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TUMORS OF THE MANDIBLE

PART II: ILLUSTRATIVE CASES

REYNALDO O. JOSON, M.D.

TABLE OF CONTENTS
Introduction .........................
Objectives ...........................
Recommended Preparation ..............
I. Physical Examination ...........
II. Radiography ....................
III. Extirpative Procedures .........
IV. Reconstructive Procedures ......
V. Segmental Mandibulectomy How I Usually Do It ............
Recommended Follow-up ................
About the Author .....................

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Primary intended users - Students of


medicine.
Estimated study time - One hour.

NOTE:

THIS MANUAL GOES WITH AN AUDIO VISUAL TAPE OR A SET OF SLIDES.

REYNALDO O. JOSON, M.D.


April, 1992

INTRODUCTION
This is the second of a series of
programs on mandibular tumors. The first
program
presents
generalities
and
principles in the diagnosis and treatment
of mandibular tumors.
This program is designed to reinforce
the first program as well as to provide
the necessary background for the subsequent parts in the series.
It contains
slides that illustrates physical examination and radiography in the diagnosis of
mandibular tumors;
different types of
extirpative procedures; and the various
types of reconstruction procedures.

OBJECTIVES
At the end of the program, the
is expected to be able to:

user

1. Recognize patients with mandibular


tumors based on inspection and
palpation.
2. Identify the two types of radiographic procedures being done on
the mandible.
3. Interpret radiographic findings on
the mandible.
4. Differentiate excision, marginal
mandibulectomy, and segmental mandibulectomy.
5. Recognize the different reconstructive procedures being
done
after an extirpation of a mandibular tumor.

RECOMMENDED PREPARATION
Before going through this program,
the
user should
have
satisfactorily
completed the first program in the series,
namely:
Joson, RO: Tumors of the Mandible:
Generalities and Principles.
Manila, 1992.

TUMORS OF THE MANDIBLE


PART II: ILLUSTRATIVE CASES
SLIDE
1.
Tumors of the mandible. This program
will show illustrative cases on tumors of the mandible.
2.

I.
Physical examination of the mandible.

3.

A patient with a mass on the


aspect of the lower jaw.

lateral

4.

A patient with a mass on the chin or


mental aspect of the lower jaw.

5.

A huge mass that deforms the face.

6.

A hard consistency of the mass will


lead to a suspicion of a
mandibular
tumor.
2

7.

II.
Radiography of the mandible.

8.

A panorex view showing


length of the mandible.

9.

An anterior - posterior view of


mandible.

10.

A lateral oblique view of the mandible, which shows the rationale of the
obliquity, which is to enable proper
visualization and study of the two
halves of the mandible.

11.

A radio-opaque lesion in the body


mandible on the left side.

12.

A radiolucent lesion in the mentum of


the mandible.

13.

A unilocular lesion at the apex of


the molar tooth which is diagnostic
of a radicular cyst.

14.

An excised radicular cyst, showing


the cyst at the apex of the tooth.

15.

A
radiolucency,
which
may
be
unilocular or multilocular, at the
crown of an impacted or un-erupted
tooth, which is diagnostic of
a
dentigerous cyst.

16.

A multilocular cyst or a soapbubble


appearance at the right side of the
mandible which is suggestive of an
ameloblastoma.

the

entire
the

of

17.

Another multilocular cyst on


the
right side of the mandible extending
to the
mentum, suggestive of an
ameloblastoma.

18.

A gross specimen of an ameloblastoma


showing the multiple cystic lesions.

19.

An osteomyelitis of the mandible with


sequestrum.

20.

A sunburst appearance which is


nostic of osteosarcoma.

21.

The patient with the osteosarcoma


the mandible.

22.

A lytic lesion in the mandible associated


with
a
thyroid
tumor,
suggestive of a metastatic follicular
thyroid carcinoma.

23.

The patient with the metastatic follicular carcinoma to the mandible.

24.

A secondary invasion of the body


the mandible.

25.

From a squamous cell carcinoma of the


gingiva.

26.

diagof

of

III.
Extirpative procedures for mandibular
tumors.

27.

Extirpative procedures.
Curettage;
excision; marginal
mandibulectomy;
and segmental mandibulectomy.

28.

An excised specimen of
cyst.
4

radicular

29.

An x-ray showing the result


marginal mandibulectomy.

30.

The marginal mandibulectomy specimen.

31.

Marginal mandibulectomy is usually


done for gingivo-alveolar cancers.

32.

A segmental mandibulectomy specimen.

33.

A hemi-mandibulectomy specimen.

34.

Reconstructive
mandible.

35.

A rib graft.

36.

A myo-osseous rib graft.

37.

A myo-osseous clavicular graft.

38.

A myo-osseous clavicular graft being


used to reconstruct a defect at the
mentum.

39.

After wiring the graft to the mandible.

40.

After skin closure.

41.

The contour
restored.

of the

chin

has

been

42.

The contour
restored.

of the

face

has

been

43.

A reconstruction using Kirschner wire.

44.

A reconstruction using
steel plate.

IV.

procedures

on

of

the

stainless

45.

An Andy-Gump deformity becuse


of
failure to reconstruct a chin defect.

46.

A facial deformity because of failure


to reconstruct a lateral mandibular
defect.

47.

Showing the depression on the side of


the face.

48.

V.
Segmental mandibulectomy
usually do it.

how

49.

Under general nasotracheal anesthesia,


with neck hyperextended and
face
facing upwards for a tumor in the
mentum.

50.

The face facing the opposite side for


a lateral mandibular tumor; with a
submandibular and submental incision.

51.

The tumor and the adjacent bone are


exposed and skeletonized prior to
segmental resection.

52.

The specimen after a segmental mandibulectomy.

53.

The defect awaiting reconstruction.

54.

A rib graft may be used.

55.

An x-ray
place.

graft

in

56.

An iliac graft may be used. This


an x-ray showing the iliac graft
place.

is
in

showing the rib

57.

A myo-osseous rib graft may also


used.

58.

A myo-osseous clavicular graft may be


used.

59.

A Kirschner wire may be used.

60.

Lastly, a metallic plate may also be


used.
This x-ray shows a stainless
steel plate used in reconstruction.

61.

Wound closure after


reconstruction.

62.

Showing restoration of facial contour.

63.

And masticatory function, which are


the aims of mandibular reconstruction.

64.

The end.

extirpation

be

and

RECOMMENDED FOLLOW-UP
After
completing
this
selfinstructional program, the user is advised
to discuss this program with his teachers
as well as his peers. He is also strongly
advised to apply what he learns in the
clinics. If he is a surgeon or a surgeonto-be, he can proceed to PART III, which
is on surgical decision-making.

ABOUT THE AUTHOR


DR. REYNALDO O. JOSON is currently
an assistant professor at the University
of the Philippines College of Medicine.
He is a staff member of the Division of
Head and Neck, Breast, Esophagus, and Soft
Tissue
Surgery of the Department
of
Surgery
at
the
Philippine
General
Hospital.
ACKNOWLEDGEMENT
DR. ALBERT B. DACO
COPYRIGHT, 1992

SEGMENTAL MANDIBULECTOMY
WITH
METALLIC PLATE RECONSTRUCTION
1.
From the Division of Head and Neck,
Breast, Esophagus, and Soft Tissue Surgery
of the Department of Surgery, University
of the Philippines College of Medicine and
Philippine General Hospital, we present a
short film on segmental mandibulectomy of
an ameloblastoma with a rreconstruction
using stainless steel plate.
2.
The patient is a 33-year old female
with a radiolucent mass on the mandible,
extending from the right third
molar
across the mentum to the left first molar.
3.
This is an outline of the mandibular
lesion.
A submandibular incision, about
one
centimeter from the rim of
the
mandible is planned.
4.
The incision is performed and carried
down to the platysma up to the rim of the
mandible.
5.
The mandible is exposed. The segment
of the mandible that will be resected is
skeletonized, that is , stripped of all
muscular and soft tissue attachments.
6.
The oral cavity is entered and the
segment of the mandible that will be
resected is freed from any other mucosal
attachments.
7.
The segment of the mandible that will
be resected is now completely free from
any form of soft tissue attachment.
1

8.
Teeth on the resection line are
extracted.

now

9.
A stainless steel plate that will
used in the reconstruction is fitted.

be

10.
A Gigli wire is used to resect the
mandible.
A one-centimeter margin
of
resection is sufficient for ameloblastoma.
11.
The right side of the
been transected.

mandible

has

12.
The left side of the
been transected.

mandible

has

13.
This shows the resected segment of
the mandible with the lesion within it.
14.
This shows the mandibular
which has to be reconstructed.

defect

15.
Holes are now being placed on the
mandibular ends. These holes will be used
for the screws.
16.
This shows the prothesis in place,
stabilized by two screws on one end and
another two screws on the other end.
17.
The chin flap has been
the stainless steel plate.

placed

over

18. The mucosal defect in the oral cavity


is then closed with chromic 3-0 sutures.
19.
After copious irrigation, the wound
is closed with a rubber drain placed deep
within.
2

20. This shows the specimen, the resected


mandible with a cystic lesion.
21. This is the patient postoperatively,
front view and side view.
22.

With the metallic plate in place.

23.
The future plan is to place dental
prosthesis to improve further the contour
of the chin as well as the masticatory
function.
24.

The end.