Surgery of Common Oral Disorders

Carcinoma of Tongue

⁕ Incidence: Usually in males above 50 years.

⁕ Predisposing factors:
A) Sepsis, spirits, smoking, syphilis, spices (5S), tobacco chewers &
lack of oral hygiene.
B) Precancerous lesions: Dental ulcers ,Leukoplakia, benign
tumors, chronic superficial glossitis and Plummer Vinson's syndrome.

• Pathology:
A) Site:
1. Sides of anterior 2/3 of the tongue is the commonest site.
2. Less commonly tip or posterior 1/3 of the tongue.
B) Dross picture-:
1. Malignant ulcer: commonest (describe it).
2. Malignant nodule.
3. Cauliflower type.
4. Diffuse type → woody tongue.

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C) Microscopic picture:
1. Squamous cell carcinoma (90%) with no cell nests denoting a
high degree of malignancy, the commonest.
2. Basal cell carcinoma or adenocarcinoma (from minor salivary
glands) are Rare.
D) Staging : TNM.
T: Primary tumor:
• To: No evidence of tumor.
• Tis: Carcinoma in situ.
• T1: less than 2 cm.
• T2: 2-4 cm
• T3: more than 4 cm.
• T4: Base involvement.
N: Lymph nodes:
• N0: No palpable L.Ns.
• N1: Ipsilateral single node less than 3 cm.
• N2 : Ipsilateral or contralateral nodes less than 6 cm.
• N3: L.Ns larger than 6 cm.
M: Distal metastasis:
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• M0: No distal metastasis.

• M1: distal metastasis.
⁕ Complications:
I) Spread:
A. Direct spread :
• Carcinoma of anterior 2/3: To the rest of the tongue, then
floor of mouth, gums & mandible.

• Carcinoma of posterior 1/3: To the soft palate, tonsil, pharynx

& larynx.

B. Lymphatic spread :
• Common and early because tongue is mobile and rich in
lymphatics.
a) Lesion in the tip → submental L.Ns → submandibular L.Ns
bilaterally.
b) Lesion in the anterior 2/3:
1- Lesion in one side → ipsilateral submandibular L.Ns.
2- Lesion in the centred one cm → submandibular L.Ns
bilaterally .

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c) Lesion in the posterior 1/3 : Upper deep cervical bilaterally.

▪ Spread from submandibular L.Ns → ipsilateral upper deep
cervical L.Ns (particularly jugulo-digastric L.N) → ipsilateral
lower deep cervical (particularly jugulo-omohyoid L.N).

C. Blood spread: Rare, more likely from tumor of posterior 1/3.

2) Dysarthria & dysphagia due to fixity of tongue
3) Haemorrhage: due to erosion of lingual vessels in tumor of
anterior 2/3 or internal carotid artery in tumors of posterior 1/3 ,
4) Inhalation pneumonia and bronchopneumonia.
5) Respiratory obstruction due to oedema of glottis or compression
of respiratory passage by enlarged nodes.
6) Infection, anaemia , cachexta & death.
⁕ Clinical picture:
I) Symptoms:
1- Usually the patient complaining of rapidly growing ulcer in tongue.

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2- Pain: is late.
 Local in the tongue due to infiltration of lingual nerve .
 Referred to the ear , auricle and temple along the chorda
tympani and auriculo-temporal nerve.
3- Excessive salivation: blood stained saliva dribbles from the
mouth.
4- Foul breath due to infection & necrosis.
5- Difficult swallowing and difficult speech.
6- Haemorrhage due to erosion of lingual or internal carotid vessels.
7 - Enlarged L.Ns in the neck.
8 - Ankyloglossia: The tongue cannot protrude fully and deviated
to the affected side due to infiltration of the muscle of tongue or
floor of mouth.
II) Signs:
1- Lesion in the anterior 2/3 or tongue show:
 Malignant ulcer (describe it), raised indurate nodule or deep
indurated fissure.

 Enlarged cervical L.Ns which are hard first mobile then become
fixed.
2- Lesion in the posterior 1/3 of tongue:
 The lesion cannot directly seen but palpated by the index
finger while insinuating the other index in the patient's cheek.

 Indirect laryngoscopy

is done to visualize the lesion.

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Surgery of Common Oral Disorders

⁕ Investigations:
1. Biopsy: from the edge of ulcer.
2. FNAC from enlarged cervical L.Ns.
3. C.Tscan & MRI to detect extent of the tumor.
4. Chest X-ray to detect lung metastases and pulmonary infections.
5. Laryngoscopy especially for cancer posterior 1/3 of tongue.
6. Metastatic work up. (Mention)

⁕ Treatment :
I) Early operable cases:
• Features: No or mobile L.Ns, no distal metastases & good general
condition.
• Methods:
A) Management of the primary:
a) Radiotherapy:
• Indication:
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 Tumor less than 2 cm (T1) equally benefit from

radiotherapy or surgery.
 Larger tumor is treated by both surgery &
postoperative radiotherapy.
 Tumors of posterior 1/3 of tongue.
 Unfit or refusing surgery.
• Advantage: avoid the disfiguring side effect of surgery.
• Disadvantage: mucositis, dysphagia & osteoradionecrosis.
b) Surgery:
• Indications: Small tumour (less than 4cm) , recurrence
after radiotherapy or radio-resistant tumor, infiltration of
bone or lesion on top of leukoplakia .
• Pre-operative preparation: Mouth washes, extraction of
carious teeth, ligation of lingual artery or external carotid
artery to minimize bleeding and tracheostomy.
• Method:
 Golssectomy: excision of the tumor with 1.5 cm safety
margin. Nowadays , this is followed by tongue
reconstructive surgery .
 Extent of glossectomy:
1- Tumor in the anterior 2/3 of tongue: → partial
glossectomy (for small lesion) , hemiglossectomy or
near total glossectomy (for large lesion).
2 - For tumor in the middle line or in the posterior 1/3
of tongue → total glossectomy (median mandibulotomy
will failitate oral resection).

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3- Commando operation: (combined mandibulectomy

and neck dissection operation):
▪ Indication: Affection of the floor of mouth or mandible.

▪ Method: The following structures are removed in one mass.

➢ Excision of the tongue with the infiltrated part of the floor

of mouth & mandible with safety margins .
➢ Total block neck dissection on ipsilateral side.
➢ Closure of the defect by various plastic procedures as
pectoralis major myocutaneous flap.

c) Post operative radiotherapy and chemotherapy :

• Indications: Large tumor , positive nodes , positive or
close margine or recurrence after surgery .
B) Management of L.Ns metastases :
•
If the L.Ns are palpable or LNs biopsy is positive modified
neck dissection is done on the ipsilateral side.
• If bilateral enlarged L.Ns: Modified neck dissection on
the more affected side & after 2 weeks as a selective block
neck dissection is performed on the contralateral side.

• Post operative radiotherapy and chemotherapy if +ve

nodes.

II) Inoperable cases: (fixed L.Ns or distal metastases).

1. Palliative radiotherapy & chemotherapy
2. Palliative resection of the primary.
3. Control of pain.
4. Tracheostomy for respiratory obstruction.

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Surgery of Common Oral Disorders

Jaw Swellings
⁕ Classifications :
I) Epulis :
• It is a swelling of the mucoperiosteum of the gum.
• It includes fibrous, myeloid, granulomatous, sarcomatous and
carcinomatous epulis.
II) Odontomes :
• Tumors or cysts related to remnants of development of teeth.
• It includes dental cyst , dentigerous cyst and adamantinoma .
III) Bone tumors :
• Benign: Osteoma , chondroma and giant cell tumor .
• Malignant : osteogenic sarcoma , fibrosarcoma , metastases
and malignant tumor of maxilla .

Epulis

⁕ Definition: Any localized swelling of mucoperiosteum of the gum.

⁕ This may be one of the followings:

1) Fibrous Epulis 2) Myeloid epulis 3) Granulomatous

(giant cell epulis) Epulis
The commonest type. Less common. Less common.
Localized inflammatory It is a giant cell It is a septic granuloma in
hyperplasia of submucosa tumor arising from relation to a carious tooth.
Origin

of gum due to irritation the inner

by carious tooth. osteoclastic layer of
the periosteum.
Fibrous mass covered by Osteoclast giant Mass of granulation tissue,
Histolog

hyperplastic squamous cells, thin walled C.T & inflammatory cells devoid
y

epithelium. vessels and fibrous epithelial covering .

tissue stroma.

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Surgery of Common Oral Disorders

Painless, slowly growing Painless, rapidly Painful, slowly growing,

pale red or white, growing, redish yellowish red,
Clinical Picture

pedunculated , smooth, blue, sessile, pedunculated, soft,

firm swelling which does lobulated, soft lobulated, swelling which
not bleed on touch. swelling which bleeds on touch.
It lies between 2 carious bleeds on touch. It is related to carious
teeth. Fixed to the bone . tooth.
The related teeth are L.Ns may be firm, mobile &
separated & loose. tender.
Treat the related teeth Excisin with a wide Excision using diathermy
Treatment

then excision of the safety margin. with treatment of carious

swelling with a wide base tooth.
of the related
mucoperiosteum .

Fibrous Epulis Myeloid epulis

Granulomatous Epulis Malignant Epulis

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Surgery of Common Oral Disorders

4. Malignant Epulis:

• This may be carcinoma (squamous cell carcinoma from the mm) or

sarcoma (parosteal fibrosarcoma arising from outer fibrous layer of
periosteum).

• Clinical picture :

 Hard, rapidly growing, ill defined , large, sessile mass or

malignant ulcer (describe it), ulcerated irregular surface fixed to
bone with separated loose related teeth.

 L.Ns may be enlarged, hard, mobile and later on fixed.

• Investigations:

1. Plain X ray: May show infiltration of bone.

2. C.T scan.

3. Excision biopsy.

• Treatment:

I ) Operable cases:

A) Management of the primary: Hemimandibulectomy &

mandibular reconstruction.

B) Management o/ L.Ns:

a- Palpable L.Ns: Modified neck dissection (i.e. COMMANDO

operation as it combined with mandibulectomy).

b- Impalpable L.Ns: follow up with no prophylactic neck

dissection except with large tumour, poorly differentiated or
difficult follow up.

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Surgery of Common Oral Disorders

II) Inoperable cases: Palliative resection, chemotherapy or

radiotherapy.

Odontomes

⁕ Types: Only epithelial odontoms occur in man & they include:

1) Dental cyst
2) Dentigerous cyst
• Irritation of paradental epithelial
• It is due to cystic
Aetiology

debris of Malassez by a carious tooth.

degeneration of dental
fallicles→ unerupted
tooth.
⁕ Pathology :A unilocular cyst lined by squamous epithelium and filled with
clear or brownish fluid .
⁕ Complications: Enlargement with loss of teeth, infection and pathological
fracture.
• Age: Usually in adult. • Children or adolescent.
• Incidence:Common. • Uncommon.
Clinical picture

• Site :More common in the upper jaw, • More common in the

related to normally erupted carious lower jaw, related to
(canine or incisor) tooth. unerupted (3rd molar)
tooth.
• Painless, well defined ,slowly growing but may reach large size,
smooth swelling which expanding the jaw & it is first hard but later
on may give egg shell crackling sensation.
• Panoramic view show well defined radiolucent area.
X-ray

With a tooth in its depth.

• Extraction of related tooth with transoral enucleation or deroofing of

Treatment

the cyst with removal of fluid & lining epithelium.

• The expanded jaw is crushed to restore its shape.

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Surgery of Common Oral Disorders

Dental cyst

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Surgery of Common Oral Disorders

Dentigerous cyst

Treatment of dental and dentigerous cyst

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Surgery of Common Oral Disorders

3. Adamantinoma
(Ameloblastoma)
⁕ It is a locally malignant tumor.

⁕ Incidence:

• More in lower jaw, more in females between 25-45 years.

• The commonest tumor of the mandible.

⁕ Pathology:

• Origin: It is a local malignant epithelial tumor arising from

ameloblast of dental follicle .

• Gross picture: The tumor arises in the angle of the mandible and
growing in its ramus and Body.

• Cut section:

1. The tumor is pink or white (according to the amount of fibrous

tissue).

2. Well encapsulated with trabeculae dividing the tumor into

equal, small lobules.

3. Some areas are cystic and contain brownish mucoid substance.

4. Some areas are solid containing fibrous tissure.

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Surgery of Common Oral Disorders

• Microscopic picture:
1. Cystic areas: Lined by squamous or columnar epithelium and
contain mucoid substance.
2. Solid areas: Fibrous tissue contains epithelial element in the
form of cords, acini, cell nests and masses of basal cells.

⁕ Complications:
1. Direct spread only in the mandible and in late cases invades soft
tissues.
2. Malignant change (carcinoma or sarcoma).
3. Recurrence due to cellular implantation during surgery.
4. Loosening and falling of teeth, ulceration, infection & pathological
fracture.
⁕ Clinical picture:
1. Painless , not tender , slowly growing well defined & lobulated
swelling in the (ingle of the mandible growing in the ramus & Body

of the mandible.
2. The swelling produce bone expansion more on the outer surface.
3. Hard but in advanced cases may give egg shell crackling sensation.
4. Related teeth are loose and mal-directed.
5. No lymph node enlargement, unless ulceration & infection occurs.

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Surgery of Common Oral Disorders

⁕ Investigations
1. Plain X-ray: Show an expanding lesion of the jaw with honey
comb appearance.
2. C. T. scan to detect extent of the tumor.
3. Biopsy is diagnostic.

⁕ D.D: From osteoclastoma of jaw

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Surgery of Common Oral Disorders

Adamantinoma Osteoclastoma
Incidence • Common, more in female. • Rare, equal in both sexes.
Site. • Angle of mandible. • Symphysis menti.
Growth. • Both ramus and body. • In the body & stop at angle.
Colour. • Pink or white . • Brownish.
Surface. • Finely lobulated. • Coarsely lobulated.
Expansion. • More on outer surface. • Equal on both sides.
X- ray. • Honey comb appearance. • Soap bubble appearance.

⁕ Treatment: Only surgery (the tumour is radioresistant) followed by

mandibular reconstruction.
1. Small tumors are excised with safety margin, a segment of
mandible extending from the inferior alveolar foramen to mental
foramen (because the tumor may spread along inferior alveolar
canal) is removed.
2. Large tumours are treated by hemimandibulectomy.

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Surgery of Common Oral Disorders

⁕ Mandibular reconstruction after mandibulectomy is essential for

occlusion of teeth, application of dentures and cosmetic. The following
methods can be used:
1. Autogenous bone graft: 2 types
a) Non-vascularized grafts taken from fibula or 5th rib .
b) Vasculaized grafts which are taken with their blood vesels (e.g.
rib with intercostal vessels) to anastomose with local blood vessels
e.g. facial vessels.
2. Mandibular plate and screws to fix the graft in place .
3. Mandibular prosthesis .

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Surgery of Common Oral Disorders

Non-vascularized grafts

Mandibular plate

and screws

Mandibular prosthesis

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Surgery of Common Oral Disorders

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