The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
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Original Title
Management of Odontogenic Tumors / orthodontic courses by Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
www.indiandentalacademy.com INTRODUCTION Treatment of odontogenic tumors is designed to eradicate the lesion and restore aesthetic form and optimal function. Because of these needs and the benign nature of these lesions, a variety of surgical techniques that preserve vital structures and facial aesthetics have been developed for the treatment of odontogenic tumors. www.indiandentalacademy.com Objectives of management: Eradication of the lesion Preservation of normal tissue to the extent possible Restoration of significant tissue loss, form & function Well-planned & executed resection & reconstruction serves the patient physically & emotionally better than repeated surgical procedure
www.indiandentalacademy.com GUIDELINES SIZE & LOCATION OF TUMOR: Small Excisional biopsy Increased size more radical Location important role in post operative morbidity Inaccessibility responsible for inadequate surgical clearance www.indiandentalacademy.com DURATION: When the tumor was 1 st noticed Fast growing in short duration immediate treatment Prognosis depends on rate of growth of tumor Slow growing more elective treatment Fast growing indicate malignant www.indiandentalacademy.com BENIGN Vs MALIGNANT : Benign tumor treat conservatively Some benign tumors behave aggressively radical treatment Benign & small enucleation Lesion involves full thickness segmental resection Lesion is extensive radical resection
www.indiandentalacademy.com Factors governing the choice of treatment method Age and health of the patient Clinical type of ameloblastoma Site of the lesion Size of the lesion Chances of recurrence Patient preference
www.indiandentalacademy.com Treatment methods Enucleation & curettage - Thermal cauterization - Carnoys solution - Cryosurgery Resection without continuity defect Resection with continuity defect www.indiandentalacademy.com ENUCLEATION: Allows the cystic cavity to be covered by a mucoperiosteal flap & the space fills with the blood clot which will eventually organize and form normal bone. INDICATIONS: Surgical excision of tumor which tend to grow by expansion, rather than by infiltration of surrounding tissues. Lesions occurring in the bone with a distinct separation b/w the lesion & the surrounding bone. Often there is a cortical margin of bone that delineates the tumor from the bone. www.indiandentalacademy.com Indicated in: Odontoma Ameloblastic fibroma Ameloblastic fibroodontoma Adenmatoid odontogenic tumor Cementoblastoma Squamous odontogenic tumor www.indiandentalacademy.com Enucleation - procedure
www.indiandentalacademy.com Enucleation - procedure www.indiandentalacademy.com ADVANTAGES: Primary closure of the wound Healing is rapid Post operative care is reduced DISADVANTAGES: After primary closure, it is not possible to directly observe the healing of the cavity Removal of unerupted teeth with the lesion Weakening of mandible making it prone to jaw fracture Damage to adjacent vital structures www.indiandentalacademy.com Curettage
Curettage - removal of the tumour by scrapping it from the surrounding normal tissue Currently - least desirable form of therapy Sehdev et al (1974) - cure rate of only 10%. Taylor (1968) - 63% recurrence rate Rankow and Hickey (1954) - 91% recurrence rate. Failure - nests of tumour cells extend beyond the clinical and radiographic margins of the lesion Chemical and electrical cauterisation have been used by surgeons in conjunction with curettage but they have reported only a slight improvement in cure rate.
www.indiandentalacademy.com INDICATIONS Unicystic ameloblastoma Small tumour - a child or a young adult Patient can be followed up for 10 years or more. Small tumour in the body of the mandible in an elderly patient, as ameloblastoma takes several years to recur www.indiandentalacademy.com Operative procedure
Intra-oral approach Mucoperiosteal flap is reflected Mandible - buccal aspect Lingual access - injury to lingual nerve & mandibular neurovascular bundle Maxilla - palatal or buccal / labial approach Rongeur or surgical bur - remove sufficient bone - expose the underlying tumor Angular / straight curettes - convex surface of the curette placed against the bony wall.
www.indiandentalacademy.com Ameloblastoma Enucleation & Curettage www.indiandentalacademy.com Adenomatoid Odontogenic tumor: www.indiandentalacademy.com Ameloblastic fibro odontoma www.indiandentalacademy.com Ameloblastic fibroma www.indiandentalacademy.com Compound odontoma: www.indiandentalacademy.com After lesion is removed - largest curette - a margin of apparently normal bone should be removed by aggressive scrapping. After thus removing 1 to 3 mm of surrounding bone, all margins are smoothened with a rongeur or a large round bur. Adjunctive treatment like cauterisation may be employed at this stage. Irrigation with normal saline Small wounds - closed primarily Large wounds - packed with gauze impregnated with compound tincture of benzoin, balsam of Peru or Whiteheads varnish
www.indiandentalacademy.com Topical antibiotic - gauze pack. The pack is removed approximately 2 to 3 inches everyday until the surgical defect is filled with granulation tissue. Oral hygiene is maintained. Complications Numerous complications - particularly extensions to vital structures Curettage procedure breaks the cortical barrier, thus paving the way for residual tumour to grow into the soft tissues, which then becomes more difficult to treat.
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Cautery (desiccation) Various types - primarily as an adjuvant to curettage, but in some cases as a primary mode of therapy. Chemical agents: -Carnoys solution -Electrocautery -Cryotherapy Cauterisation is basically an attempt to eradicate the tumour that has infiltrated beyond the clinical and radiographic margins of the tumour www.indiandentalacademy.com Cautery is empirical : (i) how far the tumour in each case has extended into the cancellous bone (ii) how far the caustic agent (heat / chemicals) penetrates into the cancellous bone (iii) how effective is the agent in eradicating the tumour cells and (iv) the possible harmful effects to normal tissue
www.indiandentalacademy.com Electrocoagulation (thermal cautery) Mehlisch et al (1972) - 50% recurrence rate More effective therapy than curettage Secondary ischaemia & necrosis - may destroy the invading tumour cells. Cautery frequently been employed as an adjuvant to other methods of therapy to give a better result (Gardner and Pecak 1980) Mehlisch et al - no recurrences
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Chemical cauterisation Carnoys solution - a fixing agent absolute alcohol chloroform glacial acetic acid ferric chloride (modification) Stoelinga and Bronkhorst (1988) - unicystic ameloblastoma and reported no recurrences Depth of penetration - cancellous bone up to 1.5 mm after 5 minutes and up to 1.8 mm after 1 hour (Voorsmit et al 1981) Use of Carnoys solution appears to be harmless and has the potential of reducing recurrences after curettage.
www.indiandentalacademy.com Technique: Teeth extracted Enucleation and curretage Bony cavity is examined Carnoys solution is applied Cotton applicator / ribbon guaze 3 minutes Copious irrigation with saline BIPP inserted & wound kept open BIPP replaced periodically Recurrence 10%
www.indiandentalacademy.com CRYOSURGERY: Alternative treatment modality Excellent results in maxillo-facial region AIM: eliminate invasive bone lesion without necessarily involving the problems of conventional anatomic radical surgery Advantage of cryotherapy is that it is possible to devitalise the tissue with liquid nitrogen to a depth of 1.5 cm The jaw can be frozen through its entire thickness if necessary. www.indiandentalacademy.com www.indiandentalacademy.com TECHNIQUE: After curettage Surrounding soft tissues are retracted & protected away with gauze and flap retractors Entire bony cavity frozen with liquid nitrogen spray Solid frost is observed 3 freezing cycles Each cycle - 1 minute Gap b/w each cycle 5 minutes Mucoperiosteal flap were sutured
www.indiandentalacademy.com Complications - sequestration, pathological fracture, transient anaesthesia of mandibular nerve More extensive the freezing, the greater the risk Another method which has been described (Weaver and Smith-1963, Bradley-1978) in which the affected segment of bone is excised, frozen in liquid nitrogen to devitalise the tissue, and then reimplanted as an autogenous graft. www.indiandentalacademy.com MARGINAL RESECTION / RESECTION WITHOUT CONTINUITY DEFECT / PERIPHERAL OSTEOTOMY / EN BLOC RESECTION Indicated in lesions which are known for recurrence Lesions that tend to grow beyond their surgically apparent capsule Treatment - when the lesion does not extent closer than 1 cm to the inferior border of the mandible. Margin of 1 to 2 cm - minimum acceptable margin. Various authors - good results with en bloc resection Lesions of the maxilla - en bloc resection is not as successful and recommend segmental resection
www.indiandentalacademy.com Procedure allows complete excision of the tumor but at the same time a continuity f the jaw bone is retained thus deformity, disfigurement & need for secondary cosmetic surgery & prosthetic rehabilitation are avoided. ADVANTAGE: Not violating the tumor margins during resection which might provide the possibility of tumor seeding in the surgical site. DISADVANTAGE: Does not discriminate b/w tumor tissue & vital structures in close approximation such as inferior alveolar nerve. www.indiandentalacademy.com Operative procedure
Intra-oral / extra-oral approach Intra-oral - good access and when the lesion is anterior to third molar region Extra-oral approach - lesion involves the ramus of the mandible or when immediate reconstruction is planned www.indiandentalacademy.com Surgical approaches to maxilla: www.indiandentalacademy.com Surgical approaches to mandible: www.indiandentalacademy.com Intra-oral approach Large mandibular lesions - a midline lip-splitting incision Connecting vertical incisions are made on the buccal and lingual Incisions - extend deep into buccal and lingual folds. The teeth bordering the surgical margin should be extracted Horizontal incisions connecting the lower ends of vertical incisions are made. The buccal and lingual mucoperiosteal flaps are then developed, but not reflected superiorly over the region of bone to be removed. www.indiandentalacademy.com Marginal Resection www.indiandentalacademy.com On exposure of the mandible, the bony segment is sectioned with an air-driven saw or bur, at least 1 to 1.5 cm from the radiographic margin of the lesion Haemorrhage - controlled by crushing the bone over small blood vessels with a blunt instrument or by using bone wax The mucoperiosteum is then undermined both lingually and facially to relieve tension. They are approximated with interrupted silk sutures.
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Segmental (partial) mandibular resection / hemimandibulectomy Segmental resection - maxillectomy and hemimandibulectomy Least number of recurrences. Indications: Infiltrative lesions Lesions posterior/ inferior border of mandible Lesions with high recurrence rate
www.indiandentalacademy.com Segmental resection: www.indiandentalacademy.com Operative procedure Depending on the size - a lip-splitting incision may or may not be necessary A submandibular incision - join the vertical lip incision Intra-orally - horizontal incision is made through the mucoperiosteum The facial and lingual flaps are advanced below the horizontal incision using a periosteal elevator. The lingual flap is raised as deep as to expose the mylohyoid attachment. A vertical mucoperiosteal incision is made 0.5 cm proximal to the anticipated anterior bony cut.
www.indiandentalacademy.com www.indiandentalacademy.com www.indiandentalacademy.com Expose the mental neurovascular bundle, which is ligated and sectioned. Preservation of the marginal mandibular branch of the facial nerve Using an air-driven saw, bur or a Gigli saw, a vertical cut is made through the mandible anterior to the lesion. Using bone forceps, the proximal part of the mandible is rotated laterally, exposing the inferior alveolar nerve and vessels, at the lingula of the mandible. They are ligated and cut adjacent to the mandibular foramen. The capsule is cut with a scalpel and the segment of mandible is disarticulated and removed using bone- holding forceps. Bleeding - controlled by digital pressure, coagulation or ligation, depending on the size of the bleeding vessel.
www.indiandentalacademy.com Resection with disarticulation: www.indiandentalacademy.com Odontogenic myxoma www.indiandentalacademy.com The patient should be fed through a naso-gastric tube for a week and scrupulous oral hygiene should be maintained. Dressings should be changed daily. Removal of drain depends on the amount of drainage. Alternate skin sutures are removed after 4 days and the remaining ones, after 6 days. After that, the naso-gastric tube may be removed and oral feeding may be begun.
www.indiandentalacademy.com Classification of Maxillectomies 1. Partial Maxillectomy(Alveolectomy): Removal of lower half of the Maxilla.
2. Subtotal Maxillectomy:: lesions which extend beyond the confines of Antrum
3. Medial Maxillectomy: Medial wall of antrum, inferior & middle Turbinates, ethmoidal air cells, Lamina papyracea (one side)
4. Total Maxillectomy: complete removal of Maxilla. www.indiandentalacademy.com Marginal (partial) maxillectomy The marginal maxillectomy is the surgical procedure most often used for tumors of maxilla when the maxillary sinus is not involved. Operative procedure Intra-oral approach Mucoperiosteal incision - 1 to 2 cm in all directions from the underlying tumour. It may be necessary to extract one or more teeth to complete these incisions. www.indiandentalacademy.com Partial Maxillectomy (Alveolectomy) www.indiandentalacademy.com Calcifying epithelial odontogenic tumor: www.indiandentalacademy.com Extra oral procedure
www.indiandentalacademy.com Total maxillectomy www.indiandentalacademy.com British Journal of Oral and Maxillofacial Surgery 45 (2007) 306310 www.indiandentalacademy.com RECONSTRUCTION Radical surgeries like segmental resection, hemimandibulectomy and maxillectomy leave the patient with a thoroughly incapacitating aesthetic and functional deficit www.indiandentalacademy.com Goals of mandibular reconstruction Re-establishment of mandibular continuity and an osseus-alveolar base Maintenance of oral functions and proper occlusion with maxillary arch. To achieve minimal impairment of function Correction of soft-tissue defects To achieve good aesthetic results.
www.indiandentalacademy.com Goals of maxillary reconstruction
Obliteration of the defect Restoration of essential function of mid face Provision of adequate structural support. Aesthetic reconstruction of external features.
www.indiandentalacademy.com Immediate Vs delayed reconstruction IMMEDIATE ADVANTAGES Single stage surgery Early retain of function Minimal compromise of esthetics DISADVANTAGES Recurrence Time consuming Infection DELAYED ADVANTAGES Good result Less recurrence Good planning
DISADVATAGES Fibrosis Wound contraction 2 nd surgery www.indiandentalacademy.com Ideal Graft: Restoration of ability to masticate Acceptable esthetic appearance Withstand physiologic forces Non-reactive in tissues Sterile Readily available www.indiandentalacademy.com CLASSIFICATION Depending on nature of bone Depending on donor Depending on the preparation Depending on the vascularity Depending on donor site: Depending on function
www.indiandentalacademy.com Depending on nature of bone Cancellous bone graft Cortical bone graft Corticocancellous grafts . Blocks . Chips . Powder Marrow graft Depending on donor Autogenous bone graft from same individual Isogenic bone graft from genetically related individual Allogenic allograft from another individual of same species Xenografts from different species
www.indiandentalacademy.com Depending on the preparation allografts and xenografts can be again divided into: a. Freezed bone grafts b. Freezed dried c. Demineralised d. Antigen extracted autolysed
Depending on the vascularity autografts can be divided into: Non vascularised Vascularised bone transfer attached on soft tissue, pedicle, microvascular free transfer.
www.indiandentalacademy.com Depending on donor site: Iliac crest graft - anterior ileum posterior ileum trephine grafts Rib graft Full thickness Split rib graft Calvarial graft Full Split Fibula
www.indiandentalacademy.com Depending on function Bridging graft or inlay graft Reconstruction graft Contour graft onlay graft. Bone substitutes www.indiandentalacademy.com Maxillary reconstruction
Prosthesis Obturator and splints Local soft tissue flaps Buccal and palatal advancement flaps Cheek flaps Buccal pad of fat
Autogenous vascularised bone by pedicled flaps Clavicle pedicled on sternocleidomastoid Rib pedicled on pectoralis major Scapula pedicled on trapezius Calvarium pedicled on temporalis Rib pedicled on latissimus dorsi
www.indiandentalacademy.com Autogenous vascularised bone by free flaps iliac crest based on deep circumflex iliac artery fibula based on peroneal artery scapula based on circumflex scapular artery radial forearm based on radial artery rib based on intercostal artery second metatarsal calvarium based on superficial temporal artery