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University of Jordan
Faculty of Dentistry
5th year (2015-2016)
Oral Surgery II
Sheet
Slide
Hand Out
Lecture No.
13
Date:
Doctor:
Zaid Baqain
Done by:
Mohammad Basel
Price & Date of
printing:
Dent2011.weebly.com
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Designed by: Hind Alabbadi
Dr.Zaid Baqain
Mohammad Basel
OS sheet# 13
Cancer’s Management
Cancers in general are better treated in specialized centers just like "King Hussein Cancer center", that’s because
treating them is a multidisciplinary procedure, so all the needed facilities should be available, that’s what
specialized centers guarantee.
The more you treat of the same cases the better you are as a specialist, anyway cancer has several treatment
modalities;
The surgery, which is the main modality for the solid tumors.
chemotherapy.
Radiotherapy.
and new modalities like the Immunotherapy.
In cancer treatment there is no White-Black thing, you need to have appropriate staging.
In order to have an appropriate treatment plan, you need to do proper diagnosis, the foundation stone in that is
to check for any Loco-regional metastasis, to define the type, to determine the genetic prototype, to determine
the exact the location, and the psychological status of the patient (some countries like Netherlands take this so
serious in determining whether to treat or not, to eradicate the tumor or not, sometimes they tend to achieve
the patients wishes to improve their psychological status".
In the diagnosis of the tumors the doctors pay an important attention to the TNM classification which cares
for the size of the tumor, the Regional lymph nodes involvement and the distant metastasis, The N here stands
for the distant metastases which is extremely important in determining the stage of the cancer, if any distant
metastasis is there then the patient is in stage 4 "which is really too late to diagnose and usually -not alwaysmakes doctors choose the palliative treatment instead of the curative one".
Another important parameter is the prognosis; which is a statistical tool that measures the survival rate for 5
years in cancer patients, this happens by taking a cross section of patients having the same stage of the disease
and then 5 years down the line how many of them will be alive and how many will be dead, this is an important
tool when it comes to health care parameters, but when it comes to an individual case the use of it won't be fair.
Types of the treatment:
1) Curative.
2) Palliative.
The difference between them is that the curative aims to fully eradicate the disease and cure the patient, while
the palliative one aims just to improve the lifestyle of the patient by trying to eradicate the symptoms without
Dr.Zaid Baqain
Mohammad Basel
OS sheet# 13
aiming for his/her full cure, that might be due to the enormous size of the tumor, its proximity to the vital
structures, or that it has already metastasized into distant positions.
Why Do we fail in cancer treatment?
** The main reason is that we fail to fully excise the tumor, and by fully excision, we mean the inclusion of a
safety margin "The bigger the better" the problem here arises from the need of functional rehabilitation in the
very small- full of vital structures, oral cavity, so sometimes we fail to include a safety margin leaving behind
some cancerous cells giving rise to another tumor after a while.
** Other reasons include the un-detected distant metastasis.
There is a theory that says that the cancer is a systemic disease affecting the whole system; So when the oral
cavity is included (having a primary tumor), this theory expects the whole GI system to be included too (another
primary tumors within the system), that’s why in the UK the diagnosis of the oral cancer includes endoscopy and
colonoscopy.
Some terms you need to be aware of:
1) Definitive Surgery: it is the curative surgery that aims to fully excise the tumor.
2) Debulking surgery: is part of the palliative treatment, aims to reduce the size of the tumor to improve the
patient's lifestyle.
NOTE: when planning the treatment don’t forget the Rehabilitation Phase it is as important as the excisional
phase.
The most common presentation of the oral cancer is an ulcer or exophytic mass, firm, painless, and hard from
palpation (if solid tumor) on the lateral border of the tongue, in such a situation you need to take a biopsy, the
bigger the size the more biopsies you take "each biopsy should be representative".
As we all know the treating team should include a pathologist, this aids in the determination of the
aggressiveness of the tumor.
What should we know about the tumor before starting our procedure?
1) Aggressive or not, this depends on the differentiation stage of the tumor, and its invasion of the proximal
nerves and vital structures, whenever you discover that the tumor is of invasive behavior you need to look deep
for distant metastasis.
2) The anatomical location, is it in the maxilla or in the mandible? Because tumors in the maxilla by the time
they present, they are big enough and we are late enough to diagnose them, that’s due the soft bone and the
multiple spaces the maxilla has.
3) The size of the tumor.
Dr.Zaid Baqain
Mohammad Basel
OS sheet# 13
4) Exploded out of the periosteum or not, because it determines the need to include or exclude the soft
tissues in our resection.
5) The duration of the lesion, is it rapidly or slowly growing, "an indicator for the aggressive behavior".
The surgical management of the tumors: "as mentioned in the previous lectures"
1) Inoculation and curettage; do not apply for malignant cancers, just the benign ones.
2) Marginal resection and excision.
3) Composite resection.
Remember when the tumor is present solely within the soft tissues you don’t need to touch the bone, and you
always need to take a clear safety margin.
The surgical management within the maxilla includes the segmental resection, partial maxillictomy and
the Maxillictomy (both sides are involved).
While doing the surgical procedure dealing with the oral cavity you should always inform the patho-lab in
advance, to get your frozen sections tested, you need always to mark each section with its original position, this
will aid in the determination of the inclusion of the margin with excised specimen.
How to approach the tumor?
In the mandible; there are several approaches :
1) Submandibular approach  when the tumor size is small.
2) Visor approach.
3) Lower lip splitting and mandiblutomy; the splitting of both sides of the lips is done when the size of the
tumor is large, this approach depends on the involvement of the floor of the mouth.
While in the maxilla:
1) Weber Ferguson approach; which is the most commonly used one.
2) " I couldn’t hear it I'm sorry".
You are not supposed to do those approaches as a GP, but you need to know that a patient with a scar had a
surgery, because patients tend to forget so it is your responsibility to figure the situation out.
How to decide to approach the tumor intra or Extra orally?
Dr.Zaid Baqain
Mohammad Basel
OS sheet# 13
This depends mainly on the size and the site of the tumor, the small ones can be accessed intraorally while
larger ones you need to think of the extra oral approaches.
When you are done with the resection, it’s the time for reconstruction:
You always need to reconstruct the tissues you excise; those are some rules that can help you in your decisions
for the reconstruction method.
1) If the excised tissue is just Mucosa and submucosa  A simple free skin graft can do the job, Skin grafts are
usually brought from the inner thigh, and it is usually of split thickness, due to the heavily vascularization of the
oral cavity.
2) When it is a muscle then you need to bring a muscle.
3) When you need the flap to retain its own blood supply, then you go with the pedicle flap.
* A new techniques:
((The vascularized tissue grafts))  you bring a vascularized tissue from a distant area (retaining part of its Artery
and Vein), then you harvest it within the oral cavity, and connect it with the already presenting blood supply.
This technique has revolutionized the treatment of oral cancer by offering a faster and a better healing, making
the reconstruction easier, yet it's not affordable everywhere due to its expenses and technical advancement.
At the end don’t forget the morbidity of the donor site, which is best managed when the site is the lower limb
"one of the causes why we choose it as our donor site".
Best of luck seniors 
Mohammad Basel.