Cancer de Cavidad Oral

5
Oral Cavity Cancer

JAY O. BOYLE, MD
ELLIOT W. STRONG, MD, FACS
Oral cavity cancer is the sixth leading cause of cancer Chronic carcinogen exposure causes mucosal
worldwide. In the United States alone, there are over cells to acquire genetic abnormalities. When these
21,500 oral carcinomas diagnosed each year, and genetics abnormalities result in the activation of
6,000 Americans die of oral cancer each year.1 The proto-oncogenes and the inactivation of tumor-sup-
incidence of oral carcinoma varies throughout the pressive genes, the cells may be afforded a growth
world, with estimates exceeding 40 in 100,000 in advantage. Dysregulated proliferation due to aber-
parts of France, Southeast Asia, Hungary and Singa- rant cell cycle control leads to clonal populations of
pore.2 Thus oral cancer is a major cause of morbidity premalignant, genetically abnormal mucosal cells.
worldwide. Ninety percent of oral malignancies are These populations of cells have a high tendency to
squamous cell carcinomas and therefore are the prin- accumulate additional genetic abnormalities due to
cipal topic of this chapter. However, the treatment of genomic instability. Genomic instability is the result
some other oral malignancies, like sarcoma and of rapid cell cycling with decreased genomic sur-
minor salivary gland carcinoma, is also primarily sur- veillance, decreased capacity to repair genetic
gical excision, and the surgical principles are applica- defects and ineffective signalling of apoptosis or
ble to the treatment of these other tumors as well. programmed cell death. In these cell populations the
The etiology of oral cancer is exposure to car- rate of accumulation of acquired genetic abnormali-
cinogens in tobacco and the tumor-promoting effects ties increases logarithmically with time.8
of alcohol. Ninety percent of the risk of oral cancer Eventually these abnormal cells acquire the
in the United States is directly attributable to smok- malignant phenotype in which they lose normal dif-
ing.3 Tobacco smoke and alcohol are synergistic in ferentiation, invade the basement membrane,
their carcinogenic effects in the oral cavity. The rel- become locally destructive, and metastasize region-
ative risk of oral cancer for heavy smokers is 7 times ally or distantly. These cells evade immune surveil-
that of nonsmokers. The risk for heavy drinkers is 6 lance of the body, produce angiogenic factors allow-
times that of nondrinkers. The risk for patients abus- ing ingrowth of blood vessels, and become clinical
ing both alcohol and tobacco is 38 times that of carcinomas.
those who abstain from both.4 Chewing tobacco and
betel quid also increase the risk of oral cancer.5 ANATOMY
Chronic carcinogen exposure creates a field effect
and the entire mucosa of the upper aerodigestive The critical functions normally accomplished by oral
tract is at risk for malignancy in smokers and tissues include articulation of speech, facial expres-
drinkers.6 After successful treatment of oral cancer, sion and cosmesis, respiration, mastication, degluti-
the risk of a second primary cancer is 3.7 percent per tion, and taste. Ablative surgery for oral cancer
year and increases to 24 percent at ten years.7 Ces- removes the malignant tumor en bloc with a margin
sation of alcohol and tobacco exposure reduces the of normal tissue, and the integrity of functionally
risk of second aerodigestive carcinoma. important structures is not violated unnecessarily.
100
Oral Cavity Cancer 101
The oral cavity is bounded anteriorly by the skin upper lip possesses two peaks forming a “cupid’s
and the vermilion border of the upper and lower lips. bow” where the filtrum ascends to the columella of
The oral cavity extends posteriorly to the circumval- the nasal septum.
late papillae of the tongue, the junction of the hard The orbicularis oris muscle receives motor inner-
and soft palates, and the anterior faucial arch. The vation from the marginal and buccal branches of the
tonsil, soft palate and posterior one-third of the facial nerve and performs a sphincteral function to
tongue are oropharyngeal structures and are not con- maintain oral competence and to facilitate articula-
sidered in our discussion of the oral cavity. Laterally tion of speech. This muscle has many attachments
the oral cavity is bounded by the buccal mucosa. from other muscles of facial expression that elevate
The oral cavity is divided into the following sub- and depress the lips. Of clinical importance is the
sites: the lip, anterior two-thirds of the tongue, floor innervation of the depressor anguli oris muscle by
of mouth, gingiva, retromolar trigone, buccal the marginal mandibular branch of the facial nerve.
mucosa, and hard palate (Figure 5–1). Figure 5–2 Sensation of the lower lip is provided by the men-
demonstrates the distribution of oral tumors by sub- tal nerve, the terminal segment of the alveolar branch
site. Tumors of different subsites demonstrate dis- of the mandibular division of the trigeminal nerve.
tinct clinical behavior. The nerve exits the mental foramen of the mandible
The lip is a common site of skin cancer. The lay- near the root of the canine tooth. Paresthesia of the
ers of the lip, from external to internal, include the chin suggests extensive mandible invasion and infe-
epidermis, dermis, subcutaneous tissue, the orbicu- rior alveolar nerve involvement by oral carcinoma.
laris oris and attached musculature, the oral submu- The anterior two-thirds of the tongue is called the
cosa and the oral mucosa. The oral submucosa con- oral or mobile tongue and is bounded posteriorly by
tains minor salivary glands, copious lymphatic the V-shaped line of the circumvallate papillae. Pos-
vessels, blood vessels and sensory nerves. The lip is terior to this line is the base of tongue, which is part
supplied by the labial arteries and veins, which are of the oropharynx. The oral tongue has ventral and
branches of the facial vessels. The generous lym- dorsal surfaces. The mucosa of the tongue is simple
phatics of the lower lip cross and drain bilaterally to stratified squamous epithelium with interspersed
level I nodes of the submental and submandibular papillae or taste buds of four morphologies: fili-
triangles. Pre- or post-facial nodes lie anterior and form, foliate, fungiform, and circumvallate.
posterior to the facial vessels in the superior aspect The tongue is comprised of intrinsic and extrinsic
of the submandibular triangle and are potential sites muscles. The intrinsic muscles are arranged in vertical
of metastasis of lip cancers. Lymphatic channels of and horizontal fascicles that allow the mobile tongue
the upper lip respect the midline and drain to sub- to change shape and consistency. There are three pairs
mandibular, periparotid, or preauricular nodes. The of extrinsic muscles that provide mobility of the
tongue: genioglossus, hyoglossus, and styloglossus.
Protrusion of the tongue is primarily accomplished by
the action of the genioglossus muscle which originates
from the mandibular tubercles on the lingual surface
of the arch of the mandible, and inserts diffusely into
the substance of the intrinsic musculature on each side
of the tongue. The motor supply to the intrinsic and
extrinsic tongue muscles is the hypoglossal nerve (CN
XII), which exits the skull through its own hypoglos-
sal canal and courses laterally and anteriorly between
the external and internal carotid arteries, immediately
inferior to the occipital artery.
The sensation of the tongue is supplied by the lin-
Figure 5–1. Diagram of the oral cavity and subsites. gual nerve, a branch of the mandibular division of the
102 CANCER OF THE HEAD AND NECK
Figure 5–2. Distribution of oral cancers by subsite. A selected series of cases presenting
to the head and neck service of Memorial Sloan-Kettering Cancer Center, New York.
trigeminal nerve (CN V3). The lingual nerve also face is innervated by alveolar branches of the second
transports parasympathetic fibers from the chorda and third divisions of the 5th cranial (trigeminal)
tympani branch of the facial nerve to the sub- nerve.
mandibular ganglion. The blood supply to the tongue The retromolar trigone is that portion of adherent
is derived from the paired lingual arteries. keratinized mucosa covering the ascending ramus of
The lymphatic drainage of the tongue begins in a the mandible from the third mandibular molar to the
rich submucosal plexus, which may drain bilaterally maxillary tubercle. It represents the area between
when lesions approach the midline, the tip, or espe- the buccal mucosa laterally and the anterior tonsillar
cially the base of the tongue. Tumors of the lateral pillar medially and posteriorly. Tumors of this small
mid-tongue drain predictably to the ipsilateral lymph region spread readily to the adjacent mandibular
nodes. The first echelon nodes for lesions of the tip bone, alveolar foramen, masticator space, oropha-
include the submental nodes. The lateral and ventral ryngeal tonsil, floor of mouth and base of tongue.
tongue lesions metastasize to submandibular or The hard palate lies within the horseshoe shape
jugulodigastric nodes while the base of tongue of the maxillary alveolar process. Keratinized adher-
drains to the jugulodigastric and deep jugular nodes. ent mucosa covers the palatal bone, which is divided
Lesions of the anterior tongue may metastasize into the primary and secondary bony palate. The pri-
directly to the low jugular lymph nodes (level IV) of mary palate consists of the palatal processes of the
the neck. maxillary bones and represents the premaxilla ante-
The buccal mucosa lines the lateral oral cavity rior to the incisive foramen. The secondary palate is
and blends with the gingiva superiorly and inferiorly made up of the horizontal processes of the L-shaped
and with the retromolar trigone posteriorly. The palatine bones. On the posterior hard palate, near the
mucosa is pierced by the Stensen’s duct of the maxillary second or third molar, are found the
parotid gland at the papilla adjacent to the second greater and lesser palatine foramina which transmit
maxillary molar tooth. their respective vessels and nerves which are the ter-
The gingiva consists of thick keratinized mucosa minal branches of the sphenopalatine vessels
with deep rete pegs and submucosal adherence to (branches of the internal maxillary artery) and
the periosteum. The mucosa covers the alveolar nerves (branches of V2). Anteriorly, the midline inci-
processes of the mandible and the maxilla. sive foramen near the incisors transmits the terminal
The mandible possesses lingual and buccal cor- branches of the nasociliary nerve and vessels to sup-
tices which envelop cancellous bone, dental sockets, ply the primary palate region. Lymphatic drainage of
and the mandibular canal transmitting the mandibu- the palate includes the deep jugular chain as well as
lar vessels and nerves (branch of CN V3). The the retropharyngeal nodes. Anterior lesions may
mandibular surface is innervated by branches of the metastasize to pre-vascular facial lymph nodes of
lingual and mental nerves while the maxillary sur- the submandibular region.
The floor of the mouth is a soft thin layer of U- A complete examination of the head and neck is
shaped mucosa overlying the insertion of the mylohy- performed to assess the precise location and extent
oid muscle laterally, the hyoglossus muscle medially, of the primary tumor, identify regionally metastatic
and the insertion of the genioglossus muscle anteri- disease and to rule out multiple primary malignan-
orly. It covers the sublingual salivary glands, sub- cies. Grossly, the earliest cancers may present as
mandibular (Wharton’s) duct, and the lingual nerve. nonulcerous white or red patches. More advanced
The blood supply is from the lingual vessels. Its lym- oral squamous cell carcinomas (SCC) present as
phatic plexus is copious and drains bilaterally in the mucosal lesions, although occasionally an SCC may
midline. The lymphatic drainage patterns include the present as predominantly submucosal with little or
submental and bilateral submandibular nodes, as well no mucosal involvement. Firm submucosal lesions
as the ipsilateral jugulodigastric nodes posteriorly. are often minor salivary gland neoplasms. SCC may
be ulcerative and invasive, fungating and exophytic
DIAGNOSIS or both (Figure 5–3). They may arise within prema-
lignant lesions such as leukoplakia or erythroplakia.
The diagnostic evaluation of a patient with oral car- The following characteristics of the lesion should be
cinoma consists of the history and the physical documented: appearance and character, location,
examination, histopathologic tissue diagnosis, and size in centimeters, texture to palpation, mobility,
imaging—when indicated. proximity to surrounding structures—especially
The clinical history begins with the present ill- bone, and the estimated palpable thickness (superfi-
ness and includes the duration and location of symp- cial vs. deeply infiltrating).
toms such as non-healing ulcer, mass in the oral cav-
ity or neck, pain, bleeding, and any symptoms of
cranial nerve deficits. A thorough exploration of the
patient’s past medical and surgical history, and the
review of systems yield operative risk data. A thor-
ough history of etiologic risk factors for squamous
carcinomas not only reflects the patient’s relative
risk of malignancy but also suggests factors that
affect the patient’s overall health, fitness for surgery
and emotional state. Current and distant abuse of
tobacco and alcohol are critical factors and may be
underreported by the patient. In many parts of the A
world the use of oral chews (“pan,” betel nuts, etc.)
is the chief etiologic factor.9 These may contain
tobacco, slaked lime and other irritants and may be
retained in the oral cavity nearly constantly. An
occupational exposure to heavy metals such as
nickel,10 and previous radiation exposure to head
and neck are other important risk factors of head and
neck cancer that are elicited in the history.
The social history impacts strongly on the
patient’s ability to comply with and tolerate treat-
ment and rehabilitation programs, and these issues
are resolved during the treatment planning phase. B
The family history reflects any familial tendencies
Figure 5–3. A, An exophytic lesion involving the right lateral bor-
toward malignant disease and completes the histori- der of the tongue. B, An endophytic lesion of the right lateral border
cal data. of the tongue.
Trismus suggests ominous pterygoid and masti- of the extent of the disease by history and physical
cator space involvement. The condition of the denti- examination and imaging, or the presence of symp-
tion should be noted as tumors may, as the first sign, toms referable to the trachea, larynx, hypopharynx
displace or loosen teeth. The distance from the and esophagus that need endoscopic assessment. It
tumor to the mandible and the mobility of the lesion is not cost-effective screening to perform panen-
in relation to the mandible are critical elements in doscopy on all patients with head and neck can-
determining the management of perimandibular cer.11–13 Symptoms suggesting lesions of the trachea,
cancers. A complete examination of the cranial larynx, hypopharynx, or esophagus include: dyspha-
nerves is performed, emphasizing sensation over the gia, odynophagia, pain, hoarseness, hemoptysis or
chin for mandibular nerve deficit, tongue mobility stridor. A careful history and meticulous head and
for hypoglossal nerve deficit, facial nerve function, neck exam is necessary to identify these lesions.
palatal elevation and gag reflex, and function of the Evaluation of the deep extent of oral cancer often
accessory nerve. A mirror or a flexible or rigid tele- requires the use of imaging modalities. Imaging stud-
scope is needed to document vocal cord mobility ies, however, will not adequately identify the superfi-
and to ensure that no lesions exist in the oropharynx, cial mucosal extent of disease, which must be estab-
nasopharynx, endolarynx, and visible hypopharynx. lished by visualization, palpation and biopsy. Plain
Small lesions of the hypopharynx may only be visi- radiographs such as panorex, dental films or a sub-
ble by direct examination under anesthesia with the mental occlusal film may demonstrate gross bone
rigid laryngoscopes. involvement but do not show early cortical invasion.
The neck should be thoroughly palpated for Computed tomography (CT) is the most common
metastatic disease in the nodal groups at risk, and for modality employed to assess the extent of oral can-
other abnormalities of the great vessels and the thy- cers (Figure 5–4). Advantages of CT include good
roid gland which might impact treatment. Masses of soft-tissue discrimination and vessel identification
the neck should be measured in centimeters, charac- and excellent definition of bone soft-tissue inter-
terized for site (level), mobility, consistency, skin faces. CT scans are readily available and affordable.
involvement, and proximity to vital structures. Nor- Cortical destruction and tumor in the alveolar canal
mal neck structures commonly mistaken for metasta- and the bone marrow can be seen on CT. Special
tic masses include: the transverse process of C2 in the coronal reconstructions of dedicated mandible CT
jugulodigastric region of thin patients, the scalene
muscles, a tortuous carotid artery, a carotid aneurysm,
a prominent carotid bulb, a cervical rib, and ptotic
submandibular glands.
A complete general physical examination should
be performed emphasizing the cardiovascular and
pulmonary systems, which are commonly abnormal
in this oral cancer population. The systemic effects of
malnutrition or excessive alcohol intake should also
be noted.
The history and physical examination with or
without adjunctive imaging and histopathologic tis-
sue diagnosis are sufficient to plan and execute sur-
gical treatment for many patients with oral cancer.
However, some patients will benefit from examina-
tion under anesthesia including direct palpation with
or without biopsy, laryngoscopy, esophagoscopy,
and bronchoscopy. The indications for examination Figure 5–4. CT scan demonstrating an invasive carcinoma in the
under anesthesia include an inadequate assessment right half of the tongue with involvement of lymph nodes at level II.
scans (Dentascan) is particularly helpful in imaging irreparably while sparing the normal tissue. Either
the mandible. CT scans of the oral cavity should be modality is effective in controlling early oral carci-
combined with neck CT to assess for suspicious sub- nomas, but the use of both modalities in combina-
clinical metastatic nodes. Axial and coronal views tion is necessary to control locally advanced disease.
with bone and soft-tissue windows with contrast The role of chemotherapy alone in localized disease
from the orbital floor to the base of the tongue as is palliative. Currently, distantly metastatic disease
well as axial views of the neck are obtained. Disad- is incurable but can often be effectively palliated
vantages of CT scanning include radiation exposure, with chemotherapy and radiation.
possible contrast dye sensitivity, dental amalgam Treatment choices are best made after consider-
interference, difficult positioning for coronal views, ing tumor factors, patient factors and resources fac-
and no direct sagittal views. tors. Tumor factors include subsite, T stage, N
Compared to CT scanning, magnetic resonance stage, histologic characteristics, endophytic vs. exo-
imaging (MRI) offers enhanced soft-tissue discrimi- phytic morphology, and proximity to bone. Patient
nation, excellent skull base and CNS assessment, factors include the patient’s age, co-morbidities, con-
sagittal views, and no radiation exposure (Figure venience, rehabilitation potential, and the patient’s
5–5). Disadvantages are that the examination takes wishes. Resource factors include the availability of a
longer, is more expensive, is poorly tolerated by well-trained surgeon or radiotherapist with a dedi-
some, and the black signal of bone makes cortical cated interest in head and neck cancer, availability
bone abnormalities difficult to see. An experimental of advanced hardware for the planning and delivery
imaging modality with promise is positron emission of radiation, and the availability of funds to pay for
tomographic scanning. Positron emission tomogra- the treatment.
phy (PET) is a nuclear medicine study that demon- The mainstay of treatment of early oral cancer is
strates the difference in metabolism of radiolabeled surgery. External beam radiation therapy alone can be
glucose molecules between normal and malignant effective for some early superficial lesions of the
tissues. The clinical usage of this modality is cur- tongue or floor of mouth but sequelae of xerostomia
rently not well-defined, but will likely aid in the
diagnosis of recurrent and metastatic lesions.14
The appropriate metastatic evaluation of the patient
with oral carcinoma is chest radiographs and serum
liver function tests. The routine use of CT scanning of
the chest, abdomen, and brain, or radionuclide bone
scanning to evaluate oral cancer patients is not cost-
effective and should be discouraged.
When all of the data from the history, physical
examination, biopsy, imaging, and metastatic work-
up are available, the tumor is staged according to the
AJCC staging system (Table 5–1).
TREATMENT GOALS AND ALTERNATIVES;

FACTORS AFFECTING CHOICE
OF TREATMENT
The surgeon’s goal is complete removal of all

cells of the primary tumor and any cancer cells in
regional lymph nodes, while preserving the integrity
Figure 5–5. A T2N0 squamous carcinoma of the left lateral border
of uninvolved structures. Similarly, the radiothera- of the tongue seen infiltrating the superficial musculature of the
pist endeavors to damage the abnormal cells tongue on an MRI scan.
and mandible irradiation, and long duration and tion include decreased cost, decreased time of treat-
expense of treatment make radiation a poor choice. ment, the generation of a surgical specimen for exam-
Also, bone involvement by oral cancer limits the ination of potential prognostic features and, in some
effectiveness of external beam radiation, so lesions of instances, an opportunity to sample the regional clin-
the gingiva and hard palate are best treated with ically negative nodes for occult disease. Advantages
surgery due to the close proximity of bone and the of radiation therapy for early lesions are preservation
high incidence of bone invasion. Advantages of of tissue and no need for general anesthetic.
surgery for T1 and T2 oral cancer compared to radia- Advanced T3 and T4 lesions are best treated with
a combination of surgery and radiation therapy.
Table 5–I. UICC/AJCC STAGING SYSTEM FOR ORAL CANCER
Improvement in locoregional control of advanced
Primary Tumor
oral cancer is attributable to the addition of postop-
(T) erative radiation.15,16
TX Primary tumor cannot be assessed Brachytherapy can sometimes be employed for
T0 No evidence of primary tumor
Tis Carcinoma in situ oral cancers (especially tumors of the tongue) utiliz-
T1 Tumor 2 cm or less in greatest dimension ing after-loading catheters.17 However, resection of
T2 Tumor more than 2 cm but not more than 4 cm in greatest
dimension
small lesions is usually simpler and less morbid, and
T3 Tumor more than 4 cm in greatest dimension surgery followed by radiation is more appropriate for
T4 Tumor (lip) invades adjacent structures (eg, through cortical
treating the large volume T3 or T4 lesion. Close
bone, tongue, skin of neck) Tumor (oral cavity) invades
adjacent structures (eg, through cortical bone, into deep proximity of the tumor to the mandible, complex sur-
[extrinsic] muscle of tongue, maxillary sinus, skin) face anatomy, and uncertainty of the tumor margins
Regional Lymph Nodes are tumor factors that also limit use of brachytherapy
(N)
NX Regional lymph nodes cannot be assessed for oral cavity cancers. Tumors of the oral cavity are
N0 No regional lymph node metastasis poorly responsive to traditional organ sparing
N1 Metastasis in a single ipsilateral lymph node, 3 cm or less
in greatest dimension
approaches combining either sequential or concomi-
N2 Metastasis in a single ipsilateral lymph node, more than tant chemotherapy and radiation therapy. The control
3 cm but not more than 6 cm in greatest dimension; or in
rates for oral cavity cancers using these regimens are
multiple ipsilateral lymph nodes, none more than 6 cm in
greatest dimension; or in bilateral or contralateral lymph the lowest of all head and neck sites.18 Chemotherapy
nodes, none more than 6 cm in greatest dimension alone for oral cavity cancers is palliative. While some
N2a Metastasis in single ipsilateral lymph node more than
3 cm but not more than 6 cm in greatest dimension complete clinical responses can be obtained, they are
N2b Metastasis in multiple ipsilateral lymph nodes, none not durable. Preoperative chemotherapy for oral can-
more than 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes,
cers is usually not helpful because adequate resection
none more than 6 cm in greatest dimension margins do not shrink with the clinical response of
N3 Metastasis in a lymph node more than 6 cm in the tumor. Studies show that microscopic tumor foci
greatest dimension
exist where previous gross tumor has been shrunken
Distant Metastasis
(M) by chemotherapy treatment. It is therefore not ordi-
MX Presence of distant metastasis cannot be assessed narily possible to reduce the extent of surgical resec-
M0 No distant metastasis
M1 Distant metastasis tion and the morbidity of oral cancer surgery by
Stage Grouping tumor shrinkage with preoperative chemotherapy.19
Stage 0 Tis N0 M0 It is important that all head and neck cancer
Stage I T1 N0 M0
Stage II T2 N0 M0
patients and their cases be discussed in a multi-
Stage III T3 N0 M0 modality treatment conference setting to insure
T1 N1 M0
appropriate management.
T2 N1 M0
T3 N1 M0
Stage IV T4 N0 MO
T4 N1 M0 SURGICAL TREATMENT
Any T N2 M0
Any T N3 M0 Most patients with oral cancer are in their fifth to
Any T Any N M1
seventh decades of life with a history of tobacco and
alcohol abuse, and therefore warrant preoperative hemorrhage, (3) the presence of any bolster or other
clearance by the patient’s medical doctor, a cardiol- aspiratable dressing material, (4) pre-existing pul-
ogist, and/or an anesthesiologist prior to surgery. All monary disease or obstructive sleep apnea, or the
patients require preoperative chest radiographs, simultaneous operation or compromise of the nasal
EKG, CBC and blood chemistry evaluation. airway, and (5) the need for frequent endotracheal
A significant portion of oral cancer patients will suctioning or ventilation support.
present in the malnourished state due to odynopha- The anesthetist should be instructed to avoid par-
gia or alcoholism. The malnourished patient will not alyzing agents if nerve stimulators are to be used to
withstand aggressive surgical and postoperative help identify motor nerves. Also, fluid overload
radiation treatment without complications. For this should be avoided in oral cancer cases. Patients
reason, preoperative nutritional support should be undergoing head and neck surgeries have a
considered for patients with weight loss greater than decreased need for intraoperative fluid replacement,
10 percent of body weight and those with low serum compared to patients undergoing abdominal surg-
albumin. The benefits of 2 or 3 weeks of enteral eries of similar duration. This is due to less third
feeding supplementation, to place the patient in a spacing of fluid and less insensate losses of fluid in
positive nitrogen balance, outweigh the risk of treat- head and neck cases compared to abdominal cases.
ment delay in these patients. Nasogastric tube place-
ment is the most common route of enteral supple- Management of Leukoplakia
mentation. However, if patients require significant
cancer resection, complex reconstruction, postoper- During the carcinogenic process, some abnormal
ative radiation therapy and extended swallowing clonal populations of mucosal cells form clinical
rehabilitation, the temporary placement of a gastros- premalignant lesions. These are manifested as
tomy tube is safe and well-tolerated. The benefits of leukoplakia or erythroplakia. Leukoplakias are com-
consistent nutrition and hydration during treatment mon lesions in smokers and patients with a previous
and rehabilitation cannot be overemphasized.20 history of head and neck cancer. These are also
In patients with oral cancer undergoing general noted in patients without heavy carcinogenic expo-
anesthesia, the management of the airway is the sure. In general, dysplastic leukoplakia should be
responsibility of both the surgeon and the anesthesi- treated while lesions harboring only hyperplasia and
ologist. Preoperative communication and preparation hyperkeratosis may be observed. Clinical character-
are critical. Patients may be difficult to orally intubate istics of lesions suggesting the presence of dysplasia
due to trismus, hemorrhage, or tumor bulk, and the include large size, tongue or floor of the mouth loca-
presence of the oral endotracheal tube may interfere tion, red color, friability, and the patient’s prior his-
with the resection. The appropriate solution is nasal tory of oral cancer or dysplasia. It should be empha-
intubation with or without flexible fiberoptic naso- sized that any lesion which is red or red-speckled
pharyngoscopic guidance. Another option for airway (erythroplakia) is of the highest risk for dyplasia or
management is preoperative tracheostomy under local carcinoma and should be biopsied.
anesthetic. In the event of an airway emergency the Treatment of dysplastic leukoplakia is generally
surgeon must be prepared to secure a surgical airway surgical. While the vitamin A analogue isotretinoin
via cricothyroidotomy or an emergent tracheostomy. (13 cis-retinoic acid or Accutane™) has been shown
This must be performed within minutes of desatura- to be effective in the treatment of dysplastic oral
tion to prevent anoxic brain injury or cardiac arrest. leukoplakia, most lesions will recur after therapy has
Similarly, postoperative airway management is been stopped and many patients do not tolerate the
critical to safe surgery of the oral cavity. Indications mucocutaneous toxicity of isotretinoin treatment. 21,22
for tracheostomy after oral cancer surgery include: Small dysplastic leukoplakia lesions may be eas-
(1) the anticipation of significant postoperative ily excised in the office under local anesthesia with
edema of the pharynx, floor of the mouth or the base millimeter margins. All excised leukoplakia should
of the tongue, (2) a significant risk of postoperative be submitted for histopathologic assessment. Laser
excision of oral leukoplakias can also be accom- Tongue cancer may spread along the mucosal
plished with good hemostasis and little tissue reac- surface to involve the floor of the mouth and the
tion.23 Other treatment options for leukoplakia mandible, or the oropharynx, or it may spread by
include destruction by electrodesiccation, and deep invasion between muscle fascicles which offer
cryotherapy with liquid nitrogen. Local recurrence little resistance to tumor spread (Figure 5–7). It is
is common and occurs in up to one-third of cases.24
SURGERY FOR ORAL CANCER
The lip is the most common site for oral cancer. It is

usually considered separately from cancers of other
oral subsites as it behaves more like skin cancer. It
occurs in sun-exposed surfaces and more commonly
on the lower lip than upper lip. It is usually diag-
nosed early due to bleeding and a visible ulcer.
Large lesions may rarely invade the mandible or the
mental nerve and foramen.
T1 and T2 lesions are usually cured by wedge
resection of the lip with primary closure, (Figure B
5–6) although primary radiation therapy is also
highly effective. Large T3 or T4 lesions require
resection of involved tissues, bilateral upper neck
dissections, complex reconstruction, and postopera-
tive radiation therapy.
Depending on the size of the mouth and the pres-
ence of dentition, up to 50 percent of the lower lip
can be resected and closed primarily in three layers
with care to close the orbicularis oris muscle
securely. Re-approximation of the vermilion line is
important cosmetically. If greater than 40 to 50 per-
cent of the lip is to be resected an Abbe or Estlander
lip switch reconstruction borrows lip tissue from the B
normal upper lip. Karapandzic advancement flaps
can also be useful for large lip reconstructions.25
Free flap reconstruction is sometimes necessary but
always inferior cosmetically and functionally due to
the lack of orbicularis oris function and difficulty
with commissure reconstruction.26
The anterior two-thirds of the tongue is the most
common site of primary lesions accounting for 40
percent of oral cancers. Most malignancies occur on
the lateral borders and ventral surface but are occa-
sionally confined to the tip or the dorsum. Even
small lesions of the oral tongue are visible and usu-
ally symptomatic, so oral tongue lesions tend to pre- C
sent in earlier stages: 37 percent stage I, 34 percent Figure 5–-6. A to C, Wedge resection of lower lip carcinoma with
stage II, 21 percent stage III, and 8 percent stage IV.27 primary closure in layers.
Peroral resection is the most common approach

for T1 and T2 lesions of the oral tongue (Figure
5–8). A partial glossectomy is easily performed
using electrocautery to maximize hemostasis. A 1 to
1.5 cm margin of normal tongue tissue is maintained
in all dimensions, and both visual assessment and
palpation of the tongue guide the resection. Intraop-
erative margin specimens for frozen section are
taken with a scalpel to minimize cautery artifact.
Resection can be performed with a carbon dioxide
laser. Whenever feasible, the resection is planned in
a transverse wedge fashion. Intraoperative frozen
sections of the margins are mandatory. The defect of
a partial glossectomy is closed in the horizontal
direction causing a foreshortening of the tongue.
The appearance and function after horizontal clo-
sure are excellent. This is preferable to a longitudi-
nal closure, which results in a thin pointed tongue.
Figure 5–7. The anatomical routes of spread of oral tongue cancer. The size and the extent of the tumor will determine
the orientation of the resection.
easy to underestimate the deep extension of tongue For many T2 and T3 oral tongue tumors, and for
tumors and great care should be exercised to take any sized tumor in the posterior portion of the
more than 1 cm cuff of normal tongue musculature tongue or floor of mouth, the mandibulotomy
as the margin of surgical resection. The midline approach provides the exposure required to perform
raphe of the tongue does not provide any substantial an oncologically sound resection. The low morbidity
resistance to tumor spread for lesions approaching of paramedian mandibulotomy is always preferred
or crossing the midline. to the poor visualization and inadequate assessment
A B C
Figure 5–8. A to C, Peroral wedge excision and primary closure of a T1 cancer of the tongue with horizontal closure.
of the deep and posterior margins that result from mucosa and mylohyoid muscles are divided posteri-
inappropriate peroral excision.28,29 In addition, the orly up to the anterior tonsillar pillar, and one cen-
majority of these patients benefit from staging elec- timeter from the medial aspect of the mandible.28
tive supraomohyoid neck dissection, which provides Appropriate tumor resection is performed through the
the neck exposure needed for the mandibulotomy exposure thus provided (Figure 5–10).
approach (Figure 5–9). The reconstruction requires the floor of mouth
This procedure begins with elective supraomohy- incision to be closed in layers, and the bone re-
oid or modified radical neck dissection, in which the approximated with the preformed plates and screws
skin and muscle flaps of the neck are raised exposing (Figure 5–11). The lip is closed meticulously in three
the lower border of the mandible. The floor of the layers with attention to the orbicularis oris muscle
mouth is exposed via the submandibular triangle. and the exact apposition of the vermilion border. The
Next the lower lip splitting incision is performed. The best reconstructive options for partial and hemiglos-
vermilion border is marked to ensure accurate sectomy are primary horizontal closure if the defect
realignment, and the lip is split sharply in the midline is not too large, or free flap reconstruction. Other
and connected with the anterior extent of the neck options include closure by secondary intention, split-
incision. The periosteum of the mandible is left undis- thickness skin grafting and pedicled flaps. After large
turbed while the soft tissues of the lip and cheek are resections of the oral tongue, patients require speech
elevated to identify and preserve the mental nerve. and swallowing therapy for functional recovery.
The gingival mucosa and periosteum are incised at Every effort should be made to achieve negative
the mandibulotomy site anterior to the mental fora- margins with the initial resection. Intraoperative pos-
men and lateral to the insertion of the digastric mus- itive frozen-section margins in tongue surgery signif-
cle. The cut is planned either between the lateral icantly reduce local control and survival, even when
incisor and the canine tooth, or directly through the additional resection and ultimately negative frozen
root of a lateral incisor tooth that is extracted. Cuts and permanent sections are obtained.30 When intra-
between tooth roots may damage both roots and both operative positive frozen sections occur it reflects a
teeth may be lost subsequently. Prior to performing tumor biology that is more invasive and aggressive
the bone cut, the 4-hole reconstructive plates for the than is estimated by the surgeon and thus warrants
lateral and inferior margin of the mandible are consideration of postoperative radiation therapy.
molded and the screw holes drilled to ensure accurate Final histopathology report of margins may show
realignment. The cut is performed at right angles to foci of premalignant change, carcinoma in situ
the alveolar ridge and angled 45 degrees anteriorly (CIS), close surgical margins (less than 5 mm) or the
below the tooth roots for better stabilization. Taking presence of microscopic foci of invasive cancer. The
care to avoid the lingual nerve, the floor of mouth presence of any of these findings at the surgical mar-
Figure 5–9. The mandibulotomy approach to tumors of the posterior oral cavity.
Figure 5–10. The mandibulotomy approach to tumors of the posterior oral cavity. Biplane fixation of
the mandible is necessary.
gin increases the risk of local recurrence twofold, vival and control of disease in the neck. In a study of
and significantly increases the mortality from oral early staged cancers of the tongue and floor of the
cancers. Any of these histologic findings suggest a mouth, the 5-year survival of patients with thin
role for postoperative radiation therapy.31,32 lesions was greater than 95 percent, while survival of
Early tongue cancers demonstrate occult spread to patients with thick lesions was less than 80 percent,
the cervical lymph nodes in 20 to 30 percent of cases. regardless of T stage (Table 5–2).34 An appreciation of
The frequency of metastasis is related to the T stage tumor depth can aid in the decision to perform elec-
and depth of invasion of tongue cancers. Increasing T tive neck dissection. Except for oral cancers less than
stage correlates with increasing incidence of metasta- 2 mm thick, all early staged oral cancer patients
tic disease. A depth of invasion by tongue cancer of should receive elective supraomohyoid neck dissec-
greater than 5 mm is associated with an increased tion (SOHND). On the other hand, elective radiother-
incidence of occult metastasis.33 Tumor depth greater apy to the neck should be employed if radiation ther-
than 2 mm is correlated with significantly lower sur- apy is the treatment selected for the primary tumor.
Survival after treatment for tongue cancers has
improved over the last 15 years, due to the use of
combined modality treatment for advanced disease,
and the aggressive treatment of the neck in early
stage disease. Franceschi reported 5-year survival of
82 percent for patients treated between 1978 and
1987 with stage I and II disease and 49 percent for
Table 5–2. THICKNESS OF ORAL CANCER PREDICTS

SURVIVAL AND TREATMENT FAILURE
Tumor 5-year Disease Treatment
Thickness Specific Survival (%) Failure (%)
< 2mm 97 2
2–8mm 83
45
>8mm 65
Data from Spiro RH, et al. Predictive value of tumor thickness in squamous
Figure 5–11. The mandibular osteotomy is fixed using miniplates cacinoma confined to the tongue and floor of the mouth. Am J Surg
which provide accurate dental occlusion, and stability. 1986,152:345–50.
stage III and IV disease. These are improvements does not pass through the mandibular periosteum
over the survival rates in their experience from the nor through the substance of the mandible.
period 1967 to 1978 (Figure 5–12).27 An additional advantage to routine mandibular
The floor of the mouth is the second most com- resection in decades past was improved access and
mon subsite accounting for 20 percent of oral can- visualization of oral cancers. However, the morbidity
cers. Due to its dependent location, carcinogens may and reconstructive challenges of segmental
pool in the floor of mouth leading to high rates of mandibulectomy led surgeons to reconsider the indi-
cancer. Because of the small size of this area, floor of cations for this procedure, and to explore the possibil-
the mouth lesions often extend to involve the tongue ity of partial-thickness mandibular resections. In these
and the mandibular gingiva. The size distribution of procedures only the alveolar ridge and/or the lingual
floor of mouth cancers at the time of diagnosis is 30 plate of the mandible is resected (marginal
percent T1, 37 percent T2, 19 percent T3, and 14 per- mandibulectomy), and the inferior alveolar artery and
cent T4.28 Forty-one percent of patients present with nerve and the continuity of the mandibular arch are
regional neck metastasis, and micrometastases are spared. In order to justify the oncologic soundness of
identified histologically in 17 percent of elective marginal mandibulectomy, studies were undertaken to
neck dissection specimens. Of all treatment failures, understand the routes of invasion and spread of cancer
21 percent recur locally, 37 percent recur in the neck in the mandible. The results allow a rational approach
and 29 percent at both sites. Staging elective suprao- to management of the mandible in oral cancer.
mohyoid neck dissection is appropriate for all but McGregor and colleagues have reported that the
very superficial T1 lesions of the floor of the mouth, primary route of SCC invasion of the edentulous
and bilateral staging neck dissection is indicated for mandible is through cortical deficiencies of the
midline lesions. Finally, survival for floor of mouth occlusal surface of the bone.38 The route of spread in
lesions is 88 percent, 80 percent, 66 percent, and 32 the dentate nonirradiated mandible is via the tooth
percent for disease of stages I to IV respectively.35 sockets, and the presence of teeth is a relative barrier
Because of the frequent involvement of the to tumor infiltration. Also, the dentate mandible has
mandible by floor of the mouth tumors, management a greater height from the floor of the mouth than
of the mandible is an important aspect of planning does the edentulous mandible due to the resorption
resections of the floor of the mouth. The key clinical of the alveolar ridge after tooth loss. Therefore,
question is: does the mandible require resection, and if tumors of the floor of the mouth must advance far-
so how much—the periosteum, a marginal mandibular ther up the gingival mucosa to reach the occlusal
resection or a segmental resection? Management of
the mandible depends on the lesion’s proximity to the
mandible, whether the mandible is dentate or edentu-
lous, the degree of atrophy of the alveolar ridge,
whether the mandible has been irradiated, and whether
there is mandibular invasion.
Historically, a segmental mandibular resection
was often performed not only for bone involvement
by cancer, but also to accomplish a monobloc resec-
tion of the primary carcinoma with cervical lymph
nodes. It was incorrectly presumed that lymphatics
from the oral cavity passed through the periosteum
of the mandible to the neck and that in-transit metas-
tasis could be resected with the mandible. The ele-
gant histologic work of Marchetta and col- Figure 5–12. Graph demonstrating improved survival in tongue can-
cer from the years 1967 through 1978 to the years 1978 through 1987.
leagues36,37 has conclusively demonstrated that the Data from Franceschi et al. Improved survival in the treatment of squa-
lymphatic drainage of the tongue and floor of mouth mous carcinoma of the oral tongue. Am J Surg 1993;166:360–5.
Figure 5–13. The routes of spread of oral cancer to the mandible in the dentate and eden-
tulous mandible.
surface of the dentate mandible than the edentulous oral carcinoma. Because the dentate mandible is rel-
mandible (see Figure 5–13). atively resistant to cancer infiltration by adjacent
Cancer invasion of the irradiated mandible lesions, marginal resection of the alveolar ridge
occurs not only through the occlusal surface but also and/or the lingual plate, sparing the alveolar artery, is
directly through cortical bone of other surfaces.39 sometimes acceptable treatment for disease in prox-
This suggests the loss of barrier function of the imity to the bone. First, the proximity of the tumor is
periosteum after irradiation. assessed by observation, palpation, and by CT scan if
In both radiated and nonirradiated mandibles, the the lesion is fixed to the bone. If the tumor is greater
spread of squamous carcinoma within the cancel- than 1 cm away from the bone, then no mandible
lous bone is generally directed inferiorly toward the resection is needed. If the tumor is less than 1 cm
inferior alveolar nerve canal. Brown and colleagues from the mandible, then a marginal resection of the
reported that the early phase of mandibular invasion mandible will ensure 1 cm margins. If the tumor
is erosive and that this phase progresses to an infil- involves the gingival mucosa and the periosteum
trative phase as the depth of invasion increases.40 In without clinical or radiologic evidence of cortical or
the histologic studies by McGregor and McDonald, cancellous bone involvement, then a marginal resec-
tumor spread proximally and distally within the can- tion of the mandible is satisfactory, because any sub-
cellous bone of the mandible was observed to be no clinical bone involvement is likely to be localized to
farther than 5 mm beyond the region of overlying the alveolar process. If the tumor is fixed to the
soft-tissue involvement, suggesting that a 5 to 10 occlusal surface with clinical or radiologic evidence
mm bony margin, beyond the extent of the soft-tis- of cortical or cancellous bone involvement, then a
sue tumor, is oncologically sound.40 On the other segmental resection is performed because, once the
hand, invasion of the alveolar canal by oral cancer occlusal cortex is breached, there is no barrier to the
allows extensive perineural spread. By this route, vertical spread of tumor through cancellous bone to
disease can travel distally or proximally to the skull the alveolar canal. Totsuka and colleagues published
base, but does not tend to seed the bone along the studies showing that marginal mandibular resection
course of the nerve or form skip lesions. Invasion of was safe for some tumors with minimal gross bone
the ramus via the body of the bone occurs readily, invasion if there was a histologically “expansive”
especially in the irradiated mandible.41 rather than “infiltrative” pattern of invasion. How-
With these principles in mind, one can develop a ever, this pattern of invasion was not readily pre-
rational approach to management of the mandible in dictable based on radiographic findings.42,43
When extensive involvement of the cancellous to reroute the duct to the posterior edge of the resec-
bone is noted, the alveolar nerve must be assessed by tion if the submandibular gland is not resected in the
frozen section, and further resection along the neck dissection. Caution is taken to identify and pre-
course of the nerve to the inferior alveolar foramen, serve the uninvolved branches of the lingual nerve as
the mental foramen, or the skull base is considered. anesthesia of the tip of the tongue will result from
Contraindications to marginal resection of the their sacrifice. Small defects may be closed primar-
mandible include gross involvement of the cortical or ily but many can be allowed to granulate and heal by
cancellous bone of the mandible, inability to pre- secondary intention. A split-thickness skin graft is an
serve the inferior alveolar artery, significant resorp- excellent reconstruction for small defects in the floor
tion of the mandible—suggesting very thin and of mouth that expose the mylohyoid muscle.
weak residual bone, a previously irradiated mand- Excision of small lesions of the floor of the
ible, and cancer abutting the mandible on more than mouth may require local resection with en bloc mar-
two surfaces. ginal resection of the mandible (Figure 5–14).44 This
Small T1 lesions that are 1 cm from the mandible may be accomplished via a peroral approach. The
are amenable to wide local excision via the peroral mucosal and soft-tissue excision is left attached to
approach. This is easier in the edentulous patient due the mandible, the extraction of teeth at sites of alve-
to better visualization. The mucosal margin is at least olar cuts is performed, and the bone cuts are per-
one centimeter. The deep margin is just below the formed with the sagittal saw and ultra-thin blades.
sublingual salivary gland for superficial lesions. Smooth cuts rather than right-angle cuts are favored
Wharton’s duct may be ligated, but the authors prefer to evenly distribute forces of mastication and pre-
Figure 5–14. Resection of floor of the mouth cancer with marginal mandibulectomy.
Figure 5–15. Segmental resection of the mandible through a lower cheek flap approach for a large
floor of the mouth carcinoma with gross mandibular bone involvement.
vent subsequent fractures. When the dentate section is always indicated in surgical treatment of
mandible is encroached upon by tumor at the lingual large floor of the mouth tumors and this provides good
plate only, a vertical partial mandibular resection inferior exposure for the resection of the mandible.
can be accomplished using the tooth roots as the ver- Tooth extractions and gingival mucosal incisions are
tical plane of resection. The related teeth are then performed. Mandibular reconstruction plates
extracted and the right-angle saw blade is used to may be pre-bent and screw holes drilled. With the soft-
resect only the lingual plate, exercising caution to tissue portion of the tumor well defined and protected,
preserve the alveolar artery. Elective or therapeutic the bone cuts are performed with the sagittal saw and
neck dissection improves the exposure of the lower the specimen removed en bloc, often with the neck
mandible. The specimen is delivered en bloc. The specimen attached as well.44 A frozen-section assess-
resulting defects of the floor of the mouth and the ment of the alveolar nerve is prudent. Reconstruction
mandible can be left to granulate, however mucosal of lateral mandibular defects with reconstruction
advancement flaps or a split-thickness skin graft can plates or free bone grafts requires excellent soft-tissue
often close these defects well.45,46 coverage with myocutaneous flaps although the fail-
Most T3 and T4 floor of mouth cancers require ure rate is 50 percent. Exposure of reconstruction
extended local resections including partial glossec- plates used for anterior arch reconstruction
tomy or a segmental mandibular resection, which is approaches 100 percent. The free tissue transfer of
performed through a lower lip splitting incision and a fibula with attached muscle and skin is the state of the
lower cheek flap exposure (Figure 5–15). The mental art reconstruction for large composite resections,
nerve is sacrificed. An elective or therapeutic neck dis- especially when the anterior arch is involved.
An alternative surgical approach to T3 and T4 and survival were: size greater than 3 cm, bone
floor of the mouth lesions that do not require seg- involvement, and positive surgical margins. As dis-
mental mandibular resection is the transcervical cussed above, marginal mandibular resection is
pull-through procedure.47 The primary tumor speci- appropriate for periosteal involvement and segmen-
men is delivered into the neck with or without mar- tal resection indicated when the cortical bone is
ginal mandibular resection. Bilateral upper neck dis- involved with cancer.
sections are usually performed. If necessary a Peroral wide local resection with marginal
marginal or lingual plate resection of the mandible is mandibular resection can be performed for smaller
accomplished. The remaining soft-tissue attach- lesions, while segmental resection requires lip split-
ments to the mandible, including the mylohyoid ting incision and lower cheek flap elevation as
muscles, are divided and the oral contents delivered described previously.
inferiorly into the neck. This provides good visual- Tumors of the retromolar trigone occur with a
ization of the tumor for the remainder of the soft-tis- disproportionately high frequency considering the
sue resection. It is critical that the oral tissues are small surface area (Figure 5–16). Fifteen percent of
properly re-suspended and that the remaining extrin- oral cancers occur in the retromolar trigone. This
sic tongue musculature is appropriately attached to site is difficult to assess clinically because of its pos-
the mandible for postoperative swallowing function. terior location, mucosal irregularity, small area, and
Maxillary and mandibular gingival lesions are visual interference by the dentition. Trismus, if pre-
often reported in the literature together as gingival sent, may also inhibit the examination, and is indica-
lesions. Surgically, lesions of the mandibular gingiva tive of pterygoid involvement. Retromolar lesions
and retromolar trigone are similar and will be dis- are relatively difficult to treat because they spread
cussed together. Lesions of the maxillary gingiva are early to deep structures such as the ascending ramus
surgically similar to those of the hard palate and so of the mandible, pterygoid muscles, the masticator
these two subsites will subsequently be addressed. space, and the skull base. Another avenue of local
Three-quarters of gingival lesions involve the spread is the foramen of the inferior alveolar nerve
mandibular alveolus and one-quarter involve the into the ramus of the mandible. Tumor may also
maxillary alveolus. A report of 283 mandibular alve- spread proximally along the perineurium or within
olar lesions from Memorial Sloan-Kettering Cancer the nerve to the trigeminal ganglion and the CNS.
Center showed the distribution of these primary Surgical access to this region is challenging. Bone
tumors to be 30 percent T1, 48 percent T2, 17 percent resection is nearly always indicated, and recurrence
T3 and 11 percent T4.48 Only 5 percent were resected is difficult to diagnose.
without bone, 32 percent were amenable to marginal
resection and 63 percent required segmental bone
resection. Local recurrence was 25 percent when the
mandible was initially involved with tumor. Occult
neck metastasis was found in only 6 of 107 elective
radical neck dissections, indicating a low incidence
of occult neck disease compared to tumors of other
subsites of the oral cavity. Staging elective suprao-
mohyoid neck dissection is indicated for T2 or larger
lesions in conjunction with segmental mandibular
resection. Five-year survival for all alveolar cancers
was 77 percent stage I, 70 percent stage II, 42 percent
stage III, and 24 percent stage IV.
Overholt49 reviewed the M.D. Anderson Hospital
experience of 155 mandibular alveolar lesions and
determined that parameters affecting local control Figure 5–16. An exophytic lesion in the retromolar trigone.
lary alveolus or partial maxillectomy may be neces-

sary if they are involved with cancer.
Soft-tissue reconstruction with primary closure,
or healing by secondary intention over the retromo-
lar trigone is occasionally satisfactory. Posteriorly-
based buccal mucosal random-pattern rotational
flaps, soft palate, tongue, and masseter muscle flaps
are all described for this area. The need for thin tis-
sue here suggests an advantage for skin grafting and
radial forearm free flap reconstructions. If the ramus
is sacrificed, a bulkier pectoralis pedicled flap may
cover reconstructive hardware but tends to pull infe-
riorly with time. The excellent bone stock of the
fibular free flap is detracted from by its association
with bulky muscle, and variable survival of the over-
lying skin paddle. It is infrequent today that a lateral
mandibular defect is left unreconstructed, but this
Figure 5–17. Bone cuts for marginal and conservative segmental defect is tolerated well by many patients and it
resections of the mandibular ramus and body.
allows easier assessment of the region for recur-
rence. Defects that are small, posterior and occur in
The peroral approach to the retromolar region is the edentulous patient are tolerated well.
rarely satisfactory due to the posterior location of the Carcinomas of the hard palate (Figure 5–18) and
trigone and the necessity for bone resection since the upper alveolus are relatively uncommon, accounting
periosteum or bone is usually involved with cancer. for 10 percent of oral cancers,50 except in areas of
Often a segmental resection of the ascending ramus Southeast Asia where reverse smoking is prac-
of the mandible and part of the pharynx is necessary. ticed.51 In the United States, carcinoma of the hard
Mandibular rim resection of the molar alveolus and palate is only half as common as carcinoma of the
the ascending ramus of the mandible is acceptable soft palate52,53 and carcinoma of the maxillary alve-
for small lesions without gross bony involvement. olar ridge is only one-third as common as carcinoma
Marginal mandibular resection of the ascending of the mandibular alveolar ridge.48 These areas are
ramus through the open mouth is not satisfactory. lined with adherent keratinized mucosa, which pro-
If bone is grossly involved by clinical or imaging
evaluation, then segmental resection of the ramus
and/or body is required. If superficial involvement
of the molar alveolus or ascending ramus is identi-
fied, then conservative segmental mandibular resec-
tion sparing the condyle and a posterior strut of
ascending ramus is satisfactory bone resection.41
Cuts are performed through the mandibular notch
and the coronoid process (Figure 5–17). The alveo-
lar foramen and nerve are included in the resection.
Intraoperatively, a frozen-section margin on this
nerve is important. Assessment of the superior
extent of the disease, including the coronoid process
of the mandible, the temporalis muscle, maxillary
tubercle, masticator space, and pterygomaxillary
space is necessary. Marginal resection of the maxil- Figure 5–18. Squamous cell carcinoma of the hard palate.
vides protection from the trauma of mastication, and

may provide relative protection of the basal nuclei
from the effects of carcinogens.
Histologically, carcinomas of the upper alveolar
ridge are nearly all squamous cell carcinomas, but
up to one-third of hard palate cancers are of minor
salivary gland origin.54 In contrast to squamous cell
carcinomas, palatal minor salivary gland tumors are
often submucosal masses rather than ulcerative or
fungating mucosal lesions. Kaposi’s sarcoma can be
seen on the hard palate of patients with acquired
immunodeficiency syndrome. Malignant melanoma
of the oral cavity, while rare, occurs most frequently
on the palate.
Lesions of the maxillary alveolar ridge are symp-
tomatic, thus allowing early diagnosis. Eighty-two
percent of maxillary alveolar ridge carcinomas are
T1 or T2 at the time of diagnosis, and 86 percent are
N0.48 Palatal carcinomas tend to be larger when Figure 5–19. Bone cuts for subtotal maxillectomy preserving the
diagnosed but only 13 percent have regional metas- inferior orbital rim and floor of the orbit.
tases when diagnosed.49 The presence of regional
metastases to the neck or locally advanced disease
decreases 5-year survival from approximately 70
percent to approximately 30 percent.53
Surgery is the treatment of choice for cancer of
the maxillary alveolus and the hard palate, and it is
frequently necessary to resect periosteum and bone
in order to ensure an adequate margin. The mucosa
and the underlying periosteum are fused in this
region forming a mucoperiosteum. Invasive carcino-
mas of this area frequently involve the periosteum or
the underlying bone, thus reducing the effectiveness
of primary radiation therapy for these lesions. How-
ever, postoperative radiation therapy for aggressive
minor salivary gland malignancies or advanced
squamous carcinoma is recommended.54,55
T1 and T2 lesions may be amenable to peroral
wide local excision with resection of the involved
mucoperiosteum and usually the underlying bone.
Mucosal incisions are performed with electro-
cautery, allowing a 1 cm margin of normal tissue.
Teeth are extracted at the osteotomy sites, and bony
cuts are performed with an oscillating saw. Many
small defects granulate well and close by secondary
intention. Primary closure is usually not possible
due to the immobility of the surrounding adherent Figure 5–20. The Weber-Ferguson incision and its subciliary and
mucosa. A posteriorly-based buccal mucosa flap brow extensions for maxillectomy.
with random blood supply is effective in closing lat- the antrum is not involved, and posterior to the ptery-
eral palatal and alveolar defects. A flap of the palatal goid plates if the posterior wall and the pterygomax-
mucoperiosteum, based on the greater palatine illary space are involved with cancer. The cut is made
artery in the posterior aspect of the hard palate, can using a curved osteotome and the heavy curved Mayo
be rotated to cover a small defect, and the donor site scissors under palpation guidance with cognizance of
left to granulate or be skin grafted. If the nasal and the proximity of the internal carotid artery in the deep
antral mucosa are intact after the resection, the oral aspect of the parapharyngeal space, and the apex of
defect can be closed with a local flap with a low risk the orbit superomedially. Hemostasis is obtained, the
of oronasal fistula formation. lacrimal sac is tacked open with chromic suture
T3 or T4 cancers with invasion of the maxillary and/or the lacrimal duct cannulated with silastic tub-
antrum or nasal cavity often require partial or subto- ing, and the cavity is skin grafted. The graft is sup-
tal maxillectomy. Advanced lesions invade the nasal ported by packing with xeroform gauze, which is sup-
cavity, maxillary sinus, the pterygomaxillary space, ported by a preformed dental obturator that is wired
pterygoid plates and skull base. T3 and T4 cancers to the remaining maxillary teeth or the alveolar bone.
requiring subtotal maxillectomy (preservation of the Only rarely is total maxillectomy (including the
infraorbital rim and floor of the orbit ) (Figure 5–19) orbital rim and floor) or radical maxillectomy
need exposure via an extended Weber-Ferguson inci- (including orbital exenteration) necessary for oral
sion and an upper cheek flap for maximum exposure cavity cancers.
(Figure 5–20), or exposure via the midface degloving
approach. A midface degloving approach provides REHABILITATION
excellent exposure for anterior lesions involving the
lower maxilla and nasal cavity bilaterally without any The rehabilitation of function after oral surgery is a
external incisions, but superior exposure is limited critical element in effective oral cancer surgery. After
above the orbital rim.56,57 After the exposure is major oral resections the patients need rehabilitation
obtained, the soft-tissue cuts and dental extractions of speech, swallowing, dentition and mastication as
are performed as needed. Alveolar cuts should be well as cosmesis. This process is best accomplished
made through the sockets of extracted teeth and not in a multidisciplinary environment which include the
between them. This allows good bony support for the head and neck surgeons, plastic surgeons, speech and
remaining teeth that will bear considerable forces language therapists, nurses, dentists, prosthodontists
from dental rehabilitation. The following cuts are per- and oral and maxillofacial surgeons.
formed using the oscillating saw: (1) from the lateral Perhaps the most important element of rehabili-
maxillary wall to the infraorbital rim preserving the tation is optimizing the patient’s resection and
latter, (2) from the infraorbital rim to the nasal cavity reconstruction at the time of surgery. While the
through the lacrimal fossa, (3) from the nasal cavity oncologic soundness of the tumor resection must not
through the alveolar ridge, and (4) through the hard be compromised for functional reasons, neither
palate (see Figure 5–19). The remaining cuts are the should excessive resection of uninvolved soft tissue,
lateral nasal wall cut, which joins the lacrimal cut to nerve or bone be performed. Whenever oncologi-
the nasopharynx using a thin osteotome and Mayo cally possible, preservation of the hypoglossal, lin-
scissors, and finally the posterior cut. The posterior gual and mental nerves should be attempted. Gentle
cut is performed only after all other aspects of the handling of tissues, hemostasis, and obliteration of
maxilla are freed. This is because significant bleeding dead space are general principles of surgery which
can occur from the pterygoid venous plexus and the should be adhered to. This, in combination with anti-
internal maxillary artery after this cut is performed. septic preparation of the oral cavity preoperatively
The expedient removal of the specimen and prompt and the use of perioperative antibiotics, may reduce
packing of the maxillectomy defect are necessary to inflammation and improve healing and reduce scar
adequately control bleeding. The final cut is made tissue formation, which will tend to maximize post-
anterior to the pterygoid plates if the posterior wall of operative function.
Reconstruction of oral defects after ablative tication requires intact sensation of the dentition,
surgery is critical for oral rehabilitation. Perhaps the gingiva, tongue and buccal mucosa, and intact motor
most important advance in head and neck surgery in function of the hypoglossal nerve for tongue muscu-
the last 15 years has been the safe and effective use lature, the facial nerve for oral competence and the
of free tissue transfer for reconstruction. Free tissue third division of the trigeminal nerve for buccinator
transfer techniques now allow the excellent recon- function. This combination of sensory and motor
struction of the mandible, skin, and mucosa of the functions allows the food to be kept in the plane of
oral cavity. Bone flaps from the fibula, iliac crest the molars without biting the soft tissues.
and scapula are available to the reconstructive sur- Continuity of the mandibular arch provides great
geon. Soft tissue from the radial forearm, lateral advantage for mastication. However, a patient with a
arm, trapezius, rectus abdominis and other sites pro- segmental defect of the body of the mandible can
vide vascularized, nonirradiated soft tissue for frequently masticate some foods satisfactorily.
reconstructive purposes. It is clear that the appropri- Occasionally a guide plane prosthesis is helpful to
ate use of these reconstructive tissues has dramati- maximize occlusion of the teeth in a patient with a
cally improved the functional outcome of oral can- lateral mandible defect. These guide plane prosthe-
cer patients. They should be employed whenever ses help overcome the deviation of the mandible to
necessary. Adequate reconstruction of the mandibu- the resected side from the unopposed action of the
lar arch, and soft tissues of the tongue and floor of intact contralateral pterygoids. An unreconstructed
mouth will significantly increase the likelihood of defect of the anterior mandible is uncommon today.
acceptable speech and swallowing after major oral This defect will prohibit mastication of solids and
cavity cancer surgery. patients will tolerate no more than a puréed diet. The
Rehabilitation of swallowing after oral cavity combination of poor mastication, swallowing,
surgery is important. Swallowing can be divided into speech and articulation, cosmetic defect and oral
the preparation phase, the oral phase and the pharyn- incompetence makes the anterior mandibular arch
geal phase. Oral cavity surgery impacts most on the defect something to be avoided in almost every cir-
preparatory phase and the oral phase. The preparatory cumstance. The oral preparatory phase of swallow-
phase of swallowing begins with lubrication of the ing can also be inhibited by trismus, which is com-
food bolus by saliva. This is impaired when pre- or mon after surgery and/or irradiation of the posterior
postoperative radiation therapy is employed. Signifi- oral cavity and oropharynx.
cant xerostomia results in the majority of irradiated The oral phase of swallowing consists of prepa-
patients. The xerostomia significantly limits the types ration of the food bolus followed by presentation to
and consistencies of food that can be swallowed. Most the oropharynx, where the swallowing reflex is initi-
patients with oral cavity radiation require frequent ated during the oropharyngeal phase. The oral phase
sips of water to maintain moisture and liquid to wash is volitional. Preparation of the bolus is accom-
down the food at mealtimes. One experimental strat- plished by the tongue, cheek, teeth and palate. After
egy to try to limit xerostomia is to use a salivary gland mastication and lubrication, the bolus is then pro-
protectant such as Salagen (pilocarpine pelled to the oropharynx by elevation of the tongue
hydrochlonde) during radiation. The benefit of Sala- against the hard palate. When the bolus is sensed in
gen™ is not yet proven and it is contraindicated in the the oropharynx the reflexive portion of the oropha-
presence of coronary artery disease. Amifostine is ryngeal phase of swallowing is initiated. Tongue ele-
approved for the prevention of radiation-induced vation can be restricted due to either loss of tissue
xerostomia. It is not widely used. A number of prepa- volume or motor function after surgery. Patients
rations are marketed for xerostomia but are not supe- with near total glossectomy can be sometimes well
rior to water for the majority of patients. rehabilitated with a palatal drop prosthesis, which
Mastication is critical to an effective preparatory lowers the level of the hard palate so that the resid-
phase of swallowing. Certainly the quality and quan- ual tongue tissue can articulate with it to propel the
tity of the teeth are important for mastication. Mas- bolus posteriorly (Figure 5–21).
staged process and the ingrowth of healthy bone into

and around the implants results in a very secure
foundation for oral prostheses.58 Osseointegrative
implants can be placed in fibula free flap recon-
structions of the mandible after the healing and
removal of the fibula fixation hardware (Figure
5–24). Osseointegrative implants should be avoided
in the atrophic edentulous mandible especially after
A
B
Figure 5–21. A, Patient with poor tongue mobility with a palatal
drop prosthesis in place. B, Palatal drop prosthesis.
The oral prosthodontist plays a critical role in the

rehabilitation of swallowing after oral cancer treat-
ment. The proper number and quality of teeth and
their alignment can be restored by maxillary and/or
gingival dentures. After resection of the maxilla or
hard palate, a dental obturator to cover the oro-antral
and oronasal fistulae is necessary for swallowing
B
without nasal regurgitation (Figure 5–22). Patients
with large maxillary defects can attain excellent
functional results with an obturator. For defects of
the soft palate, dysphagia due to nasal regurgitation,
hyponasal speech and difficulty with articulation of
speech sounds, an obturator with a nasopharyngeal
bulb is effective in minimizing nasal regurgitation
and improving hyponasal speech. The bulb is prop-
erly positioned in the nasopharynx articulating with
the posterior pharyngeal wall at the prominence of
the body of C2, allowing the remainder of the soft
palate to seal off the nasopharynx during swallowing
(Figure 5–23).
Osseointegrated implants are an important C
advance in oral rehabilitation. If adequate bone Figure 5–22. A, Maxillectomy defect with split-thickness skin graft.
stock exists, titanium posts can be placed in a multi- B, Prosthesis in place. C, Prosthesis.
radiation. Osseointegration can also be utilized They can often recommend exercises for the artic-
effectively for external fixation of cosmetic prosthe- ulation of speech and can help both the patient and
ses after extended surgery for oral cavity cancer, prosthodontist to optimize prostheses and to rec-
which includes soft tissues of the face. It is impor- ommend alternative methods of phoneme forma-
tant for the patient’s rehabilitation that they have an tion.59 Patients with significant resections of the
acceptable cosmetic appearance in public. lips, maxilla, tongue and palate will often benefit
Many patients benefit from evaluation and ther- from speech therapy.
apy by certified speech and swallowing therapists. Speech and swallowing therapists can also help
improve swallowing in patients who have undergone
oral surgery.60 A modified barium swallow under flu-
oroscopic observation by a radiologist and a speech
therapist may be helpful diagnostically.61 From this
study, abnormalities of mastication, bolus preparation
and bolus presentation of the oropharynx can be
observed and studied frequently from this data.
Strategies for improved function can be devised and
taught to the patient and exercises implemented.
Accompanying abnormalities of the pharyngeal
phase of swallowing can also be diagnosed. Based on
A
C B
Figure 5–23 A, Soft palate defect after surgical resection and free Figure 5–24. A, Panorex of osseointegrated implants in the ante-
flap reconstruction of the lateral pharyngeal wall. B, Prosthesis in rior and right lateral aspects of a fibula free flap reconstruction of the
place. C, The nasopharyngeal bulb prosthesis. mandible. B, The prosthesis in place.
the clinical findings and the modified barium swal- working together. Each can contribute significantly
low, therapists can also suggest optimal consistencies, toward the rehabilitation of speech, swallowing and
and temperatures of food that can be best managed. appearance of the oral cancer patient.
Consultation with a trained nutritionist with expe-
rience in treating head and neck cancer patients is SEQUELAE, COMPLICATIONS AND
essential to provide patients with information and THEIR MANAGEMENT
suggestions regarding optimal foods to maintain a
balanced nutrition within the patient’s consistency Complications can be minimized by appropriate pre-
restrictions. Patients with impaired oral function risk operative evaluation including medical cardiology
nutritional deficiency unless an appropriately varied and anesthesia consultation as indicated. Since the
diet is maintained. Many patients benefit from pre- majority of oral cancer patients are elderly, many will
pared commercial supplements, which are formulated have significant co-morbidities which need assess-
specifically as a balanced diet. Some patients may ment, diagnosis or intervention prior to, or after,
subsist on liquid dietary supplements alone, while the surgery. A preoperative medical evaluation is recom-
majority benefit from regular foods as tolerated with mended for all patients over the age of 60 regardless
additional dietary supplements as needed. Nearly any of their health status. Routine preoperative testing
everyday food can be puréed with liquid in a blender should screen for previously undiagnosed major
and drunk. Patients should be weighed frequently in organ diseases and should consist of at least a preop-
the postoperative period to monitor for weight loss. erative chest radiograph, serum tests of renal and
Supplemental tube feeding may be necessary while hepatic function and electrocardiography. Patients in
the patient is relearning swallowing. negative nitrogen balance due to poor nutrition
Members of the rehabilitation team must educate would be considered for a nasogastric feeding tube
the oral cancer patient regarding oral hygiene. Teeth placement and several weeks of nutritional therapy
brushing and fluoride treatments should be done at prior to surgery. Properly selected patients should
least twice daily. The patient should perform these have a low incidence of major complications.62
fluoride treatments at home regularly using molded The most common complications after oral
dental trays. Patients with post-radiation xerostomia surgery are wound related. The excellent blood sup-
require frequent sips of water, and may benefit from ply to the oral cavity helps to ensure good healing of
sialagogues such as lozenges or chewing gum; how- soft tissues and to resolve infection. Careful surgical
ever it is critical that these be sugar free as the risk of technique can help to minimize complications. It is
caries is dramatically increased after radiation treat- important to handle tissues atraumatically, avoid
ment. All patients with impaired oral function should excessive char from electrocautery, observe careful
be instructed to cleanse the oral cavity after eating. hemostasis, obliterate any dead spaces and to mini-
This may involve simple rinsing with water or saline mize bacteria colony counts by gentle antiseptic pre-
solution or irrigation with a hanging bag and warm operative preparation and copious irrigation with
saline solution. Reconstruction flaps with skin lining saline with or without antibiotics. Careful techniques
the oral cavity may require frequent brushing to of closure will help to minimize postoperative wound
eliminate accumulated skin debris and sometimes complications. Closure under tension should be
trimming of the hair growing on the skin flaps is nec- avoided, especially of an irradiated tissue. Separate
essary for patient comfort and to decrease the adher- suture layers of muscle and mucosa should be per-
ence of food. Reconstructive flaps that have been formed. Oral wounds closed by primary intention
irradiated no longer grow hair. Mouth washes, which will heal best. Many oral lesions will granulate well
contain alcohol, should be avoided as they dry the over several days to several weeks. Skin grafts can be
tissues and cause burning and discomfort. Normal helpful but are frequently lost when placed over
saline or saline with bicarbonate of soda is preferred. mobile surfaces or directly over cortical bone. Any
Successful oral rehabilitation after oral cancer exposed bone or cartilage in the oral cavity will lead
surgery requires a dedicated team of specialists to granulation tissue formation and delay of healing.
Obviously carious or infected teeth should be appropriate patient selection, preoperative evalua-
removed at the time of surgery. Twenty-four hours of tion, meticulous technique and appropriate postop-
IV antibiotics, initiated at least 1 hour prior to erative care.
surgery, may help to reduce the wound infection rate.
Other intraoperative measures to decrease com- OUTCOMES AND FUNCTION
plications include consideration of procedure dura-
tion to minimize the time of general anesthesia. Judi- Outcomes in oral cavity surgery may be divided into
cious intraoperative use of crystalloid will prevent survival and functional outcomes. Five-year survival
postoperative complications of fluid overload. Insen- rates for early (T1 and T2) oral cancers are reported
sate fluid loss in oral cavity surgery is significantly to be in the 70 to 90 percent range. In all head and
less than in abdominal surgery, which results in a neck sites, the presence of metastatic nodes to the
lower requirement of intravenous fluid for oral cavity neck decreases the survival by 50 percent. Five-year
surgery patients than for abdominal surgery patients. survival for patients with stage IV disease, espe-
Postoperative management impacts significantly cially with bulky or bilateral lower neck metastases,
on complications of oral surgery. Aggressive oral is less then 20 percent.27
irrigation should begin on the first day of the surgery. In resectable stage III and stage IV tumors with N0
It should be accomplished with normal saline or nor- or N1 disease, 5-year survival has been increased to
mal saline and bicarbonate of soda solution in hang- the 50 to 60 percent range by the aggressive addition
ing irrigation bags or via compressed air-sprayer. of postoperative radiation therapy.15,16 With improved
Major systemic complications are uncommon in local control rates a higher percentage of deaths are
oral cavity surgery. Cardiopulmonary complications due to distant disease and second primary carcinomas
occur due to pre-existing co-morbidities, the physi- rather than from uncontrolled locoregional disease.
ologic stress of surgery and fluid overload. Respira- Factors that predict survival of oral cancer
tory complications such as pneumonia can be mini- patients are low T stage, low N stage, low overall
mized by appropriate early mobilization and the use stage, and the absence of significant co-morbidities.
of sequential compression devices, and careful While the study of the molecular genetics of oral
observation for aspiration of liquids. Due to early cancer is rapidly evolving, there are currently no
mobilization, oral cavity cancer patients rarely suf- molecular markers which have been shown to pre-
fer from deep venous thrombosis (DVT) or pul- dict survival in head and neck cancer patients in
monary embolism, however, immobilized patients large prospectively gathered series. It is however
should be placed on appropriate DVT prophylaxis, likely that in the next several years valid molecular
such as subcutaneous heparin or sequential com- markers will be developed which can predict tumor
pression devices.63 behavior, response to surgical and non-surgical
The majority of wound complications will heal treatment and patient survival rates.
with aggressive cleansing and infection control. Functional outcomes for surgery for early oral
Management of co-morbidities, such as diabetes cancers is excellent. It is rare for patients to suffer
mellitus, malnutrition and hypothyroidism, in order significant loss of speech and swallowing function
to maximize wound healing is critical. Poor healing after surgical resection for T1 or T2 lesions. Even
or a persistent oral cutaneous fistula may result from large T2 lesions of the tongue rehabilitate extremely
the presence of a foreign body such as hardware, well due to the plasticity of the tongue as well as its
non-absorbable suture or sequestered bone. Persis- good blood supply, copious sensory innervation and
tent or recurrent tumor must be ruled out by biopsy the presence of intact musculature. Over 6 to 12
in any non-healing wound after oral cancer surgery. months, the patients invariably find dramatic
The frequency, complexity and duration of wound improvement in articulation of speech sounds, mas-
complications are greater in the irradiated patient. tication and swallowing. Aggressive and appropriate
In summary, the incidence of major complica- rehabilitation with speech and swallowing therapy
tions in oral cancer surgery can be minimized by and prosthodontics is critical to these results.
With increasing volumes of resected tissue, func- able procedure? Otolaryngol Head Neck Surg 1989;101:
426–8.
tional outcomes diminish. Tissues impacting most
14. Hanasono MM, Kunda LD, Segall GM, et al. Uses and limita-
on function include tongue muscle, hypoglossal tions of FDG positron emission tomography in patients with
nerve, lingual nerve, anterior mandibular arch, and head and neck cancer. Laryngoscope 1999;109:880–5.
soft palate. When extensive or multiple resections of 15. Vikram B, Strong EW, Shah JP, Spiro R. Failure at the pri-
mary site following multimodality treatment in advanced
the above structures are undertaken for advanced head and neck cancer. Head Neck Surg 1984;6:720–3.
disease, patient function may be poor even with the 16. Vikram B, Strong EW, Shah JP, Spiro R. Failure in the neck
most advanced reconstructive and rehabilitative following multimodality treatment for advanced head and
techniques. Despite improvements in postoperative neck cancer. Head Neck Surg 1984;6:724–9.
17. Rudoltz MS, Perkins RS, Luthmann RW, et al. High-dose-rate
function attributed to free flap reconstruction, the brachytherapy for primary carcinomas of the oral cavity
degree of coordination of motor and sensory func- and oropharynx. Laryngoscope 1999;109:1967–73.
tion necessary for good oral function cannot be 18. Wolf GT, Forastiere A, Ang K, et al. Workshop report: organ
preservation strategies in advanced head and neck can-
attained with the current technology. These patients
cer—current status and future directions. Head Neck
are gastrostomy tube-dependent and speak poorly. 1999;21:689–93.
Xerostomia from oral radiation therapy and trismus 19. Schuller DE, Metch B, Stein DW, et al. Preoperative
from surgery or radiation are also factors that can chemotherapy in advanced resectable head and neck can-
cer: final report of the Southwest Oncology Group.
dramatically compromise function. Laryngoscope 1988;98:1205–11.
20. Williams EF III, Meguid MM. Nutritional concepts and con-
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Cancer de Cavidad Oral

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5

Oral Cavity Cancer

TREATMENT GOALS AND ALTERNATIVES;

The surgeon’s goal is complete removal of all

SURGERY FOR ORAL CANCER

The lip is the most common site for oral cancer. It is

Peroral resection is the most common approach

Table 5–2. THICKNESS OF ORAL CANCER PREDICTS

lary alveolus or partial maxillectomy may be neces-

vides protection from the trauma of mastication, and

staged process and the ingrowth of healthy bone into

The oral prosthodontist plays a critical role in the

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