 'in continuity composite resection' can no
longer be justified. The current indications for segmental maiuli-
bulectomy include: (II gross invasion by oral cancer; (2) primary
lx>ne tumor of the mandible; (3) metastatic tumor lo the mandible;
(4) invasion of inferior alveolar nerve or canal by tumor; and
(5) massive soft tissue disease adjacent to the mandible.
MANDIBLE SPARING APPROACHES
The understanding of the mechanism of tumor invasion of the
mandible has enabled the development of mandible sparing
approaches. These include; ( l | mandibulotomy for gaining access
to large or posteriorly located tumors of the oral cavity or tumors
of the oropharynx and (2( marginal mandibulectomy.
MANDIBULOTOMY
Mandibulotomy or mandibular osteotomy is an excellent
mandible sparing surgical approach designed to gain access to the
oral cavity or oropharynx for resection of primary tumors other-
wise not accessible through the open mouth or by the lower cheek
flap approach (Fig. 6.84). The mandibulotomy can be performed
in one of three locations: (1) lateral (through the body or angle of
the mandible); (2) midline; or (3) paramedian. Lateral mandi-
bulotomy has several disadvantages. The muscular pull on the two
segments of the mandible is unequal, putting the mandibulotomy
site under significant stress causing delay in healing. Due to the
above, the patient may require intermaxillary fixation. The ability
to gain access to the suture line to maintain cleanliness following
surgery in the oral cavity is hampered due to intermaxillary
fixation leading to poor oral hygiene and potential risk for sepsis
of the suture line. In addition to this, lateral mandibulotomy
poses several anatomic disadvantages leading to denervation of
Fig. 6.84 Mandibulotomy or mandibular osteotomy is an excellent
mandible sparing surgical approach to gain access to bulky tumors of
the oral cavity or oropharynx.
194
the teeth distal to the mandibulotomy site and the skin of the
chin due to transection of the inferior alveolar nerve. It also causes
devascularization of the distal teeth as well as the distal segment
of the mandible from its endosteal blood supply. The exposure
provided by lateral mandibulotomy is limited and if the patient
needs postoperative radiation therapy, then the mandibulotomy
site is directly within the lateral portal of radiation therapy
leading to delayed healing and complications at the site of
mandibulotomy. For these reasons, lateral mandibulotomy is not
recommended. By placing the site of mandibulotomy in the
anterior midline, all the disadvantages of lateral mandibulotomy
are avoided. However, splitting the mandible in the midline
requires extraction of one central incisor tooth to avoid exposure
of the roots of both central incisor teeth which are at risk of
extrusion. Extraction of one central incisor tooth to avoid the
above alters the esthetic appearance of the lower dentition. In
addition to this, midline mandibulotomy requires division of
muscles arising from the genial tubercle, i.e. the geniohyoid and
genioglossus, leading to a delayed recovery of the function of
mastication and swallowing. Therefore a median mandibulotomy
is also not preferred for these reasons.
Paramedian mandibulotomy, on the other hand, does away
with all the disadvantages of lateral mandibulotomy and avoids
the sequelae of midline mandibulotomy. It offers significant
advantages such as wide exposure as well as preservation of the
geniohyoid and genioglossus muscles leading to preservation of
the hyomandibular complex. The only muscle requiring division
is the mylohyoid muscle which leads to minimal swallowing
difficulties. Paramedian mandibulotomy does not cause dener-
vation or devascularization of the skin of the chin or the teeth and
mandible. Fixation at the mandibulotomy site is easy and the site
of mandibulotomy does not fall within the lateral portal of
radiation therapy if the patient needs postoperative radiotherapy.
Therefore, currently, paramedian mandibulotomy remains an
optima] surgical approach for access to posteriorly located larger
lesions of the oral cavity and tumors of the oropharynx and
parapharyngeal space.
MARGINAL MANDIBULECTOMY
The current indications for marginal mandibulectomy are: (I) for
obtaining satisfactory three-dimensional margins around the
primary tumor; (2) when the primary tumor approximates the
mandible; and (3) for minimal cortical erosion or minimal erosion
of the alveolar process of the mandible. On the other hand,
marginal mandibulectomy is contraindicated when there is gross
invasion into the cancellous part of the mandible or when there
is massive soft tissue disease. Marginal mandibulectomy is also
contraindicated in patients with previously irradiated edentulous
mandible or patients with significant atrophy of the alveolar
process leading to a 'pipestem mandible'.
Marginal mandibulectomy can be performed to resect the
alveolar process, the lingual plate of the mandible or a com-
bination of the alveolar process and lingual plate of the mandible
for tumors of the anterior oral cavity (Fig. 6.85). Marginal mandi-
bulectomy can also be performed for lesions adjacent to the retro-
molar trigone whereupon the anterior aspect of the ascending
ramus of the mandible including the coronoid process and the
adjacent alveolar process of the body of the mandible are resected.
Reverse marginal mandibulectomy is indicated in patients who
have soft tissue disease such as fixation of prevascular facial lymph

Fig. 6.85 Schematic diagram of marginal mandibulectomy for cancer of
the floor of the mouth, through a lower cheek flap approach.
Fig. 6.86 The marginal mandibulectomy is performed in a smooth curve
to evenly distribute the stress at the site of resection.
nodes lo the lower cortex of the m a n d i b l e . In p e r f o r m i n g a mar-
ginal mandibulectomy, right-angled cuts at the site of the marginal
mandibulectomy should he avoided since these lead to points of
excessive stress leading to the risk of Spontaneous fracture. T h e
marginal m a n d i b u l e c t o m y s h o u l d he performed in a s m o o t h
curve to evenly distribute the stress at the site of resection ( F i g .
6.861. The exposed b o n e f o l l o w i n g marginal m a n d i b u l e c t o m y
may be left open to Ileal by secondary i n t e n t i o n or a p r i m a r y
mucosal closure between the mucosa of the tongue or f l o o r of
mouth to mucosa of the cheek can he performed. It must, h o w -
ever, he remembered that primary closure w i l l eliminate the lingual
or the buccal sulcus a n d therefore fabrication of a removable
denture is exceedingly difficult. Alternatively, a skin graft can be
applied directly over the marginally resected m a n d i b l e w h i c h
w o u l d permit retention of the sulci a n d the ability to wear a
partial denture w h i c h can be clasped to the r e m a i n i n g teeth. In
e d e n t u l o u s p a t i e n t s , t h e a b i l i t y to wear a d e n t u r e over a
marginally resected mandible is very difficult. In such a situation,
OSSeointegrated implants w i t h a fixed denture should he considered.
Where there is significant soft tissue a n d mucosal loss in addition
to marginal m a n d i b u l e c t o m y , a radial forearm free flap provides
ideal soft tissue a n d l i n i n g for reconstruction.
PARAMEDIAN MANDIBULOTOMY FOR RESECTION OF
CANCER OF THE TONGUE
The patient s h o w n in F i g . 6 . 8 7 has a p r i m a r y carcinoma of the
m i d d l e t h i r d of the oral t o n g u e . The t u m o r is staged as T2, NO,
Stage II invasive squamous cell carcinoma of the oral tongue.
However, this is a deeply i n f i l t r a t i n g t u m o r w h i c h involves a
Significant p o r t i o n of the u n d e r l y i n g musculature and therefore
an elective s u p r a o m o h y o i d neck dissection is performed for
pathologic staging of regional l y m p h nodes.
In any patient requiring m a n d i h u l o t o m y , radiographic assess-
ment of the m a n d i b l e must he performed prior to surgery. A
panoramic view of the m a n d i b l e is usually satisfactory. If, how-
ever, facilities for a panoramic view arc not available, then at least
c o n v e n t i o n a l radiographs of t h e m a n d i b l e s h o u l d he obtained
prior to surgery. M a n d i h u l o t o m y t h r o u g h an area of septic teeth
should be avoided. If there is a n y other pathology at the proposed
site of m a n d i h u l o t o m y , radiographic studies w o u l d be of tre-
mendous assistance in properly selecting the appropriate location
for m a n d i h u l o t o m y . The site of m a n d i h u l o t o m y is selected based
on the disposition of the dental sockets of the incisor and canine
teeth. T h e roots of the lateral incisor a n d canine teeth usually
diverge, creating a space between the t w o . Therefore a paramedian
m a n d i h u l o t o m y between the lateral incisor and canine tooth is
preferred. T h e angled cut of the m a n d i h u l o t o m y should he
fashioned in such a way that it does n o t amputate the roots of the
adjacent teeth. Similarly the straight vertical cut should he exactly
between the roots of the adjacent teeth to avoid undue exposure
of the roots of the adjacent teeth ( F i g . 6 . 8 8 ) .
The patient is placed under general anesthesia w i t h nasotracheal
i n t u b a t i o n on the operating table and adequate relaxation is
obtained. The best o p p o r t u n i t y to satisfactorily examine the extent
Fig. 6.87 Patient with a carcinoma of the middle third of the oral
tongue.
195
 Fig. 6.90 The
supraomohyoid neck
dissection is
completed.

Fig. 6.88 Panoramic x-ray showing the site and type of mandibulotomy.

Fig. 6.89 The incision for mandibulotomy and supraomohyoid neck

dissection.

of Ihc t u m o r is under anesthesia a n d this s h o u l d he r o u t i n e l y Fig. 6.91 Schematic diagram of paramedian mandibulotomy through a
clone. An incision is marked out as s h o w n , s p l i t t i n g the lower lip lower lip-splitting incision.
in the m i d l i n e w i t h extension of the i n c i s i o n up to the h y o i d hone
al w h i c h point the incision is extended on the side of the neck
dissection along an upper neck skin crease ( F i g . 6 . 8 9 i . Extension the left-sided shorl cheek f l a p exposes the lateral cortex a n d the
of the incision to the lateral aspect of the upper neck provides inferior border of the m a n d i b l e at the m a n d i b u l o t o m y site.
adequate exposure lo carry out (he supraomohyoid neck There are a variety of different ways in w h i c h an osteotomy
dissection. I n i t i a l l y o n l y t h e transverse part of t h e neck i n c i s i o n is m a y be p e r f o r m e d to a c c o m p l i s h m a n d i b u l o t o m y . T h e classic
made and the s u p r a o m o h y o i d neck dissection is c o m p l e t e d ( F i g . Trotter's approach divides the m a n d i b l e t h r o u g h the m i d l i n e in a
6.901. single straight vertical cut. This is clearly not desirable since
The skin incision is n o w extended in the m i d l i n e , d i v i d i n g the i m m o b i l i z a t i o n of the m a n d i b l e w o u l d be extremely difficult due
c h i n and the lower lip t h r o u g h its f u l l thickness up to the to significant m o t i o n at the site of the m a n d i b u l o t o m y causing
reflection of the mucosa at the gingivolabial sulcus. delayed u n i o n or m a l u n i o n . Alternatively, the m a n d i b l e may be
Approximately 5 mm of labial mucosa at the g i n g i v o l a b i a l sulcus d i v i d e d in a step-ladder fashion to avoid u p w a r d a n d d o w n w a r d
is left attached to t h e m a n d i b l e to facilitate closure. At t h a t p o i n t , displacement. However, a n t e r o p o s t e r i o r displacement w o u l d still
an incision is made in the labial mucosa on the left-hand side of be a problem w i t h that approach. In a d d i t i o n , the transverse cut
the m i d l i n e for a distance of a p p r o x i m a t e l y 2 cm a n d a short of a step-ladder o s t e o t o m y may a m p u t a t e the roots of teeth at that
cheek flap is elevated ( F i g . 6 . 9 1 1 . All the soft tissue attachments site a n d devitalize t h e m . A paramedian m a n d i b u l o t o m y is there-
of the c h i n are elevated f r o m the anterior aspect of the m a n d i b l e fore preferred. The m a n d i b u l o t o m y is performed in an angled
to a distance of a p p r o x i m a t e l y 2-3 cm f r o m the m i d l i n e on the fashion, d i v i d i n g the alveolar process between the lateral incisor
left-hand side, exposing the m a n d i b u l o t o m y site ( F i g . 6 . 9 2 ) . a n d canine teeth in a vertical plane for a distance of a p p r o x i -
Elevation of the cheek f l a p s h o u l d not extend up to the m e n t a l m a t e l y 10 m m , at w h i c h p o i n t the m a n d i b u l o t o m y incision in the
foramen, otherwise the mental nerve is exposed lo injury bone is angled medially. The a n g u l a t i o n in the o s t e o t o m y is below
resulting in loss of sensations of the skin of the c h i n . Elevation of the level of the roots of adjacent teeth, t h e angled cut provides a

196
Fig. 6.92 The mandibulotomy site is exposed. Fig. 6.93 Four Drill holes are made prior to Fig. 6.94 The mandible is divided and its two
bone division. segments are retracted laterally.

more stable osteotomy for f i x a t i o n . A high-speed power saw w i t h Fig. 6.95 An incision is
an ultra-thin blade is used to make the m a n d i b u l a r cuts. However, made in the floor of
the mouth.
prior to d i v i d i n g the bone, appropriate d r i l l holes are placed for
fixation of the m a n d i b u l o t o m y site using t i t a n i u m miniplates.
These d r i l l holes are placed p r i o r lo d i v i d i n g the bone to assure
accurate a l i g n m e n t of the m a n d i b u l o t o m y site at the t i m e of the
closure to avoid m a l o c c l u s i o n . T w o plane f i x a t i o n is desirable. A
four-hole m i n i p l a t e is placed on the outer cortex of the m a n d i b l e
over the m a n d i b u l o t o m y site below the level of the roots of
adjacent teeth. Using benders, the plate is appropriately m o l d e d
and shaped to tit snugly over the m a n d i b u l a r surface, l o u r d r i l l
holes are n o w made t h r o u g h the plate holes in the m a n d i b l e .
Another similar plate is shaped to fit over the lower border of the
mandible a n d four d r i l l holes are made in a vertical plane t h r o u g h
the holes in the plate but a v o i d i n g e n t r y i n t o adjacent t o o t h
sockets (Fij{. 6 . 9 3 ) . These plates are then removed a n d saved for
use later in the operation for repair of the o s t e o t o m y site. Placing
the drill holes p r i o r to the performance of the osteotomy allows
Fig. 6.96 The mucosa
accurate r e a p p r o x i m a t i o n of the t w o ends of the m a n d i b l e d u r i n g and submucosal soft
closure preserving the occlusal surfaces of the upper a n d lower tissues are divided and
dentition in perfect a l i g n m e n t . Accurate placement of b o t h m i n i - the mandible is
retracted to expose the
plates is v i t a l l y i m p o r t a n t to avoid i n j u r y to the rools of adjacent
mylohyoid muscle.
teeth. The mandible is divided exactly as planned using a high-speed
power saw. O v e r r i d i n g of the bone cuts at the a n g u l a t i o n s h o u l d
be avoided to prevent iatrogenic fracture at the m a n d i b u l o t o m y
site.
Once the m a n d i b l e is d i v i d e d , its t w o segments are retracted
laterally w i t h sharp hooks ( K g . 6 . 9 4 ) . Brisk hemorrhage f r o m the
cut surface of the m a n d i b l e is to be expected; however, this can be
easily c o n t r o l l e d w i t h electrocautery or b o n e wax. Electrocautery
is now used to d i v i d e the soft tissue a n d muscular attachments on
the t w o sides of the m a n d i b l e . As the t w o sides of the m a n d i b l e
are retracted, a mucosal incision is made in the f l o o r of the m o u t h
leaving a cuff of a p p r o x i m a t e l y I cm of mucosa at the gingiva
(Fig. 6.95). This is essential to facilitate closure of the floor of the
mouth. cavity as the m a n d i b u l a r segment is retracted laterally providing
The mucosal incision in the floor of the m o u t h extends f r o m the necessary exposure.
the m a n d i b u l o t o m y site all the way up to (he anterior pillar of the The soft tissue attachments on the medial aspect of the man-
soft palate. If the incision has to be extended further posteriorly, d i b l e i n c l u d i n g the sublingual salivary g l a n d are shown divided
then it will require d i v i s i o n of the lingual nerve w h i c h crosses the a n d the t w o halves of the m a n d i b l e are retracted w i t h loop retrac-
surgical field as it exits f r o m the m a n d i b l e to enter the lateral tors ( K g . 6 . 9 6 ) . Note that the mucosal incision in the floor of the
aspect of the tongue. The t o n g u e is retracted m e d i a l l y in the oral m o u t h has retained a cuff of mucosa a l o n g the gingiva lo facilitate

197
Fig. 6.97 Schematic diagram showing exposure of the tumor.
Fig. 6.99 The proposed site of resection is marked out.
closure. The m y l o h y o i d muscle attached to the m a n d i b l e is n o w
exposed. It w i l l have to be d i v i d e d to permit mandibular ' s w i n g '
and further exposure. The m y l o h y o i d muscle is d i v i d e d w i t h an
electrocautery in its center, leaving its lateral half attached to the
mandible. C o m p l e t e d i v i s i o n of the m y l o h y o i d muscle w i l l permit
sufficient swing of the m a n d i b l e to p r o v i d e exposure of the
tongue in the surgical field ( F i g . 6 . 9 7 ) . Adequate exposure of the
198
Fig. 6.101 The surgical defect in the middle third of the tongue.
lesion is n o w readily available in the surgical field a l l l o w i n g satis-
factory three-dimensional resection of the p r i m a r y t u m o r in con-
t i n u i t y w i t h the sublingual and submandibular salivary gland and
the adjacent soft tissues a n d l y m p h nodes in a m o n o b l o c fashion
( P i g . 6 . 9 8 ) . The proposed l i n e of resection is n o w marked out
to guide p r i m a r y t u m o r resection ( F i g . 6 . 9 9 ) . A full-thickness,
t h r o u g h - a n d - t h r o u g h three-dimensional resection of the tumor is
n o w performed using an electrocautery w i t h coagulating current.
N o t e t h a t t h e wedge-shaped resection is oriented transversely to
permit repair of the surgical defect by p r i m a r y closure. Brisk
hemorrhage f r o m the lingual artery a n d / o r its branches is to be
expected d u r i n g resection of the tongue. However, this is easily
c o n t r o l l e d w i t h appropriate hemostasis.
Surgical resection is extended f r o m the dorsum of the tongue
t h r o u g h its undersurface to include a f u l l c o m p l e m e n t of the
u n d e r l y i n g musculature, providing a true three-dimensional
excision as seen in the specimen ( F i g . 6 . 1 0 0 ) . Thus, a monobloc,
in c o n t i n u i t y resection of the p r i m a r y t u m o r w i t h the contents of
the s u p r a o m o h y o i d triangle is performed to achieve an onco-
logically sound local/regional excision of the p r i m a r y t u m o r and
its first echelon l y m p h nodes and intervening lymphatic channels.
The surgical defect in the m i d d l e t h i r d of the tongue is shown in
F i g . 6 . 1 0 3 . At this p o i n t , frozen sections are obtained from the
lateral mucosal margins a n d the deep soft tissue margin of the
surgical defect to ensure adequacy of resection. Once satisfactory

Fig. 6.102 Repair of the defect.
Fig. 6.103 Repair of the mandibulotomy with miniplates and screws.
resection is confirmed, repair of the delect begins (Fig. 6.102).
However, a nasogastric feeding tube is inserted prior to beginning
the closure. It is important to introduce the feeding lube at this
point because if there is difficulty in placement of the tube after
the wound is closed and digital manipulation is necessary, then
such manipulation may disrupt the suture line. A skin hook is
placed at the apex of the wedge-shaped surgical defect on the
dorsum of the tongue and traction is applied toward the right-
hand side. This allows the front of the tongue to draw posteriorly,
providing easy approximation of the raw areas. Closure is
performed using interrupted 2-0 chromic catgut sutures for the
muscular layer.
Closure of the tongue is completed with 2-0 chromic catgut
interrupted sutures also used for the mucosa of the tongue.
Following repair of the tongue, the retracted left half of the
mandible is allowed to fall back in its normal position. Closure of
the mucosa of the lateral aspect of the tongue to the mucosa of the
floor of the mouth on the gingiva continues with interrupted
chromic catgut sutures. As the closure proceeds anteriorly, the
mandible draws closer and closer to the mandibulotomy site until
complete mucosal closure of the floor of the mouth is accom-
plished. At this point, the mandibulotomy is repaired with fixation
using the previously shaped miniplates (Fig. 6.103).
A depth gauge is used to select the length of the screws to be
used for the miniplates. The screws should be long enough to go
Fig. 6.104 Mandibular fixation is completed with titanium miniplates
and screws.
through both cortices of the mandible for the lateral plate. How-
ever, they should not project through the lingual cortex of the
mandible in the soft tissues of the oral cavity. Similarly, the mini-
plate on the lower border of the mandible is fixed with relatively
short screws to avoid injury to the roots of the adjacent teeth.
F.very attempt is made to secure perfect alignment of the two ends
of the mandible to restore normal occlusion. The screws are
tightened snug but not too tight, otherwise the heads of the
titanium screws will break (Fig. 6.104).
Mucosal closure now begins by reapproximalion of the cut edge
of the labial mucosa to the cuff of the mucosa at the gingivolabial
sulcus on the alveolar process. This closure is accomplished using
.i-U chromic catgut interrupted sutures. Chromic catgut sutures are
used for the muscular layer of the lip, as well as the mucosal layer
of the lip, while nylon sutures are used for the skin and vermilion
border, lor perfect closure of the midline lip-splitting incision, a
fine nylon suture is first placed accuralely aligning the vermilion
border.
This suture is held as a retractor and closure of the labial mucosa
progresses in a retrograde fashion from the vermilion border up to
the gingivolabial reflection. Interrupted sutures to approximate
the muscular layer are applied in a similar fashion. Accurate
reapproximation of the skin of the lip and chin is essential to
obtain an esthetically acceptable scar. The stumps of the divided
mylohyoid muscle are reapproximated using interrupted chromic
catgut sutures. Although this reapproximation is seldom accurate,
it does permit reduction of the dead space in the submandibular
region.
A suction drain is placed in the wound and brought out through
a separate stab incision. The neck incision is closed in two layers
in a routine fashion.
In the postoperative period, the patient is maintained on naso-
gastric tube feedings for approximately one week. At that time, a
trial with pureed food is given to see whether swallowing is
successful. If, indeed, the patient is able to tolerate pureed food,
then he is gradually advanced to a soft diet over the next few days.
The postoperative view of the patient three months after surgery
shows a well-healed midline scar and esthetically acceptable external
appearance (Fig. 6.105). The intraoral view shows excellent
healing of the tongue (Fig 6.106). The postoperative panoramic
x-ray shows perfect alignment and accurate approximation of the
two segments of the mandible maintaining essentially a normal
occlusion (Fig. 6.107).
199
Fig. 6.1 OS The patient three months after surgery.
Fig. 6.106 The intraoral view showing excellent healing of the tongue.
Fig. 6.107 Postoperative orthopantomogram showing the plates and
screws in place across the mandibulotomy site.
MANDIBULOTOMY FOR RESECTION OF THE BASE OF
THE TONGUE W I T H SUPRAGLOTTIC PARTIAL
LARYNGECTOMY
Primary tumors arising in the base ol the tongue, with secondary
extension to involve the supraglottic larynx or primary tumors of
200
Fig. 6.108 Diagramatic representation of the exposure obtained
through mandibulotomy.
Fig. 6.109 The skin
incision is outlined.
the epiglottis, Willi significant extension to the base of the tongue,
require mandibulotomy for access to accomplish satisfactory surgical
resection. If involvement of the base of the tongue is minimal,
then resection of the base of the tongue in conjunction with the
supraglottic larynx can be performed via the conventional
transhyoid approach utilized for a standard supraglottic partial
laryngectomy. On the other hand, if there is extensive
involvement of the base of the tongue, then satisfactory exposure
through a transhyoid approach is not obtained and therefore a
mandibulotomy approach is preferred. A diagrammatic represen-
tation of the exposure necessary for resection of the base of the
tongue, in conjunction with supraglottic partial laryngectomy, is
shown in Fig. 6.1 OK.
The patient shown above, in Fig. 6.109, has a primary-
carcinoma of the base of the tongue with secondary extension to
the supraglottic larynx, requiring resection of the base of the
tongue in conjunction with a supraglottic partial laryngectomy.
The neck is clinically negative on both sides and, therefore,
elective neck dissection is not performed at the time of resection
of the primary tumor. However, the entire neck on both sides will
receive elective postoperative radiation therapy because both sides
of the neck remain at risk for metastatic disease.
A preliminary tracheostomy is performed under local anesthesia
after which general anesthesia is induced. Examination under
anesthesia and direct laryngoscopy are performed at this point to
adequately assess the extent of the tumor to facilitate a satis-
factory resection. The incision outlined is like a reverse letter T
(Fig. 6.109).
In Fig. 6.110 exposure of the surgical field is shown following
mandibulotomy, with paraungual extension and mandibular

Fig. 6-110 Exposure of the tumor through mandibulotomy.
Fig. 6.111 The surgical specimen is mobilized by division of the right
base of the tongue and right aryepiglottic fold.
swing o f the right h a l f o f the m a n d i b l e . A n incision i s made i n t h e
base of the tongue anterior to the palpable tumor. The base of the
tongue on the left side is retracted to the left, w h i l e the anterior
margin of t h e base of the t o n g u e on the right side, to be resected
w i t h the supraglottic larynx, is held w i t h a t o o t h e d forceps as
shown in the f i e l d . Note the b u l k y c a u l i f l o w e r - l i k e t u m o r
arising from the lingual surface of the epiglottis w i t h secondary
extension lo the base of the tongue in the center of the surgical
field. A very generous exposure is obtained by this approach
which w o u l d permit satisfactory resection of the t u m o r w i t h
adequate margins.
A somewhat anterior v i e w w i t h anterior retraction of the
surgical specimen shows the aryepiglottic fold on the right-hand
side w h i c h is now d i v i d e d , d e m o n s t r a t i n g the inferior margin of
the surgical specimen to be resected ( F i g . 6 . 1 1 1 ) . A p p r o x i m a t e l y
3-4 mm of the superior edge of the t h y r o i d cartilage on b o t h sides,
as well as the central t h i r d of the h y o i d bone, w i l l be resected
along w i t h (he specimen, to permit a m o n o b l o c resection of the
pre-epiglottic space. Division of the t h y r o i d cartilage is performed
using a power saw w i t h an ultrafine blade w h i l e the h y o i d bone is
divided just lateral to the lesser cornua on both sides using a bone
cutter. Once the cartilage cuts are made, the rest of (he resection
of the specimen is performed using an electrocautery. Bleeding
from the branches of the superior laryngeal artery on b o t h sides is
Fig. 6.112 The surgical
defect showing
remaining larynx and
tongue with intact
neurovascular pedicle
from the left side.
to be expected and these vessels are suture ligated w i t h 3-0
c h r o m i c catgut.
The surgical defect f o l l o w i n g removal of the specimen shows a
t h r o u g h - a n d - t h r o u g h resection of the base of the tongue along
w i t h the supraglottic larynx, preserving the hypoglossal nerve on
the left-hand side ( F i g . 6 . 1 1 2 ) . The r e m a i n i n g attachments of the
neurovascular bundle of the tongue on the left-hand side are seen
here. The tongue remains viable w i t h its blood supply from the
left lingual artery, w h i l e m o t i o n of t h e t o n g u e on the left side is
retained due to preservation of the left hypoglossal nerve. At the
lower part of the surgical field the transected edges of the thyroid
cartilage, as well as the arytenoids on b o t h sides, are seen.
Frozen sections are n o w obtained from the mucosal margins of
the false vocal cords on both sides, as well as the pharyngeal mar-
gins on the left and right sides and anterior margin of the mucosa
and musculature of the base of the tongue. A massive resection of
the base of the tongue in c o n j u n c t i o n w i t h the supraglottic larynx
is thus satisfactorily performed via this approach.
A nasogastric feeding tube is inserted prior to closure. Repair of
t h e surgical defect requires careful a t t e n t i o n to detail, as anatomic
c o n t i n u i t y of the upper alimentary tract is important as well as
restoration of the physiologic f u n c t i o n of d e g l u t i t i o n . The larynx
m u s t , therefore, he resuspended back to the base of (he tongue to
simulate the normal a n a t o m y and physiology d u r i n g the act of
d e g l u t i t i o n . Using a high-speed d r i l l , several drill holes are made
t h r o u g h the upper edge of the transected t h y r o i d cartilage on each
side. Approximately four to five d r i l l holes are made on each side
of the t h y r o i d lamina. The larynx is approximated back to the
musculature of the base of the tongue using 0 chromic catgut
sutures ( F i g . 6 . 1 1 3 ) . This closure is similar lo the procedure
f o l l o w i n g a standard supraglottic partial laryngectomy. No attempt
is made to o b t a i n mucosal closure between the cut edge of the
mucosa of the base of the tongue and the cut edge of the mucosa
of the supraglottic l a r y n x . On the o t h e r h a n d , these heavy sutures
are used to approximate the transected stump of the musculature
of the base of the tongue to the transected t h y r o i d cartilage as
shown here. All sutures are appropriately placed first and then tied
sequentially. Note that these sutures traverse t h r o u g h the stump
of the musculature of the base of the tongue, w h i l e the mucosal
edge is left free to epithelialize spontaneously.
The remaining closure of the m a n d i b u l o t o m y has been described
previously. The floor of the m o u t h mucosa is approximated to the
mucosa of (he lingual gingiva by interrupted 2-0 chromic catgut
201
 Fig. 6.113 The larynx Fig. 6.116 Endoscopic
is approximated back view one year after
to the musculature of surgery.
the base of the tongue.

Fig. 6.117 Post

operative photograph
showing a well healed
incision.

Fig. 6.114 Posterior

view of the specimen.

Ihc resected superior r i m of the t h y r o i d cartilage al the lower part

of the specimen. The mucosa a n d soft tissues of the petiole of the
epiglottis f o r m the inferior soft tissue margin of the specimen.
T h u s an oncologically sound surgical resection of the t u m o r is
Fig. 6.115 Caudal view
performed via the m a n d i b u l o t o m y approach.
of the specimen.
Rehabilitation of the patient, in terms of the ability to handle
secretions and restore the act of swallowing, requires much training
a n d t i m e . Once the patient is able to handle her secretions, a trial
is given w i t h pureed foods. Patients u n d e r g o i n g surgery of this
nature w i l l i n i t i a l l y be unable to take liquids by m o u t h . If the
patient is able to handle pureed foods, then he is advanced to a
soft diet a n d can take clear liquids last. Rehabilitation f o l l o w i n g a
resection of this m a g n i t u d e can take as l o n g as three months.
However, the eventual f u n c t i o n a l a n d esthetic result is very satis-
factory. T h e endoscopic view a p p r o x i m a t e l y one year after surgery
shows a p p r o x i m a t i o n of the r e m a i n i n g t o n g u e to the remaining
l a r y n x ( K g . 6 . 1 1 6 ) . A well-healed external incision is s h o w n in
K g . 6.117.

MANDIBLE RESECTION IN THE MANAGEMENT OF

sutures. The m a n d i b u l o t o m y is repaired w i t h miniplates and
screws. M y l o h y o i d muscle is resutured a n d the rest of the incision
Of the neck is closed in layers.
The posterior view of the specimen shows destruction of the
epiglottis w h i c h is c o m p l e t e l y replaced by t u m o r ( K g . 6 . 1 1 4 1 .
Note that the inferior m a r g i n of the surgical specimen is clear of
the tumor. The l a r y n x is transected at a b o u t t h e level of the u p p e r
border of the false vocal cords on b o t h sides. Al I h c upper border
of the specimen, the anterior m a r g i n of the transected base of the
tongue is seen, clear of t u m o r .
In F i g . 6 . 1 IS the caudal v i e w of the specimen is s h o w n . Note
INTRAORAL CANCER
Surgical resection of the m a n d i b l e becomes necessary w h e n a
p r i m a r y malignant t u m o r of the oral cavity d i r e c t l y extends to the
gingiva over the alveolar process, or infiltrates i n t o the mandible.
If t h e r e is direct extension of the t u m o r f r o m the alveolar process
to the cancellous part of the m a n d i b l e , or if contiguous t u m o r
i n f i l t r a t i o n to the lingual or lateral cortex of the mandible is
present, t h e n a segmental m a n d i b u l e c t o m y becomes necessary
( K g . 6.118).

202
Fig. 6.118 Segmental mandibulectomy.
Fig. 6.120 Marginal mandibulectomy of the Fig. 6.121 Marginal mandibulectomy of the
symphysis of the mandible. body of the mandible.
On the other hand, if a p r i m a r y t u m o r of the oral cavity
approximates the alveolar process or t h e lingual surface of the
mandible, then resection of a part of the mandible preserving its
arch is adequate to obtain satisfactory margins around the p r i m a r y
tumor. In this clinical setting, segmental m a n d i b u l e c t o m y is not
indicated but a marginal m a n d i b u l e c t o m y proves to be satis-
factory {Fig. 6 . 1 1 9 ) . A marginal m a n d i b u l e c t o m y can accomplish
resection of the lingual plate or the alveolar process or b o t h , but
still retains the c o n t i n u i t y of the arch of the mandible by
preserving its lower border or the lateral cortex. T h e routes of
spread of intraoral t u m o r s in p r o x i m i t y to the m a n d i b l e are such
that marginal resection is feasible in both dentate a n d edentulous
mandibles. This procedure produces m i n i m a l , if any, esthetic a n d
functional d e f o r m i t y . W h i l e p e r f o r m i n g a m a r g i n a l m a n d i -
bulectomy, every attempt should be made to avoid sharp angles in
the bone cuts, since they are weak points a n d may produce
inadvertent stress fracture at that site. Marginal m a n d i b u l e c t o m y
can be performed on any part of the mandible, i.e. symphysis,
body, or retromolar trigone (Figs 6 . 1 2 0 - 6 . 1 2 2 1 . Mandible recon-
struction is not necessary f o l l o w i n g marginal mandibulectomy,
Fig. 6.119 Marginal mandibulectomy on the body ot the mandible.
Fig. 6.122 Marginal mandibulectomy of the
retromolar trigone and coronoid process of the
mandible.
but must be considered for segmental mandibulectomy. Mandible
reconstruction, if indicated, m a y be d o n e either primarily or
secondarily. II secondary reconstruction is planned, then stabiliz-
a t i o n of the t w o stumps of the mandible, by either internal,
external, or intermaxillary fixation is indicated.
PERORAL MARGINAL MANDIBULECTOMY
Small p r i m a r y tumors of the anterior aspect of the lower gum are
suitable for excision t h r o u g h the open m o u t h including the
alveolar process, regardless of the presence or absence of teeth.
Such a resection requires marginal mandibulectomy. This oper-
a t i o n is also indicated for lesions of the floor of the m o u t h or
cheek mucosa approaching the lower alveolus.
Marginal m a n d i b u l e c t o m y can be safely performed through the
open m o u t h for small lesions particularly in the anterior aspect of
I he oral cavity. The patient shown in Fig. 6.123 has a 1 cm-sized,
ulcerated superficial carcinoma i n v o l v i n g the alveolus of the
edentulous mandible adjacent to her remaining central incisor
203

Fig. 6.124 The surgical specimen (surface view).
Fig. 6.12S The surgical specimen (side view).
t o o t h . A panoramic x-ray of t h e m a n d i b l e d i d not s h o w a n y
evidence of hone d e s t r u c t i o n beneath this lesion. This t u m o r is
therefore suitable for a marginal m a n d i b u l e c t o m y .
The surgical specimen oi marginal m a n d i b u l e c t o m y accom-
plished t h r o u g h the open m o u t h is s h o w n in Figs 6 . 1 2 4 and
6.125. Note the satisfactory mucosal a n d soft tissue margins are
secured, as seen in the surface v i e w of the specimen. In the side
view as seen in Fig. 6 . 1 2 S , the height of the surgical specimen is
shown w i t h a m p l e deep b o n y m a r g i n f o r this superficial ulcerated
204
Fig. 6.126 The appearance of the mouth one year postoperatively.
Fig. 6.127 The external appearance of the patient.
carcinoma. The surgical defect is repaired by p r i m a r y closure of
the mucosa of the f l o o r of the m o u t h to the mucosa of the lower
l i p . A l t h o u g h the sulci at the site of the resected m a n d i b l e in the
floor of the m o u t h a n d the gingivolabial region are eliminated,
the f u n c t i o n a l i m p a i r m e n t in the i m m e d i a t e postoperative period
is m i n i m a l .
T h e postoperative appearance of the m o u t h at approximately
one year shows a well-healed suture line ( F i g . 6 . 1 2 6 ) . Note the
absence of g i n g i v o l a b i a l sulcus, as w e l l as f l a t t e n i n g of the mucosa
of the f l o o r of the m o u t h . The external appearance of the patient,
however, remains unchanged ( F i g . 6 . 1 2 7 ) . In the l o n g term (In-
patient m a y need a secondary vestibuloplasty lo create sulci to
facilitate wearing a denture. Technical details of a secondary
vestibuloplasty are discussed later in this chapter. Alternatively,
one may choose to use a split-thickness skin gralt p r i m a r i l y to
cover t h e m a r g i n a l l y resected m a n d i b l e a n d t h u s restore (he sulci.
T h e technical details of p r i m a r y vestibuloplasty are also discussed
later in this chapter. On the o t h e r h a n d , a vestibuloplasty and
fabrication of a removable denture are not required if (he patient
is a suitable candidate for osseointegrated i m p l a n t s and a per-
manent fixed denture.
l i m i t e d resections for small p r i m a r y t u m o r s ol the oral cavity
w i t h marginal m a n d i b u l e c t o m y can be performed t h r o u g h the
o p e n m o u t h . On the other h a n d , if wider exposure is necessary for
access to the p r i m a r y t u m o r and its satisfactory resection, then
either a lower cheek flap approach or a visor flap approach is
r e c o m m e n d e d . In most instances, t h e lower cheek flap approach
Fig. 6.128 The lower cheek flap approach.
Fig. 6.129 Carcinoma of the lower alveolus.

is desirable since it provides satisfactory exposure and permits

resection of the primary tumor and ipsilateral cervical lymph
nodes in continuity in a monobloc fashion (Fig. 6.128).
The lower cheek flap approach involves splitting the lower lip
and the chin in the midline through its full thickness up to the
symphysis of the mandible. Ihe incision continues in the midline
up to the thyrohyoid membrane, where it turns toward the ipsi-
lateral neck along an upper neck skin crease. This transverse
component of the incision should be at least two finger breadths
below the body of the mandible to prevent inadvertent injury to
the mandibular branch of the facial nerve during elevation of the
cheek flap.

MARGINAL MANDIBULECTOMY AND REPAIR WITH

SKIN GRAFT

An intraoral photograph of a patient with carcinoma of the lower

alveolus adjacent to her remaining teeth is shown in Fig. 6.129.
The primary lesion is exophytic and relatively superficial involving
the alveolar process and attached gingiva of the adjacent teeth.
Panoramic x-ray of the mandible fails to show any evidence of Fig. 6.130 Panoramic x-ray of the mandible.
bone destruction (Fig. 6.130). Marginal mandibulectomy in this
patient is performed using a lip-splitting lower cheek flap
approach to gain exposure of the lesion. A high-speed sagittal
power saw is used to accomplish a marginal mandibulectomy in a
smooth curved fashion to evenly distribute the stress at the site of
bone resection. The surgical specimen in Fig. 6.131 shows a
satisfactory three-dimensional resection of the primary tumor.
The surgical defect shown in Fig. 6.132 demonstrates a smooth-
curved marginal resection of the mandible with sufficient cortical
bone remaining to provide stability to the mandible and to
preserve the continuity of the arch of the mandible. The surgical
defect in this patient was repaired using a Split-thickness skin
graft. The skin graft usually heals satisfactorily and provides
excellent coverage of the exposed hone (Fig. 6.133). Since the
patient has remaining teeth in the lower dentition, a removable
denture is fabricated which can be clasped to Ihe teeth to restore
lower dentition (Fig. 6.134).

If adequate vertical height of the remaining body of the

mandible following marginal mandibulectomy is available, then
osseointegrated implants can be inserted either at the time of
marginal mandibulectomy or later on. If, however, the osseo- Fig. 6.131 The surgical specimen.

205
Fig. 6.132 The surgical defect. Fig. 6.135 Patient with osseointegrated implants at the site of marginal
mandibulectomy.

Fig. 6.133 The healed skin graft. Fig. 6.136 Panoramic x-ray showing implants with fixed denture in
place.

Fig. 6.134 A removable denture. Fig. 6.137 Intraoral view of permanent fixed denture of the patient
shown in Figs 6.134 and 6.135.
Integrated implants are inserted p r i m a r i l y , satisfactory coverage
over the mandible s h o u l d be secured to avoid exposure a n d loss of
the implants. A radial forearm free flap w o u l d he ideal in that in the area of t h e m a n d i b l e where m a r g i n a l m a n d i h u l e c t o m y was
setting. Another patient s h o w n in Pig. 6 . 1 3 5 has osseointegrated p e r f o r m e d . An i n t r a o r a l v i e w of the p e r m a n e n t fixed denture is
implants placed secondarily at the silo of marginal m a n d i h u l e c t o m y shown in Fig. 6.137. Thus, when feasible, osseointegrated
w i t h a permanent fixed denture in place. I ler panoramic x-ray s h o w n i m p l a n t s s h o u l d be considered for c o m p l e t e dental rehabilitation
in Fig. 6 . 1 3 6 demonstrates the satisfactory position of the i m p l a n t s following marginal mandibulectomy.

206
MARGINAL MANDIBULECTOMY IN CONTINUITY WITH
RADICAL NECK DISSECTION (PULL THROUGH
OPERATION)
An intraoral photograph of a patient w i t h a p r i m a r y carcinoma of
the right side of the floor of the m o u t h , extending just to (he left
of the m i d l i n e , is s h o w n in F i g . 6 . 1 3 8 . She has clinically palpable
ipsilateral cervical l y m p h nodes at Level I I . The surgical procedure
planned here w i l l accomplish resection of the floor of the m o u t h
in c o n j u n c t i o n w i t h a marginal m a n d i b u l e c t o m y , w i t h a t h r o u g h -
and-through resection of the musculature of the floor of the m o u t h
in c o n t i n u i t y w i t h a right radical neck dissection. The specimen of
the p r i m a r y t u m o r is delivered in the neck in a pull t h r o u g h
fashion.
The patient is placed on the operating table under general
anesthesia w i t h a nasotracheal tube. The o u t l i n e d incision w i l l
permit elevation of the lower cheek f l a p on the r i g h t - h a n d side
(Fig. 6.139). The incision begins at the t i p of the mastoid process,
Fig. 6.1 S8 Carcinoma of the right side of the floor of the mouth
adjacent to the lower gingiva.
Fig. 6.139 The skin
ncision is outlined.
c u r v i n g anteriorly along an upper skin crease ol (he neck up to (he
m i d l i n e where it curves cephalad, d i v i d i n g the c h i n and the lower
l i p in (he m i d l i n e . A curvaceous vertical l i m b extends from about
the m i d p o i n t of the transverse incision up to the clavicle to
facilitate radical neck dissection.
T h e neck dissection is c o m p l e t e d in the usual fashion except for
Level I t h r o u g h w h i c h the specimen remains attached to the
p r i m a r y t u m o r (Fig. 6 . 1 4 0 ) . The specimen of the dissected neck
is f l i p p e d t o w a r d t h e c h i n , d e m o n s t r a t i n g the dissected neck
inferior to the digastric muscle. All attachments of the specimen
inferior and deep to the digastric t e n d o n are divided at this point.
The neck dissection specimen is n o w flipped back in the
posterior part of the neck and dissection of Level I is undertaken
(Fig. 6 . 1 4 1 ) . The upper neck flap is elevated, carefully identifying
a n d preserving t h e m a n d i b u l a r b r a n c h of the facial nerve. Soft
tissues o v e r l y i n g the body of the mandible are now incised. With
an electrocautery, the periosteum of the body of the mandible
f r o m the symphysis up to t h e insertion of t h e masseter muscle
near the angle of the m a n d i b l e is exposed. The rest of the skin
incision, d i v i d i n g the lower lip a n d the soft tissues of the c h i n , is
n o w c o m p l e t e d p e r m i t t i n g elevation o f the lower cheek flap. This
w i l l need an incision in the mucosa of the gingivobuccal sulcus
from the m i d l i n e up to the retromolar trigone (Fig. 6.142).
Fig. 6.140 The neck dissection is completed with the specimen attached
at Level I to the primary tumor.
mam
Fig. 6.141 The neck dissection specimen is flipped back.
207
 Fig. 6.144 Incision in the mucosa of the undersurface of the tongue.

Fig. 6.143 Close-up view of the surgical field. Fig. 6.145 Marginal mandibulectomy is completed in an oblique
fashion.

The mucosal incision in the g i n g i v o b u c c a l sulcus is deepened

through the soft tissue attachments, exposing the lateral cortex of
the body of the m a n d i b l e a n d p e r m i t t i n g elevation a n d retraction
of the lower cheek flap. A close-up v i e w of the surgical held shows
the primary t u m o r and the undersurface of the t o n g u e a n d the
contents of the s u b m a n d i b u l a r triangle still r e m a i n i n g attached
medial to the m a n d i b l e ( P i g . 6 . 1 4 3 ) .
An incision is n o w made in the mucosa of the undersurface of
the tongue ( F i g . 6 . 1 4 4 1 . The mucosal i n c i s i o n extends f r o m the
alveolar process of the body of the m a n d i b l e on the right side up
to the alveolar process on the left side, keeping a generous cuff of
normal mucosa a r o u n d the p r i m a r y t u m o r . T h i s i n c i s i o n o u t l i n e s
the extent of the mucosa of the floor of the m o u t h to be resected
along w i t h the p r i m a r y t u m o r . The mucosal i n c i s i o n is deepened
t h r o u g h the musculature of the undersurface of the t o n g u e a n d
the floor of the m o u t h using electrocautery.
The musculature of the undersurface of the t o n g u e as w e l l as the
Fig. 6.146 The portion of the mandible to be resected with the primary
mucosa of the floor of the m o u t h are c o m p l e t e l y d i v i d e d . A power tumor is retracted cephalad, showing the genioglossus muscle.
sagittal saw is used for m a r g i n a l m a n d i b u l e c l o m y . T h e specimen
includes the alveolar process a n d as m u c h of the lingual plate of
the mandible as possible. This w i l l require the bone cut to be in an Using a skin h o o k , the p o r t i o n of the m a n d i b l e to be resected
oblique fashion ( F i g . 6 . 1 4 5 1 . Such an o b l i q u e cut w o u l d p e r m i t w i t h the p r i m a r y t u m o r i s n o w retracted cephalad, d e m o n s t r a t i n g
resection of the musculature of the floor of the m o u t h w h i c h remains the muscular a t t a c h m e n t s at the genial tubercle ( F i g . 6 . 1 4 6 ) . The
attached to the excised p o r t i o n of the m a n d i b l e in a m o n o b l o c entire thickness of I he musculature of the floor of the m o u t h is
fashion. The m a n d i b l e is thus d i v i d e d in an o b l i q u e sagittal plane Ihus resected w i t h the marginal m a n d i b u l e c t o m y . Remaining soft
permitting resection of the alveolar process a n d the lingual plate. tissue attachments between the resected part of the m a n d i b l e a n d

208
 Fig. 6.147 The surgical
specimen.
Fig. 6.148 The surgical
defect.
the patient arc now detached using an electrocautery. T h i s p o r t i o n
of the specimen containing the primary tumor, marginally resected
mandible and the musculature of the floor of the m o u t h , is now
ready to be delivered t h r o u g h the mandibular arch to the right-
hand side of the neck. Alter its delivery in the neck, the specimen
of the primary t u m o r still remains attached t h r o u g h remaining
fibers of the hyoglossus and g e n i o h y o i d muscles. Once these are
divided, the primary tumor, resected in c o n t i n u i t y w i t h the c o n -
tents of the dissected right side of the neck, is removed.
The excised specimen shows m o n o b l o c resection of the primary
tumor of the floor of the m o u t h , w i t h marginal m a n d i b u l c c t o m y
and through-and-through resection of the floor of the m o u t h , in
continuity w i t h the cervical l y m p h nodes excised by a radical
neck dissection on the right-hand side ( H i ; . 6.1471. The resulting
surgical defect is seen in Fig. 6.148. A through-and-through defect
of the floor of the m o u t h creates a c o m m u n i c a t i o n between the
oral cavity and the dissected neck on the r i g h t - h a n d side.
A close-up view of the surgical defect at the p r i m a r y site is seen
Fig. 6.149 Close-up view of the surgical defect at the primary site.
in Tig. 6 . 1 4 9 . Note that the musculature of the undersurface of
the anterior one-third of the tongue is excised in conjunction w i t h
the floor of the m o u t h to ensure a true three-dimensional resection.
However, the c o n t i n u i t y of the arch of the mandible is preserved.
Repair of the surgical delect thus created can be easily accom-
plished by primary closure, approximating the mucosa of the right
check to the mucosa of the right lateral border of the tongue over
the marginally resected mandible. As the closure continues anteriorly,
the mucosa of the t i p of the tongue is sutured to the mucosa of the
lower l i p up to the m i d l i n e . Primary closure performed in this
fashion, however, causes significant tethering of the tongue w i t h
significant impact on the clarity of speech, mastication and
swallowing due to impaired m o b i l i t y of the tongue. On the other
hand, a surgical defect such as this is ideally suited for primary
reconstruction using a radial forearm free flap. Alternatively, a
skin graft can be employed to provide mucosal coverage in the
anterior floor of the m o u t h . It must be noted, however, that if a
skin graft is used primarily, the healing process will be prolonged
since satisfactory primary healing of the skin graft in this location
for a defect of this magnitude seldom takes place. Therefore, when
feasible, a radial forearm free flap should be used since it ensures
primary healing and also provides just sufficient soft tissue to fill
the through-and-through delect. The surgical defect in this patient,
however, was repaired by p r i m a r y closure between the mucosa of
the tongue, cheek, and the lower lip. A meticulous watertight closure
is accomplished to prevent any potential air leak leading sub-
sequently to the development of a fistula. The remaining wound
is closed in routine fashion w i t h suction drains in the neck.
The postoperative appearance of the patient, approximately
eight weeks after surgery, shows satisfactory primary healing of
the suture l i n e between the tongue and the labial and buccal
mucosa (Fig. 6. ISO). The external esthetic appearance of the healed
incision is quite acceptable (Fig. 6.151). A l t h o u g h the midline
scar is visible, accurate a p p r o x i m a t i o n of the vermilion border
retains an essentially normal appearance a n d f u n c t i o n of the lip.
Since this patient's surgical defect was closed primarily, the
m o b i l i t y of the tongue remains restricted causing functional dis-
ability w i t h speech and mastication. This patient thus required a
secondary vestibuloplasty w i t h release of the tongue and coverage
of the raw area w i t h a skin graft. The intraoral appearance of the
floor of the m o u t h f o l l o w i n g a secondary vestibuloplasty is seen
in Fig. 6 . 1 5 2 . The skin graft covers the raw area at the site of the
exposed floor of the m o u t h , releasing the tongue and restoring its
m o b i l i t y for speech and mastication.
209

Fig. 6.1 SI The external appearance of the healed incision.
The tongue can be retracted back into the oral cavity (Fig.
6.1521 and can be protruded outside the oral cavity (Fig. 6.1531.
The vestibuloplasty also recreates the lingual and buccal sulci which
facilitate fabrication of a lower denture. Use of the lower denture
restores esthetic appearance and the patient's ability to masticate.
The denture made for this patient is seen in Fig. 6.154. In
210
Fig. 6.1 S3 The tongue mobility is improved.
Fig. 6.154 Specially fabricated lower denture.
Fig. 6.155 The denture placed in the oral cavity.
Fig. 6.155 the denture is seen in the oral cavity replacing the
lower alveolus. The eventual esthetic appearance of the patient is
shown in Fig. 6.156 with a full set of upper and lower dentures.
Although the lower denture provides adequate esthetic
rehabilitation, the patient's ability to chew in this otherwise
edentulous mandible is limited. If adequate vertical height of the
Fig. 6.156 The esthetic appearance of the patient with the denture.

Fig. 6.1S7 Intraoral photograph of a carcinoma of the right side of the

tloor of the mouth.
marginally resected mandible is available, then this patient should
be considered for secondary placement of osseointegrated dental
implants and a permanent tixed denture. Clearly such dental
rehabilitation is functionally superior. If, however, this patient
requires postoperative radiotherapy, then extreme caution should
be exercised in placing osseointegrated implants in a marginally
resected irradiated mandible. The risk for implant failure and
osteoradionecrosis is significant. Currently, experience with
osseointegrated implants in irradiated mandibles is limited.
Marginal mandibulectomy provides an oncologically sound
three-dimensional resection of tumors of the oral cavity that
approach, approximate or superficially involve the mandible. The
operative procedure leaves minimal esthetic and functional
deformity, avoids the need for mandible reconstruction and offers
local control of cancer in properly selected patients, comparable to
that achieved by segmental mandibulectomy.

MARGINAL M A N D I B U L E C T O M Y W I T H RADICAL NECK

DISSECTION A N D IMMEDIATE VESTIBULOPLASTY Fig. 6.1S8 The panoramic x-ray of the mandible.

Patients who have remaining teeth in the lower dentition,

following marginal resection of a part of the mandible, can be
considered lor immediate vestibuloplasty to restore the sulci. They
can wear an intermediate dental prosthesis as soon as the skin
graft of vestibuloplasty has healed.
An intraoral photograph of a patient witli primary carcinoma of
the right-hand side of the floor of the mouth, approaching the
lingual gingiva, is shown in Fig. 6.157. Me also has clinically
palpable cervical lymph nodes at Level I, requiring a right neck
dissection. The panoramic view of the mandible fails to show any
evidence of bone destruction by the tumor (Tig. 6.158). A surgical
specimen of resection of the floor of the mouth with marginal
mandibulectomy and in continuity right radical neck dissection is
shown in Fig. 6.159. Resection of the alveolar process and most
of the lingual plate of the mandible has been accomplished in a
monobloc fashion, in continuity with the contents of the dis-
sected right side of the neck, file surgical field shows the dissected Fig. 6.159 The surgical specimen.
neck on the right side with a through-and-through delect in the
floor of the mouth with the preserved arch of the mandible (Fig.
6.160). Note particularly the exposed muscles of the undersurface denture. A very thin skin graft is likely to ulcerate and produce
of the tongue which is retracted cephalad. denture sores due to lack of supporting soft tissues over the
A split-thickness skin graft is harvested from the lateral aspect of mandible. The skin graft is draped over the marginally resected
the thigh. It must be quite thick as it will be applied directly over mandible as shown in Fig. 6.161. A long strip of the skin graft is
the marginally resected mandible which will support the lower placed over the marginally resected mandible, beginning at the

211
Fig. 6.160 The surgical field.
Fig. 6.161 The skin graft is draped over the marginally resected
mandible.
retromolai area and extending to the anterior edge of the bony
delect. The skin graft is appropriately trimmed and positioned to
create a gingivobuccal sulcus as w e l l as a lingual sulcus in the f l o o r
of the m o u t h ( F i g . 6 . 1 6 2 ) . O r c u n i m a n d i b u l a r c h r o m i c catgul
sutures w i l l h o l d t h e skin graft in place. These sutures begin f r o m
the lower border of the m a n d i b l e on the buccal aspect a n d end
at the lower bonier of the m a n d i b l e on the l i n g u a l aspect I F i g .
6.163).
Once the graft is appropriately positioned, closure of the
surgical defect begins, a p p r o x i m a t i n g the lateral edge of the skin
graft to the mucosa of the cheek a n d lower l i p using i n t e r r u p t e d
chromic catgut sutures. The medial edge of the skin graft is
sutured to the mucosa of the undersurface of the tongue also
using interrupted c h r o m i c catgut sutures. F o l l o w i n g complete
closure of the mucosal defect, the n e w l y created sulci on t w o sides
of the mandible are m a i n t a i n e d , using either bolsters of X e r o f o r m
gauze or, preferably, short segments of soft-rubber t u b i n g . Size 24
or 26 soft-rubber t u b i n g is preferable. A p p r o p r i a t e lengths of the
t u b i n g are cut to lit the g i n g i v o b u c c a l sulcus a n d the sulcus on the
lingual aspect of the m a n d i b l e .
The cut segments of the t u b i n g are t h e n placed in the n e w l y
created sulci a n d are retained there w i t h c i r c u m m a n c l i b u l a i
sutures using n o . 2 silk. The suture begins on the tube in the
212
Fig. 6.162 A gingivobuccal sulcus and lingual sulcus in the floor of the
mouth is created.
Fig. 6.16J Circummandibular absorbable sutures are used to hold the
skin graft in place.
gingivobuccal sulcus a n d goes t h r o u g h the t u b i n g and the soft
tissues a n d skin of t h e cheek, lateral to the m a n d i b l e where it
comes o u t . The same suture continues, re-entering the skin of the
submental region medial to the m a n d i b l e a n d t h e n traverses the
rubber l u b e in the f l o o r of t h e m o u t h , where it exits. Three such
sutures are placed a n d lied over the marginally resected mandible
covered w i t h the skin graft. T h e r e m a i n i n g incisions are closed in
the usual f a s h i o n .
M e t i c u l o u s oral hygiene must be m a i n t a i n e d in the post-
operative period if the skin graft is to survive a n d heal over the
m a r g i n a l l y resected m a n d i b l e . The bolsters of the rubber tubing
used to recreate the sulci are kept for a p p r o x i m a t e l y 7-8 days. In
most cases, the skin graft w i l l take w e l l a n d effectively create the
desired sulci. I m m e d i a t e l y u p o n removal of the bolsters or the
rubber t u b i n g , the patient must be seen by a prosthodontist for
fabricating an i m m e d i a t e t e m p o r a r y lower denture, w h i c h will fit
over the m a n d i b l e i n t o the new sulci. This is absolutely man-
datory, otherwise the skin graft w i l l Ratten out a n i l the newly
created sulci w i l l be lost. T h e final denture s h o u l d not be made
u n t i l a p p r o x i m a t e l y 6 - 8 weeks f o l l o w i n g surgery.
The postoperative p h o t o g r a p h of the oral cavity approximately
eight m o n t h s f o l l o w i n g marginal m a n d i b u l i ' c t o m y a n d immediate
vcstibuloplasty shows well-created l i n g u a l a n d buccal sulci (Fig.
6.164|. Immediate vestibuloplasty w i t h a skin graft is, therefore,
indicated i n patients w h o have r e m a i n i n g lower d e n t i t i o n f o l l o w -
ing marginal m a n d i h u l e e t o m y for resection of i n t r a o r a l cancer.
This reconstructive effort is simple a n d it restores sulci effectively
to permit satisfactory use of a partial lower denture. Patients such
as this are also candidates for consideration of osscointegrated
implants provided all o t h e r factors relating to the operated m a n -
dible and the patient are satisfactory. However, the need for
osscointegrated i m p l a n t s in patients w i t h r e m a i n i n g teeth is less
compelling t h a n in edentulous patients.

MARGINAL MANDIBULECTOMY IN AN EDENTULOUS

PATIENT

W h e n marginal m a n d i h u l e e t o m y is p e r f o r m e d in an edentulous Fig. 6.166 Panoramic x-ray of the edentulous mandible, showing
cortical erosion at the left retromolar trigone.
patient, extreme caution must he exercised regarding maintenance
of the structural stability of the r e m a i n i n g m a n d i b l e , otherwise
the possibility of a fracture at that site exists. If this is feared to
he the case, then the r e m a i n i n g m a n d i b l e s h o u l d be supported by
a metallic plate as a buttress to prevent spontaneous fracture.
flu- patient s h o w n in F i g . 6 . 1 6 5 has carcinoma of the retro-
molar region a n d the adjacent lower g i n g i v a on the left-hand side
w i t h invasion of the u n d e r l y i n g cortical b o n e . A p a n o r a m i c x-ray
of the edentulous m a n d i b l e (fig. 6 . 1 6 6 ] demonstrates cortical
erosion of the m a n d i b l e at the retromolar trigone r e q u i r i n g at
least a marginal m a n d i h u l e e t o m y . This patient u n d e r w e n t a
supraomohyoid neck dissection in c o n j u n c t i o n w i t h m a r g i n a l
mandihuleetomy for excision of the p r i m a r y tumor. In T i g . 6 . 1 6 7
the surgical field shows the lower cheek flap elevated in the usual
fashion r e m a i n i n g lateral to the outer cortex of the m a n d i b l e f r o m
the symphysis at the anterior m i d l i n e up to the m a n d i b u l a r n o t c h
posteriorly. The s u p r a o m o h y o i d neck dissection has been c o m -
pleted. T h e extent of b o n e resection to be u n d e r t a k e n at t h e site
of the p r i m a r y t u m o r is marked at the angle of the m a n d i b l e w i t h Fig. 6.167 The extent of bone resection is outlined on the mandible.
resection of the posterior part of the body of the m a n d i b l e a n d the
anterior part of the ascending ramus of the m a n d i b l e . A p p r o p r i a t e
three-dimensional resection is t h e n undertaken using a h i g h - surgical defect in the m a n d i b l e is s m o o t h e d o u t . Note that the
speed power saw. T h e surgical specimen viewed f r o m the lateral r e m a i n i n g m a n d i b l e is very t h i n and tenuous a n d is therefore at a
aspect is s h o w n in r i g . 6 . 1 6 8 . Note a three-dimensional resection risk of spontaneous fracture. A l o n g m i n i p l a t e is therefore used to
has been accomplished w i t h a satisfactory deep margin to excise support the r e m a i n i n g m a n d i b l e to prevent a fracture ( F i g . 6.169).
the alveolar process of the m a n d i b l e in a m o n o b l o c fashion. The The m i n i p l a t e is appropriately shaped to tit the lateral cortex of

213
 Fig. 6.170 Miniplate stabilization of thin, remnant mandible after
marginal resection.

Fig. 6.168 The surgical specimen (lateral aspect).

Fig. 6.171 Postoperative intraoral view showing a well-healed radial

forearm flap.

Fig. 6.169 The miniplate is shaped to fit the lateral cortex of the Fig. 6.172 External
mandible. postoperative
appearance of the
patient.
the mandible e x t e n d i n g f r o m I h c upper end of the ascending
ramus up lo the anterior aspect of the b o d y of the m a n d i b l e .
Several screws are used to h o l d the m i n i p l a t e in p o s i t i o n . T h e
point of m a x i m u m stress is at the angle of the m a n d i b l e a n d by
application of the plate, stress at that site is reduced a n d a
spontaneous fracture avoided. In this patient a p r i m a r y closure
could be easily achieved between the mucosa of the floor of the
m o u t h and the buccal mucosa. However, if the soft tissue a n d
mucosal defect are significant, t h e n a free flap is necessary to
achieve a satisfactory mucosal closure a n d protect the metallic
plate used to support the m a n d i b l e .
The patient whose panoramic x-ray is s h o w n in F i g . 6 . 1 7 0
underwent composite resection of the tonsillar fossa, adjacent soft
palate, base of t h e t o n g u e and f l o o r of t h e m o u t h f o r squamous
cell carcinoma of the tonsil w h i c h had failed to respond lo radiation used to support the m a n d i b l e near the angle a n d provide the
therapy. A satisfactory m o n o b l o c three-dimensional resection of necessary strength to avoid a spontaneous fracture. Surgical defect
the tonsil t u m o r warranted the need for a marginal mandi- in this patient was repaired using a radial forearm free flap to
bulectomy, excising the c o r o n o i d process of the m a n d i b l e a l o n g provide replacement of the soft tissue defect a n d mucosal cover-
w i t h the anterior half of the ascending ramus of the m a n d i b l e a n d age. T h e postoperative intraoperative p h o t o g r a p h shows a well-
the alveolar process of I be posterior part of the body of the healed radial forearm free flap replacing the soft palate, tonsillar
mandible. However, the posterior a n d inferior cortex of the m a n - fossa, posterior p h a r y n g e a l wall, retromoiar region a n d the
dible could be preserved a l o n g w i t h an intact t e m p o r o m a n d i b u l a r adjacent base of t h e t o n g u e ( F i g . 6 . 1 7 1 1 . It is crucial lo achieve a
joint. The previously irradiated r e m a i n i n g m a n d i b l e w o u l d be at a p r i m a r y closure of the mucosal defect to avoid sepsis and exposure
very high risk for spontaneous fracture. Therefore, an A-0 plate is of the A-0 plate. I n f e c t i o n a n d exposure mandates removal of the

214
plate and poses the risk of spontaneous fracture of the previously
irradiated a n d n o w infected residual weakened m a n d i b l e . In a
setting such as that, it w o u l d he best to proceed w i t h segmental
resection of the m a n d i b l e a n d consider fibula free flap recon-
struction. Postoperative external appearance of the patient shows
excellent retention of the c o n t o u r of the face w i t h m a i n t e n a n c e
of the c o n t i n u i t y of the arch of the m a n d i b l e a n d , thus, a very
desirable f u n c t i o n a l a n d esthetic result ( F i g . 6 . 1 7 2 ) .

COMPOSITE RESECTION—SEGMENTAL
MANDIBULECTOMY—COMMANDO OPERATION

A composite resection, c o m m a n d o o p e r a t i o n , is i n d i c a l c d for

primary t u m o r s of the oral c a v i t y w h i c h e x t e n d to i n v o l v e the
mandible (Fig. 6 . 1 7 3 ) . On occasion, a composite resection may
b e indicated for patients w i t h p r i m a r y t u m o r s h a v i n g extensive
soft tissue disease a r o u n d the m a n d i b l e r e q u i r i n g the need to
sacrifice an i n t e r v e n i n g segment of m a n d i b l e to a c c o m p l i s h an
i n c o n t i n u i t y resection o f the p r i m a r y t u m o r i n c o n j u n c t i o n w i t h
neck dissection. Thus, a c o m m a n d o operation or a composite
Fig. 6.173 Segmental mandibulectomy.
resection entails excision of the intraoral p r i m a r y t u m o r a l o n g
w i t h a segment of the i n t e r v e n i n g m a n d i b l e performed in c o n -
junction w i t h ipsilateral neck dissection as a m o n o b l o c surgical
resection.
The patient s h o w n in F i g . 6 . 1 7 4 has p r i m a r y squamous cell
carcinoma of the oral t o n g u e w i t h extension to the adjacent f l o o r
of the m o u t h a n d the lingual g i n g i v a . The p r i m a r y t u m o r is a
deeply i n f i l t r a t i n g t u m o r o c c u p y i n g l i t e r a l l y t h e right h a l f o f the
oral tongue w i t h i n f i l t r a t i o n of its musculature a n d causing
restriction in the m o b i l i t y of the t o n g u e . Radiologic studies fail to
demonstrate any b o n e destruction of the m a n d i b l e but there is
extensive soft tissue disease plastered against the lingual surface of
the mandible on the r i g h t - h a n d side. In a d d i t i o n to this, the
patient has clinically palpable cervical l y m p h node metastasis at
Level II as shown in Fig. 6 . 1 7 5 . The incision for the operation is
a standard trifurcate incision for neck dissection b e g i n n i n g at the
tip of the mastoid process a n d c u r v i n g anteriorly, r e m a i n i n g at
least two finger breadths below the body of the m a n d i b l e along an Fig. 6.174 Deeply infiltrating tumor of the right halt of the oral tongue.
upper neck skin crease up to the m i d l i n e of the neck at the level
of the hyoid b o n e ( F i g . 6 . 1 7 6 ) . At that p o i n t t h e i n c i s i o n turns
cephalad, d i v i d i n g the skin a n d soft tissues of the c h i n a m i the view shows c o m p l e t e d dissection of Levels I I , 111, IV and V w i t h
lower lip in the m i d l i n e . A vertical curvaceous c o m p o n e n t of exposure of the digastric muscle a n d hypoglossal nerve w i t h the
the incision begins at the region of the posterior border of the specimen reflected cephalad ( F i g . 6 . 1 7 9 ) . As the operation pro-
sternocleidomastoid muscle on the transverse incision a n d it ceeds cephalad t o w a r d Level I, no a t t e m p t is made to dissect the
extends d o w n to the clavicle at the midclavicular p o i n t . Since the contents of the submandibular triangle w h i c h remain attached
clinically palpable cervical l y m p h nodes d i d n o t i n v o l v e soft t h r o u g h the floor of the m o u t h a n d the soft tissues medial to the
tissues along the course of the spinal accessory nerve, a m o d i f i e d m a n d i b l e to the p r i m a r y site. All the soft tissue attachments of
radical neck dissection Type I, preserving the accessory nerve, is the deeper l y m p h a t i c s a n d vessels are d i v i d e d in order to expose
planned. The sequential steps of m o d i f i e d radical neck dissection the e n t i r e inferior surface of the digastric muscle. The tail of the
Type I are described in Chapter 9. However, the o p e r a t i o n begins parotid g l a n d may have to be d i v i d e d to clear the retromandibular
w i t h dissection of the posterior t r i a n g l e of the neck by elevation l y m p h nodes. Several pharyngeal veins traversing over the digastric
of the posterior skin flap ( F i g . 6 . 1 7 7 ) . T h e posterior triangle t e n d o n a n d medial to the inferior belly of the digastric muscle are
dissection is c o m p l e t e d , carefully preserving the accessory nerve, d i v i d e d a n d ligatcd. At this juncture, the upper end of the internal
the phrenic nerve a n d the brachial plexus. Phe cutaneous roots of jugular vein is d i v i d e d w i t h its s t u m p d o u b l y ligated at the base of
the cervical plexus are d i v i d e d a n d dissection f r o m the posterior the s k u l l .
triangle extends up to the lateral aspect of the carotid sheath. T h e neck i n c i s i o n is extended cephalad in the m i d l i n e dividing
The anterior skin flap is elevated next. Phe lower e n d of the the skin of the c h i n a n d the lower l i p t h r o u g h its full thickness
sternocleidomastoid muscle is detached f r o m the clavicle a n d the ( F i g . 6 . 1 8 0 ) . T h e upper skin flap of the neck dissection is now
manubrium to expose the carotid sheath. T h e i n t e r n a l jugular elevated, r e m a i n i n g deep to the platysma w h i c h is retained on the
vein is divided (Fig. 6 . 1 7 8 ) . Dissection n o w proceeds cephalad flap. M e t i c u l o u s a t t e n t i o n s h o u l d be paid to identification and
along the carotid sheath up to the digastric muscle. A close-up careful preservation of the m a r g i n a l branch of the facial nerve to

215
Fig. 6.17S The patient has a clinically palpable lymph node at Level II in
the right neck.
Fig. 6.178 The internal jugular vein is divided and Levels II, III and IV
are dissected.

Fig. 6.176 The outline of the skin incision. Fig. 6.179 Close-up view of the completed dissection showing the
digastric muscle and hypoglossal nerve.

Fig. 6.180 The skin of

the chin and lower lip
is divided in the
midline.

Fig. 6.177 The posterior skin flap is elevated and the contents of the
posterior triangle are dissected.

216

Fig. 6.182 The entire lateral cortex of the mandible is exposed from the
mandibular notch up to the midline at the symphysis menti.
maintain the function of the lower lip and the competency of the
oral cavity. The upper skin flap is elevated up to the lower holder
of the mandible, extending from the midline of the chin all the
way up to the angle of the mandible. Division of the upper lip in
the midline through its full thickness is now completed up to the
lateral cortex of the mandible at the symphysis.
A mucosal incision is now placed in t h e gingivohuccal sulcus,
remaining close to the attached gingiva. The lower cheek flap is
elevated remaining right over the lateral cortex of the mandible
from the midline, all the way up to the angle of the mandible,
keeping all the musculature in the cheek flap (Fig. 6.181 Using
electrocautery, t h e masseter muscle is now detached from the
lateral aspect of the ascending ramus of the mandible all the way
up to the mandibular notch. This maneuver provides exposure of
the entire lateral cortex of the mandible Irom the mandibular
notch up to the midline at the symphysis menti (Fig. 6.182). A
close-up view of the surgical field shows t h e primary tumor with
the exposed segment of the mandible to be resected to achieve a
monobloc composite resection of the primary tumor, intervening
soft tissues in the floor of the mouth and at Level I, along with a
segment of the mandible and the contents of the dissected neck
Fig. 6.183 The exposed segment of the mandible with the primary
tumor, intervening soft tissues in the floor of the mouth and the
contents of the dissected neck on the right-hand side.
Fig. 6.184 A sagittal power saw is now used to divide the mandible.
on the right-hand side (Fig. 6.183). Since there is no invasion of
t h e bone, a hemimandibulectomy is not necessary. The ascending
ramus of the mandible can be safely preserved and used for
restoration of the continuity of the mandible using a fibula free
flap. Thus, the segment of the mandible to be resected in this
patient extends from the angle of the mandible posteriorly up to
the lateral incisor tooth anteriorly.
A sagittal power saw is now used to divide the mandible at the
designated locations (Fig. 6.184). lirisk hemorrhage should be
expected following division of the mandible from its cut ends.
Bone wax is used to control the bleeding. Extreme caution should
be exercised not to allow the power saw to cut through the soft
tissues medial to the mandible, otherwise excessive hemorrhage
will result from laceration of the pterygoid muscle posteriorly and
(he musculature of the floor of the mouth anteriorly. Close-up
view of the surgical field shown in Fig. 6.18S demonstrates the
divided ends of t h e mandible with the segment of the mandible
to be resected along with the primary tumor. The mandible is
divided at both places with straight cuts to facilitate introduction
of a vascularized free graft of fibula to achieve a satisfactory
reconstruction.
217
Fig. 6.185 Close-up view of the surgical field demonstrates the divided Fig. 6.186 The surgical field at the completion of resection.
ends of the mandible with the segment of the mandible to be resected
along with the primary tumor.

Once the mandible is d i v i d e d , the p r i m a r y t u m o r can n o w be Fig. 6.187 The extent

easily delivered i n t o the surgical f i e l d . An Adair c l a m p is used to of resection of soft
grasp the tip of the t o n g u e a n d deliver the tongue out i n t o the tissue of the tongue.
surgical field. Using an electrocautery, a mucosal i n c i s i o n is placed
around the surface extent o f t h e p r i m a r y t u m o r w i l h a generous
cuff of n o r m a l mucosa a n d the adjacent soil tissues lo secure satis-
factory margins. Using the electrocautery, a three-dimensional
resection o f t h e p r i m a r y t u m o r a l o n g w i t h t h e u n d e r l y i n g soft
tissues and musculature of the tongue a n d f l o o r of m o u t h is
performed, remaining i n c o n t i n u i t y w i t h the m a n d i b l e and the
contents o f t h e dissected neck. I n this patient, i i w i l l e n t a i l
division of the tongue f r o m its tip up lo the circumvalate papillae
in the m i d l i n e where the incision turns laterally up to the soft
palate. The hyoglossus a n d genioglossus muscles are d i v i d e d . Brisk
hemorrhage from the lingual artery is to be expected w h i c h is
appropriately controlled, f i n a l l y the m y l o h y o i d muscle is detached
from the hyoid hone a n d the r e m a i n i n g soft lissue attachments of
the specimen are d i v i d e d lo deliver the specimen. The extent of
mucosal and soft tissue resection clearly depends on the surface
extent and invasive nature of the p r i m a r y t u m o r a n d the involve-
ment of the u n d e r l y i n g musculature, soft tissues, a n d neuro-
vascular bundles.
Once the specimen is r e m o v e d , appropriate hemostasis is
secured in the surgical field. A m o n o b l o c resection of the p r i m a r y
minor in c o n j u n c t i o n w i t h the contents of the dissected neck a n d Fig. 6.188 Surgical
the intervening soft tissues, l y m p h a t i c s a n d m a n d i b l e is thus specimen
accomplished (Fig. 6.186). Note that a complete henii- demonstrating
monobloc excision.
glossectomy has been p e r f o r m e d on the r i g h t - h a n d side s h o w i n g
the cut surface of the t o n g u e t h r o u g h its m i d l i n e d e m o n s t r a t i n g
the genioglossus a n d hyoglossus muscles.
The tongue is retracted a n t e r o - i n l e r i o r l y to demonstrate the
mucosal surface of the r e m a i n i n g hall Of the t o n g u e in the surgical
field (Fig. 6 . 1 8 7 ) . f r o z e n sections are o b t a i n e d f r o m appropriate
areas of the surgical defect d e p e n d i n g on the extent ol the p r i m a r y
tumor and the j u d g m e n t of the surgeon regarding the p r o x i m i t y
o f the t u m o r t o the surgical m a r g i n s
The surgical specimen shows the p r i m a r y t u m o r in c o n j u n c t i o n
w i t h a segment of the b o d y of the m a n d i b l e a n d the contents of
tin 1 dissected neck on the r i g h t - h a n d side r e m o v e d in a m o n o b l o c
fashion (Fig. 6 . 1 8 8 ) . A close-up v i e w of the surgical specimen
shows the surface extent of the p r i m a r y t u m o r a n d the preserved
continuity between the primary tumor, the floor of the mouth, a

218
 Fig. 6.189 Close-up
view of the specimen.

Fig. 6.190 Postoperative orthopantomogram showing the fibula free

flap in perfect position.

segment of the m a n d i b l e , a n d soft tissues a n d l y m p h a t i c s in the

floor of the m o u t h a n d l y m p h nodes at Level I ( F i g . 6 . 1 8 9 ) .
Immediate reconstruction of the m a n d i b l e a n d the resected
portion of the tongue is accomplished using a composite fibula
free flap w i t h its attached musculature a n d o v e r l y i n g skin to
restore the c o n t i n u i t y of the resected p o r t i o n of the m a n d i b l e and
reconstruct the right half of the tongue.
Ihc harvest of the composite free flap generally begins s i m u l -
taneously ( l u r i n g the course of the composite resection. As soon as Fig. 6.191 External appearance of the patient one month after surgery.
the surgical specimen is available, appropriate measurements are
taken f r o m the resected segment of the m a n d i b l e to fabricate the
fibula free flap to match the resected p o r t i o n of the m a n d i b l e .
Appropriate osteotomies are made in the fibular graft to achieve
the desired shape, c o n t o u r a n d curvature of (he graft to match the
mandibular defect. A p p r o p r i a t e shaping a n d t r i m m i n g of the soft
tissue and skin c o m p o n e n t of the flap are undertaken to recon-
struct the resected portion of the tongue. Microvascular anastomoses
are completed and thus a composite reconstruction is achieved in
a single stage operative procedure.
A nasogastric feeding tube is inserted. The remaining mandibular
teeth on the left-hand side are placed in i n t e r - m a x i l l a r y f i x a t i o n
w i t h arch bars and wires to m a i n t a i n occlusion a n d position of the
reconstructed fibular graft, f o l l o w i n g this, the incisions arc closed
in the usual fashion w i t h suction drains in the neck. Special
attention s h o u l d be given to closure of (he lower lip for perfect
alignment of the v e r m i l i o n border. T h e mucocutaneous j u n c t i o n
Fig. 6.192 Postoperative intraoral view showing well healed skin
of the v e r m i l i o n border is accurately aligned w i t h a n y l o n suture
component of the fibula free flap.
and retrograde closure of the mucosal aspect of the l i p incision is
performed first b e g i n n i n g at the v e r m i l i o n border and proceeding
up to the gingivolabial sulcus. Accurate a l i g n m e n t of the mus- patient is started on pureed foods by m o u t h and gradually-
culature of the l i p is performed next f o l l o w e d by accurate closure advanced to a soft diet. A postoperative panoramic view of the
of the skin of the lower l i p a n d c h i n lo achieve a perfectly aligned reconstructed m a n d i b l e shows (he fibula free flap in perfect
skin closure. position achieving a satisfactory m a n d i b u l a r reconstruction (Fig.
A tracheostomy is performed at the c o n c l u s i o n of the operation 6 . 1 9 0 1 . External appearance of the patient approximately one
to faciliate clearance of p u l m o n a r y secretions postoperatively and m o n t h f o l l o w i n g surgery shows accurate restoration of (he facial
for provision of a satisfactory airway to facilitate s m o o t h post- c o n t o u r a n d restored arch of the m a n d i b l e (Fig. 6.191). Intraoral
operative recovery. tflood loss d u r i n g this procedure is m i n i m a l view demonstrates the skin c o m p o n e n t of the composite fibula
and b l o o d transfusion is seldom necessary. If there is no tension free flap used for reconstruction of the right half of the tongue
on the suture l i n e of the mucosa in the oral cavity, t h e n p r i m a r y (Fig. 6 . 1 9 2 ) . At this juncture, the patient is ready to start post-
healing should be expected w i t h i n 1-2 weeks. At that p o i n t the operative radiation therapy. A n a t o m i c , esthetic, and functional

219
reconstruction of the composite resection defect is thus achieved In F i g . 6 . 1 9 6 , the specimen of the dissected contents of the
in a single operative procedure. right side of the neck is seen, r e m a i n i n g attached t h r o u g h Level I
to the undersurface of the m a n d i b l e in the submental region. The
s u p r a o m o h y o i d triangle of the left side of the neck is also
VISOR FLAP APPROACH FOR RESECTION OF TUMORS
dissected, w i t h the specimen r e m a i n i n g attached to the primary
OF THE ORAL CAVITY
t u m o r t h r o u g h the let! submandibular triangle. A close-up view
s h o w i n g the exposed submental region is seen in Fig. 6.197. The
The advantage of a visor flap approach to the oral cavity is that it visor flap has been developed completely by connecting the mucosal
avoids splitting the lower l i p a n d c h i n in the m i d l i n e . The oral i n c i s i o n in the gingivobuccal sulcus, b e g i n n i n g at the retromolar
cavity is exposed via a single transverse skin incision e x t e n d i n g trigone on the r i g h t side and e x t e n d i n g up to the left retromolar
from the mastoid process on o n e side to that on the other, along trigone. In the neck the visor flap is elevated up to the under-
an upper neck skin crease. T h e visor flap requires a n o t h e r incision surface of the m a n d i b l e f r o m the angle of the m a n d i b l e on one
in the gingivobuccal a n d gingivolabial mucosa w i t h d i v i s i o n of all side up to I he angle of t h e m a n d i b l e on t h e other side. At this
the soft tissues Literal lo the m a n d i b l e , p e r m i t t i n g elevation a n d p o i n t , sharp retractors are used lo retract the lower l i p and the
retraction of the visor flap to expose the oral cavity f i g . 6 . 1 9 3 . visor flap, f a c i l i t a t i n g d i v i s i o n of the soft tissue attachments on
Although the exposure p r o v i d e d by the visor flap approach is the outer cortex of the m a n d i b l e , to permit separation of the visor
satisfactory for t u m o r s of t h e anterior oral cavity, it is clearly f l a p f r o m t h e m a n d i b l e , t w o Penrose d r a i n s are n o w used (Fig.
inadequate if a primary tumor of the oral cavity extends 6.1971 lo retract the visor flap towards the upper l i p a n d expose
posteriorly to involve the m i d d l e t h i r d of the t o n g u e or the region the m a n d i b l e a n d the oral cavity.
of the retromolar gingiva on either side. A n o t h e r disadvantage of In F i g . 6 . 1 9 8 , the m a n d i b l e is retracted caudad s h o w i n g the
the visor flap i s anesthesia o f t h e s k i n o f t h e c h i n a n d l o w e r l i p p r i m a r y t u m o r o f the f l o o r o f t h e m o u t h . Note the l i m i t a t i o n s i n
due to sacrifice of m e n t a l nerves. gaining adequate exposure of the retromolar trigone with the
A patient w i t h a locally advanced p r i m a r y carcinoma of the visor flap. Mucosal incisions are n o w made on the undersurface of
anterior floor of the m o u t h , w i t h direct extension to the edentulous
mandible, is s h o w n in F i g . 6 . 1 9 4 . He also has c l i n i c a l l y palpable
cervical l y m p h nodes in the right side of the neck. T h e operative
procedure planned here consists of a right radical neck dissection
and a left s u p r a o m o h y o i d neck dissection together w i t h resection
of the anterior arch of the m a n d i b l e (segmental m a n d i b u l e c t o m y )
w i t h the floor of the m o u t h a n d undersurface of the tongue. A
transverse skin incision has been taken b e g i n n i n g at the right
mastoid process and g o i n g across the upper neck skin crease up to
the left mastoid process. T h e upper and lower skin flaps are
elevated in the usual way a n d the right neck dissection begins
first. This is carried out as usual except Level I w h i c h remains
attached to the musculature of the floor of the m o u t h w h i c h w i l l
be resected in a m o n o b l o c fashion ( F i g . 6 . 1 9 5 ) .

Fig. 6.194 Locally advanced carcinoma ol the anterior floor ol the

mouth.

Fig. 6.193 Visor flap approach for exposure of the anterior oral cavity. Fig. 6.195 Right radical neck dissection is completed.

220
Fig. 6.196 The specimen of the dissected Fig. 6.197 Close-up view of the exposed Fig. 6.198 The mandible is retracted caudad,
contents of the right side of the neck. The left submental region. and the visor flap is retracted cephalad to
supraomohyoid triangle remains attached to expose the primary tumor.
the submental region.

Fig. 6.199 The surgical specimen. Fig. 6.200 Close-up view of the primary tumor.

the tongue and in the floor of the m o u t h posterior to the t u m o r , Fig. 6.201 The surgical
leaving adequate margins. The musculature of the undersurface of defect.
the tongue is d i v i d e d w i t h electrocautery up to the region of the
angle of the m a n d i b l e on b o t h sides. At this p o i n t , a power sagittal
saw is used to d i v i d e the m a n d i b l e just anterior to the angle on the
right side a n d just lateral to the m e n t a l foramen on the left side.
f o l l o w i n g d i v i s i o n o f the m a n d i b l e , the r e m a i n i n g muscular
attachments of the hyoglossus a n d the g e n i o h y o i d muscles are
divided. The specimen of the p r i m a r y t u m o r of the floor of the
m o u t h is delivered, w i t h the arch of the m a n d i b l e , a n d contents
of the right radical neck dissection a n d left s u p r a o m o h y o i d neck
dissection ( F i g . 6 . 1 9 9 ) . A close-up view of the specimen shows
satisfactory mucosal and soft tissue margins a r o u n d the p r i m a r y
tumor a n d a three-dimensional resection of the d e p t h of the
tumor in continuity with the mandible (Fig. 6.200).
The surgical defect seen in F i g . 6 . 2 0 1 shows the stumps of the
mandible a n d the raw surface of the transected musculature of the
tongue in its anterior a n d m i d d l e thirds, as well as the slumps of
the muscles attached to the superior surface of the h y o i d bone.

221
 Fig. 6.202 The two
stumps of the
mandible and the hard
palate are seen with
the tongue retracted
anteriorly.

The two slumps of the mandible and the hard palate arc scon i Fig.
6.202i, wiih the tongue retracted anteriorly and inferiorly. Note
the extent of the bony defect which needs repair to restore the
continuity of the mandible. A surgical defect of this magnitude
with loss of the arch of the mandible and soft tissues in the oral
cavity is best repaired with a microvascular composite osteo-
cutaneous free flap. Appropriate planning for such reconstruction
should therefore be done in every instance for a satisfactory post-
operative result.

RESECTION OF A SEGMENT OF MANDIBLE WITH

IMMEDIATE RECONSTRUCTION USING VASCULARIZED
BONE GRAFT

When resection of a segment of the mandible is indicated for

carcinoma of the oral cavity, immediate reconstruction of the
resected mandible should be considered. Resection of the body of
the mandible produces one of the most significant esthetic and
functional deformities in surgery for oral cancer. The esthetic
appearance of the patient is unacceptable and the functions of
speech and mastication are also seriously compromised. The impact
of resection of the anterior arch is devastating. The patient shown
in Fijj.v 6.203 and 6.204 had arch resection without immediate
reconstruction. Mans patients drool saliva after resection of the
anterior arch of the mandible and have significant swallowing
difficulties. The optimal method of reconstruction of the resected
mandible at the present time is replacement using a vascularized
bone graft.
The patient whose preoperative profile demonstrating facial
contour is shown in Fij». 6.205 has carcinoma of the lower gum
involving the retromolar trigone and the body of the mandible
(Fig. 6.206|. There is significant induration due to infiltration of
the adjacent musculature of the floor of the mouth, mandating
resection of the floor of the mouth with the body of the mandible.
The surgical specimen of the resected tumor with satisfactory
mucosal, soft tissue and bony margins is shown in H g . 6.207.
The surgical delect thus created (Fig. 6.2081 requires replacement
of the bone and soft tissues in the floor of the mouth as well as
mucosal lining in the oral cavity.

222
Fig. 6.206 Carcinoma of the lower gum.
Fig. 6.207 The surgical specimen of composite resection.
Fig. 6.208 The surgical defect.
A composite microvascular free graft of a segment of fibula, w i t h
its attached muscles a n d o v e r l y i n g s k i n , is used to reconstruct the
surgical delect in this patient ( F i g . 6 . 2 0 9 ) . The fibula free flap is
fabricated i n t o a n e o m a n d i b l e by m u l t i p l e osteotomies lo m a t c h
the curvature, a n g u l a t i o n a n d shape o f t h e resected m a n d i b l e . T h e
Fig. 6.209 Composite fibula free flap.
Fig. 6.210 Postoperative panoramic x-ray of the mandible.
Fig. 6.211 Postoperative photograph showing restoration of normal
contour of the face.
t e c h n i c a l details of microvascular c o m p o s i t e tissue transfer are
b e y o n d the scope of this b o o k a n d the reader s h o u l d refer to many
excellent papers a n d books o n t h a t subject. T h e postoperative
p a n o r a m i c v i e w of the m a n d i b l e shows the bone graft in position
attached to the stumps of the m a n d i b l e (Pig. 6.210). In the
postoperative view, t h e external appearance of the patient shows
the restored c o n t o u r o f the c h i n ( F i g . 6 . 2 1 1 ) .
Microvascular composite free tissue transfer is currently con-
sidered t h e state ot t h e art in reconstruction of major composite
223
defects following resection for advanced carcinomas of the oral
cavity. Caution must, however, be exercised in the selection of
patients who are candidates for such a major reconstructive effort.
The selection of patients should take into account the age and the
medical condition of the patients, the size of the surgical defect
and its resultant disability, as well as the overall prognosis.
DENTAL REHABILITATION FOLLOWING MANDIBLE
RECONSTRUCTION
Complete anatomic and physiologic rehabilitation of the oral
cavity following cancer ablation and reconstruction of the
mandible requires either a satisfactory removable lower denture
clasped to remaining teeth or the use of osseointegrated implants
to facilitate a permanent fixed denture. If osseointegrated dental
implants are to be used, they are preferably performed .secondarily
after satisfactory healing of the bone rather than primarily at the
time of free flap reconstruction of the mandible. The patient
whose intraoral photograph is shown in Fig. 6.212 has a central
salivary carcinoma of the lower gum. His preoperative CT scan
shows expansion of the involved mandible by tumor (Fig. 6.213).
Fig. 6.212 Patient with central salivary carcinoma of the lower gum.
Fig. 6.213
Preoperative CT scan
showing expansion of
the mandible.
I le underwent segmental inandibulectomy. The specimen is shown
in Fig. 6.214. A radiograph of the specimen shows the extent of
bone invasion (Fig. 6.215). The postoperative intraoral picture
shows satisfactory mucosal healing (Fig. 6.216). The mandible
was reconstructed with a microvascular free flap of fibula.
A minimum of twelve months should elapse before osseo-
integrated implants are considered. A panoramic x-ray of the
reconstructed mandible should show satisfactory bony union
between the graft and the mandible and satisfactory bony healing
of the graft at the sites of multiple osteotomies. The first step is to
assess the site for positioning of the implants for which con-
sultation from an oral-maxillofacial surgeon should be obtained.
Ideally, the placement of the implants should he performed by an
appropriately qualified oral surgeon. If metallic titanium plates
and screws used for reconstruction of the mandible are in the way
where the implants are likely to be placed, then they are removed
to clear that area to receive the implants.
The location and number of implants to be placed are best
assessed by the oral surgeon who will assume the responsibility of
placement of the implants and their subsequent exposure and
eventual fabrication of the permanent fixed denture. The satis-
factorily integrated implants are exposed four to six months
Fig. 6.214 Radiograph of the specimen.
Fig. 6.215 The surgical
specimen.
 Fig. 6.218 Serial panoramic x-rays of the mandible, showing
reconstructed mandible immediately postoperatively, after bone healing
and removal o( miniplates and screws and after dental implants.
Fig. 6.217 The finished permanent fixed denture.

f o l l o w i n g placement. For details of the technical aspects of place- Fig. 6.219 The
ment of osseointegrated i m p l a n t s , t h e i r subsequent exposure, a n d patient's external
fabrication a n d f i x a t i o n of a p e r m a n e n t fixed d e n t u r e , t h e reader appearance after
is referred to appropriate textbooks of oral surgery a n d d e n t a l mandible
reconstruction.
i m p l a n t o l o g y . T h e f i n i s h e d p e r m a n e n t lixed d e n t u r e is s h o w n in
Fig. 6 . 2 1 7 . Serial p a n o r a m i c views of t h e m a n d i b l e s h o w the
immediate postoperative appearance of t h e reconstructed m a n -
dible, alter removal of plates a n d screws a n d alter placement of
implants ( F i g . 6 . 2 1 8 | . At Ibis l i m e , the patient is considered f u l l y
rehabilitated f o l l o w i n g ablative cancer surgery a n d reconstruction
to restore f o r m a n d f u n c t i o n . I b i s external appearance is seen in
Fig. 6 . 2 1 9 .
Certain trends in the surgical m a n a g e m e n t of oral cancer have
become apparent over the last 15 years, p a r t i c u l a r l y w i t h reference
to the m a n a g e m e n t of Ihe m a n d i b l e . W i t h the u n d e r s t a n d i n g of
the biological b e h a v i o r of progression of oral cancer, fewer a n d
fewei patients undergo the ' c o m m a n d o ' o p e r a t i o n . Increasing
numbers of patients undergo marginal mandibulectomy or
m a n d i b u l o t o m y lor access to the oral c a v i t y for larger lesions ( F i g .
6.220). W h e n , however, segmental m a n d i b u l e c t o m y is under-

225
 Fig. 6.220 The numbers of patients undergoing marginal
mandibulectomy, mandibulotomy and segmental mandibulectomy from
1984 to 2000 at MSKCC.
taken, an increasing proportion of patients are considered to be
candidates for mandible reconstruction (Fig. 6.221).
RESECTION OF THE MAXILLA FOR PRIMARY TUMORS
OF THE ORAL CAVITY
Primary epithelial tumors of the oral cavity arising on the hard
palate, upper gum, upper gingivobuccal sulcus and anterior aspect
of the sofl palate require consideration of resection of the maxilla
in surgical treatment planning. If the primary tumor involves the
underlying hard palate or the upper gum, then resection of the
maxilla becomes mandatory (Fig. 6.222). Even when a tumor is
adherent to, or in direct contiguity with the maxilla, maxillary
resection should be considered. The resection may be just
alveolectomy (A), palatal fenestration (15), or partial maxillectomy
(C). Radiographic evaluation for assessment of bone invasion is
indicated but it must be remembered thai early invasion of bone
is often not demonstrated on radiographic studies. Satisfactory
evaluation of the hard palate requires either conventional
tomograms or preferably CT scans in the coronal plane.
Preoperative dental evaluation is vitally important to assess the
status of dentition in the vicinity of the primary tumor. If any
Fig. 6.221 Numbers of patients w h o are
considered to be candidates for mandible
reconstruction at MSKCC.
denial care is necessary, it should be done either preoperative^ or
inlraoperatively with appropriate assistance from a dental
surgeon. If any part of the upper gum or hard palate is to be
resected, leading to communication between the oral cavity and
the nasal cavity or the maxillary antrum, then appropriate
impressions of the upper alveolus and hard palate are obtained
preoperative^. These will help to make dental cast models which
will facilitate fabrication of an immediate hard palate surgical
obturator, to be used intraoperative^ for restoration of the
surgical defect.
Small lesions which are easily accessible through the open
mouth can be resected in conjunction with a limited partial
maxillectomy via the peroral approach. The patient shown in Fig.
6.223 has a squamous cell carcinoma of the upper gum presenting
on the labial surface of the upper gum adjacent to the canine and
premolar teeth. A CT scan of the patient demonstrates that the
disease involves only the soft tissues and there is no destruction or
invasion of the underlying bone (Fig. 6.224). A peroral partial
maxillectomy could easily be performed securing a satisfactory
surgical resection with negative mucosal soft tissue and bony
margins (Fig. 6.225). The surgical defect in this patient is best left
open, to be rehabilitated with fabrication of a dental obturator.
Absolute hemostasis is secured with the use of electrocautery.
Fig. 6.222 Types of maxillary resections.
Fig. 6.223 Early squamous cell carcinoma of the upper gum.
Fig. 6.224 Axial view of the CT scan demonstrates no underlying bone
erosion or destruction.
Fig. 6.22S The surgical specimen after peroral partial maxillectomy.
Fig. 6.226 Approximately one month after surgery, the surgical defect
has epithelialized nicely.
Sharp edges at the margins of the cut ends of the bone are
smoothed out with a line burr. Xeroform packing is introduced
into the surgical defect and an immediate dental obturator is
placed over the defect and retained in position by wiring it to the
remaining teeth. Approximately one week following surgery, the
packing is removed and the defect is allowed to granulate. In
approximately 3-4 weeks, adequate epithelialization at the
surgical defect occurs (Fig. 6.226). Al this point, a permanent
dental obturator is fabricated w i t h teeth to restore the
dental/alveolar/palatal defect. The obturator restores the patient's
ability to speak and cat normally and also restores the external
appearance of the face ( K g . 6.227).
However, when access is difficult or the primary tumor is large,
then the upper cheek flap approach is indicated (Fig. 6.228). This
requires a modified Weber-Ferguson incision with either a Lynch
or a subciliary extension depending on the location of the primary
tumor and the exposure necessary. In most instances, if only the
hard palate or the upper gum is to be resected, then neither the
Lynch nor the subciliary extension is necessary.
The placement of the Weber-Ferguson incision is very
important esthetically. The philtrum of the upper lip is divided
Fig. 6.227 The external appearance of the patient with a permanent
dental obturator in place.
Fig. 6.228 The upper cheek flap approach.
exactly in the midline from the vermilion border up to the
columella, where the incision turns laterally along the nasal
vestibule and then follows the ala of the nostril and the lateral
aspect of the nose, respecting the nasal suhunils.
The patient shown here presented initially with a long-standing
history of multifocal areas of hyperkeratoses and in situ
carcinomas in the oral cavity. As seen in her intraoral photograph,
she had undergone excision of a superficial squamous cell
carcinoma of the mucosa of the right cheek with skin graft
coverage several years ago (Fig- 6.229). At this time, however, she
developed a new primary carcinoma involving the right upper
gingivobuccal sulcus with extension of tumor almost up to the
margin of the previously employed skin graft. The lesion involves
the region of the maxillary tubercle of the upper alveolus on the
right-hand side. The tumor measures 2.5 cm on its surface and
appears to be deeply infiltrating the soft tissues. She also has a
diffuse area of keratosis involving the junction of the hard and
soft palate which clinically appears to be benign. A conventional
Fig. 6.229 Carcinoma of the right upper gingivobuccal sulcus.
Fig. 6.230 Coronal tomogram showing bone erosion.
coronal tomogram of the hard palate through the region of the
tumor shows erosion of the alveolar process on the right side with
t h i n n i n g out of the palatal bone (Fij>. 6.230). Although there is
no gross bone destruction, there is an indication of early invasion
of the bone by tumor on this radiograph.
The surgical procedure necessary for resection of this tumor is a
partial maxillectomy excising the alveolar process and hard palate
on the right side, in conjunction with soft tissues of the cheek and
the adjacent mucosa as well as the lower half of the right maxilla.
General anesthesia is administered w i t h the airway secured via an
endotracheal tube introduced through the oral cavity. After satis-
factory relaxation is obtained, the head and neck area is isolated
as usual. The endotracheal tube is positioned at the Jeft oral
commissure and is secured in place with appropriate taping. A
ceramic corneal shield is introduced into the right conjunctival
sac to protect the cornea. A Weber-Ferguson incision is marked
(l-'ig. 6.231) prior to induction of anesthesia and endotracheal
intubation.
Fig. 6.231 A Weber-Ferguson incision is marked.
Fig. 6.232 The orbicularis oris and the musculature around the ala of
the right nostril are divided.
The skin incision is made w i t h a scalpel, but afterwards an
electrocautery is used to divide the rest of the thickness of the
right upper cheek flap. The orbicularis oris and the musculature
around the ala of the right nostril are divided with the electro-
cautery up to the anterior surface of Ihe maxilla (Fig. 6.232).
Bleeding is usually controlled with electrocoagulation; however,
major branches of the facial artery require ligation.
A mucosal incision is now made in the upper gingivolahial and
gingivobuccal sulcus, leaving an appropriate cuff of mucosa
attached to the hard palate as a margin around the periphery of
the tumor (Fig. 6.233). A cuff of mucosa is left attached to any
part of the gum which is to be retained for reapproximation of
the cheek to the gum. On the other hand, if the gum is to he
sacrificed, then the incision in the labial and buccal mucosa is
placed with a satisfactory margin around the tumor. Soft tissues of
the check are then elevated remaining directly over Ihe anterior
aspect of the bony wall of the maxillary antrum. As the cheek flap
is elevated laterally and superiorly, the infraorbital nerve exiting
from the intraorbital foramen comes into view. Care should be
taken to preserve this nerve if possible since its sacrifice will result
in permanent anesthesia of the skin of the cheek.
Fig. 6.233 A mucosal incision is made in the upper gingivolabial and
gingivobuccal sulcus.
Fig. 6.234 Close-up view of the exposure.
A close-up view of the exposure obtained so far shows the tumor
freed up anteriorly and laterally (Fig. 6.234). Using the electro-
cautery, an incision is now made in the mucosa of the upper gum
and the hard palate to encompass the primary tumor circum-
ferentially. The incision is deepened through the mucoperiosteum
up to the underlying bone of the alveolar process and the hard
palate. A power saw is then used to divide the alveolar process as
well as the hard palate through the line of mucosal incision.
Similarly, the anterior wall of maxilla is divided with the saw. After
all the bone cuts are made with the power saw, a small curved
osteotome is used to fracture the remaining bony attachments
to remove the specimen. Final soft tissue attachments of the
specimen are divided using a Mayo scissors.
The surgical specimen shows complete removal of the primary
tumor with a generous cuff of normal mucosa on all its margins
and the alveolar process as its medial margin (Fig. 6.235). The
surgical defect following removal of the specimen shows absence
of Ihe lower half of the maxilla and the posterior part of the
alveolar process, creating a direct communication between the oral
cavity and the maxillary antrum (Fig. 6.236). The surgical field is
irrigated with Bacitracin solution. If the mucosa of the maxillary
Fig. 6.235 The surgical specimen.
Fig. 6.236 The surgical defect.
antrum is edematous, then it is curetted out to prevent any pseudo-
polyp formation. On the other hand, if this mucosa appears to be
normal, it is best left alone. If the antral mucosa is retained, then
a skin graft is not necessary.
Sharp spicules of bone are smoothed out using a power drill
with a line burr. A split-thickness skin graft is used in this patient
for lining of the denuded bone in the maxillary antrum. The skin
grail will facilitate speedy healing of the delect and provide a nice
smooth lining over the raw areas.
The skin graft is sutured to the mucosal edges of the defect and
draped over the maxillary antrum, where it is retained in position
with a snug packing of Xeroform gauze. The packing is placed
tight enough to stretch the graft out entirely over the raw surfaces
of the surgical defect.
A previously fabricated immediate temporary dental obturator
is now wired to the alveolar process ( H g . 6.2371. Since this
patient is edentulous, multiple drill holes are made in the
remaining alveolar process through which wires are threaded to
anchor the obturator. On the other hand, if teeth are present, then
the obturator is wired to the remaining teeth to keep it in
position. I'he obturator satisfactorily covers the surgical defect,
230
Fig. 6.237 The dental obturator is wired to the alveolar process.
Fig. 6.238 The skin incision is closed.
holds the packing in position, and permits the patient to start oral
alimentation postoperatively.
The incision is then closed in two layers. Chromic catgut
interrupted sutures are used for approximation of the soft tissues
and muscles. The mucosa of the check is reapproximated to the
cull of mucosa left over the remaining alveolus with interrupted
sutures. Meticulous attention must he paid in accurate reapproxi-
mation of the vermilion border of the upper lip, the philtrum, and
the skin edges around the ala of the nose.
The skin incision is closed with 5-0 nylon interrupted sutures
d i g . 6.2381. Dressings are not necessary but Bacitracin ointment
is applied over the suture line. In the postoperative period the
patient receives extra humidity with a vaporizer and mask to
prevent dryness of the oral cavity. Clear liquids are permitted by
mouth the day following surgery and the patient proceeds to a
pureed diet over the next 24 hours. The patient is instructed to use
frequent oral irrigations to keep the maxillectomy defect clean.
Irrigations of the oral cavity and the surgical site are necessary,
particularly after every meal. Occasional minor bleeding episodes
may occur from granulation tissue in the immediate postoperative-
period while the skin graft is healing. However, once satisfactory
Fig. 6.239 Photograph of the oral cavity three months following surgery
shows a healed skin graft.
Fig. 6.240 The final dental prosthesis.
healing is achieved, the defect remains nice and clean. The post-
operative photograph of the oral cavity, three months following
surgery, shows a well-healed skin graft (Fig. 6.239).
A final dental prosthesis with teeth is fabricated approximately
three months after surgery (Fig. 6.240). This dental prosthesis
effectively plugs the surgical defect and also Incorporates the
remaining denture. When inserted in the oral cavity, it retains
well, as seen in the patient's mouth (Fig. 6.241). The prosthesis
provides satisfactory restoration of speech and mastication. A
frontal view of the patient's postoperative appearance with the
dental obturator in place, shows a well-healed skin incision and
an acceptable esthetic result (Fig. 6.242). It is Important lo re-
emphasize that in any type of surgery for primary tumors of the
oral cavity where removal of the alveolar process or hard palate is
indicated, continuous communication between the surgeon and
the prosthodontist is essential for the satisfactory outcome of
functional and esthetic rehabilitation.
Fig. 6.241 The prosthesis seen in the patient's mouth.
Fig. 6.242 Frontal view of the patient's postoperative appearance.
RESULTS OF TREATMENT
The single most important factor which affects long-term results
following treatment for carcinoma of the oral cavity is the stage
of disease at the time of presentation. For early staged tumors,
excellent cure rates are anticipated. However, once regional lymph
node metastases become apparent, a significant drop in the cure
rates is to be expected (Fig. 6.243). The five-year survival rates for
patients with oral cancer treated on the I lead and Neck Service at
the Memorial Sloan-Kettering Cancer Center (MSKCQ between
I960 and 1995 are shown in Fig. 6.244. The overall survival is
stage- and site-dependent (Fig. 6.245).
With the employment of adjuvant postoperative radiation
therapy, significant improvement in survival for patients with
advanced stage oral carcinoma is observed compared to single
modality treatment. Such combination of treatment modalities
Fig. 6.243 Oral cancer cure rates. Fig. 6.245 Site distribution and survival by site at MSKCC.

Fig. 6.246 Stage distribution and survival by stage for cancer of the soft
palate at MSKCC.

Fig. 6.244 Stage distribution and survival by stage for oral cancer at Fig. 6.247 Stage distribution and survival by stage for cancer of the
MSKCC. tonsil at MSKCC.
Fig. 6.248 Stage distribution and survival by stage f o r cancer of the Fig. 6.249 Stage distribution and survival by Stage for cancer of the
base of the tongue at MSKCC. pharngeal wall at MSKCC.

has also altered the patterns of failure such that nearly one-third
of the patients now develop distant metastases which eventually
lead to death, lungs and bone are the most frequently involved
sites for distant metastasis. In approximately one-third of the
patients, multiple primary tumors develop either in the upper
aerodigestive tract, lung, or other sites. Long-term prognosis in
these patients depends on the stage and extent of multiple
primary lesions.
The survival results for each of the primary sites in the
oropharynx by stage of disease al the time of treatment are shown
in Figs 6.246-6.249. For each site the stage distribution is also
shown to indicate the relative frequency of early versus advanced
stage disease. Decline in cancer mortality is seen for several
primary sites in the United States. Oral cancer has shown the
highest reduction in mortality in recent ytjars in the United States
(Fig. 6.250). Fig. 6 . 2 5 0 Decrease in mortality rate f r o m oral cancer in the US.