# ORAL CANCER --- ## RESECTION AND RECONSTRUCTION --- **Magdalen Foo** **Oral Maxillofacial Surgeon** ---   ---  #### Presenter Information **Magdalen Foo** Oral Maxillofacial Surgeon | | | | :--- | :--- | | **Describe** | Describe the clinical aspect, diagnosis and management of oral cancer | | **Understand** | Understand the role of Multidisciplinary Team in head and neck cancer management | | **Appreciate** | Appreciate the contribution of the dentist pre, during and post head and neck cancer treatment | #### Clinical Knowledge and Management - Describe the clinical aspect, diagnosis, and management of oral cancer. #### Collaborative Care - Understand the role of the Multidisciplinary Team in head and neck cancer management. #### Dental Professional Contributions - Appreciate the contribution of the dentist pre, during, and post head and neck cancer treatment. # Head and neck cancer statistics in Australia * **7th** most commonly diagnosed cancer in Australia * **>5000** new cases of head and neck cancer diagnosed in **2020** * **>1000** deaths from head and neck cancer in **2020**   #### National Impact and Prevalence - **7th** most commonly diagnosed cancer in Australia - **>5000** new cases of head and neck cancer diagnosed in **2020** - **>1000** deaths from head and neck cancer in **2020** A graphical presentation featuring the text 'HEAD AND NECK CANCER' above an illustrative map of Australia containing multiple human figures. The inset includes the statistic '13 people are diagnosed every day', aligning with the slide's context of >5000 new cases in Australia in 2020.  A composite figure illustrating 'The 8-Step Oral Cancer Screening'. It details inspections of the mouth, including the gingiva, buccal mucosa, lip, palate, and tongue. There is no extractable text from the provided image. The image consists of six distinct medical photographs—one orbital radiograph, one panoramic X-ray (indicated by a blue arrow), and four close-up clinical photos of oral lesions—but it contains no caption, legend, or accompanying text.       Lateral view clinical photograph of a patient's face and jaw profile. Panoramic dental X-ray showing the maxillary and mandibular arches with missing teeth, highlighted by a blue arrow indicating the left mandibular ramus. Close-up intraoral photograph of a reddish lesion affecting the soft tissue of the oral cavity. Close-up clinical photo showing redness and crusting on the lower lip and chin area. Close-up view of a furred, red lesion covering the anterior denture bed under the upper prosthesis. Close-up intraoral view of a large, lobulated, white-red lesion on the right buccal mucosa of a patient with yellowed dentition. # Signs and symptoms - **Lump in the neck** - **Mobile teeth** - **Swelling or sore on the lip that won't heal** - **Difficulty or painful swallowing** - **Changes in speech** - **Bleeding or numbness in the mouth** - **White or red patches on the mouth, tongue or gums** - **Unexplained weight loss** This is a typographic pattern composed of rectangular shapes, each containing text in white against a gradient of blue and green colors. --- #### Common Indicators - Lump in the neck - Mobile teeth - Swelling or sore on the lip that won't heal - Difficulty or painful swallowing - Changes in speech - Bleeding or numbness in the mouth - White or red patches on the mouth, tongue or gums - Unexplained weight loss # Investigations * **Biopsy** - removal of a small amount of tissue which is sent to a pathologist to determine if cancer cells are present * **Radiographs** – OPG and chest x-ray * **Imaging** - PET, CT and MRI scans to determine the location, **stage** and spread of cancer * An **flexible** nasal endoscope is used to examine the nose, sinuses, larynx and pharynx #### Diagnostic Procedures - **Biopsy**: Removal of a small amount of tissue sent to a pathologist to determine if cancer cells are present. - **Radiographs**: OPG and chest x-ray. - **Imaging**: PET, CT, and MRI scans to determine the location, stage, and spread of cancer. - **Endoscopy**: A flexible nasal endoscope is used to examine the nose, sinuses, larynx, and pharynx. # Clinical Staging of Head and Neck Cancer (TNM) - Used to designate the extent of disease and to determine the most appropriate treatment for patient - Uniform staging system provides comparisons of results of types of treatment - Helps predict treatment response and outcomes #### Purpose and Utility of TNM Staging - Used to designate the extent of disease and to determine the most appropriate treatment for the patient. - Provides a uniform staging system to allow for comparisons of results across different types of treatment. - Helps predict treatment response and clinical outcomes. # Management * Every patient with oral cancer should be presented at a Multidisciplinary Team (MDT) Meeting * Integrated team approach to healthcare whereby medical and allied health professionals consider all relevant treatment options and collaboratively develop an individual and care plan for each patient   Every patient diagnosed with oral cancer should be presented at a Multidisciplinary Team (MDT) meeting to ensure comprehensive care. #### Collaborative Care Planning - An integrated team approach involves medical and allied health professionals. - All relevant treatment options are considered collaboratively. - An individualized care plan is developed for each patient. A decorative figure consisting of interlocking hexagons on the right side, adjacent to a large black shape containing text. The scene relates to 'Management' principles for oral cancer care. Two interlocking hexagonal outlines in the top-left corner. These are decorative elements related to the general topic of management. | Multi-Disciplinary Team | | :--- | | **Dentist evaluates and treats the mouth and teeth (before, during and after treatment)** | | GP | Head and Neck Surgeon | Radiation oncologist | | Medical Oncologist | Cancer nurse | Dietitian | Speech Pathologist | | Other allied health professionals e.g. social workers, pharmacists, physiotherapist and counsellors | Radiologist | Pathologist |  #### Core MDT Members - **Dentist:** Evaluates and treats the mouth and teeth before, during, and after treatment. - **General Practitioner (GP)** - **Head and Neck Surgeon** - **Radiation Oncologist** - **Medical Oncologist** - **Radiologist** - **Pathologist** #### Nursing and Allied Health Support - **Cancer Nurse** - **Dietitian** - **Speech Pathologist** - **Other Allied Health Professionals:** Social workers, pharmacists, physiotherapists, and counsellors. A multi-disciplinary team diagram listing roles and descriptions such as 'GP', 'Dentist evaluates and treats the mouth and teeth (before, during and after treatment)', 'Radiation oncologist', and 'Other allied health professionals'. # Treatment - Curative versus palliative - **Surgery** – primary modality of treatment for oral cancer. Removes tumour and lymph nodes - Adjuvant radiotherapy depends on pathological staging, surgical margins and nodal status - Radiotherapy used on its own to treat when organ preservation e.g. oropharyngeal cancers. Used concurrently with chemotherapy - Chemotherapy – standard of care in locally advanced head and neck SCC #### Primary Treatment Goals - **Curative:** Aimed at eliminating the disease. - **Palliative:** Aimed at symptom relief and quality of life. #### Surgical Intervention - Surgery is the primary modality of treatment for oral cancer. - It involves the removal of the tumor and associated lymph nodes. #### Radiation and Chemotherapy - **Adjuvant Radiotherapy:** Utilized based on pathological staging, surgical margins, and nodal status. - **Primary Radiotherapy:** Used as a standalone treatment for organ preservation (e.g., oropharyngeal cancers), often concurrently with chemotherapy. - **Chemotherapy:** Considered the standard of care in locally advanced head and neck squamous cell carcinoma (SCC). ```html <table border="1"> <tr> <th>Cancer</th> <td>Diagnosis, prognosis <br>Treatment modality <br>Radiation fields <br>Start dates</td> </tr> <tr> <td>Patient</td> <td>Treatment goals <br>Socio-economic factors <br>Quality of life <br>Motivation</td> </tr> <tr> <td>Oral Health</td> <td>Dental history <br>Oral hygiene <br>Maintenance ability</td> </tr> <tr> <td>Dentition</td> <td>State of dentition <br>Existing oral health <br>Future rehabilitation potential and considerations</td> </tr> </table> ```  #### Clinical Assessment Factors - **Cancer Factors** - Diagnosis and prognosis - Treatment modality - Radiation fields - Treatment start dates - **Patient Factors** - Treatment goals - Socio-economic factors - Quality of life - Motivation - **Oral Health Factors** - Dental history - Oral hygiene - Maintenance ability - **Dentition Factors** - State of dentition - Existing oral health - Future rehabilitation potential and considerations A structured table detailing pre-treatment dental assessment factors, categorized into sections like Cancer, Patient, Oral Health, and Dentition. # During radiotherapy and chemotherapy * **Changes in taste** * **Oral hygiene maintenance – mucositis** * **Systemic considerations – pancytopenia, opportunistic infections** #### Clinical Considerations During Active Treatment - **Changes in taste:** Common side effect during therapy. - **Oral hygiene maintenance:** Managing complications such as mucositis. - **Systemic considerations:** Monitoring for pancytopenia and opportunistic infections. # Post treatment dental management ## Regular review and maintenance Regular review and maintenance are crucial to ensure the longevity and functionality of dental restorations and procedures. This involves periodic check-ups and necessary adjustments or repairs as needed. ## Motivation Motivation is key in encouraging patients to adhere to their post-treatment care guidelines. It involves fostering a positive mindset towards oral health and providing support and education to help patients stay on track with their dental management plan.   #### Regular Review and Maintenance Regular review and maintenance are crucial to ensure the longevity and functionality of dental restorations and procedures. This involves periodic check-ups and necessary adjustments or repairs as needed. #### Patient Motivation Motivation is key in encouraging patients to adhere to their post-treatment care guidelines. It involves fostering a positive mindset towards oral health and providing support and education to help patients stay on track with their dental management plan. Icon of crossed tools, representing regular review and maintenance in the context of post-treatment dental management. Icon of a head with gears, symbolizing motivation for patients in post-treatment dental management. # Recommendations for dental follow-up * Initially 3 monthly review for caries and periodontal management * Once oral condition stabilize, 6 monthly recalls – look out for mucosal changes, xerostomia, candidiasis, changes in occlusion * Fluoride at each recall – Neutrafluor 5000 toothpaste and fluoride varnish #### Clinical Follow-Up Schedule - **Initial Phase:** 3-monthly reviews focusing on caries and periodontal management. - **Stabilization Phase:** Once the oral condition stabilizes, move to 6-monthly recalls. #### Monitoring and Prevention - **Screening:** During recalls, monitor for: - Mucosal changes - Xerostomia - Candidiasis - Changes in occlusion - **Fluoride Therapy:** Administer at each recall, including Neutrafluor 5000 toothpaste and fluoride varnish. | Surgery | Primary modality of treatment for oral cancer | Ablation and neck dissection | Reconstruction | | :--- | :--- | :--- | :--- |  Surgery serves as the primary modality of treatment for oral cancer. The surgical process is generally divided into three main components: - **Ablation**: The surgical removal of the primary tumor. - **Neck Dissection**: The management and removal of regional lymph nodes. - **Reconstruction**: The restoration of form and function following tissue loss. A flowchart-style diagram illustrating the surgical process for oral cancer treatment. It consists of three horizontal blocks starting with 'Primary modality of treatment for oral cancer', followed by 'Ablation and neck dissection', and concluding with 'Reconstruction', outlining the sequential steps in the procedure. # Assessment in oral cancer ## Utility of CT and MRI in assessment of mandibular involvement in oral cavity cancer **Andreea Nae**<sup>1</sup>, **Gerard O'Leary**<sup>1</sup>, **Linda Feeley**<sup>2</sup>, **Cassie Fives**<sup>2</sup>, **Brendan Fitzgerald**<sup>2</sup>, **Elena Chiriac**<sup>3</sup>, **Patrick Sheahan**<sup>1</sup> *World J Otorhinolaryngol Head Neck Surg* 2019 Mar 22; 5(2): 71–75 *The results suggest that combined CT and MRI have diagnostic utility in detecting mandibular invasion by oral cancer, but with significant false positive rate* #### Diagnostic Utility of Imaging Research into the utility of CT and MRI for assessing mandibular involvement in oral cavity cancer (Nae et al., 2019) indicates the following: - Combined CT and MRI have diagnostic utility in detecting mandibular invasion by oral cancer. - These imaging modalities are associated with a significant false positive rate. # Outcomes | ✓ | **Histological grading** is a significant predictor for treatment failure and recurrence | | :--- | :--- | | 🧬 | **Tumour** size and lymph node status are also prognostic factors |   #### Prognostic Factors for Treatment Failure Several factors serve as significant predictors for recurrence and treatment failure in oral cancer: - **Histological Grading**: Acts as a significant predictor for treatment failure and recurrence. - **Tumor Size**: A critical prognostic factor in patient outcomes. - **Lymph Node Status**: A key indicator for determining prognosis. Orange panel with a checkmark icon and text stating that histological grading is a significant predictor for treatment failure and recurrence. Grey panel with a DNA helix icon and text indicating that tumor size and lymph node status are also prognostic factors. ### Slide Title # Surgery The Effect of the Surgical Margins on the Outcome of Patients with Head and Neck Squamous Cell Carcinoma ### Key Definitions & Findings **Consider margins of $5\text{ mm}$ and $>$ as clear, $1\text{--}5\text{ mm}$ as close and $< 1\text{mm}$ as involved.** There is significant impact of positive surgical margins on the outcome in recurrence rate and overall survival. **Adjuvant radiotherapy/chemotherapy cannot fully compensate for the close and positive margins.**    #### Margin Definitions and Impact Surgical margins are categorized based on the distance between the tumor and the edge of the resected tissue: - **Clear Margins**: 5 mm or greater. - **Close Margins**: 1 mm to 5 mm. - **Involved (Positive) Margins**: Less than 1 mm. #### Clinical Implications - Positive surgical margins have a significant negative impact on recurrence rates and overall survival. - Adjuvant radiotherapy or chemotherapy cannot fully compensate for the presence of close or positive margins. A large orange abstract geometric shape serves as a decorative sidebar element for the 'Surgery' section title on the left side of the slide. A slide containing text discussing surgical margins for Head and Neck Squamous Cell Carcinoma. It defines clear (>=5 mm), close (1-5 mm), and involved (<1 mm) margins and notes the adverse impact of positive margins on survival. A series of yellow, dotted line dashes located in the bottom right corner, likely serving as a visual accent or page break element. # Surgical margins **What is the adequate margin of surgical resection in oral cancer?** **Richard W Nason**, Abdulaziz Binahmed, Kumar A Pathak, Ahmed A Abdoh, George K B Sándor *Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009 May;107(5):625–9* > *Survival improves with each additional millimeter of clear surgical margin. This systematic evaluation of surgical margins suggests that an adequate resection in oral cancer should provide a margin of greater than 3 mm on permanent pathology section.* #### Determining Adequate Resection Margins Systematic evaluation of surgical margins (Nason et al., 2009) suggests the following regarding survival and pathology: - Patient survival improves with each additional millimeter of clear surgical margin. - An adequate resection in oral cancer should provide a margin of greater than 3 mm on the permanent pathology section. - Radical neck first described by Crile in 1906, involved removal of all lymphatic structures between mandible and clavicles - Shah stratified cervical lymph nodes into 6 group levels - Currently, selective neck dissection with the preservation of non-lymphatic structures  #### Evolution of Neck Dissection - **Radical Neck Dissection**: First described by Crile in 1906, this procedure involved the removal of all lymphatic structures between the mandible and the clavicles. - **Nodal Stratification**: Shah stratified cervical lymph nodes into six group levels to better organize surgical approaches. - **Modern Approach**: Current practice favors selective neck dissection, which focuses on the preservation of non-lymphatic structures. An anatomical illustration of the human neck showing cervical lymph node levels labeled IA, IB, II, III, IV, V, and VI according to Shah's stratification. # Surgery – ablation and neck dissection <img width="422" height="239" alt="surgery – ablation and neck dissection" src="https://i.imgur.com/YVjYq5W.jpeg"/> > **Surgery – ablation and neck dissection**  The surgical management of oral cancer involves a coordinated approach of tumor ablation and neck dissection to ensure regional control of the disease. A close-up surgical photo depicting a procedure involving the neck. An instrument is visible on the left, and the text overlay identifies the procedure as 'ablation and neck dissection'. ### **Head and neck cancer** 1. **After resection, more than 50% of the resection require reconstructions of the defect** 2. **This may involve soft tissue reconstruction or involve a bony reconstruction** 3. **Maxillomandibular resection may involve a rim (marginal) or complete segment (segmental)** 4. **A marginal mandibulectomy can be reconstructed with local flaps or skin graft, whereas a segmental mandibulectomy requires an osteocutaneous flap** #### Reconstruction Requirements and Techniques 1. After resection, more than 50% of cases require reconstruction of the resulting defect. 2. Reconstruction may involve soft tissue alone or include bony reconstruction. 3. Maxillomandibular resection is classified by the extent of bone removal: - **Marginal (Rim) Resection**: Removal of a portion of the bone. - **Segmental Resection**: Removal of a complete segment of the bone. 4. Reconstruction methods vary by the type of resection: - A marginal mandibulectomy can be reconstructed using local flaps or skin grafts. - A segmental mandibulectomy requires an osteocutaneous flap. # Reconstruction ### LADDER ## FREE FLAPS * **RESTORATIVE FLAPS** * ZINN FLAP * GABARUS FLAP * SCHENKEL FLAP ## REGIONAL FLAPS * FREE FLAPS * PIC VLAST ## LOCAL FLAPS * **PIBCAA** (BUCVLA) * PIC VLAST ## SKIN GRAFT * BICAM (SHE) ## PRIMARY CLOSURE * PIC VLAST ## SECONDARY HEALING * INJECT AND CLOSURE * INJECT AND CLOSURE --- **COMPLEX** : TREATMENT **SIMPLE** : TREATMENT  #### Reconstructive Ladder Hierarchy The selection of reconstruction techniques follows a progressive ladder from simple to complex treatments: - **Secondary Healing** - Inject and closure - **Primary Closure** - **Skin Graft** - **Local Flaps** - **Regional Flaps** - **Free Flaps (Restorative Flaps)** A 'RECONSTRUCTION LADDER' diagram illustrating a hierarchy of medical treatment methods. The y-axis represents complexity, moving from 'SIMPLE' to 'COMPLEX' treatments as one moves up the ladder. The levels listed in order of increasing complexity include 'Secondary Healing', 'Primary Closure', 'Skin Graft', 'Local Flaps', 'Regional Flaps', and 'Free Flaps'. # T1 SCC Lateral tongue ## Primary closure <img src="path_to_image" alt="T1 SCC Lateral tongue Primary closure">   #### T1 SCC Lateral Tongue - Primary closure is utilized for small defects such as T1 Squamous Cell Carcinoma (SCC) of the lateral tongue. A medical photograph of the oral cavity showing the lateral tongue. It is labeled 'T1 SCC Lateral tongue', depicting a cancerous lesion on the right side, which is being retracted by a gloved finger. A medical photograph of the oral cavity following the procedure mentioned in the text, 'Primary closure'. The image shows the mouth with a surgically repaired tongue area.  A medical photograph showing an intraoperative view of a patient's face. The image depicts a 'Facial artery musculomucosal (FAMM) flap' procedure as labeled in the text on the left, with the mouth held open by metal retractors. # Regional flap **Temporalis muscle flap**   #### Regional Flap Options - **Temporalis muscle flap**: A regional flap used in head and neck reconstruction. A profile view photograph of an elderly person's face, with a solid blue square obscuring their eye area. The image is captioned 'Regional flap' and specifically identifies the 'Temporalis muscle flap'. A close-up photograph inside a person's mouth, showing the gingiva and teeth with signs of inflammation and small lesions. This image relates to the context of a 'Regional flap' procedure. # Reconstruction ## Timeline of Reconstruction Progress | Year | Event | | :--- | :--- | | Before 1950s | Before 1950s, resected cancer was left without reconstruction | | 1965 | In 1965, Bakamjian first described the deltopectoral flap | | 1973 | In 1973, Daniel and Taylor reported the first free flap which involved removal of tissue from the donor site and transplantation to another site of the body with anastomosis of the vessels | | 1976 | In 1976, Panje and Harashina simultaneously described the use of free flaps to reconstruct defects of the oral cavity | | 1979 | In 1979, Ariyan described the pedicled pectoralis major myocutaneous flap | | 1990s | In the 1990s, free flap was the dominant technique for cancer defect reconstruction. The use of **osteocutaneous free flaps** to reconstruct mandibular defects was advanced |  #### Timeline of Reconstruction Progress - **Before 1950s**: Resected cancer was typically left without reconstruction. - **1965**: Bakamjian first described the deltopectoral flap. - **1973**: Daniel and Taylor reported the first free flap, involving tissue removal from a donor site and transplantation to another site with vascular anastomosis. - **1976**: Panje and Harashina simultaneously described the use of free flaps for oral cavity reconstruction. - **1979**: Ariyan described the pedicled pectoralis major myocutaneous flap. - **1990s**: Free flaps became the dominant technique for cancer defect reconstruction, specifically advancing the use of osteocutaneous free flaps for mandibular defects. A timeline diagram illustrating the historical progression of cancer reconstruction techniques. The vertical axis is labeled 'Reconstruction'. ## Challenges in jaw reconstruction Malposition of the bone graft can negatively affect * facial symmetry * appearance * support * occlusal function * masticatory movement * dental rehabilitation <!-- Image (582, 142, 888, 843) -->  #### Impact of Bone Graft Malposition Incorrect positioning of bone grafts can lead to significant negative outcomes, including: - Impaired facial symmetry and appearance - Loss of structural support - Compromised occlusal function and masticatory movement - Difficulties in dental rehabilitation A photograph showing the lower face of a patient, likely illustrating the concept of jaw reconstruction or asymmetry. A blue bar obscures the eyes, and the image is paired with a list detailing challenges such as 'facial symmetry' and 'appearance' mentioned in the OCR text. # Inferior Jaw reconstruction * Incorrect positioning of the fibular free flap * Inadequate fixation of the bone graft <img src="1689731152-34.jpg" alt="X-ray image showing inferior jaw reconstruction with surgical hardware and incorrect positioning of the fibular free flap.">  #### Inferior Jaw Reconstruction Risks - Incorrect positioning of the fibular free flap. - Inadequate fixation of the bone graft. X-ray image showing inferior jaw reconstruction with surgical hardware and incorrect positioning of the fibular free flap. # Surgical planning * **3D printing first described by Hideo Kodama in 1981 when he started manufacturing 3D plastic models** * **Surgical planning was improved, which facilitated resection, flap harvesting, and graft positioning**   #### Evolution of 3D Planning - **1981**: 3D printing was first described by Hideo Kodama, beginning with the manufacture of 3D plastic models. - **Advancements**: Improved surgical planning has facilitated more precise resection, flap harvesting, and graft positioning. A blue highlighted figure detailing the history of 3D printing, noting it was first described by Hideo Kodama in 1981. A green highlighted figure explaining how 3D printing improved surgical planning, specifically facilitating resection, flap harvesting, and graft positioning. | Surgical planning | | :--- | | increased accuracy, | | improved bone to bone contact, | | decreased operating room time, | | lower surgeon stress, | | reduced ischemia time in the microvascular free flap reconstruction | | enhanced treatment outcome | #### Benefits of Surgical Planning - Increased accuracy - Improved bone-to-bone contact - Decreased operating room time - Lower surgeon stress - Reduced ischemia time in microvascular free flap reconstruction - Enhanced treatment outcomes   A composite image featuring a close-up clinical photograph of a mandibular ulcer or lesion on the left side, and a panoramic dental X-ray (OPG) on the right. The caption for the figure, displaying the text 'Mandibular SCC' which identifies the condition shown in the medical photos and X-ray. <p align="center"> <img src="https://files.oaiusercontent.com/file-2Vhkir1+ijOqGBHWpl0KyF?se=2025-01-05T01%3A08%3A16Z&sp=r&sv=2024-08-04&sr=b&rscc=max-age=%2710800%27%2C%20retry-after=%270%27%2C%20max-stale=%27%27%2C%20must-revalidate&rscd=cache-control%3Dmax-age%3D10800&sig=q3iNq9t2bqL4fiwoh3QyD1s3%2BKtePwTVMWt0riZx8zk%3D" alt="Figure 1" width="600" /> </p>  A medical scan, specifically a CT angiogram of two lower legs. The image features technical text overlays including 'PRE-SURGICAL ASSESSMENT' and 'Angiography'. **PLANNING THE RESECTION** Preoperative high-resolution computed tomography (CT) <img src="URL_OF_IMAGE" alt="CT scan of a patient's neck showing anatomical structures including the jawbone, vertebrae, and airway">  #### Preoperative Imaging - Preoperative high-resolution computed tomography (CT) is essential for planning the resection. A medical photograph of an axial computed tomography (CT) scan. The text to the left identifies the image as 'Preoperative high-resolution computed tomography (CT)' for 'planning the resection'. The scan depicts a cross-section of a patient's neck, clearly showing bright white bone structures of the jaw and spine against the darker grey of surrounding soft tissue. # Surgical simulation and planning PROPLAN CMP® Graft Design, Stereolithographic Guide Designed for: [Name] [Image showing a person holding a printed document with anatomical illustrations and text, including the "PROPLAN CMP" logo] !</img> Case 0: M Case Num: ric Paln: Mandible reconstruction with PSP Mandible  [Image on the right side showing how the PSP Mandible reconstruction guides are designed based on the patient's asymmetry, comparing the patient's anatomy to a virtual "average paw" geometry.</img>   #### Simulation and Design Tools - **PROPLAN CMP®**: Software used for graft design and stereolithographic guide creation. - **PSP Mandible**: Patient-specific planning for mandible reconstruction designed based on individual patient asymmetry compared to virtual anatomical standards. A person holding a printed document labeled 'PROPLAN CMP' which features a grant design guide and text. Computer-generated medical diagrams showing a cranial reconstruction simulation, including a vertical view and an upper view of the Mandible. **SURGICAL TEMPLATE** **3D printed surgical template fabricated to guide the procedure of tumour resection**  #### Surgical Templates - 3D printed surgical templates are fabricated to guide the precise procedure of tumor resection. A 3D medical illustration showing a surgical template (in white) fitted onto biological tissue (in red and purple) to assist in tumour resection.  A medical illustration of a lower leg skeleton (tibia and fibula) under the 'SURGICAL PLANNING' heading. The image displays anatomical measurements with specific values like 47.3mm, 28.1mm, 56.9mm, and 25.6mm overlaid on the model.  A medical radiograph or X-ray image displaying a post-surgical jaw, identified by the title 'Post op OPG' at the top. The image shows the result of a mandibular surgery with metal plates and screws I framed along the jawbone, with visible text overlays containing technical data. # POST OP ### PHOTO <p align="center"> **<img title="Post Op Photo taken on the right side of the subject's face" src="https://i.postimg.cc/zj4X52FF/Screenshot-2025-01-30-221826.png" height="666px" alt="Post Op Photo taken on the right side of the subject's face"> ** </p>  #### Post-Operative Documentation - Clinical photography is used to document post-operative results and facial symmetry. A side profile photograph of an older male subject in a post-operative state, labelled in the document context as 'POST OP PHOTO'. The patient is shown turning their head to the right, wearing a pink shirt, with the eye area digitally masked for privacy. ### Scapular Flap  ### Osteocutaneous Flap  - **Scapular Flap**: Image shows a person with a flap on their lower lip and chin area. - **Osteocutaneous Flap**: Image shows a person with a flap on their face, specifically around the mouth and chin area.      #### Flap Selection for Facial Defects - **Scapular Flap**: Utilized for reconstruction of the lower lip and chin area. - **Osteocutaneous Flap**: Applied to complex defects involving the mouth and chin area requiring both bone and skin. Photo showing a person with a flap on their lower lip and chin area, referenced as the 'Scapular Flap'. Photo showing a person with a flap on their face, specifically around the mouth and chin area, labeled as the 'Osteocutaneous Flap'. Photo showing a person with a flap on their lower lip and chin area, referenced as the 'Scapular Flap'. Photo showing a person with a flap on their face, specifically around the mouth and chin area, labeled as the 'Osteocutaneous Flap'. Photo showing a person with a flap on their lower lip and chin area, referenced as the 'Scapular Flap'. # Pre-op assessment ## Allen's test   #### Pre-operative Assessment - **Allen's Test**: Performed as part of the pre-operative assessment to ensure adequate collateral circulation before harvesting certain flaps (e.g., radial forearm). Photo of a patient's hand resting on a blue surgical drape, showing redness on the wrist and knuckles. The OCR text labels this as 'Pre-op assessment Allen's test'. ## Marginal mandibulectomy **Radial forearm free flap reconstruction** <img src="image.jpg" alt="Image" />   #### Marginal Mandibulectomy Reconstruction - **Radial forearm free flap**: A common choice for reconstruction following a marginal mandibulectomy. X-ray of the lower jaw showing a marginal mandibulectomy and a radial forearm free flap reconstruction. The image highlights the jawbone and multiple filled teeth. Photo of a patient's mouth, focusing on the teeth and gums following a radial forearm free flap reconstruction. The image also captures a blue gloved hand from a medical professional.   A portrait of a woman with short blonde hair, whose eyes are obscured by a blue rectangle. The image is situated above the text 'Restoring form and function'. A close-up of a person's arm and hand, displaying a surgical scar with slight redness. This photo is placed above the text 'Minimal surgical morbidity'. Reconstruction and oral rehabilitation <img src="OMMjcHgtjqw.jpeg" alt="Description of the image"/>   #### Integrated Rehabilitation - The final goal of treatment is the successful integration of surgical reconstruction and functional oral rehabilitation. A close-up photograph of a patient's mouth showing oral structures and potentially a prosthetic or surgical site, under the heading 'Reconstruction and oral rehabilitation'. A clinical X-ray or scan image likely depicting oral structures relevant to reconstruction, placed beside the photograph under the main title 'Reconstruction and oral rehabilitation'. # QUALITY OF LIFE : * Individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns   Quality of Life (QoL) is defined as an individual's perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns. A graphic illustration of a red and white ribbon, commonly used as a symbol for awareness campaigns. It is positioned next to the text block defining 'QUALITY OF LIFE'. <table> <thead> <tr> <th>Outcome</th> <th>None (Mean Score)</th> <th>Mild (Mean Score)</th> <th>Moderate-severe (Mean Score)</th> </tr> </thead> <tbody> <tr> <td>Eating</td> <td>~70</td> <td>~58</td> <td>~45</td> </tr> <tr> <td>Speech</td> <td>~82</td> <td>~70</td> <td>~56</td> </tr> <tr> <td>Aesth</td> <td>~85</td> <td>~75</td> <td>~56</td> </tr> <tr> <td>Soc Disrupt</td> <td>~91</td> <td>~86</td> <td>~61</td> </tr> <tr> <td>Physical</td> <td>~50</td> <td>~47</td> <td>~39</td> </tr> <tr> <td>Mental</td> <td>~52</td> <td>~49</td> <td>~40</td> </tr> <tr> <td>Overall QOL</td> <td>~80</td> <td>~72</td> <td>~50</td> </tr> </tbody> </table>  #### Mean Outcome Scores by Severity | Outcome | None | Mild | Moderate-Severe | | :--- | :---: | :---: | :---: | | Eating | ~70 | ~58 | ~45 | | Speech | ~82 | ~70 | ~56 | | Aesthetics | ~85 | ~75 | ~56 | | Social Disruption | ~91 | ~86 | ~61 | | Physical | ~50 | ~47 | ~39 | | Mental | ~52 | ~49 | ~40 | | Overall QOL | ~80 | ~72 | ~50 | A bar chart displaying 'Mean Score' (y-axis) versus 'Outcome' (x-axis) for Quality of Life (QOL), with categories like Eating, Speech, and Soc Disrupt. Three shades represent groups: None (lightest), Mild, and Moderate-severe (darkest). Scores decrease from None to Moderate-severe for all outcomes, often below 100, with values roughly matching the provided table, indicating a correlation between symptom severity and QOL score. based on image text (which describes the pdf menu): | * 1. Pain | | :--- | | * 2. Appearance | | * 3. Activity | | * 4. Recreation | | * 5. Swallowing | | * 6. Chewing | | * 7. General questions | | * a) Health Related QoL month before developing cancer | | * b) Health Related QoL during past 7 days | | * c) Overall QoL | from the pdf context: **UNIVERSITY OF WASHINGTON** **QUALITY OF LIFE QUESTIONNAIRE** **1. Pain** **2. Appearance** **3. Activity** **4. Recreation** **5. Swallowing** **6. Chewing** **7. General questions** a) **Health Related QoL month before developing cancer** b) **Health Related QoL during past 7 days** c) **Overall QoL** #### University of Washington Quality of Life Questionnaire The questionnaire assesses the following domains: 1. Pain 2. Appearance 3. Activity 4. Recreation 5. Swallowing 6. Chewing #### General Assessment Questions - **Health-Related QoL:** Assessment of the month before developing cancer. - **Recent Health-Related QoL:** Assessment during the past 7 days. - **Overall QoL:** General perception of current quality of life. # QOL BY TREATMENT **2 issues most important to patients were activity and mood** **A greater proportion of those who received adjuvant radiotherapy rated QoL as worse than at diagnosis compared to those who received primary surgery only - this group experienced more pain and poorer swallowing**   #### Patient Priorities and Treatment Impact - **Primary Patient Concerns:** The two issues identified as most important to patients are activity and mood. - **Adjuvant Radiotherapy:** A greater proportion of patients who received adjuvant radiotherapy rated their Quality of Life as worse than at the time of diagnosis compared to those who received primary surgery only. - **Symptom Burden:** The radiotherapy group experienced higher levels of pain and poorer swallowing function. This block presents key findings on Quality of Life (QoL), stating that the two most important issues for patients were activity and mood. This block notes that those who received adjuvant radiotherapy had worse QoL ratings than the primary surgery-only group, specifically citing more pain and poorer swallowing. # QOL > "Health related QoL in treatment planning, and more personalised follow-up support" > "Results can be invaluable when counselling patients with a new diagnosis" <img src="placeholder_figure.png" alt="Slide layout with two overlapping stylized blue boxes containing the above text">   #### Clinical Application of QoL Data - **Treatment Planning:** Health-related Quality of Life data should be integrated into treatment planning and used to provide more personalized follow-up support. - **Patient Counseling:** These results are invaluable when counseling patients with a new diagnosis regarding their expectations and potential outcomes. A stylized graphic element consisting of overlapping dark blue and light gray rectangles containing the text: 'Health related QoL in treatment planning, and more personalised follow-up support'. This figure is part of a slide layout explaining benefits of QoL assessment. A stylized graphic element featuring overlapping dark blue and light gray rectangles with the text: 'Results can be invaluable when counselling patients with a new diagnosis'. This figure accompanies the theme 'QOL' on the slide. Questions ? [^1]: Original PDF page 1: [[W3 Oral Cancer.pdf#page=1|W3 Oral Cancer, p.1]] [^2]: Original PDF page 2: [[W3 Oral Cancer.pdf#page=2|W3 Oral Cancer, p.2]] [^3]: Original PDF page 3: [[W3 Oral Cancer.pdf#page=3|W3 Oral Cancer, p.3]] [^4]: Original PDF page 4: [[W3 Oral Cancer.pdf#page=4|W3 Oral Cancer, p.4]] [^5]: Original PDF page 5: [[W3 Oral Cancer.pdf#page=5|W3 Oral Cancer, p.5]] [^6]: Original PDF page 6: [[W3 Oral Cancer.pdf#page=6|W3 Oral Cancer, p.6]] [^7]: Original PDF page 7: [[W3 Oral Cancer.pdf#page=7|W3 Oral Cancer, p.7]] [^8]: Original PDF page 8: [[W3 Oral Cancer.pdf#page=8|W3 Oral Cancer, p.8]] [^9]: Original PDF page 9: [[W3 Oral Cancer.pdf#page=9|W3 Oral Cancer, p.9]] [^10]: Original PDF page 10: [[W3 Oral Cancer.pdf#page=10|W3 Oral Cancer, p.10]] [^11]: Original PDF page 11: [[W3 Oral Cancer.pdf#page=11|W3 Oral Cancer, p.11]] [^12]: Original PDF page 12: [[W3 Oral Cancer.pdf#page=12|W3 Oral Cancer, p.12]] [^13]: Original PDF page 13: [[W3 Oral Cancer.pdf#page=13|W3 Oral Cancer, p.13]] [^14]: Original PDF page 14: [[W3 Oral Cancer.pdf#page=14|W3 Oral Cancer, p.14]] [^15]: Original PDF page 15: [[W3 Oral Cancer.pdf#page=15|W3 Oral Cancer, p.15]] [^16]: Original PDF page 16: [[W3 Oral Cancer.pdf#page=16|W3 Oral Cancer, p.16]] [^17]: Original PDF page 17: [[W3 Oral Cancer.pdf#page=17|W3 Oral Cancer, p.17]] [^18]: Original PDF page 18: [[W3 Oral Cancer.pdf#page=18|W3 Oral Cancer, p.18]] [^19]: Original PDF page 19: [[W3 Oral Cancer.pdf#page=19|W3 Oral Cancer, p.19]] [^20]: Original PDF page 20: [[W3 Oral Cancer.pdf#page=20|W3 Oral Cancer, p.20]] [^21]: Original PDF page 21: [[W3 Oral Cancer.pdf#page=21|W3 Oral Cancer, p.21]] [^22]: Original PDF page 22: [[W3 Oral Cancer.pdf#page=22|W3 Oral Cancer, p.22]] [^23]: Original PDF page 23: [[W3 Oral Cancer.pdf#page=23|W3 Oral Cancer, p.23]] [^24]: Original PDF page 24: [[W3 Oral Cancer.pdf#page=24|W3 Oral Cancer, p.24]] [^25]: Original PDF page 25: [[W3 Oral Cancer.pdf#page=25|W3 Oral Cancer, p.25]] [^26]: Original PDF page 26: [[W3 Oral Cancer.pdf#page=26|W3 Oral Cancer, p.26]] [^27]: Original PDF page 27: [[W3 Oral Cancer.pdf#page=27|W3 Oral Cancer, p.27]] [^28]: Original PDF page 28: [[W3 Oral Cancer.pdf#page=28|W3 Oral Cancer, p.28]] [^29]: Original PDF page 29: [[W3 Oral Cancer.pdf#page=29|W3 Oral Cancer, p.29]] [^30]: Original PDF page 30: [[W3 Oral Cancer.pdf#page=30|W3 Oral Cancer, p.30]] [^31]: Original PDF page 31: [[W3 Oral Cancer.pdf#page=31|W3 Oral Cancer, p.31]] [^32]: Original PDF page 32: [[W3 Oral Cancer.pdf#page=32|W3 Oral Cancer, p.32]] [^33]: Original PDF page 33: [[W3 Oral Cancer.pdf#page=33|W3 Oral Cancer, p.33]] [^34]: Original PDF page 34: [[W3 Oral Cancer.pdf#page=34|W3 Oral Cancer, p.34]] [^35]: Original PDF page 35: [[W3 Oral Cancer.pdf#page=35|W3 Oral Cancer, p.35]] [^36]: Original PDF page 36: [[W3 Oral Cancer.pdf#page=36|W3 Oral Cancer, p.36]] [^37]: Original PDF page 37: [[W3 Oral Cancer.pdf#page=37|W3 Oral Cancer, p.37]] [^38]: Original PDF page 38: [[W3 Oral Cancer.pdf#page=38|W3 Oral Cancer, p.38]] [^39]: Original PDF page 39: [[W3 Oral Cancer.pdf#page=39|W3 Oral Cancer, p.39]] [^40]: Original PDF page 40: [[W3 Oral Cancer.pdf#page=40|W3 Oral Cancer, p.40]] [^41]: Original PDF page 41: [[W3 Oral Cancer.pdf#page=41|W3 Oral Cancer, p.41]] [^42]: Original PDF page 42: [[W3 Oral Cancer.pdf#page=42|W3 Oral Cancer, p.42]] [^43]: Original PDF page 43: [[W3 Oral Cancer.pdf#page=43|W3 Oral Cancer, p.43]] [^44]: Original PDF page 44: [[W3 Oral Cancer.pdf#page=44|W3 Oral Cancer, p.44]] [^45]: Original PDF page 45: [[W3 Oral Cancer.pdf#page=45|W3 Oral Cancer, p.45]] [^46]: Original PDF page 46: [[W3 Oral Cancer.pdf#page=46|W3 Oral Cancer, p.46]] [^47]: Original PDF page 47: [[W3 Oral Cancer.pdf#page=47|W3 Oral Cancer, p.47]] [^48]: Original PDF page 48: [[W3 Oral Cancer.pdf#page=48|W3 Oral Cancer, p.48]] [^49]: Original PDF page 49: [[W3 Oral Cancer.pdf#page=49|W3 Oral Cancer, p.49]] [^50]: Original PDF page 50: [[W3 Oral Cancer.pdf#page=50|W3 Oral Cancer, p.50]] [^51]: Original PDF page 51: [[W3 Oral Cancer.pdf#page=51|W3 Oral Cancer, p.51]]