SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere Nutzervereinbarung und die Datenschutzrichtlinie.
SlideShare verwendet Cookies, um die Funktionalität und Leistungsfähigkeit der Webseite zu verbessern und Ihnen relevante Werbung bereitzustellen. Wenn Sie diese Webseite weiter besuchen, erklären Sie sich mit der Verwendung von Cookies auf dieser Seite einverstanden. Lesen Sie bitte unsere unsere Datenschutzrichtlinie und die Nutzervereinbarung.
The buccal mucosa includes the mucosal
surfaces of the cheek and lips from the line of
contact of the opposing lips to the
pterygomandibular raphe posteriorly.
This extends to the line of attachment of the
mucosa of the upper and lower alveolar ridge
superiorly and inferiorly.
The muscle of the cheek is the buccinator
The buccal fat pad is superficial to the fascia
covering the buccinator muscle and gives the
cheeks a rounded contour.
Branches of the maxillary and mandibular
nerves (cranial nerves V2 and V3) provide
sensory innervation to the skin, the cheek,
and the mucous membranes lining the
The facial nerve (cranial nerve VII) provides
motor innervation to the muscles of the
cheeks and lips.
The lips and cheeks function together as
an oral sphincter propelling food into the
If the facial nerve is paralyzed, food tends
to accumulate within the cheek along the
affected side so that saliva and food
dribble out of the corner of the mouth.
After carcinoma of the lip, oral tongue, floor of
the mouth, and lower gum, carcinoma of the
buccal mucosa is the fifth common carcinoma
of the oral cavity.
It usually occurs in the sixth and seventh
decades of life, and is more prevalent in men
than in women.
Tobacco and betel nut chewing appear to play
an important role in the cause of these
Carcinomas of the buccal mucosa often occur
in association with pre-existing leukoplakia
and tend to have multiple primary sites and
Excision of the oral leukoplakia may reduce
the subsequent development of carcinoma.
These tumors usually arise in the area
adjacent to the lower molars along the
occlusal line of the teeth.
Leukoplakia - A chronic white
mucosal macule which cannot
be scraped off, cannot be
given another specific
diagnostic name, and does not
disappear with removal of
potential etiologic factors
4-18% progress to invasive
Erythroplakia is the clinical
diagnostic term - A chronic
red mucosal macule which
cannot be given another
specific diagnostic name and
cannot be attributed to
traumatic, vascular or
inflammatory causes, i.e. it is
a diagnosis of exclusion.
Higher risk of cancer
development (~ 30%)
Clinically, there are three distinct types: exophytic,
ulcerative, and verrucous.
The patient may present with pain or bleeding,
trismus, or cervical lymphadenopathy.
Posterior extension may result in involvement of the
lingual or dental nerves, which may cause ear pain.
Extension behind the pterygomandibular raphe into
the pterygoid muscles or into the buccinator and
masseter muscles may cause trismus.
In advanced stages, the tumor may destroy the entire
cheek and invade the adjacent bones and the neck.
Infection is common and mastication becomes
difficult. Death usually occurs as a result of poor
nutrition and general debilitation
Infiltrating lesions of the buccal mucosa can
invade the buccinator muscle, extend to the
buccal fat pad, and invade the subcutaneous
Carcinomas of the buccal mucosa frequently
spread by direct invasion into the
gingivobuccal sulcus, the upper and lower
alveolar ridges, the hard palate, the maxilla,
and the mandible.
Lymph node metastasis occurs in approximately
9% to 31% of the patients during the course of
The submandibular lymph nodes are most
frequently involved; involvement of the upper
cervical and the parotid lymph nodes is less
common. The risk of subclinical disease is 16%.
Distant metastases are rare, as patients often
die of uncontrolled local disease before distant
metastases are manifested clinically.
>90 % Squamous cell carcinomas
Spectrum of diseases from benign
lesions like leukoplakia, lichen planus,
SMF to verrucous carcinoma to well
differentiated squamous carcinoma
Malignant Minor salivary gland tumors
such as Adenoid cystic,
carcinoma (< 10%) are uncommon
Malignant Melanoma, Lymphoma,
sarcoma occur rarely.
History & Clinical examination , including head &
Assessment of performance & nutritional status
Investigations for histological diagnosis – Punch
Investigations to determine the extent of the
OPG/ Dental occlusal view
CT Scan / MRI for extent of disease
USG for N0 neck in select cases
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T1, T2 N1 M0
T3 N0, N1 M0
Stage IV A T1, T2, T3 N2 M0
T4a N0, N1, N2 M0
Stage IV B Any T N3 M0
T4b Any N M0
Stage IV C Any T Any N M1
Stage I – IV A : Curative
Stage IV B-C : Palliative
The aim of treatment:
Loco regional control
Preservation of anatomy & function
Quality of life
Proximity to bone
Status of cervical nodes
Tumor pathology ( histological type, grade, & depth of
General medical conditions
Tolerance of treatment
Acceptance of expected sequelae of therapy
Surgery : wide excision +/- marginal
Radiotherapy : Radical external RT/
N0 : Observe or
SOHD ( if cheek flap raised , USG suspicious,
thick tumor or poor follow up expected) followed
by Frozen section, if positive nodes, MND is
N+ : MND/RND
Post op RT as per guidelines
Surgery + Post op RT or CT-RT
Surgery : Composite resection of the buccal
mucosa with mandible or upper alveolus or
overlying skin with reconstruction
N0 : SOHD followed by FS, if positive nodes,
N+ : MND/ RND
Management is controversial
Perceived risk that the tumor may become more
aggressive if it recurs after RT.
Many tumors that recur after treatment are
biologically more aggressive. Therefore, it is
reasonable to treat these lesions with irradiation
if surgery is not feasible.
Wang reported a series of patients with
verrucous carcinoma treated with RT; the
results were comparable to those for patients
treated for squamous cell carcinoma.
Used as single modality in early disease (Stage I &
Combined with post operative adjuvant
radiotherapy in advanced disease(Stage III & IV)
Wide excision of tumor in all dimensions with
adequate margins & appropriate neck dissection
essential for locoregional control of disease
Treatment time is shorter.
The risk of immediate and late radiation sequel
Irradiation is reserved for recurrence, which
may not be resectable.
Pathological assessment, accurate staging.
Disadvantage: functional & cosmetic
impairment, increased morbidity when bilateral
neck is addressed.
Modified neck dissection is sufficient treatment
for the ipsilateral neck for patients with N1
Radiation therapy is added for
N1 with PNE/LVI
N2,N3 stages, for control of contra lateral
For invasion through the capsule of the node,
For multiple positive nodes
RND : superficial & deep cervical fascia with its enclosed
LN (level I-V) is removed in continuity of SCM, omohyoid
muscle, internal & external jugular veins, spinal accessory
N & submandibular gland
MND : is finding more acceptance & preference to RND in
managing N0 neck because of severe morbidity related to
RND such as, shoulder dysfunction, poor cosmesis, facial
edema (level I-V LN)
SOHND : least morbid, provides most satisfactory
sampling of the LN at the level I, II, III which are greatest
Extended SOHND : level I-IV LN dissection
Marginal mandibulectomy: partial-thickness (marginal)
For small lesions with minimal bone invasion, a short
section of mandible is removed in continuity with the
tumor (e.g., removal of the mandible from the angle to
the mental foramen).
- Removal of the mandible symphysis to the condyle
on one side.
- Major cosmetic and functional loss
- Reconstruction is performed with a composite
2. Location & extent of the tumor / lesion
3. Tumor dimensions
4. Distance from various margins of excision
5. Nodal dissection
1. Histologic type
3. Extent of disease including depth of
4. Perineural invasion
5. Lymphovascular invasion
6. Bone / Cartilage / Skin / Soft tissue involvement
7. Margins of excision, submucosal spread, In – situ
8. Nodal status – no. & size of nodes, perinodal extension
& level of nodes
9. Status of cut margins
1. In RND/ MND status of internal jugular vein
2. Presence of predisposing factors - leukoplakia, SMF
3. Dysplasia/ in situ elements
Adequate surgical clearance is not achievable
Extensive Infra Temporal Fossa involvement
Extensive involvement of base skull
Extensive soft tissue disease – skin edema /
Clinically fixed nodes
Infiltration of Internal / Common carotid artery
Extensive infiltration of prevertebral muscles
Better functional and cosmetic outcome
Elective irradiation of the lymph nodes can be included with
little added morbidity, whereas the surgeon must either
observe the neck or proceed with an elective neck dissection
(sometimes bilateral depending on the primary site),
The surgical salvage of irradiation failure is probably more
likely than the salvage of a surgical failure.
The risk of postoperative complications is avoided
Small (preferably < 3cm ) tumors
Well defined borders
Lesion away from bone
Tumors of the anterior two thirds of the buccal
mucosa without involvement of gingiva are ideally
suited for brachytherapy alone.
Advanced primary – T3 or T4
Close or positive margins of excision
Depth of invasion
High grade tumor
LVI & PNI
Bulky nodal disease N2/N3
Extra nodal extension
Multiple level involvement
T1 and T2 lesions
Ipsilateral field arrangement that includes the
primary lesion and the level I and II lymph
The anterior and superior borders of the field
should be at least 2 cm from the borders of
the primary tumor. The posterior border
should be at the posterior aspect of the
spinous processes if the nodes are to be
Inferior border is at the thyroid notch.
T3 and T4 lesions
Patients with significant tumor extension
toward the midline are treated with parallel
opposed fields weighted 3 : 2 toward the side
of the lesion.
The low neck is treated with an anterior field
with a 6-MV x-ray beam to 50 Gy in 25
fractions once daily
Doses of 66 Gy in 2-Gy fractions for positive
60 Gy in 2-Gy fractions or 59.4 to 63 Gy in 1.8-Gy
fractions to high-risk regions.
54 Gy in 1.8-Gy fractions for low-risk regions.
An LAN is often used, treated to either 50 Gy in 2-
Gy fractions or 50.4 Gy in 1.8-Gy fractions.
Interstitial implants with iridium wires or seeds
in nylon ribbons can be considered for
treatment of early, small lesions that have not
invaded the buccogingival sulcus, the gingiva,
Usually a minimum tumor dose of 60 to
70 Gy in 5 to 8 days is delivered through a
single-plane or double-plane implant on the
thickness of the lesion.
The buccal mucosa tolerates high-dose RT
with a low risk of late complications.
Trismus may develop if the muscles of
mastication receive high doses of
- Used in NACT (T4b and N3 cases)
- Used in CTRT
The FOM is a horseshoe-shaped area that
is confined peripherally by the inner aspect
(lingual surface) of the mandible.
sublingual/ranine veins are visible.
The frenulum is a mucosal fold that
extends along the midline between the
openings of the submandibular ducts .
and its duct.
The deep part of
gland and its duct.
artery and veins.
The inferior surface of the tongue is covered with a thin
transparent mucous membrane through which one can see the
A sublingual caruncle (papilla) - opening of the submandibular
2- lingual vein,
Arrow- Wharton's duct opening,
The lesion usually presents as a smooth,
movable, solitary , asymptomatic, round,
or as a circumscribed intramuscular
DD: granular cell tumor(S-100 positivity ) - salivary gland
tumors, namely, acinic cell carcinoma or oncocytoma-
Treatment: The treatment of
choice for rhabdomyoma is
Cavernous hemangiomas are composed of large,
irregular, deep dermal and subcutaneous blood-
filled channels that impart a purplish discoloration
to the overlying skin. readily blanch with
compression, giving them a characteristic "bag of
worms" feel. The lesion may expand and darken
with crying, when agitated, or when placed in a
Occlusal Radiographs – Computed Tomography.
The causes of vasoformative tumors are unknown. One hypothesis postulates that
placental cells, such as the trophoblast, may be the cell of origin for hemangiomas.
DD:The diagnosis of hemangiomas is straightforward from the history
and the clinical examination, and the differential diagnosis is limited.
For intraosseous lesions, the differential diagnosis can be more
challenging, with the radiographic appearance being similar to that of a
giant cell lesion or an ameloblastoma.
EXCISON OF THE LESION
Cystic hygromas are abnormal growths
that usually appear on a baby’s neck or
head. They consist of one or more cysts
and tend to grow larger over time. The
main symptom of a cystic hygroma is the
presence of a soft, spongy lump. This
lump most commonly appears on the
Radiography : CT Scan
DD: Branchial cleft cyst -Thyroglossal duct cyst -
Ranula -Goiter -Soft tissue tumors -Neck abscess
Treatment: The first step
of treatment is surgery.
A lipoma can usually be diagnosed by its
appearance alone. They present as slow growing
asymptomatic lesions with yellowish color and
soft, doughy feel, generally with no gender
X-Ray: No X-ray Picture
DD: Other connective tissue lesions such as granular cell
tumor, neurofibroma, traumatic fibroma, and salivary gland
lesions (mucocele and mixed tumor).- Normal Fat – Well-
Treatment: Lipomas usually
are not treated, because most
of them don't hurt or cause
It might remove the lipoma if
it is painful, gets infected, or
bothers the patient.
Neurofibroma is an uncommon benign tumor of the oral
cavity derived from the cells that constitute the nerve
sheath. Neurofibroma is seen either as a solitary lesion
or as part of the generalized syndrome of
neurofibromatosis (usually neurofibromatosis type 1
[NF-1], also called von Recklinghausen disease of the
skin). Patients usually present with an uninflamed,
slowly enlarging, asymptomatic lesion that varies
greatly in size from tiny nodules to large pendulous
masses. Oral neurofibromas usually present as
submucosal, nontender, discrete masses that range in
size from a few millimeters to several centimeters. The
lesions are typically pedunculated or sessile, usually
painless, but occasionally pain or paresthesia is
reported due to nerve compression.
DD: Granular cell tumor -Fibroma -Scar tissue -
Neurilemmoma (schwannoma) -Leiomyoma –Rhabdomyoma.
Solitary oral neurofibromas
are usually treated by surgical
excision, depending on the
extent and the site.
Pleomorphic adenoma is a benign salivary gland tumor
that exhibits wide cytomorphologic and architectural
diversity. Pleomorphic adenoma usually presents as a
slow-growing, painless mass, which may be present for
many years. On gross examination, a pleomorphic
adenoma is a single firm, mobile, well-circumscribed
mass. Its color may vary from whitish-tan to gray to
bluish, and its size may range from a few millimeters to
quite large or even giant. Pleomorphic adenomas are
irregularly shaped and have a bosselated surface.
Computed-tomography (CT) images showed a distinct
radiolucent, homogeneous lesion extending anteriorly in the
area where the left sublingual gland (sublingual sulcus)
DD: other salivary gland tumors of submandibular/minor salivary
glands.- lymphomas, non-neoplastic entities of salivary glands such as
ranulas, retention cysts, sialolithiasis, sialadenitis, and cystic lesions of
the floor of the mouth such as dermoid cysts.
Treatment: Early total surgical
resection of the sublingual gland
and its neoplastic mass in normal
margins for benign tumors is the
treatment of choice to avoid
Schwannomas are usually solitary
lesions; however, some are seen as
multiple lesions as part of
Neurofibromatosis type I. The solitary
neurilemoma is a slow growing,
encapsulated tumor that typically arises
in association with a nerve trunk. As it
grows it pushes the nerve aside. Usually
the mass is asymptomatic, although
tenderness or pain may occur in some
DD: Lipoma – Fibroma –Neurofibroma - Rhabdomyoma -
The clinical course is characterized by an initial period of slow
and indolent growth that is usually asymptomatic. In most
cases the tumor goes unnoticed until it has invaded local
nerves and structures causing varying symptoms depending
on location. Thus, most patients will present with locally
The tumor is typically a firm, poorly circumscribed, and
unencapsulated mass. Tumor size typically averages from 1
to 8 cm in maximum dimension. Tumor size greater than 3 cm
has been associated with increased rates of distant
metastasis. The cut surface is white to gray-white with a solid
appearance. Hemorrhage and necrosis are rare features and
should raise the suspicion of high-grade transformation into
DD: benign mixed tumor, mucoepidermoid carcinoma and
polymorphous low-grade adenocarcinoma (PLGA).
ES is a poorly differentiated neuroectodermal tumor with
small, round and blue cells. Swelling, pain, increased CRP,
leukocytosis, and elevated temperature may be the first signs
of oral ES, occurring also in odontogenic infections . Also
there is apical osteolysis, loss of sensibility and loosening of
Axial MRI scan revealing a bone destroying mass of approximately 7 × 8 × 6
cm 3 surrounding the mandible and massively infiltrating the soft tissue of the floor
of the mouth and the tongue.
Etiology :More than 90% of cases show a characteristic
translocation t(11;22)(q24;q12) resulting in the fusion of the EWS and
FLI-1 genes. This gene rearrangement causes a fusion product which
functions as an oncogenic aberrant transcription factor with structural
variability and potentially prognostic impact . Immunoreactivity against
FLI-1 and CD 99 can help to confirm the diagnosis
Treatment of ES should
include wide surgical
resection and (neo-)adjuvant
Oral melanomas arise silently, with few symptoms until progression has
occurred. Most people do not inspect their oral cavity closely, and
melanomas are allowed to progress until significant swelling, tooth
mobility, or bleeding causes them to seek care. Pigmented lesions 1.0
mm to 1.0 cm or larger are found.
On physical examination, the pigmentation of these lesions varies from
dark brown to blue-black ; however, mucosa-colored and white lesions
are occasionally noted, and erythema is observed when the lesions are
The cause of oral melanoma or melanoma of any mucosal
surface remains unknown. In contrast, cutaneous lesions are
linked directly to fair-skinned and blue-eyed persons with a
history of blistering sunburns, and the incidence has
increased dramatically (approximately 4-6% per year) over the
same period. However, mucosal exposure to sunlight is
unlikely, and, therefore, cutaneous melanoma and mucosal
melanoma are different diseases.
DD : Haemangioma -Melanotic macule-Oral mucosal nevi-
Amalgam tattoo-Kaposi Sarcoma
The most common presentation of cancer of the floor of the mouth is a
painless inflamed superficial ulcer with poorly defined margins.
Preexistent or coincident leukoplakia can be observed in adjacent
tissues in approximately 20% of cases. The presence of erythroplasia
strongly suggests an invasive tumor. A small ulceration or nodular
lesion may remain asymptomatic for long periods, so the patient may
not seek medical attention. Vague symptoms of soreness in the
regional mucosa could be attributed to an aphthous ulcer. In fewer than
50% of cases, the ulcer is localized only to the floor of the mouth on
Tobacco and alcohol have additive effects on oral cancer. Tobacco
includes smokeless tobacco derivatives, such as snuff and betel nut.
Some people seem to be more vulnerable than others to the effect of
these irritants. The nature of the increased vulnerability may be
genetic, familial, or acquired (eg, immunosuppression, syphilis,
Plummer-Vinson syndrome, chronic candidiasis). These risk factors
and the underlying pathogenesis do not disappear following surgical
excision or radiation therapy for the cancer. The organs remain
DD: Lymphoma – Adenoid cystic carcinoma – Adenocarcinoma –
Mucoepidermoid Carcinoma – Liposarcoma –Rabdomyosarcoma –
Ranula - Infected Teeth – Radionecrosis of mandibular soft tissues.
Treatment : Various therapeutic
measures are available for managing
localized carcinomas of the oral cavity,
including surgical excision, radiation
therapy, electrodesiccation, cryotherapy,
laser-beam excision, chemotherapy,
and a combination of these methods.