HEAD NECK 13 mandible

7. MANDIBLE

 

7.1 ODONTOGENIC(ODONTOMA)

 

These lesions arise from odontogenic remnants (tissue involved in

tooth formation) and are invariably benign.

 

7.1.1 FOLLUCULAR CYSTS (DENTIGEROUS CYTS)

 

These  cysts are derived from the dental lamina, the outer  enamel

epithelium  of  developing teeth.  A remnant of  this  tissue  is

sequestered during development. It occurs in women between  30-40

years

 

Clincially, these lesions present with an enlargement of ramus of

the mandible and on absent molar tooth.

 

Microscopically,  these  cysts  have a fibrous  wall  lined  with

squamous epithelium.  Cysts develops at the site of an  un-erupted

tooth. 

 

X-ray  shows  the  cyst  with  unerupted  tooth  in  its  cavity. 

Treatment  is  intraoral  excision of the cyst  with  its  lining

membrane.

 

7.1.2 RADICULAR CYST

 

These  arise  due  to inflammation of  the  epithelial  structure

involved in formation of the root.  It is enclosed within a dense

connective   tissue   lining  covered  internally   by   squamous

epithelium.

 

Treatment  is extraction of the tooth and exicision of  the  cyst

lining.

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HEAD NECK 12 Tongue Cancer

5.3 TONGUE

 

Carcinoma originates at the tip or along the free borders:   Area

of hyperkeratosis develops first.

 

Later  this  develops  into an ulcerated  lesion  with  exophytic

undermined border.

 

Palpation  detects  hardness  and  indicates  that  invasion  has

occurred beyond the ulcer.

 

Spread   cancer  of  the  tip  of  the  tongue  metastasises   to

ipsilateral sub mandibular nodes and later the nodes at the  angle

of  the mandible are involved. 

 Forty percent have nodes  at  the time of presentation.

 

CLINICAL

 

The patient presents with :

-  Pain

-  Salivation

-  Fixation of Tongue

-  Dysphagias

-  Difficulty in speech

-  Foetor

 

Diagnosis

 

Multiple biopsies establish the diagnosis and the extent in large

tumours.

 

TREATMENT

 

T1NoMo lesions can be treated by radiotherapy or surgery as small

lesion  is  removed  with 1.5 cm margin  of  healthy  tissue  all

around.  Lesion of upto 1cm can be treated by interstitial radion

with Iridium192 wire. 

 

Combined  operation  including  wide resection of  a  small  oral

lesion  if  they  have nodes at the time  of  presentation,  they

require radial neck dissection.

 

Treat  all  larger lesions with preoperative  radiation  therapy,

following  this with a radical neck dissection and in  continuity

excision of any residual cancer.

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HEAD NECK 11 Oral cancer

5.2 ORAL CAVITY

 

Ten  percent of all malignant tumours of the head and neck  occur

in the oral cavity and 95% being squamous carcinomas.

 

Risk is higher in male than in females.

 

ETIOLOGY

 

There  is a strong relation between smoking and oral  carcinomas,

in regions where oral cancer has the highest mortality.

 

IN ANDHRA PRADESH

 

A state in India-there is prevalence of a carcinoma of the palate

called "Chutta Cancer" in smokers.

 

It  is possible that thermal trauma and tobacco tar  provide  the

carcinogenic stimulus.

 

IN UTTAR PRADESH AND BIHAR

 

Tobacco  and  slaked  lime is habitually sucked by  men  in  some

districts.

 

A quid is kept in the lower gingivo-labial fornix for hours during

the day.

 

A high incidence of carcinoma is found at this site.

 

Betal  nut  chewing  is  practice  among  Indian,  Javanese   and

Malayans.   Ground  betal nut and slaked lime used results  in  a

high incidence of cancer.

 

Alcohol  has a suggested role in oral cancer, poor  oral  hygiene

and  oral  sepsis are also present in this group and may  have  a

contributary role.

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HEAD NECK 10 Malignant tumors Lip

5. MALIGNANT TUMOURS

Sqaumous cell carcinoma make up the majority of all carcinomas of

the oral cavity, highly differentiated tumours occur less  often,

anaplastic lesions are rare.

Adenocarcinomas are met with and originate in the minor  salivary

glands.

5.1 LIP

Squamous cell carcinomas are the common malignant tumours of  the

lip  and  represent  nearly 15% of all  head  and  neck  cancers.

Basal cell carcinomas are less frequent.

ETIOLOGY

Important relationship exists between tumours of lip and exposure

to sunlight.

*  Complexion plays a role, susceptible are the fair skinned  and

   ligh haired.

*  Dark haired and dark skinned individuals are resistant.

*  Tobacco   chewing  and pipe smoking have been suspected  as  a

   cause of lip cancer.

*  It  is possible that the stems of wood and clay pipes soak  up

   tobacco tar directly and cause the disorder.

PATHOLOGY

*  The  tumour is a squamous carcinoma and occurs most  often  on

   the lower lip.

*  It is low grade well diffentiated lesion

CLINICAL

*  Lower lip in the site in 70%

*  Though slow growing, some patients may present when the lesion

   has reached a large size, destroying the entire lip.

*  There may be cervical lymphnodes, usually submental nodes.

*  An  ulcer of the lip which fails to heal should  be  suspected

   early.

TREATMENT

*  Treatment  for  small lesions is local  excision  under  local

   anaesthesia.

*  Radiation can also achieve good results in lesion below 2  cm.

   and can be given as outpatient therapy.

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HEAD NECK 9 Leukoplakia

HYPERKERATOSIS

White patches are sometimes seen on oral mucosa called

leukoplakia.  

This is a specific premalignant lesion.

 

*  Microscopic change show hyperplasia, keratosis and

   dyskeratosis, i.e. loss of normal stratification, irregularity

   in   the   size  and  shape  of   cells,   abnormal   staining

   characteristics.

 

*  Palpation will reveal a definite firmness of the mucosa.

 

*  Cancer will develop in 5% of such patients.

 

*  Local irritant associated with this lesion are smoking, sepsis,

   sharp  tooth,  spirits  and spices (in  betel  chewing)  these

   should be eliminated.

 

Local   excision   may   be   useful.    

Radiation therapy is contraindicated.

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HEAD NECK 8

4.4 GIANT CELL (REPARATIVE) GRANULOMA

 

Usually  occurs on the gums as a red epulis or intra bony  lesion

of  maxillary  or mandibular bones because of a bleed in  to  the

marrow and is slow growing, reddish, smooth sessile tumour  which

bleeds easily.

 

Histologically  lesions show stratified squamous epithelium  with

interspersed  fibroblastic  proliferation,  multinucleated  giant

cells and heamosiderin pigments, all these constitute  diagnostic

microscopic criteria.

 

Treatment of this soft tissue lesion is by complete excision  and

curreting  

 

4.5 HEMANGIOMA

 

Capillary hemangioma are sometimes seen on the mucosa of the oral

cavity  in  infants and like hemangiomas elsewhere  they  regress

spontaneously.

 

*  Rarely  large vascular malformations will involve  the  entire

   side  of  the mouth including the tongue; gingiva  and  buccal

   mucosa.

 

Treatment  is  difficult expectant treatment in follow up they  do regress with age

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HEAD NECK 7 Mouth ulcers Cysts

Usually  a  single ulcer opposite a sharp tooth  or  ill  fitting

denture usually along lateral margin of tongue.

A dental consultation is required.

Cysts  are a common lesion occuring in the posterior  surface  of

the lip, floor of the mouth; tongue and buccal mucosa.

* These are the salivary gland-bearing areas.  These cysts  mucus

  result  from  the  obstruction of the duct  of  minor  salivary

  glands.

* Treatment is by excision under local anaesthesia.

4.3 RANULA

This is a cyst caused by obstruction or damage of the mouth of  a

sub-lingual gland of the floor of the oral cavity. Fig.14.1

*  The cyst elevates the floor of the mouth and pushes the tongue

   to the opposite side.

*  Treatment is by excision of the cyst.

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