Craniomaxillofacial Reconstructive and Corrective Bone Surgery - part 2 ppt

7 Review of Benign Tumors of the Maxillofacial Region and Considerations for Bone Invasion Joachim Prein Tumors in the maxillofacial region are located in the soft and hard tissues. Those located in the facial skeleton are rare and can be of dental origin (odontogenic) or arise from bony tissues (osteogenic). No matter whether they are benign or malignant, clinically they often are symptomless for a long time. Only rarely do they cause pain. Even on x-ray films their appearance is very uniform. Most of them present as mono- or polycystic lesions. Even the distinction of whether these lesions are well delineated or not does not help to determine whether a tumor is benign or malignant. 1 Although examinations with computed tomography (CT) or magnetic resonance imaging (MRI) give much more precise information about the contents and delineation of these lesions, in most of the cases it is not possible to establish a diagnosis. This can only be done through a biopsy and a histologic examination. These biopsies should always be open biopsies to receive sufficient material in quantity and quality. This is important because many benign or malignant tumors can present with histologically similar pictures. This is true for odontogenic tumors (e.g., for the ameloblastoma and its variants, such as ameloblastic fibroma or ameloblastic fibroodontoma). Also, it may be difficult to differentiate between fibrous dysplasia and ossifying fibroma, osteoblastoma and osteosarcoma, or desmoplastic fibroma and fibrosarcoma. A very close cooperation between the clinician, pathologist, and radiologist is mandatory to receive an exact diagnosis. The pathologist needs all clinical and radiologic information because tumors that are histologically similar may have different diagnoses according to their different anatomic locations. A correct treatment plan can, of course, only be es- tablished with a precise preoperative diagnosis. Odontogenic Tumors and Tumorlike Lesions Tumors and tumorlike lesions of dental origin are less common than those of osseous origin. Most reflect a state out of the development of a tooth. Because epithelial and mesenchymal tissues are involved in the formation of tooth bud, both components can be involved in the formation of an odontogenic tumor. Most odontogenic tumors are benign, and some are not even tumors, but rather tumorlike lesions or hamartomas, such as all odontomas. Therefore, most are clinically as well as radiologically and histologically well delineated and can be treated with curettage, enucleation, or sometimes fenestration. Their radiologic appearance is very uniform and often resembles a follicular cyst (Figure 7.1). An infiltrative pattern of growth into the bony structures has histologically only been observed with ameloblastomas (Figure 7.2) and ameloblastic fibrosarcomas. Because of size and location of some benign lesions, such as keratocysts, myxomas, or adenomatoid odontogenic tumors, it may be necessary to perform a complete resection of the involved bony area and a reconstruction thereafter. Char- acteristic of keratocysts is their high rate of recurrence (between 32% and 63%). In some instances, it has been reported that intraosseous carcinomas have developed out of keratocysts. Table 7.1 mentions odontogenic lesions that necessitate a curettage or enucleation only, and according to size and location, a defect filling with cancelleous bone (Figures 7.3 and 7.4). The ameloblastoma is a locally aggressive tumor that ne- cessitates a complete resection with clear margins. Neither radiologic characteristics, such as mono- or polycystic appear- ances, nor resorption of tooth roots, nor the different histologic subgroups allow a differentiation between more or less aggressive tumors. Until a few years ago, resorption of tooth roots has been interpreted as pathognomonic for ameloblastomas. Meanwhile, this phenomenon has been observed in connection with several odontogenic and nonodontogenic tumors and tumorlike lesions. It was found, however, that it does not indicate a higher aggressivness of the lesion. Table 7.2 shows a list of lesions in which radiologically re- sorptions of tooth roots have been observed. Although in rare instances true malignant ameloblastomas with lymph node or skeletal metastases have been described, a neck dissection together with the resection of the tumor is 59 60 J. Prein FIGURE 7.1 Cystic lesion in the left mandibular angle region with a retained molar. The x-ray appears similar to a follicular cyst. Within the cyst wall, an ameloblastoma was found. F IGURE 7.2 Epithelial islets pathognomonic for an ameloblastoma are found to infiltrate the bony structures. TABLE 7.1 Benign odontogenic tumors and tumorlike lesions. Adenomatoid odontogenic tumor Ameloblastic fibroma and myxoma Odontogenic myxoma and fibroma Dentinoma Cementoma Cementifying fibroma Odontoma Calcifying epithelial odontogenic tumor Calcifying odontogenic cyst Odontogenic keratocyst Follicular and radicular cysts Histomorphologically, several types of ameloblastomas are described. The attempt to assign different grading ranks to the various types has not proven to be clinically sound. Particu- larly in connection with the description of malignant ameloblastomas, the acanthous type ameloblastoma has been misinterpreted as squamous cell carcinoma or adenoid cystic carcinoma or adenocarcinoma. Ameloblastomas are predominantly located in the mandible and rarely appear before the age of 18. This is an important criterion because it helps in some instances to differentiate between ameloblastoma and lesions such as ameloblastic fi- bromas and myxomas. In most instances, after complete resection of the tumor with the bone, a primary reconstruction with a reconstruction plate and a free bone graft is performed. Only rarely and depending on size and location of the defect is a primary reconstruction with a microvascular graft indicated. The most important precondition for a successful primary reconstruction is a reliable stabilization with plates and screws together with a reliable closure of the soft tissues around the grafts. The following case clearly demonstrates this. A 41-year-old patient presented with a symptomless moderate swelling of his left mandibular angle area. On x-ray, a polycystic lesion was found and, after an open biopsy, it was diagnosed as an ameloblastoma. After resection of the tumor through a partial mandibulec- tomy the defect was bridged with a 2.7 reconstruction plate. A bone graft was taken from the iliac crest and the bony defect immediately reconstructed. Two years after the removal of the tumor the plate was removed on the patient’s request. As a rule we do not remove these plates because they are not responsible for any resorption of the bone graft through stress protection. At the occa- sion of the plate removal, dental implants were inserted into the bone graft (Figures 7.5–7.7). 7. Benign Tumors of the Maxillofacial Region 61 FIGURE 7.3 Extensive polycystic lesion in the left ramus and mandibular angle area in an 18-year-old man. The swelling was painless and the patient did not complain about loss of sensitivity in his left lower lip. Diagnosis: odontogenic keratocyst. F IGURE 7.4 Although the lesion was very extensive and reached into the area of the joint, conservative treatment with curettage and filling of the cavity with autogenous cancellous bone was performed. The patient will remain in a follow-up control for many years. TABLE 7.2 Lesions with possible tooth root resorption on x-rays. Ameloblastoma Ameloblastic fibroma Odontogenic myxoma Adenomatoid odontogenic tumor Cementoma Calcifying odontogenic cyst Odontogenic keratocyst Ossifying fibroma Fibrous dysplasia Desmoplastic fibroma Eosinophilic granuloma Giant-cell granuloma Hemangioma Osteosarcoma Plasmocytoma not indicated. As far as clinical behavior is concerned, the ameloblastoma can be compared with a basalioma. Infre- quently, ameloblastic fibrosarcomas or ameloblastic odon- tosarcomas are observed. Regional metastasis have not been described with these. 2–4 Nonodontogenic Tumors and Tumorlike Lesions Within the Facial Bones Mesenchymal tumors in the jaw bone have other characteristics compared with those of the same name in the postcranial skeleton. They are less often benign than odontogenic tumors. Some appear almost exclusively in facial bones, such as the osteoma and the ossifying fibroma, and some, such as the giant-cell tumor, are not found in the facial bones. On the other hand, the giant cell granuloma, except as a brown tumor with hyperparathyroidism, is not observed outside the facial bones. For the pathologist, however, it may be difficult or impossible to differentiate between a giant cell tumor and a giant cell granuloma. Therefore, precise information about the clinical situation is mandatory for the pathologist. Rec- ognizing that giant cell tumors do not appear in the facial bones is one of the most important observations made in re- cent years. Until the mid-1970s, many patients were overtreated with mutilating resections because giant-cell gran- ulomas were misinterpreted as giant-cell tumors. An important diagnostic sign is the vitality of the teeth. They often remain vital although their roots are located in the empty spaces of the cystic lesions (Figures 7.8 and 7.9). 62 J. Prein FIGURE 7.6 Reconstruction of the mandibular defect with a reconstruction plate and an autologous bone graft taken from the iliac crest. F IGURE 7.7 Two years after the reconstruction, the reconstruction plate was removed and dental implants inserted. FIGURE 7.5 Polycystic lesion in the left mandibular retromolar and angle area. Diagnosis: ameloblastoma. The establishment of a special registry for tumors of the facial skeleton including odontogenic lesions in 1971 by the Ger- man-Austrian-Swiss Association for the Study of Tumors of the Face and Jaws (DÖSAK) and the analysis of all the giant- cell lesions in the registry has led to the recognition that malignant giant cell tumors do not appear in the facial skeleton. It was in 1974 that the DÖSAK sponsored a symposium under the chairmanship of Professors Uehlinger and Rema- gen during which several reclassifications had to be done. In benign tumors, one has in general to differentiate between cartilaginous, osteofibrous, cystlike lesions, and lesions that derive from the vessels. Most of the round-cell tumors and lymphatic tumors are malignant. On x-ray examinations it is rarely possible to establish a diagnosis, because very few pathognomonic signs exist. Lesions appearing in the mandible allow more often at least approximate conclusions than those in the maxilla, whereas on regular x-ray films a very monot- onous appearance of the lesions is observed. In the mandible, most appear to be cystlike, regardless of whether they are benign or malignant. Some allow at least approximate conclusions according to the degree of metaplas- tic bone formation, which is dependent on age and further ac- tivities within the tumor. The following list mentions the main benign nonodontogenic lesions in the facial skeleton: Chondroblastic: enchondroma chondroblastoma chondromyxoid fibroma osteochondroma Osseous origin: osteoma osteoblastoma and osteoid-osteoma ossifying fibroma fibrous dysplasia Histiocytosis x: Langerhans cell granuloma Vascular origin: hemangioma Probably semimalignant: desmoplastic fibroma Unknown etiology: central giant-cell granuloma juvenile bone cyst aneurysmal bone cyst Radical excision is necessary for all cartilaginous lesions because they have a strong tendency for recurrence. Resec- tion or enucleation is sufficient for osteoma, osteoblastoma, ossifying fibroma, hemangioma, central giant-cell granulo- mas, and aneurysmal bone cysts. A juvenile bone cyst is an empty hole without an epithelial lining. Apparently, the opening and the subsequent bleed- ing into the cavity initiates reossification of the area. Surgical contouring, or in smaller lesions enucleation, is the treatment for fibrous dysplasia. Because of the tendency for recurrence or regrowth, clinical and radiologic follow-up for many years is indicated. The tendency toward malignant transformation is very low, although proven malignant transformation has been seen in connection with radiotherapy for a fibrous dysplasia. The treatment of eosinophilic granuloma depends on its monostotic or multilocular appearance. Although desmoplastic fibroma may be considered as semimalignant and its growth pattern may be infiltrative into the cancellous areas of the bone, a first operative step can be enucleation for those well delineated on x-rays and more radical resection for those not well demarcated or in the case of recurrences. Generally, radiotherapy is not indicated for any of the above- mentioned lesions. On the contrary, radiotherapy may be harm- 7. Benign Tumors of the Maxillofacial Region 63 FIGURE 7.8 Extensive cystic lesion in the right horizontal part of the mandible surrounding the roots of the teeth 44, 45, 46, and 47. All teeth remained vital. Diagnosis: giant-cell granuloma. F IGURE 7.9 After careful curettage of this lesion and defect filling with autogenous cancellous bone, only tooth 47 lost its vitality. ful since it may cause a transformation of some of these lesions into osteosarcomas. Radiotherapy may even cause secondary osteosarcomas without any lesions in this area. References 1. Prein J, Remagen W, Spiessl B, Uehlinger E. Atlas of Tumors of the Facial Skeleton. Odontogenic and Non-odontogenic Tumors. New York: Springer Verlag; 1985. 2. Prein J, Remagen W, Spiessl B, Schafroth U. Ameloblastic fibroma and its sarcomatous transformation. Pathol Res Pract. 1979;11:123–130. 3. Pindborg JJ, Hjorting-Hansen E. Atlas of Diseases of the Jaws. Copenhagen: Munksgaard; 1974. 4. Takahashi K, Kitajima T, Lee M, Iwasaki N, Inoue SI, Matsue N, et al. Granular cell ameloblastoma of the mandible with metastasis to the third thoracic vertebra. Clin Orthop. 1985;197: 171–180. 64 J. Prein 8 Oral Malignancies: Etiology, Distribution, and Basic Treatment Considerations Anna-Lisa Söderholm Treatment Considerations The most common oral malignancy (90% to 97%) is squamous cell carcinoma, 1,2 followed by adenocarcinomas of various types (2% to 3%). 1 Sarcomas, extranodal lymphomas 3–5 and metastases from distant cancers 6–8 are rare. Other malignant tumors, including melanomas and tumors of dental origin, occasionally occur in the oral and maxillofacial region. Oral Squamous Cell Carcinoma Epidemiology Oral cancer is the fifth most common malignancy worldwide, with the incidence of new tumors per thousand estimated at 378.5 for all countries, with 272.3 in developing countries and 106.2 in developed countries. 9 Worldwide, however, a 3% to 4% relative frequency is usually encountered. For example, in Malaysia oral carcinomas ranks second among all histologically confirmed malignant tumors. 10–12 The approximate annual incidence rate in the United States is 1.2/10 5 for squamous cell carcinoma (SCC) of the lip and 7/10 5 (30.600 new cases) for oral SCC, which when combined constitutes ap- proximately 3% of all reported malignancies in 1990. 2,13 In the Scandinavian countries, the incidence of lip and oral cancer is fairly low. 14 The national cancer registries in the Scandinavian countries constitute ideal sources of material for epidemiological studies. The data in the Finnish Cancer Reg- istry can be considered virtually complete in relation to cov- erage of cancers diagnosed in Finland. 15 In Finland, the mean age-adjusted incidence rates for 1991 were 3.1/10 5 (lip), 2.3/10 5 (oral) for males and 0.6/10 5 (lip), 1.3/10 5 (oral) for females. 16 The incidence of oral cancer decreased slowly but steadily from 1953 until 1976, especially in men, 17 but from 1977 on the figures have increased. 16 Etiology Tobacco use, especially smoking, is generally considered the main etiologic factor for mouth cancer. Other causes include alcohol abuse, some drugs, environmental factors, and viruses. 18–23 Analysis of the national Finnish Cancer Registry records of cancer of the lip, mouth, and pharynx for the oc- currence of secondary primaries revealed 9092 cases diagnosed between 1953 and 1989. The observed numbers of patients were compared with the expected on the basis of the incidence rates in the Finnish population (Figure 8.1). There were 1130 patients (12%) with new tumors. The standardized incidence rate (SIR) of contracting a new cancer was 1.2 for lip cancer patients (95% CI 1.1–1.3) and 1.4 for patients with cancer of the oral cavity or pharynx 95% (CI 1.2–1.4) (Table 8.1). A concentration of the excess risk for tobacco-related new tumors in lip cancer patients, which, for example, is a significant excess risk of lung cancer (SIR 1.4), supports the role of smoking as a risk factor for lip cancer (Table 8.2). A variation of the relative risk by subsite and sex in oral cancer seemed more likely to support a multifactorial rather than a clearly tobacco-related etiology in these cancers 24 (Table 8.3). Analysis of the Finnish Cancer Registry material by occupa- tion and social status pointed, on the other hand, in the case of oral cancer, more to an alcohol than smoking etiology. The role of occupational factors seemed to be minimal. 25 These figures from the Finnish Cancer Registry statistically are highly reliable since both the observed numbers of new tumors and the expected numbers relate to the same set of data. Initial Symptoms The symptoms of oral squamous cell carcinoma are often diffuse and nonspecific. For example, mucosal hyperplasia and different types of mucosal ulcers are common in elderly patients with dental prostheses, and malignant changes are often not recognized by the patients at an early stage. This cre- ates an opportunity for dentists to detect early cancer when patients present with complaints concerning dental prostheses. The main presenting symptoms for cancer of the mandibular region are listed in Table 8.4. 26 The list also cor- responds for other sites of the oral cavity. However, pain as the first complaint has been reported in 50% to 66% of intraoral carcinomas depending on the site, 2 an interesting and 65 important symptom. Although a very early cancerous lesion may be painless, more advanced cancer lesions are not. In several studies, the interval between presenting symptoms and the tissue diagnosis of cancer has been reported to be ap- proximately 4 months. 2,26,27 Findings At clinical examination, a nonhealing, indurated ulcer or firm lump is always suspicious for cancer. Premalignant lesions usually exist as leukoplakias or erythroplakias, while early frank invasive cancers may manifest as small, asymptomatic mucosal masses or ulcers. The role of the patient’s own den- tist, performing regular oral examinations including system- atic inspection and palpation of the entire oral and oropha- ryngeal mucosa, is important. The examination always must be extended extraorally with bimanual palpation of the floor of the mouth, simultaneously with the submandibular and sub- mental regions. Still, too few oral mucosal lesions are biopsied, and the follow-up of precancerous lesions is often ne- glected. Lesions classified as premalignant erythroplasia, leukoplakia, and lichen planus have to be thoroughly excised or regularly biopsied. If the histologic diagnosis is severe or moderate dysplasia, close follow-up is mandatory. 2 Distribution by Site and Stage Tongue cancer (ICD-7 140) represents 35% to 50% of the malignant tumors occurring in the oral area (Table 8.5). 2,13,24 66 A L. Söderholm TABLE 8.1 The excess risk of getting a new primary cancer among patients with lip cancer and cancer of the mouth and oropharynx respectively. The number of cases recorded in the national Finnish Cancer Registry 1953–1989 and SIR:s for a new primary cancer in these patients. 24 Person-years New Cancer type Patients at risk cancers SIR Lip 5633 51,951 901 1.2 Mouth and oropharynx 3454 15,764 229 1.4 TABLE 8.2 The excess risk (SIR:s) of getting a new primary cancer among patients with lip cancer in Finland 1953–1989 by site. 24 New cancer N SIR Lip 4 0.28 Mouth, pharynx 16 1.9 Larynx 23 2.0 Lung 269 1.4 Esophagus 18 1.2 Stomach 107 1.1 Colon 26 0.81 TABLE 8.3 The excess risk (SIR:s) of getting a new primary cancer among patients with cancer of the mouth and pharynx in Finland by site. 24 New cancer N SIR Lip 8 3.5 Mouth, pharynx 11 5.8 Larynx 1 0.54 Lung 52 1.8 Esophagus 5 1.4 Stomach 18 0.73 Colon 13 1.5 Thyroid gland 3 2.2 NHL* 4 1.5 Hodgkin’s disease 2 2.7 Leukemia 9 2.3 * Non-Hodgkin’s lymphoma TABLE 8.4 Presenting symptoms and signs (one or several for each case) in 162 patients with oral carcinoma of the mandibular region. 26 Number of Symptom or sign patients Percentage Ulceration 103 64% Palpable tumor alone 36 22% Pain 28 17% Soft tissue hyperplasia 19 12% Symptoms of infection 6 4% Paraesthesia 5 3% Mobility of teeth 5 3% Trismus 3 2% Mandibular fracture 3 2% Weight loss 2 1% Delayed healing of extraction wound 1 1% TABLE 8.5 Numbers of patients with cancer of the mouth and pharynx diagnosed between 1953 and 1989 in Finland by subsite. 24 Site (ICD-7) Number of patients Person-years at risk Tongue (141) 1,228 6,172 Oral cavity (143,4) 1,217 6,640 Pharynx (145,7,8) 1,014 2,952 FIGURE 8.1 Standard incidence ratio (SIR). About one third of the oral cavity cancers (ICD-7 143–144) occur in the mandibular region (Figure 8.2). 26 This region represents an important, distinct entity associated with special problems related to the diagnosis, evaluation of bone extension, treatment planning, surgical techniques, reconstructive proce- dures, treatment results, and prognosis. The distribution of 162 cases of mandibular cancer is shown in Table 8.6. 26 The TNM classification (UICC) 28,29 (Table 8.7) and staging system followed is generally that of the American Joint Committee for Cancer (AJCC) Staging and End Results Re- porting (1988), 30 although several modifications and ampli- fications have been suggested for getting better prognostic re- liability. 31,32 A large number of the tumors are, despite efforts toward earlier tumor detection, still advanced at diagnosis. 2,13,31,33,34 Involvement of the underlying bone (T 4 ) is common, both in the maxillary and mandibular areas (52%) (Figure 8.3). 26,34 Clinical Examination and Diagnosis Oral squamous cell carcinoma can usually be easily diagnosed by inspection of the oral mucosa and palpation by an experi- enced clinician (Figure 8.4a). However, initial carcinoma in connection with a leukoplakia or lichen planus might be ne- glected (Figure 8.4b). Histologic examination of a biopsy specimen gives the final diagnosis. No tumor should be treated without confirmation of the histologic examination. The biopsy should be adequate, and it should be obtained from a representative portion of the tumor so that the pathologist can examine the tissue properly. In general, the most satisfactory biopsy of an intraoral lesion is the incisional biopsy (i.e., removal of a small portion). If, however, cancer is suspected in a very small lesion whose gross appearance would be altered by the biopsy, immediate referral would be preferred. It is of the utmost importance that the clinician who will apply the definitive treatment should see the extent of the lesion before the biopsy is taken in order to judge the extent of the resection or irradiation to be instituted. 2 For tumors in areas where biopsies are difficult to obtain (e.g., base of tongue or na- 8. Oral Malignancies 67 FIGURE 8.2 Outline of mandibular region. F IGURE 8.3 TNM classification and stage of 162 squamous cell carcinomas of the mandibular region diagnosed between 1973 and 1985 in Finland. 34 TABLE 8.6 Location of 162 tumors in the mandibular region on diagnosis. 26 Males Females Total Location N % N % N % Lower alveolar ridge 49 59% 50 63% 99 61% Sublingual sulcus 27 33% 17 22% 44 27% Lower buccal sulcus 3 3% 9 11% 12 8% Retromolar area 4 5% 3 4% 7 4% Totals 83 100% 79 100% 162 100% TABLE 8.7 TNM classification of oral cancer. 28,29 Primary tumor (T) T 1 Tumor Յ2 cm in greatest dimension T 2 Tumor Ͼ2 cm but Յ4 cm in greatest dimension T 3 Tumor Ͼ4 cm in greatest dimension T 4 Tumor invades adjacent structures Regional lymph node (N) N 0 No regional lymph node metastasis N 1 Metastasis in a single ipsilateral lymph node, Յ3 cm in greatest dimension N 2 Metastasis in a single ipsilateral lymph node, Ͼ3 cm but Ͻ6 cm in greatest dimension; in multiple ipsilateral lymph nodes, none Ͼ6 cm in greatest dimension; or in bilateral or contralateral lymph nodes, none Ͼ6 cm in greatest dimension N 3 Metastasis in a lymph node Ͼ6 cm in greatest dimension TNM stage groups: IT 1 N 0 II T 2 N 0 III T 1–3 N 1 , T 3 N 0 IV T 4 , any of N 2 , N 3 , or distant metastatic disease sopharynx) it is necessary to perform the biopsy on the patient by fiberoscopy under general anesthesia. Lymph node biopsy is carried out only when a primary lesion cannot be identified, and in such instances, it is preferable for the entire lymph node to be excised. In clinically obvious cancer lesions, radiologic examination should be performed prior to the confirmatory biopsy for evaluating tumor extension and possible bone involvement. A thorough medical history, general health examination (including laboratory tests), and presurgical clearance, is, of course, mandatory. Evaluation or Determination of Tumor Extension For the evaluation of tumor extension in the middle and upper face, surrounding soft tissues in the mandibular region and neck, computerized tomography (CT) and especially magnetic resonance imaging (MRI) are invaluable. For the detection of cervical lymph node metastasis according to several studies, ultrascan provides the most reliable information, 35 which can be combined with fine-needle aspiration biopsy. Preoperative assessment of possible lymph node spread is extremely important in treatment planning. Lymph node involvement at diagnosis is associated with poorer prognosis, which will influence the choice of reconstruction at the local tumor site. Preoperative assessment of bone infiltration is one of the main problems in treatment planning in patients with cancer of the mandibular region. How large a resection is necessary? Mandibular bone involvement can occur at an early stage through small defects in the bony cortex and that type of in- 68 A L. Söderholm FIGURE 8.4 (a) A clinically obvious carcinoma of the left mandibular edentulous ridge in a 67-year-old female. The diagnosis was confirmed by biopsy. (b) A 0.5-cm area of erythroplasia in a 51-year- old man was excised. At histologic examination carcinoma in situ was found. Resection with 1.5-cm margins and reconstruction with local flaps from the tongue was performed. Histologic examination of the surgical specimen revealed infiltrative carcinoma. a b F IGURE 8.5 (a) Orthopantomogram of a 55-year-old male with a T 2 gingival squamous cell carcinoma of the right mandibular body region, showing diffuse local destruction at the upper margin. (b) Com- a b puterized tomogram of the same patient showing bone destruction of the right mandibular body, which is predominantly lingual. [...]... of the jaw Cancer 1983;51 :23 11 23 16 54 Delegado R, Maafs E, Alfeiran A, et al Osteosarcoma of the jaw Head Neck 1994;16 :24 6 25 2 55 Russ JE, Jesse RH Management of sarcoma of the maxilla and mandible Am J Surg 1980;140:5 72 576 56 Söderholm A-L, Lindqvist C, Teppo L, et al Bone resection in patients with mandibular sarcoma J Craniomaxillofac Surg 1988;16 :22 4 23 0 57 Söderholm A-L, Lindqvist C, Heikinheimo... 1986:80–111 23 Strauss M, Baum S, Kaufman RA Osteomyelitis of the head and neck: sequential radionuclide scanning in diagnosis and therapy Laryngoscope 1985;95:81–84 24 Blahd WH, Rose JG Nuclear medicine in diagnosis and treatment of diseases of the head and neck: II Head Neck Surg 19 82; 4 :21 3 22 3 25 Datz FL Indium 111-labeled leukocytes for detection of infection: current status Semin Nucl Med 1994 ;24 (2) : 92 109... tumors metastatic to mouth and jaws Oral Surg Oral Med Oral Pathol 1965 ;20 :350–3 62 59 Gullane PJ Mandibular reconstruction New concepts Arch Otolaryngol Head Neck Surg 1986;1 12: 714–719 60 Gullane PJ, Havas TE Mandibular reconstruction after cancer surgery Facial Plast Surg 1987;4 :22 1 23 2 61 Hellem S, Olofsson J Titanium-coated hollow screw and reconstruction plate system (THORP) in mandibular reconstruction... Head Neck 1990; 12: 483–487 51 McQuarrie DG Oral cancer In: McQuarrie DG, Adams GL, Shons AR, Brown GA, eds Head and Neck Cancer: Clinical Decisions and Management Principles Chicago: Year Book Medical Publishers; 1996 :21 9 24 3 52 Söderholm A-L, Lindqvist L, Sankila R, et al Evaluation of various treatments for carcinoma of the mandibular region Br J Oral Maxillofacial Surg 1991 ;29 :22 3 22 9 53 Clarc JL,... oropharynx in different social and occupational groups in Finland Oral Oncol Eur J Cancer 1994;30B :20 9 21 5 26 Söderholm A-L Carcinoma of the mandibular region Br J Oral Maxillofac Surg 1990 ;28 :383–389 27 Rindum J, Pindborg JJ Intraoral Cancer Ugeskrift Laeger 1986;149:8–9 28 Spiessl B Die TNM-Klassification (1987 neu aufgelegt) Dtsch Z Mund Kiefer Gesichts Chir 1988; 12: 83–85 29 UICC, International Union... cancellous bone and progresses much more rapidly there than it does in the more resistant and dense cortical bone The dense cortical bone is superimposed on the cancellous bone and, thus, obscures changes in the cancellous bone Important radiographic findings that may eventually occur in osteomyelitis include periosteal reaction, osteoporosis, new bone formation, and sequestrum formation .22 As these... mandible Laryngoscope 1976;86:908– 920 29 Peterson LJ Microbiology of head and neck infections Oral Maxillofac Clin North Am 1991;3 (2) :24 7 25 7 88 30 Lewis RP, Sutter VL, Finegold SM Bone infections involving anaerobic bacteria Medicine 1978;57 :27 9–305 31 Gupta DS, Gupta MK, Naidu NG Mandibular osteomyelitis causes by actinomyces israelii J Maxillofac Surg 1986; 14 :29 1 29 3 32 Roine I, Faingezicht I, Arguedas... into consideration only the maxillae and palatine bones (Tables 10 .2 and 10.3, Figure 10 .2) The types of deformity are as follows: those that involve the maxillae, palatine bones and the FIGURE 10 .2 Location of maxillary deformities (Mx) (From Greenberg3) L1 Maxillae, palatine bones and floor of nose L2 Those which involve the antra L3 Those which involve the antra and nasal aperture L4 Alveolar process... radiation .22 The indium-labeled leukocyte scan can be interpreted without a technetium bone scan .22 If local accumulation of leukocytes occurs that is higher than surrounding bone activity, the scan is interpreted as positive If no local accumulation occurs, the scan is negative A technetium scan can be used as an overlay to better localize the infection .22 Experience with the indium-labeled-leukocyte... Neck Surg 1993;119:1031–1036 72 Söderholm A-L, Lindqvist C, Haglund C Tumor markers and radiological examinations in the follow-up of patients with oral cancer J Craniomaxillofac Surg 19 92; 20 :21 1 21 5 73 Söderholm A-L, Lindqvist C, Skutnabb K, et al Bridging of mandibular defects with two different reconstruction systems J Oral Maxillofac Surg 1991;49:1098–1105 74 Söderholm A-L, Rahn BA, Suutnabb U, Lindquist . the mouth and pharynx diagnosed between 1953 and 1989 in Finland by subsite. 24 Site (ICD-7) Number of patients Person-years at risk Tongue (141) 1 ,22 8 6,1 72 Oral cavity (143,4) 1 ,21 7 6,640 Pharynx. Publishers; 1996 :21 9 24 3. 52. Söderholm A-L, Lindqvist L, Sankila R, et al. Evaluation of various treatments for carcinoma of the mandibular region. Br J Oral Maxillofacial Surg. 1991 ;29 :22 3 22 9. 53 1987;4 :22 1 23 2. 61. Hellem S, Olofsson J. Titanium-coated hollow screw and reconstruction plate system (THORP) in mandibular reconstruction. J Craniomaxillofac Surg. 1988;16:173–183. 62. Lindqvist

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