Jaw carcinomas

Jaw carcinomas

Introduction

Jaw carcinomas are malignant epithelial tumors that arise from a lining mucosa (gingival, palatine, sinus or nasal) and infiltrate, invading the underlying bone.

It may be due to degeneration of a benign tumor lesion of the jaws (ameloblastoma). 

1. Definitions

There are 2 types depending on the origin: (according to Michelle Auriol)

• Odontogenic carcinomas: when they develop from odontogenic epithelial residues, or from benign tumors of the jaws.
• Non-odontogenic carcinomas : when they develop from neighboring epithelial tissues. 

2. Topographical forms of maxillary carcinomas 
   1. The mandible 
3. Primary intraosseous carcinoma

• Definition 

• It is a carcinoma primarily affecting the jaws, without any original connection with the oral mucosa, nor an underlying odontogenic cyst.
• It probably originates from residues of the odontogenic epithelium
• Frequency 

• Rare 
• 12% of oral cavity carcinomas
• 40% of mandible tumors
• Seat 

• Posterior mandibular predominance (90% of cases).
• The maxilla is exceptionally affected (seat often more anterior).
• Clinical aspects

1. Ulcerative-vegetative aspect:

• Ulceration of +/- regular shape, with vegetative, reddish base, provoked or spontaneous bleeding
• Bone destruction with early dental signs

2.  Budding aspect:

• Bud ± thick, protruding from the healthy mucosa.
• This aspect is more common. 
• The tumor occupies a segment of the alveolar wall on both sides, the teeth embedded in the tumor buds
• Adenopathies 

• Given the significant lymphophilia of squamous cell carcinomas of the VADS cervical lymph node metastases.
• ADP firm or hard painless, increases rapidly in mobilizable volume at first, then fixes
• Radiological examination

1. Osteolytic aspect: 

• Most common aspect.
• Incomplete image surrounded by a bone in the process of destruction
• Teeth appear to be hanging in the gap.
• Destruction of the basilar edge —> Pathological fracture.
• The inferior alveolar canal is often not visible

Jaw carcinomas

2. Boring aspect:

• Diffuse rarefaction without limits.
• Porous bones.
• Moth-eaten appearance. 
• The basal edge can be affected. Its destruction creates the lace image

Jaw carcinomas

• Other clinical aspects 

1. Pseudo-osteitic forms:

Poor prognosis, because the discovery is often late. 

• Subacute Osteitis Table 
• Painful tooth, pus at the neck 
• Congestive mucosa, sometimes ulcerated. 
• early chin hypoesthesia. 

2. Pseudo-pyorrhoeic forms 

• Recent mobility worsens —> spontaneous fall

3. Hypo-esthetic form:

The onset is marked by the onset of a sensory disturbance in the form of neuralgia, hypoesthesia or anesthesia in the territory of the inferior alveolar nerve.

• Topographical forms 

1. The previous form: 

Clinical appearance often ulcerative-vegetative and osteolytic. Due to the height of the bony rampart at the level of the anterior region , this form can spare the floor for a certain time.

2. The side shape: 

In this form, the mylohyoid is affected more quickly the more posterior the location. 

3.  The posterior form: 

Very poor prognosis. The posterior commissural region , the soft palate, the cheek, the tongue and the floor of the mouth are rapidly invaded.

• Anatomo-pathology

• It is no different from other squamous cell carcinomas. 
• These are often well-differentiated lesions, often keratinizing.
• It is therefore difficult to exclude an oral origin, as well as a possible metastatic lesion, particularly of pulmonary origin, a frequent source of mandibular metastases.
• Diagnosis 

The diagnosis of CIOP meets specific criteria:

• The lesion must be intraosseous without any oral or cutaneous mucosal lesion initially noted;
•  The assessment should not find any other primary tumor lesion at the time of diagnosis; 
• The histology is of the squamous cell carcinoma type.
• Evolution 

• The prognosis is poor. Metastases to regional  or distant lymph nodes are frequent.
• Death occurs in 50% of cases within two years of the initial diagnosis.

2. Secondary carcinomas of the mandible

• If we consider mandibular metastases in relation to bone metastases in general, it turns out that they represent only 1.5%. 
• When faced with a carcinoma that appears to be metastatic, it is important to look for the primary tumor, either in the ENT and stomatological sphere or at a distance (kidney, prostate, lung, breasts, etc.)
•  It may be a virgin tumor or one that has already been treated .

2. The maxilla 

• Rare as those of the mandible.
• The most common squamous cell carcinomas. 
• Arises from the mucosa: buccal, sinus, ethmoid-nasal or from epithelial remains of certain benign tumors.
• Very serious prognosis, particularly due to the regional extension and proximity to the base of the skull.
• They are divided into infrastructure tumors and mesostructure tumors.

1. Carcinomas with oral origin 

• Clinical 

• These tumors present early symptoms and are often immediately accessible to sight, biopsy and x-ray.
• They arise from the palatine mucosa —> characteristic vegetative lesion.
• They arise from the gingival mucosa —> sometimes vegetative ulceration.
• Teeth move, extraction does not lead to healing. 
• Ipsilateral ADP, submax, high jugular, they can be bilateral in median lesions. 
• Topographical forms

1. Previous location: 

The vestibule, the lip, the anterior part of the palate, the ENA, the nasal septum , the floor of the nasal fossae

2. Posterior and tuberosity location: 

• Frequent, 
• The vestibule, cheek and soft parts.
• The intermaxillary commissure, the soft palate, pterygomaxillary region, often painful causing trismus

3. Pure palatal localization: 

• Very rare, 
• Depending on its lateral or median location, anterior or posterior, to the sinus cavity, one or both nasal fossae are more or less threatened

Jaw carcinomas

2. Carcinomas with sinus origin

• Very common 1/3 of tumors of the ethmoido-maxillary massif and nasal cavities
• They develop in a closed cavity, 
• They are difficult to diagnose, 
• They externalize late
• They are always discovered at a late stage
• Oral signs 

• Palatal or alveolar arch. 
• Dental mobility giving a pseudo-osteitic, pseudo-pyorrhoeic appearance. 
• Tooth loss.
• Toothache, sometimes facial neuralgia. 
• Suborbital pain or anesthesia.
• Spread to the oral mucosa 
• Difficulty in determining the starting point.

Jaw carcinomas

• Morphological signs 

• Facial deformation due to a deep process.  
• Erasure of the internal angle of the orbit.  
• Arching of the nasal bones. 
• Erasure of the nasolabial and nasolabial folds.
• Rhinological signs 

• Permanent unilateral nasal obstruction
• Serous, sero-hemorrhagic, purulent discharge. 
• Prolonged epistaxis. 
• Eye signs 

• Diplopia 
• Unilateral exophthalmos. 
• Tearing 
• Lower eyelid edema

• Clinical forms 
• Endo sinus forms: 

Table of maxillary sinusitis but:

• Age 
• Continuity of pain 
• The existence of suborbital hypoesthesia should raise awareness 

Rx: homogeneous, low-density opacity in the sinus instead of sinus lucency

• Sinus floor tumors:

• They arise from the dependent region of the sinus
• Downward evolution 
• The extension will be done forward, it will make the cheek and the canine fossa bulge inwards, it will make the palatine vault bulge 
• Palpation of the palate feels like wet cardboard,
• The prognosis is favorable, because this form attracts attention early, 
• Rx: partial disappearance of the antero-external wall of the sinus 
•  Filling of the lower sinus floor
• Tumors of the middle part of the sinus:

Tumors with anterior location:

• They fill the canine fossa and the vestibule
• Invasion of soft tissues is very rapid

Posteriorly located tumors:

• Toothache
• Trismus + rapid invasion 
• Gloomy prognosis 
• Sinus ceiling tumors: 

Central tumors: 

• They are revealed by orbital signs, lacrimal syndrome, exophthalmos, eyelid edema, chemosis, internal ophthalmoplegia and diplopia.

External tumor: 

The tumor occupies the entire malar region 

Internal tumor: 

It develops in the ethmoido max region and the base of the skull, the prognosis is very poor

• Global sinus epithelioma: All walls are destroyed

3. Diagnostic approach 

• Examination: 

• Specify alcohol and smoking habits;  
• Look for the notion of weight loss and recent weight loss;
• Specify the functional signs: pain and its characteristics, hypo or hyperesthesia of a nerve area, discomfort in the OB or in protraction of the tongue;
• Look for the appearance of cervical ADP, or more rarely, hemorrhage. 
• Specify the duration of the development and the therapeutic procedures carried out 
• Look for the concept of previous surgery.

Jaw carcinomas

• Clinical examination 

The exo-oral examination: 

• Specify the location of the swelling and the condition of the covering skin;
• Specify its clinical limits, by palpating the tumor induration 
• Check for the presence or absence of satellite adenopathies;
• Specify the consistency of the tumor by palpation;

Mouth opening examination: looking for LOB 

Examination of the oral cavity: 

• Capital and methodical, it allows examination of the lateral, upper and posterior oropharyngeal walls, the palate, the lower and upper vestibules, the teeth and the gums.
• Inspection: allows the lesion to be located.
• Endooral palpation: highlights the characteristic induration of cancerous lesions, the limits of which most often extend beyond the overlying mucosal lesion and highlights abnormal dental mobility
• Diagnosis 

Differential diagnosis 

• Osteitis of hematogenous origin
• V neuralgia
• Malignant tumors of the accessory salivary glands of the upper jaw. 
• Chronic sinusitis    
• Osteitis of common or specific dental origin
• Sarcomas
•  Osteolytic osteopathies
• Benign tumors of the jaws of dental or non-dental origin
• Periodontal diseases 
• Precancerous lesions

Positive diagnosis

• Clinical arguments

• Age
• Background
• Risk factors
• Call signs
• the lesion
• Adenopathies
• Radiological arguments 

• Panoramic or retro alveolar: 
• Bone invasion
• CT scan: Assesses tumor extension
• Anatomopathology 

• It is systematic
• Reference exam

4. Extension report 

• A chest X-ray (to look for lung metastases) 
• Biological tests (liver tests and tumor markers) 
• A CT scan (cervical region tumor); otherwise MRI 
• Endoscopic exploration of the VAS  
• An ultrasound of the upper abdominal region

Conclusion 

Oral cavity cancers are a major public health problem. They are particularly lethal pathologies since the 5-year relative survival rate is 34%.

What the odontostomatologist should be alerted to 

• Ulceration that does not heal after treatment
•  Tooth mobility and unexplained toothache.            
• Delayed healing after extraction.
• Sensitivity disorder
• Palatal or alveolar arching as well as facial deformity. 

Jaw carcinomas