Complex and compound odontomas. Odontomas are a malformation of dental tissue. Their division into complex and composite is purely arbitrary. In a complex odontoma, calcified dental tissues are located chaotically and form a dense conglomerate. A composite odontoma contains individual tooth-like structures in which all tissues are correctly represented, as in a normal tooth.
Odontomas are more common in young people and appear during teething. In adults, they are often discovered by chance or due to inflammation. The growth of odontomas is self-limiting and is associated with the completion of the formation and eruption of teeth.
Clinical picture. Usually odontoma appears when reaching large sizes. Jaw deformation occurs due to thinning bones. With further tumor growth the periosteum and mucous membrane shell over her, odontoma as it were“cuts through.” Often like this painting develops in people who use removable denture. When probing through a defect mucous membrane shell tool rests in tight tooth-like tissue. IN place localization of odontoma is usually noted delayed tooth eruption. When addition of infection the disease is sometimes misdiagnosed like chronic osteomyelitis.
The radiograph of odontoma is characteristic (Fig. 142). A limited homogeneous shadow, density shadow-like tooth crowns with uneven edges and stripes enlightenment all around her (capsule). With compound odontoma the shadow is not uniform due to the presence of areas of rarefaction corresponding to fibrous layers between individual tooth-like inclusions.
Diagnosis of odontoma, How usually presents no difficulties.
Treatment consists of removing the odontoma with capsule. Operation shown at clinical manifestations (deformation of the jaw
Fig. 142 Complex odontoma of the upper jaw on the left.
sti, fistulas, etc.). A small odontoma, asymptomatic and an accidental radiological finding, does not require treatment.
Cementomas develop from odontogenic connective tissue, differentiates into cement, and is intimately associated with the root of one or more teeth.
Among cementomas, there are benign cementoblastoma (true cementoma), cementing fibroma, periapical cementoma (periapical fibrous dysplasia) and gigantic cementoma (familial multiple cementomas).
Benign cementoblastoma (true cementoma). This benign tumor is characterized by the formation of cement-like tissue, in which various stages of mineralization are determined. The neoplasm is most often localized on lower jaw in the area of large or small molars and intimately welded to their roots. Removal of such teeth leads to a root fracture, and only an X-ray examination reveals cementoma.
The course of the tumor is usually asymptomatic. In case of destruction of the cortical plate, mild pain is noted
Fig. 143 Benign cementoblastoma of the lower jaw on the right
upon palpation and jaw deformation. X-ray reveals destruction bone tissue rounded in shape with clear boundaries due to alternating areas of rarefaction and compaction due to uneven mineralization, surrounded by a capsule in the form of a clearing zone. The formation seems to come from the root of the tooth, which is not completely formed; its periodontal gap in the area of the tumor is not defined (Fig. 143).
Macroscopically, the tumor is a yellow-white tissue, which, depending on the degree of mineralization, can be dense or soft, like cheese. Microscopically, the tumor consists of varying degrees mineralized cement-like tissue. The soft tissue component is represented by vascular dense fibrous tissue with the presence of osteoclasts and large, highly stained cells with a single nucleus.
Surgical treatment consists of removing the tumor and capsule.
Periapical cement dysplasia - a tumor-like lesion in which the formation of cement tissue is disrupted, essentially similar to fibrous bone dysplasia. This disease is rare and affects the jaws diffusely, involving not only bone tissue, but also the roots of groups of teeth. It is asymptomatic. It is often discovered by chance during an X-ray examination or tooth extraction complicated by a root fracture. The radiograph reveals diffuse destructive changes in the form of alternating large dense shadows associated directly with the roots of the teeth and corresponding in intensity to them, with areas of rarefaction of varying degrees.
shapes and sizes. The roots of the teeth located in the affected area do not have a periodontal gap. Some of the dense areas, merging with each other, form conglomerates, some of them are located in isolation. The boundaries of dense foci are not always clear; a gradual transition of pathological tissue into normal bone is observed (Fig. 144).
The microstructure is similar to a cemented fibroma. Surgical treatment is not performed; observation is recommended.
Myxoma (myxofibroma). Odontogenic myxoma is a benign tumor with local invasive growth. It does not have a capsule and, destroying the bone, grows into soft tissue. Observed comparatively fast growth tumors due to the accumulation of mucous substance. Often recurs, does not metastasize. It is observed mainly in young and middle-aged people.
Clinical manifestations uncharacteristic. There is a painless protrusion of the jaw at the site of the tumor. Teeth within the boundaries of the neoplasm can be mobile and shift, and the roots can dissolve. The skin and mucous membrane do not change. An x-ray reveals bone destruction in the form of small cellular formations separated by bone partitions (the appearance of “soap bubbles”).
Differential diagnosis carried out with ameloblastoma, giant cell tumor. The diagnosis is confirmed by morphological examination.
Macroscopically, the tumor tissue is grayish in color, soft
consistency with a mucus-like component. Microscopically, it consists of round and angular cells lying in a myxoid stroma. Often other connective tissue components are present in a myxoma; in such cases, the tumor is called myxofibroma, myxochondroma, etc.
Treatment. Resection of the jaw is indicated.
Odontogenic crayfish. These are malignant epithelial odontogenic tumors. They are very rare.
Malignant ameloblastoma characterized by all the signs of malignant growth of the primary tumor and metastasis.
Primary intraosseous cancer arises from the remains of odontogenic epithelium. Differs in clinical course from cancer of the oral mucosa and paranasal sinuses nose, growing along the length into the jaw bones. Radiating pain and Vincent's symptom are observed in the absence of visible bone changes. Only an X-ray examination reveals bone destruction of a malignant nature: osteolysis without clear boundaries in the form of “melting sugar”.
Other cancers arising from odontogenic epithelium may develop from the epithelium of odontogenic cysts, including primary cysts (keratocysts) and odontogenic (follicular) cysts. They are rare.
Primary odontogenic cancer must be differentiated from hematogenous metastases malignant tumor in the jaw. To confirm metastasis, identification of the primary focus and morphological verification (evidence of its connection with the primary tumor of another organ) are important. Detection of metastasis determines the doctor’s tactics in treating the patient and gives an idea of the prognosis.
Odontogenic sarcomas - malignant connective tissue odontogenic tumors. They are very rare. There are ameloblastic fibrosarcoma and ameloblastic odontosarcoma, which differ microscopically in the presence of dysplastic dentin and enamel in the latter.
Odontogenic epithelial cysts of the jaws. A cyst is a cavity with a shell, which consists of an outer connective tissue layer and an inner layer, lined predominantly with stratified squamous epithelium. The cyst cavity is usually filled with fluid yellow color, opalescent due to the presence of cholesterol crystals in it, sometimes a cheesy mass of gray-dirty-white color (with keratocyst). Its growth is due to intracystic pressure, which leads to atrophy of the surrounding bone tissue and proliferation of the epithelium. The etiopathogenesis of odontogenic cysts is different. A cyst, the development of which is based on an inflammatory process in the peri-apical tissue, is called root (radicular).
Other cysts are a malformation of odontogenic epithelium. Among them are the primary cyst (keratocyst), tooth-containing (follicular), eruption cyst and gingival cyst.
Jaw cysts occupy first place among other odontogenic formations. They are found in persons of different ages, are formed on the upper jaw 3 times more often than on the lower jaw. Clinical and radiological manifestations of various odontogenic cysts and methods of their treatment have much in common. However, each type of cyst has its own characteristics, allowing them to be differentiated from each other.
Root (radicular) cyst. The occurrence of a root cyst is associated with the development of chronic inflammatory process in the periapical tissue of the tooth. The latter contributes to the formation of granuloma. Inside this granuloma, epithelial remnants (islets of Malasse) of the periodontal ligament, activated by inflammation, proliferate, which first leads to the formation of a cystic granuloma, and then a cyst.
Clinically, a root cyst is usually found in the area of a damaged or treated tooth, and sometimes in a seemingly healthy one, but previously subjected to trauma, less often in the area of an extracted tooth.
The cyst grows slowly over many months and even years, unnoticed by the patient, without causing discomfort. It spreads mainly towards the vestibule of the oral cavity, while thinning the cortical plate and leading to protrusion of the jaw area.
When a cyst arises from a tooth whose root faces the palate, thinning and even resorption of the palatal plate is observed. A cyst that develops within the boundaries of the maxillary and nasal cavities spreads towards them.
Upon examination, a smoothness or bulging of the transitional fold of the arch of the vestibule of the oral cavity of a round shape with fairly clear boundaries is revealed. When localized on the palate, limited swelling is noted. By palpation, the bone tissue above the cyst bends; with sharp thinning, the so-called parchment crunch (Dupuytren's symptom) is determined, in the absence of bone - fluctuation. The teeth located within the boundaries of the cyst may be displaced, then their crowns converge, and when the causative tooth is percussed, a dull sound occurs. Electroodontodiagnosis (EDD) of intact teeth located in the cyst zone reveals a decrease in electrical excitability.
Often a cyst is diagnosed when its contents suppurate, when inflammation of the surrounding tissues develops, such as periostitis; Vincent's symptom may be observed - numbness of the lower lip due to the involvement of the lower alveolar nerve in the acute inflammatory process. With the formation of a cyst on the upper jaw, it is possible chronic inflammation maxillary sinus.
The X-ray picture of a root cyst is characterized by rarefaction of bone tissue of a round shape with clear boundaries. The root of the causative tooth faces the cavity of the cyst (Fig. 145). The relationship of the roots of adjacent teeth with the cystic cavity may vary. If the roots protrude into the cavity of the cyst,
On the radiograph, the periodontal gap is absent due to resorption of the endplate of the sockets of these teeth. If the periodontal fissure is identified, then such teeth are only projected onto the area of the cyst, but in fact their roots are located in one of the walls of the jaw. In some cases, the roots of the teeth are pushed apart by the growing cyst. Root resorption, as a rule, does not occur.
A large cyst of the lower jaw thins the base of the latter and can lead to a pathological fracture. A cyst growing towards the bottom of the nose causes destruction of the bone wall. The cyst located within the boundaries of the maxillary sinus has a different relationship with its bottom. Preservation of an unchanged bone bottom is characteristic of a cyst adjacent to the maxillary sinus (Fig. 146, a). Thinning of the bone septum and its dome-shaped displacement are characteristic of a cyst pushing back the sinus (Fig. 146, b).
A cyst penetrating into the sinus is characterized by the absence of a bone wall, while a dome-shaped soft tissue shadow is defined against the background of the maxillary sinus (Fig. 146, c).
Diagnosis of a root cyst based on the clinical and radiological picture usually does not cause difficulties. In doubtful cases, puncture of the cyst and cytological examination of the contents are performed.
Microscopically, the membrane of the root cyst consists of fibrous tissue, often with inflammatory round cell infiltration, and is lined with non-keratinizing stratified epithelium.
Treatment is surgical. Cystectomy, cystotomy, two-stage surgery and plastic cystectomy are performed.
Primary cyst (keratocyst) develops mainly in the lower jaw, is observed relatively rarely, begins unnoticed and long time does not appear. Upon examination, a slight painless bulging of the jaw area in the area of one of the large molars is detected. In some patients
The cyst is detected due to the addition of an inflammatory process, sometimes found by chance during an X-ray examination for other diseases.
The keratocyst spreads along the length of the jaw and does not lead to significant bone deformation. Therefore, it is determined when it reaches large sizes. The cyst extends to the body, angle and ramus of the jaw.
The X-ray picture is characterized by the presence of extensive bone loss with clear polycyclic contours, while uneven bone resorption creates the impression of multi-chamber. Often the coronoid and condylar processes are involved in the process. The cortical plate becomes thinner and is sometimes absent in some areas. An x-ray usually reveals the periodontal gap in the roots of the teeth, projecting onto the area of the cyst (Fig. 147).
A primary odontogenic cyst is diagnosed based on characteristic clinical and radiological manifestations. It should be differentiated from ameloblastoma. With the latter, pronounced swelling of the jaw is observed. The final diagnosis is made after morphological research biopsy material. Pro-
Jaw cancer is unpleasant and dangerous disease, which requires prompt treatment. Statistics show that 15% of all visits to dentistry are associated with various neoplasms originating from bone tissue. Not all of them are caused by the development of cancer cells. Only 1-2% are a sign of cancer. For of this disease there is no specific age. Jaw cancer develops in both older people and infants. Treatment of the disease in in this case has many difficulties, since large vessels and nerves are located in this area. Each patient requires an individual approach.
Why does the disease occur?
Cancer cells usually develop from spongy bone marrow, periosteum, neurogenic cells, blood vessels and odontogenic structures. Reasons for development of this disease have not yet been fully studied. However, experts have established several main factors that cause jaw cancer to develop:
- The injury is chronic. This includes a bruise, an incorrectly installed crown, filling, as well as a prosthesis that causes constant rubbing of the gums.
- Damage to the oral mucosa.
- Inflammatory process.
- Smoking.
- Ionizing radiation.
Jaw cancer: symptoms
How to recognize the disease? On initial stage the cancer proceeds without any symptoms. The first symptoms are:
- Numbness skin faces.
- Bad breath and also purulent discharge from the nose.
- Headache.
- Pain in the lower or upper jaw for no apparent reason.
Similar symptoms may be signs of other ailments, for example, neuritis, sinusitis, sinusitis, and so on. For an accurate diagnosis, the patient must undergo additional examination. In many cases, the possibility of timely cancer treatment is lost.
Other signs
With sarcoma, other symptoms gradually appear. Patients begin to complain about:
- Swelling in the cheek area.
- Pain or numbness in teeth located in close proximity to the tumor.
- Loose teeth, which is a sign of osteoporosis.
- Increase
- Curvature of the jaw and deformation of the face.
Jaw cancer, the symptoms of which are described above, can progress very quickly. As a result of development, tissue swelling often occurs, which ultimately leads to asymmetry. After this, patients begin to complain of severe pain.
Serious consequences
Cancer of the upper jaw usually spreads to the eye area. Often tumors begin to germinate and cause the following consequences:
- Displacement of the eyeball.
- Tearing.
- Pathological fracture in the jaw area.
- Nosebleeds that recur for no particular reason.
- Headache radiating to the frontal region or temples.
- Pain in the ear area. This phenomenon occurs after the trigeminal nerve is involved in the process.
In addition to the above, the patient may experience small bleeding ulcerations localized on the mucous membrane of the mouth, gums, cheeks and other soft tissues. Often there is a violation of the opening and closing of the jaws. This makes it difficult to eat. This phenomenon indicates that cancer tumor spread to the masseter and pterygoid muscles.
Symptoms for cancer of the lower jaw
Cancer is characterized by slightly different symptoms. This should include:
- Pain on palpation.
- Loss and looseness of teeth.
- Discomfort and pain when contacting teeth.
- Bad breath.
- Bleeding ulcers on the oral mucosa.
- Numbness of the lower lip.
It is worth noting that located in the lower jaw, it develops quite quickly and is accompanied by pain syndrome, as well as rapid metastasis.
Diagnosis of pathology
Jaw cancer on early stage very difficult to diagnose due to nonspecific symptoms. After all, signs of the disease can be attributed to other ailments. Diagnosis of jaw cancer is carried out at the stage of metastases. Many patients are not alarmed by the symptoms described above. In addition, the disease can proceed for a long time without obvious signs. This makes it difficult to diagnose in its early stages.
X-rays can detect the disease. If cancerous tumors originate precisely from odontogenic material, then such an examination provides much more information than other methods. X-rays can reveal destruction of septa and widening of periodontal fissures.
The pictures make it possible to see any changes: healthy teeth do not come into contact with the bone, the alveolar edge has unclear contours, the decalcification zone has spread to the body of the jaw, and so on.
We determine the disease by x-ray
So, how can you detect jaw cancer using an x-ray? Diagnosis of this disease is a complex process. X-ray allows you to determine the presence of pathology by the following signs:
- Bone destruction.
- Destruction of spongy loops.
- Blurred transitions healthy bones to the area of destruction.
- Intertwined stripes formed as a result of the merging of several foci of destruction.
Other diagnostic methods
In addition to X-rays, jaw cancer, the photo of which is presented above, can be diagnosed in other ways. The patient must undergo a complete general clinical examination, including blood and urine tests, fluorography of the respiratory system. These studies can reveal the presence of an inflammatory process in the body, acceleration of the erythrocyte sedimentation rate, as well as anemia. To exclude metastases, a lung examination is required.
Often, a computer method is used to diagnose jaw cancer. This makes it possible to determine the exact location of oncological tumors. In addition, tomography and scintigraphy are used. A specialist may prescribe an examination such as a puncture test. This method allows you to determine metastasis.
The most accurate diagnostic method is to study the affected tissue in a laboratory. In some cases, trepanation of the jaw is required. If the tumor does not originate from the bone, then the material can be taken from the hole formed after tooth extraction.
Jaw cancer: treatment
Pathology therapy is complex. It includes not only surgical intervention, but gamma therapy. Surgeries are being carried out to remove the jaw. This may be disarticulation or resection. Jaw cancer is not treated with chemotherapy, as it does not produce results.
To begin with, the patient is subjected to gamma radiation. It allows you to significantly reduce the size of the cancer tumor. Three weeks later, the jaw is removed. In some cases, more extensive surgery is required, which often includes orbital exenteration, lymphadenectomy and debridement of the paranasal sinuses.
After operation
Several years after the operation, orthopedic correction is required, which allows you to hide all the defects. It is usually carried out using various bone plates and splints. Such procedures require patience from the patient, since in some cases there is a need to restore swallowing and chewing functions, as well as speech.
It is worth noting that restoration of the lower jaw is a very complex process that does not always end successfully. In such situations, stainless steel, tantalum, and plastic are often used to fix implants.
Forecast
Can jaw cancer come back? The prognosis in this case is disappointing, since relapse can occur within several years after surgery. The five-year survival rate for this pathology is no more than 30%. When cancer is detected in late stages, this figure is significantly reduced. The five-year survival rate in this case is no more than 20%.
28.5. SURGICAL TREATMENT OF MALIGNANT TUMORS OF THE JAWS
Resection of the lower jaw . To systematize resections of the lower jaw, we recommend using the classification of M.V. Mukhina (1985), which is presented in table 28.5.1.
Table 28.5.1. Classification of resections of the lower jaw (according to M. V. Mukhin, 1985).
|
Resection without breaking the continuity of the jaw |
Resection with disruption of jaw continuity. |
|
|
Without articulation in the temporomandibular joint |
With disarticulation in the temporomandibular joint |
|
|
Resection of the outer compact plate of the jaw (for cysts, osteoblastomas, etc.) |
Resection of the chin area of the jaw * |
Resection of the condylar process |
|
Resection of the alveolar process (sometimes with an adjacent area of the jaw body)** |
Resection in the area of the jaw body * |
Resection of the jaw branch |
|
Resection of the lower edge of the jaw |
Resection of the entire jaw body from corner to corner** |
Resection of part of the body and branch of the jaw * |
|
Resection at the corner Resection of the anterior edge of the branch Resection of the posterior edge of the branch | ||
|
Resection of the coronoid process |
Resection of the body and part of the jaw branch* |
Half jaw disarticulation Full jaw disarticulation |
* - it is necessary to indicate from which tooth to which the resection of the jaw body was performed.
** - for malignant tumors, resection of the lower jaw can be accompanied by simultaneous removal of the lymphatic system of the neck, submandibular region, ligation of the carotid artery, tracheotomy, etc.
Let's look at this operation using an example half articulation of the lower jaw, which is carried out for some benign and malignant tumors.
In the preoperative period, the patient needs to make a Vankevich splint (see section 17.4., volume II of this manual), which will be needed to hold the jaw fragment and graft in the correct position.
The operation is performed under endotracheal anesthesia. An arcuate skin incision is made parallel to the edge of the jaw and 2 cm below it. The incision begins in the retromandibular fossa, bordering the angle of the jaw and continuing to the center line.
All layers of soft tissue are dissected layer by layer down to the bone with ligation of the facial artery and vein.
For benign tumors, the periosteum is preserved in whole or in part, and for malignant tumors, the affected bone is isolated along with the surrounding soft tissue. The body and branch of the lower jaw are exposed from the muscles surrounding it (masticatory, medial pterygoid, mylohyoid, etc.).
After the surrounding soft tissues, both externally and internally, are separated from the edge of the jaw to the edge of the alveolar process, they begin to dissect the mucous membrane around the teeth on the buccal and lingual sides (Fig. 28.5.1).
The jaw is sawed in the mental (middle) section using a Gigli saw (circular saw).
By displacing the affected area of the jaw outward, the coronoid process is released by cutting the temporal muscle tendon with scissors.
The lower jaw is retracted downwards and outwards, the articular head is freed from the articular capsule and the lateral pterygoid muscle.
The jaw is disarticulated (twisted). Hemostasis.
The wound of the mucous membrane is sutured from the side of the oral cavity with synthetic thread or chrome-plated catgut. Then a second layer of catgut is applied to the submucosal tissue, and the wound is sutured layer-by-layer (in two rows).
For benign tumors of the lower jaw, bone grafting is performed simultaneously.
Rice. 28.5.1. Scheme of stages (a, b, c) of lower resection
For malignant tumors that have not spread beyond the bone tissue, as well as for osteomyelitis bone grafting is not carried out at this stage.
For malignant tumors of the jaw that have extended beyond the bone or with regional metastases, it is necessary to simultaneously combine resection of the lower jaw with fascial-sheath excision of the neck tissue or Crile’s operation.
Resection of the maxillary bone carried out under endotracheal anesthesia. Indications include some benign and malignant tumors.
Approaches (for resection of the maxilla) from the oral cavity are the best for cosmetic reasons. But they significantly limit the surgical field, so they are used only in the initial stages of the development of a malignant tumor. Extraoral approaches are much more often used.
Dieffenbach used an incision extending from the bridge of the nose through the bridge of the nose and the middle of the lip. Velpeau - an incision from the beginning of the zygomatic arch, directed obliquely to the corner of the mouth. Malgaigne - to the cut Velpeau added a cut in the middle of the upper lip. Kocher used the cut near filtrum to the nostril and then outward around the wing of the nose, along the edge of the nose upward and inward to the inner corner of the eye, and if necessary, this incision is further supplemented by an incision that goes outward and downward along the lower edge of the muskuli orbicularis oculi. Weber applied a cut through the middle filtrum, which goes around the wing of the nose and rises up the side wall of the nose to the inner corner of the eye, and from here goes outward along the lower edge of the orbit.
Rice. 28.5.2. Scheme of stages (a, b, c) of resection
maxillary bone.
The anterior surface of the maxillary bone and its frontal zygomatic, alveolar and palatine processes are exposed in the chosen way.
The soft tissue flap is separated together with the periosteum.
Then the bone connections of the maxillary bone are separated in four places (the zygomatic and frontal processes are sawed, the hard palate is cut in the midline and the posterior surface of the maxillary bone is separated from the pterygoid process of the sphenoid bone)
The division of bones must be performed within healthy tissues, without destroying or touching the tumor. Bone forceps are used to grasp the released bone and dislocate it with rotational movements.
The fibers of both pterygoid muscles attached to the posterior surface of the bone are cut. The resulting huge wound is packed and careful hemostasis is performed. (Fig. 28.5.2- 28.5.3).
To maintain the position of the eyeball after resection of the maxillary bone, the temporal muscle is cut off from the branch of the lower jaw together with the coronoid process to the level of the horizontal branch (method Kö nig, 1900) and strengthen this area of the muscle under the eyeball in the inner corner of the wound at the site of the resected frontal process using chrome catgut or polyamide thread.
Rice. 28.5.3. Type of postoperative defect formed as a result of resection of the maxillary bone (a, b).
To prevent cicatricial contracture of the medial pterygoid muscle, which leads to a sharp limitation in mouth opening, its intersection is performed.
When suturing a wound, you should strive to separate soft tissues nasal and oral cavity. This is possible if saved soft sky and mucoperiosteal flap of the hard palate. They are sewn to the incision line of the transitional fold of the buccal mucosa. The resulting cavity is tamponed with an iodoform tampon and removed through the nostril from the operated side. The skin flap is placed in place and sutured tightly with catgut and polyamide thread.
V. G. Tsentilo (1992) proposes to simultaneously resect the medial pterygoid muscle along with part of the tissue of the anterior part of the peripharyngeal space in a block with the maxillary bone. The advantage of this method is that the radicalism of the operation increases due to the fact that the medial pterygoid muscle and part of the tissue of the anterior peripharyngeal space adjacent to it in the tubercle area are included in the block of tissue removed along with the maxillary bone. Thus, the ablasticity of the surgical intervention increases in case of posterior localization of a malignant tumor of the upper jaw due to the fact that the affected area of the bone is not exposed, but is removed surrounded by adjacent soft tissues.
Removal of neck lymph nodes carried out by conducting operationsKraila, fascial-sheath excision of the cervical tissue, upper fascial-sheath excision of the cervical tissue (operation Banach).
Rice. 28.5.4. Skin incisions used in the Krile operation: 1 - according to Krile, 2 - according to Kocher, 3 - according to Duquesne, 4 - according to Brown.
Rice. 28.5.5. Scheme of fascial-sheath excision of cervical tissue according to A.I. Pachesu and
al. (drawings and their descriptions are taken from the book by A.I. Paches, 1971):
a - lines of skin incisions are drawn on the neck for fascial-sheath excision of the cervical tissue. Transverse incision: 2 cm below the lower edge of the lower jaw from the outer edge of the sternocleidomastoid muscle to the submental region. Vertical: from the angle of the lower jaw to the external leg of the sternocleidomastoid muscle; after mobilization of the skin flaps, a surgical field is formed, covered with the subcutaneous muscle of the neck, within the following boundaries: the posterior edge of the sternocleidomastoid muscle, the midline of the neck, the clavicle, the lower edge of the mandible (the dotted line shows the fascial incisions).
b - dissect the subcutaneous muscle of the neck, the second and third fascia of the neck above the sternocleidomastoid muscle from the mastoid process to the clavicle. The specified muscle is isolated from its case bed and pulled back as much as possible. Before dissecting the fascia, the external jugular vein (boxed above) is cut and ligated with catgut.
c - along the midline of the neck, the superficial, second and third fascia of the neck are dissected. The fascia is shifted and the sternohyoid muscle is exposed.
d - the sternocleidomastoid muscle is retracted as much as possible. This exposes the fascia that covers the cervical tissue along with the lymphatic vessels and nodes of the neck. The fascia of the neck is cut transversely above the collarbone to the internal jugular vein; it is detected and freed from surrounding tissue.
Rice. 28.5.5. (continuation):
d - excise the cervical tissue along neurovascular bundle. Together with this fiber, the fiber is first removed in a single block from the lateral triangle of the neck. The fifth fascia of the neck of the scalene muscles is excised to the location of the accessory nerve.
e - the accessory nerve is isolated and raised. The underlying tissue is grabbed with tweezers, pulled down and excised in a single block. The parotid fascia is dissected (in the frame above), the lower pole of the parotid gland is sutured and resected. Next, the fiber is excised along outer surface posterior belly of the digastric muscle. The tissue is shifted towards the outer surface of the internal jugular vein, while maintaining the integrity of the glossopharyngeal and accessory nerves. The tissue is carefully excised along the internal jugular vein to the level of the common facial vein - it is ligated and transected. Fiber is removed from the area of the fork of the common carotid artery. External carotid artery bandaged in cases where excision of the cervical tissue is performed simultaneously with removal of the primary tumor. Next, the tissue located along the hypoglossal nerve is excised.
g - tissue is removed from the submandibular triangle. The facial artery is ligated over the digastric muscle and divided. The salivary duct of the submandibular gland is crossed. h - a drainage tube is inserted into the wound. The neurovascular bundle is covered with the sternocleidomastoid muscle, which is sutured with several catgut sutures to the sternohyoid muscle.
The block of tissues removed includes fiber and The lymph nodes neck, sternocleidomastoid muscle, internal jugular vein, accessory nerve, submandibular gland and lower pole of the parotid gland.
All this is carried out within the following boundaries: the midline of the neck, the clavicle, the anterior edge of the trapezius muscle, the lower pole of the parotid gland and the lower edge of the mandible.
After this operation, significant deformation of the neck is observed, atrophy of the neck muscles occurs, and the shoulder sag.
Fascial-sheath excision of cervical tissue proposed by A. I. Paches et al. (1968, 1969, 1971). Despite its radical nature, this intervention is less traumatic than Crile’s operation, because is performed without removing the internal jugular vein, sternocleidomastoid muscle and accessory nerve. Thus, this operation involves the removal of the cervical tissue, lymph nodes, submandibular gland and the lower pole of the parotid gland. The surgical technique proposed by A.I. Paches et al. presented in Figure 28.5.5.a-h. Fascial-sheath excision of the cervical tissue does not cause the serious complications that arise during the Crile operation.
V. G. Tsentilo (1994) recommends including the lymph nodes of the submental triangle and lymph nodes located along the omohyoid muscle in the block of tissue removed, which increases the radicalism of this operation.
Superior fascial-sheath excision of the cervical tissue (Vanaha operation)
consists not only of removing the submental and submandibular lymph nodes, but also the deep cervical lymph nodes in the area from the posterior belly of the digastric muscle to the upper edge of the tendon of the omohyoid muscle, as well as both submandibular glands and resection of the lower pole of the parotid glands.
In order to prevent cancer cells from being pushed through the lymphatic vessels, V. G. Tsentilo (1996) recommends, at the initial stage of removing a block of tissue, to clamp or ligate the facial arteries at the posterior bellies of the digastric muscles, which reduces venous return and creates a decrease in pressure in the facial vein system, as well as redistributes the movement of interstitial fluid away from the lymphatic bed and reduces lymph flow in the tissues of the removed block. In the block of tissue removed, the author includes the anterior edge of the sheath of the sternocleidomastoid muscles in the area surgical field, and before their intersection, it stitches the fascial legs of the facial and anterior jugular veins, coagulates their adducting ends after intersection. The developed method can be used to combat metastases of malignant tumors of the tip of the tongue, floor of the mouth and lips, when lymph nodes in the suprahyoid region are not yet detected by palpation or when a single mobile lymph node is detected in the submental triangle (V. G. Tsentilo, 1996) .
Unilateral Vanach surgery is performed only if there is a suspicion of metastasis in the submental or submandibular region, i.e. should be used as an extended biopsy method.
Indications: malignant neoplasms.
Anesthesia: due to the high traumatic nature of the operation, it is better to perform it under endotracheal anesthesia.
Technique of operation (Fig. 95). The patient's position is on his back with a cushion placed under his shoulders. The purpose of surgery if a patient has a malignant tumor is to radically remove the tumor, so the surgeon must operate within healthy tissue. Sometimes the external carotid artery and internal jugular vein are pre-ligated.
Rice. 95. Stages of resection of the lower jaw.
A - principle of dissection of soft tissues; B - the coronoid process is crossed, the body of the jaw is sawed; B - the jaw is separated from the muscles attached to it; articulation is performed at the joint. 1 - cutting line of the jaw body; 2 - line of intersection of the coronoid process; 3 - m, mylohyoideus; 4 - m. digastricus; 5 - angle of the lower jaw; 6 - soft tissue flap; 7 - bone forceps; S - crossed coronoid process; 9 - joint of the lower jaw.
The lower lip and soft tissue of the chin are dissected along the midline to the bone. From here, the incision is made along the edge of the lower jaw and along the posterior edge of the branch 3-5 cm above the angle of the jaw. If it is necessary to remove regional lymph nodes, the incision from the chin is continued not along the edge of the lower jaw, but along the digastric muscle to mastoid process. To approach the deep cervical lymph nodes, an additional incision is made along the anterior edge of m. sternocleidomastoideus with intersection at the hyoid bone of the posterior abdomen m. digastricus and m. stylohyoideus. Remove the submandibular salivary gland with lymph nodes located in its bed, preferably as a single block with part of the lower jaw. From the side of the vestibule of the mouth, the mucous membrane is cut along the gingival edge to the bone, after which the mucous membrane from the side of the oral cavity is cut at the same distance. Soft tissues are peeled away from the bone, starting from the chin area. At the level of the intended intersection of the bone, a tooth is removed or a section of the jaw without a tooth is used. WITH inside the jaws carry out the Gigli saw. The lower jaw is sawed along the midline and retracted outward, after which the soft tissue is cut from the inside of the jaw body to the coronoid process with a scalpel or Cooper scissors.
Removal of the lower jaw due to a malignant tumor should be performed with disarticulation at the temporomandibular joint or, in extreme cases, resect the branch above the for. mandibulare, since cancer cells can spread through the lymphatic pathways of the neurovascular bundle and through the spongy substance of the bone into the branch of the lower jaw. Therefore, you need to cut off m with scissors. pterygoideus medialis and reaching the mandibular foramen, cross the neurovascular bundle. The bleeding inferior alveolar artery is ligated.
Using Liston pliers or Cooper scissors, the coronoid process is separated. Ligamentous apparatus The temporomandibular joint is dissected by pulling it downwards and turning it inside the area of the jaw to be removed. To avoid injury to the maxillary artery m. pterygoideus lateralis is cut directly at the articular process. The jaw is carefully dislocated from the joint, trying to remove the entire block of tissue being removed at the same time. The exposed ends of the bone are covered with soft tissue using catgut sutures. The operation is completed by suturing the oral mucosa to the buccal mucosa with catgut sutures. Sutures are placed on the skin wound. When removing the chin area, to prevent the tongue from retracting, the ligature with which it is stitched is pulled forward and secured to a bandage or splint. To prevent the formation of a hematoma, gauze turundas are inserted into the area of the removed jaw and submandibular space for 1-2 days. To eliminate the displacement of the remaining bone areas, various splints are used.
When deleting benign tumors don't cut lower lip along the midline, and make an incision bordering the angle of the lower jaw along the lower border of the submandibular triangle to avoid damage to the ramus marginalis mandibularis facial nerve. The area of the jaw to be removed is excised subperiosteally. There is no need to remove regional lymph nodes. The operation can be completed by transplanting a bone graft into the area of the resulting defect in the lower jaw.
11.9.2. Resection of the upper jaw
Resection of the upper jaw using the Weber method. Before surgery, a protective palatal plate is made. Indications: benign neoplasms of the upper jaw, cancer of the mucous membrane of the alveolar edge of the upper jaw, malignant tumors of the nose and paranasal sinuses.
Anesthesia: endotracheal anesthesia. To facilitate and speed up the operation, you can first ligate the external carotid artery on the operated side.
Patient position: lying on your back, head slightly turned in the direction opposite to the one being operated on.
The operation begins with the removal of the middle incisor on the affected side. The Weber incision is made along the lower edge of the orbit from its inner corner to the outer one, not reaching it by 1-1.5 cm. If it is necessary to remove the zygomatic bone, this incision is continued obliquely outward and downward. From the inner end of the first incision along the base of the lateral surface of the nasal dorsum, a second incision is made, bending around the wing of the nose to the base of the nasal septum. A vertical incision is used to dissect upper lip along the midline. Throughout the entire length, the incision is deepened to the bone. The mucous membrane from the vestibule of the mouth is dissected along the transitional fold from the vertical incision of the lip to the tubercle of the upper jaw. After incision of the soft tissues and hemostasis, the skin-fat cheek flap is separated along with the facial muscles from the bone according to the line of the skin incision. By separating the tissue from the bone, the anterior edge of the masticatory muscle is exposed and, with a scalpel, it is separated from the lower edge of the zygomatic bone. The septum orbitale is dissected along the lower edge of the orbit and, together with the eyeball, is pushed upward. If the lower wall of the orbit is not destroyed by the tumor, it is advisable to preserve part of this wall to prevent downward displacement of the eyeball.
In the oral cavity, the mucous membrane of the alveolar process and hard palate is dissected along the midline. Using a raspatory, soft tissue is separated 0.5 cm on both sides of this incision. If it is possible to preserve the soft palate, cut it off with a transverse incision from the hard palate and connect the incision made with the incision of the mucous membrane made in the vestibule of the mouth. Then the upper jaw is separated from the zygomatic bone with a Gigli saw, passed through the lower orbital fissure under the lower edge of the zygomatic arch,
or using an osteotome. The direction of the cut, if possible, should be carried out not vertically, but horizontally: this preserves part of the lower wall of the orbit and prevents the lowering of the eyeball.
After dissecting the nasal mucosa along the edge of the nasal notch, the frontal process of the upper jaw is freed from the soft tissues and cut with Liston bone nippers or cut with a chisel. The level of intersection depends on the location of the tumor.
Using a chisel or osteotome, the alveolar process at the site of the extracted tooth and then the hard palate are crossed from front to back. After this, the connection between the pyramidal process of the palatine bone and the pterygoid process of the main bone is dissected.
The upper jaw is grabbed with bone forceps or fingers through a gauze napkin by the alveolar process and dislocated, cutting off the soft tissue holding it with curved scissors. Bleeding is stopped by ligating or suturing the bleeding vessels. In case of severe bleeding, especially from the maxillary artery, the wound is quickly packed. Then, gradually removing the tampons, the bleeding vessels are sheathed. The walls and bottom of the operating cavity are carefully examined, the cells of the ethmoid bone are scraped out with a sharp spoon, and the protruding bone edges are smoothed out.
The postoperative cavity is filled with iodoform gauze swabs moistened with petroleum jelly, which are held in place using a previously made protective plate fixed to the teeth of the healthy side. Submersible catgut sutures are placed on the subcutaneous tissue, and the edges of the skin wound are sutured with silk. The first change of tampons is carried out 5-10 days after surgery.
Resection of the upper jaw using the intraoral method. Using a scalpel or electric knife, an incision is made in the mucous membrane along the transitional fold, starting from the central incisors and continuing to the last molar, going behind the maxillary tubercle. The upper jaw is exposed with a rasp to the lower orbital edge, outward to the zygomatic process and inward to the pyriform foramen. The jaw is resected along with the tumor using the cutting method.
The first group includes removal of the outer or inner compact plate of the jaw, resection of the alveolar or coronoid process, the lower edge of the body or angle, the anterior or posterior edge of the jaw ramus.
When performing resection with a violation of the continuity of the jaw, the latter can be performed without disarticulation (second group of operations) and with disarticulation in the temporomandibular joint (third group).
Rice. 11.21. Levels of possible resections of the lower jaw depending on the size of the cancer tumor
Rice. 11.22. Stages of the operation of resection of the lower jaw with articulation at the joint
In operations of the second group, resection is performed in the area of the chin of the jaw, in the area of the body of the jaw, the entire body of the jaw from corner to corner, the body and part of the jaw branch.
In operations of the third group, resection of the condylar process, jaw branches, parts of the body and branches of the jaw, half disarticulation of the jaw, and complete disarticulation of the jaw are performed (Fig. 11.22).
In case of a malignant tumor, resection of the lower jaw is performed with fascial-sheath excision of the cervical tissue.
Resection of the lower jaw
Indications: malignant neoplasms. Anesthesia: due to the high traumatic nature of the operation, it is better to perform it under endotracheal anesthesia. Technique of operation (Fig. 95). The patient's position is on his back with a cushion placed under his shoulders. The purpose of surgery if a patient has a malignant tumor is to radically remove the tumor, so the surgeon must operate within healthy tissue. Sometimes the external carotid artery and internal jugular vein are pre-ligated. The lower lip and soft tissue of the chin are dissected along the midline to the bone. From here, the incision is made along the edge of the lower jaw and along the posterior edge of the branch 3-5 cm above the angle of the jaw. If it is necessary to remove regional lymph nodes, the incision from the chin is continued not along the edge of the lower jaw, but along the digastric muscle to the mastoid process. To approach the deep cervical lymph nodes, an additional incision is made along the anterior edge of m. sternocleidomastoideus with the intersection of the t. digastricus and m. at the hyoid bone of the posterior abdomen. stylohyoideus. The submandibular salivary gland with the lymph nodes located in its bed is removed, preferably in a single block with part of the lower jaw. From the side of the vestibule of the mouth, the mucous membrane is cut along the gingival edge to the bone, after which the mucous membrane from the side of the oral cavity is cut at the same distance. Soft tissues are peeled away from the bone, starting from the chin area. At the level of the intended intersection of the bone, a tooth is removed or a section of the jaw without a tooth is used. From the inside Removal of the lower jaw due to a malignant tumor should be done with disarticulation at the temporomandibular joint or, in extreme cases, the branch of the jaw should be resected using a Gigli saw. The lower jaw is sawed along the midline and retracted outward, after which the soft tissue is cut from the inside of the jaw body to the coronoid process with a scalpel or Cooper scissors. above for. mandibulare, since cancer cells can spread through the lymphatic pathways of the neurovascular bundle and through the spongy substance of the bone into the branch of the lower jaw. Therefore, you need to cut off m with scissors. pterygoideus medialis and reaching the mandibular foramen, cross the neurovascular bundle. The bleeding inferior alveolar artery is ligated. Using Liston pliers or Cooper scissors, the coronoid process is separated. The ligamentous apparatus of the temporomandibular joint is dissected by pulling it downwards and turning it inside the area of the jaw to be removed. To avoid injury to the maxillary artery m. pterygoideus lateralis is cut directly at the articular process. The jaw is carefully dislocated from the joint, trying to remove the entire block of tissue being removed at the same time. The exposed ends of the bone are covered with soft tissue using catgut sutures. The operation is completed by suturing the oral mucosa to the buccal mucosa with catgut sutures. Sutures are placed on the skin wound. When removing the chin area, to prevent the tongue from retracting, the ligature with which it is stitched is pulled forward and secured to a bandage or splint. To prevent the formation of a hematoma, gauze turundas are inserted into the area of the removed jaw and submandibular space for 1-2 days. To eliminate the displacement of the remaining bone areas, various splints are used. When removing benign tumors, the lower lip is not dissected along the midline, but an incision is made bordering the angle of the lower jaw along the lower border of the submandibular triangle to avoid damage to the ramus marginalis mandibularis of the facial nerve. The area of the jaw to be removed is excised subperiosteally. There is no need to remove regional lymph nodes. The operation can be completed by transplanting a bone graft into the area of the resulting defect in the lower jaw.
Rice. 95. Stages of resection of the lower jaw. A - principle of dissection of soft tissues; B - the coronoid process is crossed, the body of the jaw is sawed; B - the jaw is separated from the muscles attached to it; articulation is performed at the joint. 1 - cutting line of the jaw body; 2 - line of intersection of the coronoid process; 3 - m, mylohyoideus; 4 - m. digastricus; 5 - angle of the lower jaw; 6 - soft tissue flap; 7 - bone forceps; S - crossed coronoid process; 9 - joint of the lower jaw.
