Surgical Oncology xxx (2011) 1e10

Contents lists available at ScienceDirect

Surgical Oncology
journal homepage: www.elsevier.com/locate/suronc

Review

Mandibular conservation in oral cancer

Latha P. Rao a, Mridula Shukla c, Vinay Sharma b, Manoj Pandey b, *
a

Department of Oral & Maxillofacial Surgery and Cleft & Craniofacial Surgery, Amrita School of Dentistry, Amrita Institute of Medical Sciences, Kochi, India
Department of Surgical Oncology, Institute of Medical Sciences, BHU, Varanasi 221005, India
c
Department of Pathology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
b

a r t i c l e i n f o

a b s t r a c t

Article history:
Accepted 21 June 2011

Surgery is one of the established modes of initial denitive treatment for a majority of oral cancers.
Invasion of bony or cartilaginous structures by advanced upper aero-digestive tract cancer has been
considered an indication for primary surgery on the basis of historic experience of poor responsiveness
to radiation therapy [1]. The mandible is a key structure both in the pathology of intra-oral tumours and
their surgical management. It bars easy surgical access to the oral cavity, yet maintaining its integrity is
vital for function and cosmesis. Management of tumours that involve or abut the mandible requires
specic understanding of the pattern of spread and routes of tumour invasion into the mandible. This
facilitates the employment of mandibular sparing approaches like marginal mandibulectomy and
mandibulotomy, as opposed to segmental or hemimandibulectomy which causes severe functional
problems, as the mandibular continuity is lost. Accurate preoperative assessment that combines clinical
examination and imaging along with the understanding of the pattern of spread and routes of invasion is
essential in deciding the appropriate level and extent of mandibular resection in oral squamous cell
carcinoma. Studies have shown that local control rates achieved with marginal mandibulectomy are
comparable with that of segmental mandibulectomy. In carefully selected patients, marginal mandibulectomy is an oncologically safe procedure to achieve good local control and provides a better quality
of life. This article aims to review the mechanism of spread, evaluation and prognosis of mandibular
invasion, various techniques and role of mandibular conservation in oral squamous cell carcinoma.
2011 Elsevier Ltd. All rights reserved.

Keywords:
Mandibular conservation
Mandibular preservation
Mandibular invasion
Marginal mandibulectomy
Segmental mandibulectomy
Oral squamous cell carcinoma
Oral carcinoma

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Mechanism of mandibular invasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prediction of mandibular invasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Clinical evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Radiological evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Intraoperative evaluation of mandibular invasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Histopathological examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Segmental vs. marginal mandibulectomy/mandibular preservation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prognosis in cases with mandibular invasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Uncited references . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Authorship statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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* Corresponding author. Tel.: 91 542 2309511; fax: 91 542 2361014.

E-mail address: manojpandey@vsnl.com (M. Pandey).
0960-7404/$ e see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.suronc.2011.06.003

Please cite this article in press as: Rao LP, et al., Mandibular conservation in oral cancer, Surgical Oncology (2011), doi:10.1016/
j.suronc.2011.06.003

L.P. Rao et al. / Surgical Oncology xxx (2011) 1e10

Introduction
In the past it was standard practice to resect mandible as part of
the excision of many intra-oral cancers. Initially it was thought
necessary for adequate tumour clearance [2e4]. One of the pioneers
to study the involvement of mandible in oral cancers was Panagopoulos (1959), he found mandibular involvement in 12/48 cases
and proposed that the bone involvement in oro maxillary tumours
occur by extension of the neoplasm through nutrient channels [5].
His observations were based on demonstration of tumour cells in
Volkmans canal in few cases. Later on, despite the histological proof
that many of the mandibles sacriced were uninvolved [6,7],
segmental or hemimandibulectomy remained the mainstay of
surgical treatment for oral cancers adjacent to mandible because it
provided excellent exposure and easy closure of the surgical defect.
The functional and cosmetic consequences associated are devastating
to the patients due to impairment of occlusion, mandibular deviation,
overall decreased range of motion, temporomandibular joint pain,
poor contour of the symphysis and diet restricted to soft foods. The
mandible is critical with respect to dentition and mastication, speech,
and swallowing and maintaining a patent airway. With improvement
and advances in the imaging as well as reconstruction techniques the
balance has swung in favor of mandible-sparing surgeries, where the
results are cosmetically and functionally superior.
Clinical evaluation and preoperative radiological studies have
been used to evaluate bony invasion and to decide on the extent of
mandibulectomy. Understanding of the mechanism of invasion and
spread within the bone, and changes associated with loss of teeth
is crucial in the successful management of the tumours in close
proximity to mandible.
This literature review was carried out to assess the role of
mandibular preservation in case of carcinomas in close proximity to
the mandible and the correlation between clinical and radiological
ndings in such carcinomas.
Materials and methods
A detailed Pubmed (Medline) search was made using key words
mandibular involvement, or mandibular invasion, or mandibular

preservation, or mandibular conservation, or segmental mandibulectomy, or marginal mandibulectomy and oral cancer, or
oral squamous cell carcinoma, or carcinoma of the oral cavity. The
literature review was carried out till June 2011. The following string
was used for literature search:((mandible OR mandibular) AND
involvement) AND ((cancer OR carcinoma OR neoplasm OR tumor
OR tumour) AND (oral OR head OR neck))
Results
The search revealed 330 articles. Abstracts of all articles were
reviewed to identify the relevant studies, by this process, 76 full
articles of studies thus identied were then obtained and back
references were checked. Of these 92 articles, only 6 were listed as
clinical trials, no randomized controlled trials were identied
(chart 1). The inclusion criteria was the study should be on oral
squamous carcinoma, should be dealing with either identication
of mandibular invasion preoperatively or dealing with mandibular
preservation and their results in humans. The articles which were
not directly dealing with mandibular involvement or conservation
or preservation in oral squamous cell carcinoma, were excluded
from the review. The articles on mandibular excision for tumours
other then oral cancer, benign diseases and non-human studies too
were excluded.
Mechanism of mandibular invasion
Carcinoma of the mandibular region is dened as carcinoma
arising from the mandibular alveolar ridge, lower buccal sulcus,
sublingual sulcus or mandibular retromolar trigone [8]. It had long
been assumed that oral squamous cell carcinoma had the potential
to spread via the lymphatics within the mandibular lingual periosteum [9]. Composite resection of oral cancer with en bloc
resection of a segment or hemi mandible with neck node dissection was the main stay of treatment for oral squamous cell carcinoma to allow complete extirpation of tumour [2,10,11]. It was also
felt that involvement of the inferior dental canal or perineural
spread adversely inuenced the possibility of a limited surgical
approach [12,13].

Chart 1. Showing the result of literature search at a glance.

Please cite this article in press as: Rao LP, et al., Mandibular conservation in oral cancer, Surgical Oncology (2011), doi:10.1016/
j.suronc.2011.06.003

L.P. Rao et al. / Surgical Oncology xxx (2011) 1e10

In 1971, Marchetta rst challenged the concept of periosteal

lymphatics for mandibular invasion and attempted the rst
mandibular conservation procedure [4,6]. It was thought that the
oral cavity carcinoma travels along the surface mucosa and the
submucosal soft tissues until it approaches the attached gingiva
where tumour cells may come in contact with the periosteum of
the mandible. In the dentate patient, tumour cells were thought to
migrate through the periodontal ligament spaces into the mandible
[14,15]. In the edentulous patient, the tumour cells migrate onto the
occlusal surface of the alveolus and enter into the mandible via
dental pits [7,16e19]. McGregor and MacDonald [10] reported that
the inferior alveolar nerve could also be invaded and therefore
should be resected along with the mandibular canal during
a marginal mandibulectomy.
With increasing understanding of disease spread and biological
behaviour of oral cancer it is now clear that majority of the spread
to mandible occurs by direct inltration of the tumour through
alveolar ridge or lingual cortical plate [11,17,18]. It has also been
noted that tumours enter at the point of abutment. Histological
studies of the tumourebone interface have revealed that the site
of tumour entry into the mandible entirely depends on the location of the tumour in relation to the jaw; the alveolar crest in case
of carcinomas of the alveolar mucosa or the lingual cortical bone
in the event of tumours lying lingual to the mandible and perineural spread occurred only in case of advanced tumours [13].
Brown [17] and Brown et al. [18], stated that inclusion of the
neurovascular bundle in the marginal resection is not necessary.
Other less common routes of entry into the mandible have been
described such as via the mental and mandibular canals or the
lower border of the mandible which can be invaded by direct
spread from cervical lymph nodes. Brown [19] studied the
mechanisms of cancer invasion of the mandible, and concluded
that there is no preferred pathway of tumour entry into the
mandible. He reported that tumours enter the mandible at the
point of abutment which is related to the site of the primary
tumour. It has always been believed that mandible could be
preserved if there is normal tissue intervening between tumour
and the bone [6,20,21].
Earlier studies on bone destruction by squamous cell carcinomas on or adjacent to the lower jaw have generally dealt with
large tumours and preoperatively irradiated specimens [22,23]. As
the early stage of bony involvement can be considered to be
amenable to mandible-sparing surgery, detailed knowledge of the
growth patterns in tumours that have not yet completely destroyed
the mandibular bone is mandatory [13].

Prediction of mandibular invasion

There is no single imaging technique that can accurately predict
mandibular invasion in oral squamous cell carcinoma. From
a treatment perspective, it is crucial to determine the bone
involvement caused by these tumours and, more importantly, the
extent of bone involvement, since an underestimation may lead to
a partial resection, resulting in local recurrence and potential
metastasis [24]. As a consequence, surgeons are often inclined to
perform segmental resections to avoid undertreatment, i.e. positive resection margins, which is reected in high percentages
(35e78%) of resected mandibles with no evidence of mandibular
invasion, resulting in considerable cosmetic and functional defects
[7,25e28].
So a careful correlation of clinical and imaging ndings is warranted for the assessment of mandibular invasion and setting the
bony margins of resection. The mandibular involvement is further
assessed intraoperatively.

Clinical evaluation
A detailed clinical examination is important in evaluating the
tumour invasion (Fig. 1). Clinical assessment of mandibular invasion
is performed by bimanually assessing the mobility of the tumour
mass in relation to the mandible or xity of the tumour to mandible.
Inspection and palpation of the tumour and adjacent structures
usually pick up additional signs of mandibular invasion namely,
cortical thickening, symptoms of inferior alveolar nerve paraesthesia, and bony irregularities and pathological fractures if any
[29,30]. According to reported literature, clinical evaluation carries
a sensitivity ranging from 32%e96% [6,13,20,25,27,29,31e34].
Several studies had shown preoperative clinical assessment as
the primary method for determining mandibular invasion [29,35].
But the clinical assessment of large oral cancers especially in the
presence of trismus due to submucous brosis related to tobacco
and betel nut chewing [36,37] or due to pterygoid or masseter
muscle involvement that precludes bimanual palpation of the
mandible, can sometimes be inaccurate and therefore unreliable.
Similarly it is not possible to detect subtle cortical invasion with
clinical examination alone [38,39]. A careful clinical and radiological
correlation is required to achieve the ultimate goal of not sacricing
any more bone than needed to remove the entire tumour.
Radiological evaluation
Controversy still exists about the best way to image the mandible
in the management of oral cancer when there is a chance that
a resection of the mandible will be required as part of the treatment.
The literature review showed that there is no single investigation
that can predict whether tumour has invaded the mandible with
100% reliability (Table 1).
Radiologically, plain lms, orthopantomograms (OPG), computed
tomography (CT) scans, magnetic resonance imaging (MRI) and bone
scans have been used with varying degrees of accuracy [40].
Panorex radiographs play an important role in the detection of
bone invasion by oral carcinoma especially in determining the
superioreinferior extent of the tumour in the bone, which is one of
the most important factors inuencing the selection between rim
and segmental resection of the mandible (Fig. 2) [29,32,41e44].
They also represent the mandible in a way that is easy to extrapolate to the clinical situation and is therefore useful for planning the
surgical procedure [45]. Nakayama et al., (1999) advocated the use
of panoramic radiography combined with intra-oral radiography as
the initial imaging modality to determine the extent of superoinferior invasion of the mandible in gingival carcinoma [43].
According to Hong et al. (2001) when deciding the required
anterioreposterior limits of resection, among the different kinds of
imaging modalities, intra-oral periapical lms with the paralleling
technique seem to provide the most valuable information, due to
their ne anatomical detail [46]. But the panorex and intraoral
radiographs carry the disadvantage of not detecting early invasion
of mandible with less than 30% of mineral loss [47,48]. The interforaminal area is difcult to assess by panorex radiographs due to
the superimposition of cervical vertebrae.
CT scan has become standard technique for staging malignant
tumours of the head and neck region. It is a sensitive method of
assessing squamous cell carcinoma of mandibular region in terms of
its size, location, spread in the bone as well as soft tissue & regional
lymph node involvement [27,34,49,50]. With axial & coronal CT scans
even subtle tumour invasions of angle and ramus of the mandible can
be detected (Fig. 3). Because of the partial volume effect in the curved
bony surfaces as in anterior mandible and alveolar processes, and
metal artifacts, the specicity of CT scan remains low [51]. But with
latest 128 slice CT scans, the 3D reconstruction and planning of the

Please cite this article in press as: Rao LP, et al., Mandibular conservation in oral cancer, Surgical Oncology (2011), doi:10.1016/
j.suronc.2011.06.003

L.P. Rao et al. / Surgical Oncology xxx (2011) 1e10

Fig. 1. Clinical photograph showing the lesions, A) Supercial lesion of the buccal mucosa extending to retromolar trigone, B) Small lesion in the gingivobuccal sulcus, C) Ulceroinlterative lesion in the gingivobuccal sulcus extending on to the alveolus, D) Extensive lesion on the gingivo buccal sulcus with involvement of alveolus and mandible.

surgical margins have become more accurate (Fig. 3). The cone-beam
CT and dentascan have shown promising results in identication of
mandibular invasion by oral carcinoma [52e57].
MRI scan is superior to CT scans as it detects early soft tissue and
medullary involvement and not as effected by metal artifacts
[58,59]. However it is less reliable in evaluation of cortical bone
involvement because of lack of signal from cortex secondary to its
low number of mobile hydrogen ions [60,61]. Imaizumi et al.(2006)
reported on low specicity of MRI scan to detect mandibular
cortical invasion and inferior alveolar canal involvement [62]. The
large number of false positive results obtained with MR imaging in
contrast to CT scan seemed to be attributed to chemical shift artifacts induced by bone marrow fat. Namely, it was considered that
the black line of the cortex adjacent to the tumour mass was
obscured by spatial misplacement of fat, or severe periodontal
disease or secondary changes from tooth extraction. MR imaging
often showed the tumour and the surrounding inammation in the
bone marrow with similar signal intensity, resulting in overestimation of the tumour extent.
Bone scintigraphy is generally considered as the most reliable
method of detecting bone invasion & distant metastases (Fig. 4).
Increased bone turnover in squamous cell carcinoma gives rise to

hot spots on bone scan thus detecting even periosteal involvement. But as the osteoblast activity can be high in osteomyelitis,
children, fractures, or even periodontal diseases, the specicity of
bone scintigraphy is rather low. Several studies have reported on
high sensitivity & low specicity of bone scans [17,25,27,32,63].
Schimming et al.(2000) reported 100% sensitivity and 91.6% specicity for computer-aided 3-D 99mTc-DPD-SPECT(TechnetiumDicarboxy propan-single photon emission CT) and conventional
99m Tc-DPD-SPECT in their comparison of these imaging modalities with clinical examination, panoramic radiography, and CT scan
in the assessment of mandibular bone invasion by squamous cell
carcinoma in 50 cases [64].
The various studies comparing the effectiveness of various
investigative modalities in detecting mandibular invasion in oral
squamous cell carcinoma have failed to demonstrate 100% accuracy
with any one technique [34,50,65,66]. Results of these studies show
superior results when the data from different imaging techniques is
correlated with the clinical ndings [67].
Brown and Lewis eJones (2001) in their review of different
investigative modalities commented that the decision to resect the
mandible as part of the management of oral cancer should be taken
on the evidence of clinical examination, intra-operative periosteal

Please cite this article in press as: Rao LP, et al., Mandibular conservation in oral cancer, Surgical Oncology (2011), doi:10.1016/
j.suronc.2011.06.003

L.P. Rao et al. / Surgical Oncology xxx (2011) 1e10

Table 1
showing sensitivity and specicity of various radiological techniques in detecting bony invasion in various series.
OPG

CT

Sensitivity (%)

Specicity (%)

78
57

88
92

69.6
92
97
80
64

66.7
88
70
72
97

85
86.6

89.5
80

76
91
71

93
66
64

Sensitivity (%)

MRI
Specicity (%)

Sensitivity (%)

Scintigraphy
Specicity (%)

100
91.3

88
96.3

96
39.1

54
96.3

100
89
91
64

39
94

96
73

53

97
57
96.3
89
93.8
92.5

53

90

93
100

93
92

80
50
78
61

94
86
80
88

100

stripping and at least two imaging techniques that complement

each other in terms of specicity and sensitivity [68].
Babin et al. (2008) reported on fusing of positron emission
tomography with CT scan images to maximise data information
[69]. Positron emission tomography/CT fusion showed a sensitivity
of 100% with specicity of 85%. Van Cann et al., (2008) reported on
combinations of CT and bone SPECT, or MRI and bone SPECT to
predict mandibular invasion without yielding false negative results
[70]. If CT or MRI showed mandibular invasion, bone SPECT was
not performed avoiding unnecessary costs. Gu et al., (2010)
reported improved sensitivity in detection of mandibular invasion
by squamous cell carcinoma of the oral cavity with combined
analysis of CT, MR, and PET/CT than when they were assessed
independently [71].

Sensitivity (%)

Specicity (%)

89

79

100

66.7

100 SPECT
100
94
100 SPECT

29
67
73
91.6

95

72

71
100

71
88

98

47

50

Weisman & Kimmelman (1982) [25]

OBrien et al., (1986) [31]
Imaizumi et al., (2006) [62]
Zupi et al., (1996) [33]
Rao et al., (2004) [29]
Muller & Slootweg (1990) [42]
Acton et al., (2000) [50]
Close et al., (1986) [49]
Curran et al., (1996) [39]
Zupi et al., (1996) [33]
Van den Brekel et al., (1998) [65]
Schimming et al., (2000) [64]
Ord et al., (1997) [34]
Bolzoni et al., (2004) [59]
Brown et al., (1994) [73]
Totsuka et al., (1991) [77]
Leipzig (1985) [108]
Bahadur (1990) [27]
Tsue et al., (1994) [20]
Kalavrezos et al., (1996) [24]
Lane et al., (2000) [66]

Histopathological examination
Both macroscopically and histologically, distinct patterns of
mandibular bone invasion by the carcinoma have been identied

Intraoperative evaluation of mandibular invasion

McGregor and MacDonald (1988) advocated the clinical assessment of mandibular invasion by lifting the periosteum at the time of
surgery [72]. Brown et al. (1994) compared several methods for
assessing bone invasion and found that periosteal stripping at the
time of resection represented an accurate predictor of the presence
of mandibular invasion [73]. They reported only one case of false
prediction in 35 cases analyzed. They recommended the assessment
of macroscopic invasion of the mandible after periosteal stripping as
a helpful and worthwhile addition in planning the resection of the
mandible in oral cancer surgery. Pandey et al., (2009) too have
reported on the ndings on periosteal stripping namely subperiosteal reaction, cortical expansion, and presence of pathologic
fracture as signicant predictors of bone invasion [30].
Forrest et al. (1995) advocated frozen- section analysis of
cancellous bone to conrm the adequacy of bony margins [74].
Oxford and Ducic (2006) had presented the frozen- section analysis
of bone margins as a reliable method to evaluate bony margins
intra-operatively [75]. Wysluch et al., (2010) assessed the effectiveness of intra-operative frozen- section analysis of trephine
drilled bone specimens and found 94% consistency between the
frozen- section analysis and routine histopathological examination
of decalcied bone specimen techniques, with a sensitivity of 79%
and specicity of 98%. This technique promised to be suitable for
intra-operative detection of malignant bone inltration [76].

Fig. 2. Orthopantomogram: A) showing loss of teeth and early doubtful invasion B)

Showing denite invasion of mandible C) Extensive invasion reaching almost to the lower
border of mandible D) Invasion of the lower border of mandible from a large lymph node.

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L.P. Rao et al. / Surgical Oncology xxx (2011) 1e10

Fig. 3. Computerized tomography scan showing A) tumour of the buccal mucosa and gingivobuccal sulcus abutting the mandible with possible early erosion of outer cortex.
B) Tumour of the upper alveolus with extension in retromolar trigone and involvement of mandibular ramus. C) tumour of the tongue and lateral oor of mouth with extension to
the alveolus and destruction of mandibular bone. D) 3-D reconstruction showing the destruction of outer cortex of mandible. E) 3-D reconstruction of the same patient
demonstrating the destruction of inner cortex.

[13,77] (Fig. 5). The tumour can advance in the bone either as
a broad front, referred to as arrosion or in a diffusely inltrating
pattern [13]. In the arrosive pattern, the tumourebone interface is
well demarcated one with a continuous layer of new bone and
connective tissue. The second tumour pattern, inltrative, is
a diffuse one with extensive, irregular destruction of bone and
spread into cancellous bone. The inltrative pattern is marked by
nests and cords of tumour cells along an irregular tumour front, and
the erosive pattern exhibits a broad, pushing tumour front [5,37].
Wong et al. (2000) reported a signicantly worse prognosis for
inltrative pattern of mandibular invasion when compared with
the arrosive pattern [78]. The inltrative pattern clearly exhibited

a more aggressive behavior with an increased likelihood of positive

margins, recurrence, death with disease, and shorter disease-free
survival. The 3-year disease-free survival was 30% for the inltrative pattern and 73% for the arrosive pattern.
Hong et al. (2001) had reported an underestimation of tumour
invasion width in mandible by 9.2 mm and tumour invasion depth by
3.4 mm, when the radiological ndings and the actual defect from
histopathological ndings were compared in 21 patients with
gingival squamous cell carcinoma of the molar region [46]. Two
specimens showed the microscopic tumour extension within the
medullary bone, without any perforation of the lingual and buccal
cortices, into the mandibular body and ramus. These ndings
reected that, especially in inltrative pattern, it was difcult to
determine the resection margin anteroposteriorly because bone
invasion by tumour cells spreading transmedullarly is not radiologically identiable. Moreover, the tumour cells rapidly spread between
cancellous bony trabeculae and there was no denite resistance to
spread. The surgeons, therefore, should be more cautious in planning
the width of resection especially if a bone defect of the gingival
carcinoma is thought to be an inltrative defect in radiological
studies. In general terms, an excision margin of at least 1e2 cm of
normal bone on either side is recommended [7,17,21,46,79e82]. More
aggressive resection is advised in selected cases when the invasive
bone defect is apparently identied in the radiographs [46].

Segmental vs. marginal mandibulectomy/mandibular preservation

Fig. 4. Bone scintigraphic scan showing two areas of increased isotope uptake in right
mandible and at the arch.

Despite signicant improvement in functional oromandibular

reconstruction, segmental mandibular defects remain a source of
functional and cosmetic difculty for patients with head and neck

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L.P. Rao et al. / Surgical Oncology xxx (2011) 1e10

Fig. 5. Photomicrograph showing A) Tumour invasion in mandible in a broad front (E) characteristic of erosive pattern with no bony remnants within the tumour mass, tumour cells
are separated from the normal bone by a well demarcated brous zone (F). B) Tumour invasion in the mandible as irregular cords and islands (I) characteristic of inltrative pattern,
partially lysed bone spicules (B) are present within the tumour mass with no clear cut demarcating tissue between tumour and bone. C) Tumour invasion (T) into the perineural space
of the inferior alveolar nerve bundles. D) Tumour invasion (T) into the mandible involving the superior portion of the inferior alveolar canal with no invasion of nerve bundles (N). E)
Diffuse irregular tumour inltrating bone, brous marrow (FM) and bony remnants (B). F): Fatty marrow in post radiotherapy patient. (reproduced with permission from Pandey M
et al. Patterns of mandibular invasion in oral squamous cell carcinoma of the mandibular region. World Journal of Surgical Oncology 2007, 5:12 doi:10.1186/1477-7819-5-12).

cancer. Although the application of free-ap allows for single- stage

composite reconstruction [83], the use of free-ap technology
requires signicantly more health care resources than simpler
reconstructions [84]. Therefore, preserving the continuity of the
mandibular arch, when oncologically feasible, remains the preferred
surgical alternative. Preservation of mandibular continuity can be
achieved either by temporarily dividing the mandible, allowing
access to the posterior oral cavity and oropharynx (mandibulotomy),
or by resection of only a portion of either the vertical height or
sagittal diameter of the mandible (marginal mandibulectomy).
Marginal mandibulectomy was described by Crile in 1923 as an
incision that is carried down to the underlying bone, and thence
into the bone by a sharp chisel or saw, so that a slice of bone can be
split off in one piece, bearing the undisturbed cancer off as on
a bone platter. [85].
Contemporary marginal mandibulectomy usually refers to
resections of either the inner table or alveolar ridge of the mandible
[86]. In the absence of radiographic evidence of mandibular invasion, marginal mandibulectomy has been shown to be a sound
oncologic procedure for patients with cancers of oor of the mouth.
Marginal mandibulectomy has been used in cases in which the
tumour abuts the mandible, is adherent to the periosteum, or
where resection of the alveolar process is necessary to obtain
a third dimension on the deep surface of the tumour [87].
Unlike tumours of the anterior oral cavity that are more
amenable to marginal mandibular resection; carcinomas of the

retromolar trigone and advanced tumours of the adjacent tonsillar

fossa have historically been treated with posterior segmental
mandibulectomy [88]. The retromolar trigone is the most posterior
aspect of the oral cavity. It is a pyramidal-shaped region of mucosa
covering the ascending ramus of the mandible and bordered by the
buccal mucosa laterally, the tonsillar fossa medially, the maxillary
tuberosity superiorly, and the molar teeth inferiorly. The oral
mucosa adheres tightly to this non-tooth-bearing portion of the
mandible. Invasion of the mandibular ramus in this region is
difcult to determine preoperatively; however, when involved,
extensive bone inltration by tumour is common [21,73,89]. The
lack of a reliable radiographic assessment of the retromolar trigone
makes surgical decision making in this region difcult. Studies
indicate that the incidence of mandibular invasion in retromolar
trigone cancers is as high as 75% [20,22,90].
In 1983, Wald and Calcaterra reported the result of the treatment of mandibular gingival cancer, and the failure rates for
marginal and segmental groups were similar. The advanced stages
required a radical operation with segmental mandibulectomy;
however, the locoregional recurrence rate was high despite this
treatment [89]. Byers et al. (1984) reported local recurrence of 7% in
their series of 110 patients undergoing various forms of mandibulectomy with or without coronoidectomy for retromolar trigone cancer [88].
Shaha et al. (1984) used marginal mandibulectomy for the
treatment of smaller oor of the mouth malignancy and segmental

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mandibulectomy for the larger tumours. This resulted in 21%

recurrence at the primary site following marginal mandibulectomy
[80].
Barttlebort et al. (1987) reported 25% local recurrence rate
following marginal mandibulectomy. The local failures had
occurred in soft tissues and not in bones [90].
Collins and Saunders (1987) described the intra-oral ramus
marginal mandibulectomy in 2 of 8 patients treated with conservative mandibulectomy for oral cavity carcinomas adjacent to or
clinically attached to the mandibular periosteum without clear
radiographic evidence of bone destruction. The intra-oral defects in
both of these patients were closed primarily, and both patients had
normal recovery of speech and swallowing [79].
Randall (1987) recommended marginal mandibulectomy only
when there was no radioragphic evidence of bone lesion and less
than 50% of the mandibular circumference was involved by the
tumour [91]. The studies of Totsuka et al. (1991a,b) regarding
mandibular gingival carcinoma showed almost the same survival
rate at 2-year follow-up after marginal technique (86%) and
segmental technique (82%) [44,77].
Shaha (1992) reported that whenever the tumour is close to the
mandible or adherent to the periosteum, consideration should be
given to marginal mandibulectomy. In 65 patients that the author
reported, 22 underwent marginal mandibulectomy. Most of the
patients had oblique mandibulectomy including resection of the
upper rim and medial cortex of the mandible [92].
Barttelbort and Ariyan (1993) compared two types of mandibular preservation procedures namely rim (marginal) mandibulecctomy and lingual sagittal mandibulectomy in fresh cadaver
human mandibles in terms of strength [93]. Using strain gauge
techniques, it was noted that the rim mandibulectomy was more
resistant to fracturing than was lingual sagittal mandibulectomy
and maintenance of a 1-cm-thick segment of bone inferiorly was
required to reduce the risk of fracture formation.
The posterior marginal mandibulectomy was used by Pinsolle
et al. (1997) in 14 patients with tumours of the oral cavity and
oropharynx without preoperative radiographic evidence of bone
erosion. These authors reported no complications associated with
the mandibulectomy and good maintenance of cosmesis [94].
Ord et al.(1997) reported a local control rate of 92.3% [34] and
Werning et al. (2001) published a local control rate of 87.4% in
a study of 222 patients [35] with marginal mandibulectomy.
Petruzzelli et al., (2003) reported a local control rate of 93.75%
(15 out of 16 patients) with posterior marginal mandibulectomy for
tumours of the posterior oral cavity &/or oropharynx [95].
Guerra et al. (2003) reported equal locoregional recurrence rate
and survival rate in 106 patients with oral squamous cell carcinoma
treated by segmental or marginal mandibulectomy [96]. In
marginal resection group 10 cases (20%) showed a local recurrence,
whereas in the segmental resection group there were 19 (33.9%)
recurrences. Analysis of these 2 modalities in their study showed
no evidence of disease at 2 years after surgery for the segmental
and marginal were almost the same, 56% and 61%, respectively.
Tei et al. (2003) reported a recurrence rate of 13.3% and 29.4%
and 5 year survival rate of 78.1% and 72.8% with marginal mandibulectomy and segmental mandibulectomy respectively [97].
Bone fracture due to insufcient thickness of the remaining
mandible after marginal resection occurred in 4 of the 45 marginal
resection cases.
Brown et al. (2005) stressed on the need to consider the extent
of bone resorption after the loss of teeth in the clinical management
of the mandible invaded by squamous cell carcinoma [98]. They
described a guide to help the surgical team in the decision-making
process and increase the accuracy of mandibular resection to
maximize the chance of cure without increasing morbidity. The

classication of bone resorption pattern in edentulous jaws given

by Cawood and Howell (1988, 1991) was used as the basis on which
treatment planning was carried out depending on radiographic
ndings [99,100]. They advocated a rim or marginal mandibulectomy in radiologically negative tumours which are close to
the mandibular region or abut onto mandible, in dentate or
recently extracted cases. In rounded or knife e edge ridges or at or
depressed ridges, with radiological evidence of mandibular invasion, a segmental resection is always preferred [98].
Prognosis in cases with mandibular invasion
The prognostic impact of mandibular invasion by oral squamous
cell carcinoma (SCC) is controversial. There have been reports of
decreased survival rates and increased recurrence with bone
invasion and survival rates independent of bone invasion. There
have been conicting reports by the same authors, who had
compared rim and sagittal marginal mandibulectomy in one study
and marginal mandibulectomy with segmental mandibulectomy
[95e101].
Ogura et al. (2002) showed that bony invasion identied on
dental CT images was a signicant prognostic factor in cervical
metastases [101]. Tankere et al. (2002) [102] and Guerra et al.
(2003) found no statistical relationship between the presence of
histological bone invasion and the risk of local recurrence [97,99].
The size of bone resection >4 cm and tumour invasion of surgical
margins were found to be associated with increased local recurrence rates [102].
OBrien et al. (2003) reported a series of 94 patients who
underwent marginal resections and 33 underwent segmental
resections. Among patients with bone invasion, the local control
rate was higher following segmental resection when compared to
marginal resections (87% vs 75%) but this was not statistically
signicant. Survival was signicantly inuenced by positive soft
tissue margins but not bone invasion or the type of resection [103].
Shaw et al. (2004) reported on strong correlation between
mandibular invasion and disease- specic survival rates [104]. Patel
et al. (2008) assessed the effect that extent of bone invasion has on
recurrence and survival in 111 patients treated with marginal and
segmental mandible resection [105]. Five-year local control was
similar following marginal (83%) and segmental mandibulectomy
(86%). There was no correlation with presence or extent of bone
invasion. Survival at 5 years was 71% and this correlated with bone
invasion and involved margins, but not with extent of mandible
invasion or resection.
Pandey et al. (2009b) reported tumour stage, margin of surgical
excision and nodal stage as predictors of survival in their study of
51 patients with squamous cell carcinoma of mandibular region.
They found no signicant difference in survival between patients
with pathologically positive mandible with those not having
mandibular involvement and concluded that mandibular conservation might be carried out, even in presence of involved mandible
if negative resection margins could be achieved [106].
Conclusion
Segmental resections cause severe functional and cosmetic
problems due to loss of the continuity of the mandible. Functional
morbidity after mandibular resection depends on the maintenance
of arch continuity. This can be achieved in the case of segmental
resections mainly with microvascular transfer of vascularized bone
grafts.
Conservative resection of the mandible is safe as long as
marginal mandibulectomy does not lead to compromise of soft
tissue margins, and in cases where there are no radiographic

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L.P. Rao et al. / Surgical Oncology xxx (2011) 1e10

evidence of bone involvement or the bony defect does not extend

beyond the bony canal [107]. However, the nal decision of the
mandibulectomy technique should be based on clinical judgment
in the operating room, assessing the proximity of the tumor to the
mandible and its adherence to the mandible [108]. Segmental
resection should be reserved for patients with extensive bone
invasion or those with limited invasion in a thin atrophic mandible.
Conict of interest statement
None declared.
Authorship statement
Guarantor of the integrity of the study: Manoj Pandey
Study concepts: Manoj Pandey, Vinay Sharma, Latha P. Rao
Study design: Manoj Pandey, Latha P. Rao
Denition of intellectual content: Manoj Pandey, Mridula Shukla
Literature research: Mridula Shukla, Latha P. Rao
Clinical studies: Not applicable
Experimental studies: Not applicable
Data acquisition: Latha P. Rao, Vinay Sharma
Data analysis: Manoj Pandey, Mridula Shukla
Statistical analysis: Not applicable
Manuscript preparation: Vinay Sharma, Latha P. Rao, Mridula
Shukla
Manuscript editing: Manoj Pandey, Mridula Shukla
Manuscript review: Manoj Pandey, Mridula Shukla
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Please cite this article in press as: Rao LP, et al., Mandibular conservation in oral cancer, Surgical Oncology (2011), doi:10.1016/
j.suronc.2011.06.003