CANCER OF LOWER ALVEOLAR

RIDGE & RETROMOLAR TRIGONE

DR. RAHILA AZIZ
PGR-1ST YEAR
OMFS-PIMS
ANATOMY OF LAR

The lower alveolar ridge is defined as the bony

ridge of mandible that harbors the tooth roots. It
is bounded

Anteriorly, by the mandibular buccal vestibule

Posteriorly, by the free mucosa of the FOM
extends along the ramus
ending at the retromolar trigone
ANATOMY OF RMT
The RMT is a triangular area of
mucosa, overlying the mandibular
ramus, immediately posterior to
the 3rd molars. The base of the
triangle is posterior to the last
mandibular molar and the apex is
in continuity with the maxillary
tuberosity behind the last upper
molar.
RMT is bounded laterally by the
gingival buccal mucosa and
medially by anterior tonsillar
pillar. Pterygomandibular raphe
(PMR), which is a central fibrous
band extending from pterygoid
hamulus superiorly to mylohyoid
line inferiorly, lies under this
triangular fold of mucosa. PMR
provides attachment to
buccinators and superior
constrictor muscles.
INCIDENCE & ETIOLOGY
• LAR cancer accounts for about 5.2% of all the
oral cavity cancers.
• Smoking and alcohol use are major risk
factors for oral cavity cancer with higher
risk associated heavy smoking and
alcohol use. It is In addition, some risk
factors that are specific to the alveolar
ridge are a diet with low vegetable
intake, poor oral hygiene, and
periodontal disease which may contribute
to chronic inflammation and increased
cell turnover rate.
• RMT is considered to be the 4th most common
site for oral cancer with an incidence rate of
8% of all oral cancers.
Etiology of oral cancer including RMT is
multifactorial. Cigarette smoking and
alcohol consumption remains the most
important risk factors for oral cavity
cancer including RMT. Regular alcohol
consumption is associated with the
increased risk of oral cancer including
retromolar subsite of oral cavity.
• Betel nut chewing is one of key factors
causing the increase in the incidence of
retromolar cancers in Southeast Asia.
About 600 million people are exposed to
the habit of betel nut chewing making it
the fourth most-consumed drug after
nicotine, ethanol, and caffeine. 
HISTOLOGICAL TYPES

OSCC VERUCCOUS CA ADENOCARCINOMA

Is the most common Is the 2nd most common 2.4% of all LAR cancers
histological type of oral cancer histological type of oral cancer 4.5% of all RMT cancers
that occurs in LAR and RMT occurring in LAR and RMT areas
areas making up making up

89% of all LAR cancers 4.2%of all LAR cancers

92% of all RMT cancers 0.9% of all RMT cancers
 CLINICAL PRESENTATION

• LAR

Early lesions are often asymptomatic and can

be detected by routine oral examination. As
lesions progress, the patient may experience
pain presenting complaints include bleeding
(from ulceration), loose teeth, problems with
denture fit, numbness of the teeth or lips, and
trismus (secondary to pterygoid involvement).
Some patients may also present after
transformation of premalignant lesions. Oral
leukoplakia is a descriptive diagnosis, referring
to a white “patch” or “plaque.” Among these
lesions, dysplasia or carcinoma occurs in up to
17-25% of lesions.
CLINICAL PRESENTATION

•RMT

Cancers of RMT area may present as isolated

ulcerative or endophytic lesions and may
present with involvement of adjacent
structures, that are, buccal mucosa laterally
or tonsillar fossa medially.
Patients often present with advanced stage
disease presenting with trismus as an initial
presenting symptom.
Due to it’s proximity to the maxilla, mandible,
and pterygomandibular raphe (PMR), the
cancer of RMT has a significant tendency for
local invasion of these sites. One or more
adjacent subsites are involved in 73 to 84%
of cases reported. The most common sites of
local involvement are reported to be the

- anterior tonsillar pillar (80%)

- soft palate (59%)
HISTORY

The chief complaint should be evaluated by determining onset, location,

duration, intensity, frequency, progression, character, severity, triggers, factors
that improve or worsen the condition, effect on function, and results of previous
treatments.
Comprehensive histories of autoimmune disease, allergic disease, cardiovascular
disease, hypertension, diabetes, hyperthyroidism, infectious disease, as well as
cancer are important considerations in developing an accurate diagnosis. The
medication history of current prescription and nonprescription medications, their
dosages, schedules, and patient compliance should be reviewed and recorded.
Tobacco exposure, specifically cigarette, cigar, pipe and chewing tobacco history
should be recorded. In case of positive alcohol history alcohol consumption should
be quantified as type, frequency, and duration of use.
EXAMINATION

The examination proceeds in 3 phases:

(1) obtaining vital signs (temp, pulse, resp rate, BP)

(2) examination of the head, neck, and the oral cavity

The principle screening test for oral cancer is a physical examination that consists of systematic inspection and palpation. The
extraoral soft tissues are examined first, followed by the intraoral soft tissues. Any deviations such as ulcerations, swelling,
tenderness or fluctuance, are recorded.

When oral cancer metastasizes, it most commonly spreads through the lymphatic system to the cervical chain of lymph nodes
in the neck. Thus, the status of the cervical lymph nodes, especially the upper deep nodes, at presentation is important.
Particularly in case of LAR/RMT cancer, the lesion should be thoroughly examined for size, shape, color, borders, margins,
extent along with involvement of surrounding and the underlying structures.

(3) obtaining radiographic and laboratory studies.

DIAGNOSTIC IMAGING

• CT and MRI are referred to as the “gold standard”

for imaging oral cancer.
The images are evaluated along with clinical and
histopathological data. An optimal combination of
preoperative examination methods to predict bone
invasion is necessary for the planning of definitive
therapy for oral cancer patients.
MANDIBULAR BONE INVASION

• The LAR/RMT cancer can invade the underlying bone via cortical
bone defects or the foramina present in the mandible
(mental,mandibular)
Invasion can be either of the 2 patterns
- Erosive or Expansive
- Invasive or Infiltrative

A CT scan can more accurately characterize the pattern of invasion

and shows that an infiltrative pattern has a poor prognosis as width
and DOI is typically greater in tumors with infiltrative pattern.
• Pre-treatment assessment of mandibular invasion can be done via
Clinical exam
Plain radiography
Bone scintigraphy
SPECT
CT scan
MRI
USG

MRI demonstrated higher sensitivity whereas, CT shows highest

degree of specificity in the detection of mandibular invasion.
SURGICAL TREATMENT FOR CA OF LAR & RMT

Surgical options for the treatment of the cancer of LAR includes:

1. Conservative/Marginal/Rim Mandibulectomy

. Anterior Marginal Mandibulectomy

. Posterior Marginal Mandibulectomy
. Sagittal Mandibulectomy
. Marginal mandibulectomy of RMT tumor

2. Segmental Mandibulectomy
ANTERIOR MARGINAL MANDIBULECTOMY

Anterior Marginal Mandibulectomy

Is indicated for the mandibular tumors with extensions into FOM or the lingual gingiva. A
circumferential mucosal incision is given which is extended into the periosteum of the
alveolar ridge around the lesion. The dental extractions can be performed prior to executing
the osteotomies. Atleast 1 cm of mandible must be left intact to preserve the mandibular
stability.
POSTERIOR MARGINAL MANDIBULECTOMY

Posterior Marginal Mandibulectomy

Marginal mandibulectomy of the posterior LAR or RMT usually requires resection

of the posterior mandibular alveolar ridge as well as the coronoid process in order
to ensure a completely tumor free margin.
SAGITTAL MANDIBULECTOMY

Sagittal/Coronal Mandibulectomy

It involves the removal of the entire lingual plate.

Anteriorly, the osteotomies are performed in the coronal plane whereas the
osteotomies of the posterior mandible are performed in sagittal plane.
In order to preserve the inferior buccal cortical plate, a marginal mandibulectomy is
performed in combination with sagittal mandibulectomy.

Reconstruction

Reconstruction after the mandibulectomy may require re-approximation of soft

tissues of FOM with resorbable sutures, skin grafts, local intraoral flaps or
microvascular reconstruction surgery.
SURGICAL TREATMENT FOR CA OF RMT

For the surgical excision of advanced RMT lesions typically requires extensive resection of

- mandible
- masticatory muscle
- tonsillar fossa
- soft palate

THE RETROMOLAR OPERATION

Hemi mandibulectomy with resection of the masseter and pterygoid muscles in continuity with
an ipsilateral radical neck dissection.
Inclusion of the coronoid process is necessary to ensure that an adequate bone margin is
obtained.
In cases of severe alveolus resorption, segmental resection is preferred instead of mandibular
conservative surgery.
RADIATION THERAPY TECHNIQUES

T1-T2 LESIONS
Preferred treatment for patients with T1-T2 lesions is surgery
If the patient is unsuitable for surgery, the Radiotherapy is preferred.

RT may be administered with an either

Ipsilateral en-face combination of 6MV xrays and electrons
OR
2MV xray beams arranged in a wedge pair
More preferred because it is possible to vary the depth of target volume more precisely and under-dosimg of the tumor
is less likely.

T1-T2 lesions which extending into the soft palate or tongue would be treated with parallel opposed fields weighed 3:2
to the size of tumor

Patients receive 74.4 Gy in 62 fractions over 6 weeks with a field reduction at 45.6 Gy.

The low neck is treated with an anterior 6MV xray field matched at the thyroid notch and receives 50Gy in 25 fractions.
RADIATION THERAPY TECHNIQUES

T3-T4 LESIONS
Patients with T3-T4 lesions have a relatively low chance of cure with radiotherapy alone and are optimally treated with surgery
and post-op RT

Post-op radiation dosage varies with margins

-ve R0 – 60Gy
+ve R1 – 66Gy
Gross residual R2 – 70Gy

Patients are treated once daily at 26Gy/fraction, 5 days a week in a continuous course

Patients with positive margins should be considered for treatment with an altered fractionation technique (AFP)

Patients not suitable for surgery are treated with radiation of 76.8Gy in 64 fractions over 6.5 weeks combined with concomitant
chemotherapy.

Patients who cannot receive aggressive treatment receive moerate dose palliative radiation that is 20Gy in 2 fractions with a one-
week inter-fractional interval OR 30Gy in 10 fractions over 2 weeks.
CONCLUSION

The malignant lesions originating from RMT and LAR region

frequently present with variety of clinical confusions and require
appropriate evaluation and management.
Sensitive as well as specific diagnostic tests need to be employed
for the assessment of early mandibular invasion. The candidates for
surgery must be chosen carefully so that an appropriate surgical
intervention followed by post-operative radiotherapy can be carried
out for best possible results.