Holtzclaw et alFigure 5-5: BioXclude placement. Figure 5-6: Suture placement.Figure 5-7: 2 weeks. Figure 5-8: 45 days. Discussion tal ridge resorption may be reduced by 125% and vertical resorption may be reduced by 244%.3Dimensional changes in ridge morphology fol- Use of barrier membranes such as BioXclude™lowing extraction of teeth can drastically affect helps the process of site preservation throughfuture treatment options. Studies have shown rapid closure of the surgical site. This seals thethat alveolar ridge width may decrease by up to underlying graft from harmful bacteria of the oralfifty percent within 12 months of tooth extraction cavity, aiding bone and gingival tissue maturation.and that the majority of this loss occurs within thefirst 3 months.2,3 These negative changes can BioXclude™ is a processed, dehydrated, andbe avoided through the process of site preserva- sterilized graft of human placenta amnion andtion. By simply grafting the tooth socket and any chorion tissue. Human placental tissue is immu-residual defects at the time of extraction, horizon- noprivileged and, as such, does not elicit a foreign The Journal of Implant & Advanced Clinical Dentistry • 49
Holtzclaw et albody inflammatory response.4 This membrane Disclosure:differs from other membranes currently available Dr. Holtzclaw is a member of the clinical advisory board for Snoasis Medical.in the fact that it has inherent anti-inflammatoryand anti-bacterial properties.5 Additionally, this References:membrane also contains high amounts of lam- 1. S hulman L. Surgical considerations in implant dentistry. Int J Oral Implantolinin-5 in the amnion layer of the graft. Laminin-5is a protein with a high affinity for cellular adhe- 1988; 5:37-41.sion of gingival epithelial cells6, providing a bio-active matrix for cellular migration. This allows 2. S chropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissuefor rapid sealing of the underlying graft material contour changes following single tooth extraction: a clinical and radiographicused for site preservation. Furthermore, immu- 12-month prospective study. Int J Peridontics Restorative Dent 2003;nohistochemical stain analysis of BioXclude™ 23(4):313-323.has also shown the membrane to contain growthfactors such as platelet derived growth fac- 3. Iasella J, Greenwell H, Miller R, Hill M, Drisko C, Bohra A, Scheetz J. Ridgetors alpha and beta (PDGF-α, PDGF-β) as well preservation with freeze dried bone allograft and a collagen membraneas transforming growth factor beta (TGF-β). compared to extraction site alone for implant site development: a clinical and histologic study in humans. J Perioodontol 2003; 74(7):990-999. In addition to its unique composition advan-tages, BioXclude™ has other benefits as well. 4. C hen E, Tofe A. A literature review of the safety and biocompatibil-BioXclude™ is relatively thin (300µm) with self- ity of amnion tissue. J Implant Adv Clin Dent 2009; 2(3):67-75.adhering properties once it becomes moist. Thiseliminates the need for suturing of the membrane. 5. P ark C, Kahanim S, Zhu L et al. Immunosuppressive property of driedSimply place the membrane into the extraction human amniotic membrane. Opthalmic Res 2009; 41:112-113.socket during site preservation procedures andBioXclude™ practically seals itself to the socket. 6. P akkala, T Virtanen I, Oksanen J, et al. Function of laminins and laminin-binding integrins in gingival epithelial cell adhesion. J Periodontol 2002; 73(7):709-719. This case report demonstrates proof of prin-ciple that BioXclude™ is an effective product forsite preservation procedures. The unique proper-ties of this membrane combined with its ease ofuse make it an ideal product for this procedure. ● Correspondence: Dr. Dan Holtzclaw 711 W. 38th Street Suite G5 Austin, TX 78705, USA [email protected] • Vol. 3, No. 3 • March/April 2011
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Decoronation for Ridge Abu-Saleh Preservation in Implant Dentistry:A Clinical Technique and Case ReportDr. Tareq Abu-Saleh1 AbstractBackground: Several methods have been Results: Clinical and radiographic findings wereadvocated to compensate for bone loss in ante- reported in one year follow-up visit and were sat-rior maxilla and achieve satisfactory esthetic isfactory in terms of preservation of bone dimen-results in implant treatment. Some of these sions horizontally and vertically. Another findingmodalities are considered time consuming, tech- was the coronal growth of interseptal bone whichnique sensitive, expensive, and unpredictable. allowed for reformation of interdental papillae.Methods: In this report, decoronation of a max- Conclusions: Considering patient desiresillary incisor tooth and submerging its root and her existing condition, decoronationwas used to preserve alveolar bone level mini- was a valid treatment option from the per-mizing the need for bone augmentation in a spectives of function, esthetics, and main-severely resorbed maxilla. Dental implants tenance of dentition. Controlled studies arewere placed adjacent to the retained tooth. recommended to validate these findings.KEY WORDS: Esthetic dentistry, implant dentistry, restorative dentistry, periodontitis, decoronation. 1. Department of Oral Medicine and Periodontology, University of the Western Cape, Cape Town, South Africa The Journal of Implant & Advanced Clinical Dentistry • 55
Abu-Saleh Introduction existing bone and simplify the surgical phase.13 Another common esthetic challenge faced inThe loss of maxillary anterior teeth can lead toesthetic, functional, and psychological problems the anterior maxillary area is the partial or com-necessitating prompt treatment.1,2 Extraction of plete loss of papillae causing what is calledteeth is accompanied by loss of alveolar bone black triangles.14 The horizontal level of theboth in vertical and horizontal directions.2-4 As tip of interdental papilla between teeth wasthe labial cortical plates surrounding roots of reported to be critically associated with thethe anterior maxillary teeth are thin, extraction of vertical distance between the contact pointsthese teeth often results in fracture of cortical and the interdental crest of bone between theplates which leads to considerable bone loss.5 two adjacent teeth. The reported optimum dis- tance is 5mm or less.15 As the distance exceeds The amount and rate of bone resorption 5mm (for example, due to interdental bone loss)vary between individuals and among differ- the position of the tip of the papilla shifts sig-ent sites in the same person.6 Bone resorp- nificantly towards the interdental crest.16,17tion can be further complicated by pre-existingchronic periodontitis, trauma, periapical infec- As the contact point between two implant sup-tions, previous apicectomies and surgical extrac- ported crowns is attempted to correspond to that oftion which could lead to extensive resorption of natural teeth, loss of bone may be accompanied bythe labial plates. Deficiency in alveolar ridge loss of papillae. This may result in “black triangles”may then compromise replacement of missing which necessitate the contact points be shiftedteeth resulting in poor esthetics, or requires apically to close the deficiency. This is further com-ridge augmentation prior to implant placement.3 plicated by the fact that a distance of at least 3mm between two implants is necessary to maintain the Atraumatic extraction of teeth has been sug- interproximal height of bone after remodeling of thegested for ridge preservation by reducing trauma biologic width, while 1.5-2 mm is sufficient betweento the alveolar plates. Occasionally, examination of an implant and natural tooth. This inter-implant dis-the sockets after extractions reveals perforations tance might cause difficulties in achieving estheticof the buccal plates.7 It has been suggested that emergence profile at time of restoration.4,18covering the sockets with hard and/or soft tissuegrafts might compensate for the bone resorption Although several tissue management tech-and soft tissue loss during healing process.3,8 niques and site development procedures were advocated to improve the esthetic outcome of Another suggested option for bone preserva- implant prosthesis, the complete restoration oftion in one-unit replacement is immediate implant the lost soft tissue contour particularly that of theplacement in a flapless technique after extraction interdental papilla for adjacent implants placedof teeth.9,10 This maintains the soft tissue archi- in the esthetic zone remains unpredictable.4tecture of the original teeth by supporting theinterdental tissues around the implants which One of the tested methods for maintain-helps maintain the interproximal bone and height ing alveolar bone is decoronation of teeth, andof papillae.11,12 The use of expansion osteotomes intentional submergence of roots on the prem-for the creation of implant beds can preserve ise that retaining the root will help preserve the56 • Vol. 3, No. 3 • March/April 2011
Abu-SalehFigure 1: Initial presentation of patient. Figure 2: Note gingival recession.Figure 3: Patient had soft friable gingiva with areas of Figure 4: Patient had soft friable gingiva with areas ofamalgam tattoos (right view). amalgam tattoos (left view).alveolar bone.6,19-27 The procedure involves gin- preservation but the method had some draw-gival mucoperiosteal flap elevation, sub-crestal backs, especially the accompanying inflamma-removal of the tooth crown leaving the root in the tion, cyst formation or even bone resorption.21,24alveolus (whether or not it was endodonticallytreated).22,23,24 This method has been tested clini- In this report, tooth decoronation of a cen-cally, radiographically, and histologically in animal tral incisor was utilized to preserve alveolar bonemodels as well as in humans. It has been pre- and maintain papillae next to endosseos implantssented to prevent bone resorption.6,19-21, 28 Gener- in a patient with severe maxillary alveolar boneally the results were satisfactory in terms of bone resorption. The clinical and radiological findings were noted one year following the treatment. The Journal of Implant & Advanced Clinical Dentistry • 57
Abu-SalehFigure 5: Tooth #8 was extracted atraumatically and the Figure 6: The two FPD’s were splinted to support thesocket was well debrided. socket.Figure 7: Osteotomes were used for implant bed Figure 8: Bony defects were curetted and grafted.preparation. not contributory and she was non-smoker. The CASE REPORT patient was well oriented about dental treatment and her oral plaque control was satisfactory.A 48 year old female patient was referred by herdentist to the department of Oral Medicine and The patient presented with localized severePeriodontics, University of the Western Cape, chronic periodontitis around tooth #8 withSouth Africa, for implant placement in the ante- severe bone loss and grade III mobility (figurerior region. Due to a gap between her ante- 2). The FPD in the upper right quadrant was veryrior fixed partial dentures (FPD’s), the patient mobile. Tooth #9 was involved to a lesser extentexperienced embarrassment when talking in and had grade I mobility. Diffuse patches offront of people (figure 1). Medical history was58 • Vol. 3, No. 3 • March/April 2011
Abu-SalehFigure 9: Radiograph showing dental implants in position. Figure 10: Second stage surgery.Figure 11: Tooth #9 being decoronated. Figure 12: Sealed decoronated root #9.black discolorations were noted on the mucosa severe alveolar bone loss around tooth #8 andoverlying the roots of teeth #7-10. The gingiva periapical lesions and calcified canals at teethwas soft, friable and of thin biotype (figures 3, #’s 22 and 27. Impressions were taken and4). The patient experienced premature contacts study casts were prepared and mounted usingin protrusive jaw movement, which aggravated occlusal records in maximum intercuspal posi-the periodontal disease around tooth #8. Earlier tion to study treatment options for the patient.orthodontic treatment resulted in that the patienthad class 3 molar relationship. Periapical radio- Multiple treatment options were discussedgraphs and Orthopantomograph (OPG) showed with the patient, all of them included initial phase of treating the periodontal disease and reduction The Journal of Implant & Advanced Clinical Dentistry • 59
Abu-Salehof occlusal trauma. Treatment options with long using osteotomes rather than drills for osteotomyduration (such as ridge augmentation modalities), of the thin areas of bone, avoiding by this ridgeor ones that involved fitting removable prostheses augmentation by block grafts (figure 7). Singlewere rejected by the patient. Cantilevers or splint- implants (Ankylos, Friadent, Germany) were placeding of implants to natural teeth were discouraged in a submerged, two-stage surgical protocol (fig-prosthetically. Initially, treatment options included: ure 8). A minimal fenestration (1-2 mm) at the● Extraction of both 8 and 9 followed by implant surface of #7 was grafted with autogenous bony scraps and healing was uneventful (figure 9). placement of 6 or 8-units FPDs utilizing Three months later the second stage surgery was teeth #5, 4, 11 and 12 as abutments. performed and two sulcus formers were screwed● E xtraction of 8 and 9 followed by placement in place. Modified Palacci flaps were used to bulk of single implants in 7 and 10 regions, then the papillae (figure 10). Tooth #9 was then dec- final restoration with a 4-unit implant supported oronated, removing the surrounding sulcular epi- FPD, and two PFM crowns at 6 and 11. thelium as well, until the root was level with crestalConsidering previous non-satisfactory experience bone (figure 11). The root was conditioned andwith tooth supported FPDs, the long span of miss- restored with composite resin restoration and theing teeth, the need for provisional restorations, and peripheries were smoothened (figure 12). An inter-the possibility of massive alveolar bone resorption positional piece of connective tissue was used toat extraction sites, it was finally agreed to extract cover the root and augment the soft tissue espe-the tooth #8 and then place single implants at #7 cially in the papillae area (figure 13). Healing wasand 10 areas, followed by decoronation of tooth uneventful. After a healing period of 4 weeks, the#9. Restoration of the two implants would be tissue was bulky both vertically and horizontally (fig-with 4-unit FPD’s, and for teeth #6 and 11 with ures 14, 15). The sulcus formers were removed,PFM crowns. The patient consented to the treat- and two abutments (3.0 mm - 15°) were screwedment plan as well as photographic documenta- and torqued to 35N for both implants and periapi-tion at multiple treatment and follow-up visits. cal radiographs were taken to verify full engage- The first phase consisted of the treatment of peri- ment of both abutments to implant surfaces. Finalodontal disease starting with plaque control instruc- impression was taken with polyether impressiontions and patient education followed by professional material (Impregum® (Penta), 3M ESPE, USA)scaling and root planning. Points of high occlusal using an open tray technique. Two PFM crownsload were reduced. Tooth # 8 was extracted were delivered to restore teeth #6 and 11. Anatraumatically, the socket was curetted thoroughly implant supported prosthesis was used provi-and a blood clot was formed (figure 5). The old sionally to shape the soft tissue contours aroundFPDs were modified and splinted with orthodontic the implants, then an implant supported four-unitwires and composite resin then fitted to support the FPD was fabricated to restore implants 7/10.socket walls (figure 6). The preservation of tooth#9 was beneficial as it helped to retain the FPDs. On three months and six months follow-up The surgical phase started two months later. visits, the tissues were healthy and maintainedImplant beds were prepared in the 7 and 10 areas the bulk. Radiographs showed coronal growth60 • Vol. 3, No. 3 • March/April 2011
Abu-SalehFigure 13: Connective tissue graft used to cover Figure 14: After soft tissue healing, the ridge gaineddecoronated root #9. sufficient bulk vertically and horizontally (facial view).Figure 15: After soft tissue healing, the ridge gained Figure 16: At the one year follow-up visit, gingival tissuessufficient bulk vertically and horizontally (occlusal view). were healthy and aesthetically pleasing.of interseptal bone. One year later, papillae were challenging procedure due to the difficulty ofrestored and the esthetics were pleasing to the obtaining predictable esthetic results. In thepatient (figures 16, 17). Periapical radiographs anterior maxilla, esthetic and functional treat-showed regeneration of bony defects, stable ment outcomes depend highly on the level ofalveolar bone levels, and absence of signs of any alveolar ridge reconstruction or preservation.pathology around the retained root (figures 18-21). Insufficiency of alveolar bone may necessitate an augmentation procedure to achieve opti- Discussion mum results.1-4 It might be advisable to pre- serve rather than reconstruct the papillary tissueImplant placement in the anterior maxilla is a The Journal of Implant & Advanced Clinical Dentistry • 61
Abu-SalehFigure 17: Patient smile at one year follow-up visit. Figure 18: Massive defect in site #8.Figure 19: Bone regenerated in the socket of site #8. Figure 20: Coronal growth of interseptal bone was evident at 1-year follow-up visit (implant #7)since preservation can result in a more predict-able outcome and avoid extensive surgeries.2 alveolar bone and to maintain the dimensions of the alveolar ridge horizontally and vertically.21,22,25 Post-extraction resorption was reported to be This is especially important if proved to pre-prevented or compensated for by some methods serve interdental septa in the anterior regionincluding, socket preservation procedures, vari- which supports the interdental papillae, losing ofous grafting techniques and immediate implant which is a commonly encountered esthetic prob-placement.5,7,9,10 Decoronation of teeth and sub- lem.14,15 When two or more contiguous teethmergence of their roots has been suggested in are missing, esthetic outcome of implant treat-the literature in order to preserve the remaining ment becomes more complicated in this sense62 • Vol. 3, No. 3 • March/April 2011
Abu-SalehFigure 21: Coronal growth of interseptal bone was evident the need for ridge augmentation before implantat 1-year follow-up visit (implant #10) placement. Alveolar bone level around the implants was stable and helped support the papil-and prevention of bone loss is encouraged. lae that later on reformed and filled the interden- Generally, restoration of the height of the tal spaces. The retained root had already been treated by apicectomy and the root canal treat-alveolar ridge is less predictable than the ment was redone as retaining roots without rootwidth. Preservation of vertical bone level was canal treatment was reportedly not favourable.21not always reported following decoronationand some reports indicated that bone loss The coronal aspect was sealed in order tooccurred and roots were exposed.21,24 However, prevent leakage of sealer that was reported tothis report showed that bone preservation not induce inflammation or foreign body reaction andonly helped maintain existing bone dimension cyst formation.23,26 Also, in order to avoid cystbut also enabled vertical bone growth which formation, the sulcular epithelium was removed.21was observed coronally to the remaining root. No periapical pathologies or cysts were noted inDebridement of the extraction socket resulted in the one-year follow-up visit of this patient. Theremoval of granulomatous tissue and significant, composite was cup-shaped and the peripheriesthough incomplete, socket regeneration with- were smoothened and contoured in order notout any bone graft within two months. That was to tear the soft tissue coverage and expose thepresumably aided by the support of the proxi- root, which is a commonly encountered prob-mal wall of the extraction socket by the adjacent lem.21,24 The root was covered with a connec-remaining root. The papillae of the extraction tive tissue graft limiting communication with oralsocket were supported by the modified pontic.3 cavity and subsequent periodontal disease.6 The retained root in the alveolar process Another advantage of retaining the root wasserved the objective of retaining bone dimen- its potential to support a post-crown even thoughsions and vertical bone apposition was observed the root did not support a future prosthesis.25coronal to the root one year later. It minimized That allowed for temporization using a fixed rather than removable prosthesis and avoided early or transmucosal loading of implants during the osseointegration period. The root was not loaded nor splinted to the implant-supported bridge. Therefore, should any complication arise in the future, the root can be extracted without modify- ing the bridges and with minimum bone loss.24 Conclusions The combined procedure of regenerating the socket and retaining the root presented an eco- nomic, safe, and time saving option for the severely The Journal of Implant & Advanced Clinical Dentistry • 63
Abu-Salehresorbed maxilla and met the needs and expecta- Correspondence:tions of the patient. Bone height at interproximal Dr. Tareq Abu-Saleh,surfaces adjacent to edentulous areas was pre- Assistant professor in periodontics,served to support the formation of papillae. The Taibah University, Saudi Arabiamethod was satisfactory esthetically with regard Cell: 00966597983090to papillary form and the degree of filling between E-mail: [email protected], teeth and pontics. Controlled studiesare recommended to validate these findings. ●Disclosure 12. S alama H, Salama MA, Garber D et al. The 22. O ’Neal RB, Gound T, Levin MP et al.The author reports no conflicts of interest with interproximal height of bone: a guidepost to Submergence of roots for alveolar boneanything mentioned in this article. predictable esthetic strategies and soft tissue preservation. I. Endodontically treated roots. contours in anterior tooth replacement. Pract Oral Surg Oral Med Oral Pathol 1978; 45(5):References: Periodontics Aesthet Dent 1998; 10(9): 1131- 803-810.1. A twood DA. Some clinical factors related to rate 1141. 23. G ound T, O’Neal RB, del Rio CE et al. of resorption of residual ridges. J Prosthet Dent 13. R ambla-Ferrer J, Peñarrocha-Diago M, Submergence of roots for alveolar bone 2001; 86(2): 119–125. Guarinos-Carbó J. Analysis of the use of preservation. II. Reimplanted endodontically expansion osteotomy for the creation of implant treated roots. Oral Surg Oral Med Oral Pathol2. O ’Brien TP, Hinrichs JE, Schaffer EM. The beds. Technical contributions and review of the 1978; 46(1): 114-122. prevention of localized ridge deformities using literature. Med Oral Patol Oral Cir Bucal 2006; guided tissue regeneration. J Periodontol 1994; 11(3): E267-71. 24. v on Wowern N, Winther S. Submergence of 65(1): 17-24. roots for alveolar ridge preservation. A failure 14. T arnow DP, Cho SC, Wallace SS. The effect (4-year follow-up study). Int J Oral Surg 1981;3. S eibert JS. Treatment of moderate localized of inter-implant distance on the height of inter- 10(4): 247-250. alveolar ridge defects. Preventive and implant bone crest. J Periodontol 2000; 71(4): reconstructive concepts in therapy. Dent Clin 546-549. 25. R odd HD, Davidson LE, Livesey S et al. North Am 1993; 37(2): 265-280. Survival of intentionally retained permanent 15. Tarnow DP, Magner AW, Fletcher P. The effect incisor roots following crown root fractures in4. E lian N, Jalbout ZN, Cho SC et al. Realities and of the distance from the contact point to the children. Dent Traumatol 2002; 18(2): 92–97. limitations in the management of the interdental crest of bone on the presence or absence of papilla between implants: three case reports. the interproximal dental papilla. J Periodontol 26. C ohenca N, Stabholz A. Decoronation - a Pract Proced Aesthet Dent 2003; 15(10): 737- 1992; 63(12): 995-996. conservative method to treat ankylosed teeth 744. for preservation of alveolar ridge prior to 16. C hoquet V, Hermans M, Adriaenssens P et permanent prosthetic reconstruction: literature5. Irinakis T. Rationale for socket preservation after al. Clinical and radiographic evaluation of the review and case presentation. Dent Traumatol extraction of a single-rooted tooth when planning papilla level adjacent to single tooth dental 2007; 23(2): 87–94. for future implant placement. J Can Dent Assoc implants. A retrospective study in the maxillary 2006; 72(10): 917-22. anterior region. J Periodontol 2001; 72(10): 27. F ilippi A, Pohl Y, von Arx T. Decoronation 1364-1371. of an ankylosed tooth for preservation of6. S imon JH, Kimura JT. Maintenance of alveolar alveolar bone prior to implant placement. Dent bone by the intentional replantation of roots. 17. Grunder U. Stability of the mucosal topography Traumatol 2001; 17(2): 93–95. Oral Surg Oral Med Oral Pathol 1974; 37(6): around single tooth implants and adjacent 936–945. teeth: 1-year results. Int J periodontics 28. S alama M, Ishikawa T, Salama H et al. restorative Dent 2000; 20(1): 11-17. Advantages of the root submergence technique7. Levitt D. Atraumatic extraction and root retrieval for pontic site development in esthetic implant using the periotome: a precursor to immediate 18. S alama H & Salama, M. The role of orthodontic therapy. Int J Periodontics Restorative Dent placement of dental implants. Dent Today 2001; extrusive remodeling in the enhancement of 2007; 27(6): 521–527 20(11): 53-57. soft and hard tissue profiles prior to implant placement: A systematic approach to the8. L ambert PM, Skerl RF, Campana HA. Free management of extraction site defects. Int J autogenous graft coverage of vital retained Periodontics Restorative Dent 1993; 13(4): roots. J Prosthet Dent 1983; 50(5): 611-617. 312–333.9. N owzari H. Esthetic Implant Dentistry. Compend 19. S imon JH, Jensen JL, Kimura JT. Histologic Contin Educ Dent 2001; 22(8): 643-50. observations of endodontically treated replanted roots. J Endod 1975; 1(5): 178–180.10. Saadoun AP. Immediate Implant Placement and Temporization in Extraction and Healing Sites. 20. J ohnson DL, Kelly JF, Flinton RJ et al. Histologic Compend Contin Educ Dent 2002; 23(4): evaluation of vital root retention. J Oral Surg 309-312. 1974; 32(11): 829–833.11. Mankoo T. contemporary implant concepts in 21. L evin M, Getter L, Cutright D et al. Intentional esthetic dentistry – Part 3: adjacent immediate submucosal submergence of nonvital roots. J implants in the esthetic zone. Pract Proced Oral Surg 1974; 32(11): 834–839. Aesthet Dent 2004; 16(4): 327-334.64 • Vol. 3, No. 3 • March/April 2011
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Neck Dissection Wiliams et alfor Oral CancerFayette C. Williams, DDS, MD1 • Brent B. Ward, DDS, MD, FACS2 Sean P. Edwards, MD, DDS, FRCD(C)3AbstractBackground: Cancer of the oral cavity and Results: Neck dissection remains the stan-oropharynx strikes over 35,000 patients each dard treatment for cervical metastases fromyear in the United States. At least one-third oral cancer. While the radical neck dissectionof these patients will present with metas- described over 100 years ago resulted in sig-tases to the neck. The status of the cer- nificant morbidity, modern selective and modi-vical lymph nodes remains the strongest fied neck dissections maintain oncologic safetyprognostic indicator for oral cancer. Appropri- while minimizing morbidity. Difficulty still exists inate diagnosis and management of the neck is identifying which patients with clinically negativecritical in the success of oral cancer treatment. necks require removal of cervical lymph nodes. Emerging technologies may eventually reduceMethods: The history and anatomy rel- the incidence of unnecessary neck dissections.evant to cervical lymphadenectomy arereviewed. The technique is described and Conclusions: Modern multi-disciplinarya surgical case is illustrated. The authors care strategies incorporate dentists as vitalreview the common complications of neck members of the cancer team. Dental pro-dissection and their management. Future fessionals are on the forefront of oral can-directions in the diagnosis and manage- cer detection and should be familiar with thement of cervical metastases are discussed. rationale and implications of neck treatment. KEY WORDS: Mouth neoplasms, neck dissection, lymph node excision, oral cancer1. Clinical Faculty, John Peter Smith Hospital, Department of Oral and Maxillofacial Surgery, Fort Worth, Texas, USA. Formerly, Fellow in Oral and Maxillofacial Oncologic Surgery University of Michigan Medical Center, Ann Arbor, Michigan, USA 2. Assistant Professor and Program Director Oral and Maxillofacial Oncologic Surgery University of Michigan Medical Center, Ann Arbor, Michigan, USA. 3. Assistant Professor and Chief, Pediatric Oral and Maxillofacial Surgery C.S. Mott Children’s Hospital, University of Michigan Medical Center, Ann Arbor, Michigan, USA. The Journal of Implant & Advanced Clinical Dentistry • 69
Williams et alFigure 1: Incision marked. Figure 2: A) Platysma; B) Lymphatic tissue. INTRODUCTION survival to half that of patients with no neck disease.9-11 Appropriate diagnosis and man-An estimated 35,000 new cases of oral and agement of the neck is therefore critical inoropharyngeal cancer will be diagnosed in the overall success of oral cancer treatment.the United States in 2009, and over 7,500deaths will be attributed to this disease.1 AnatomySquamous cell carcinoma is the predominantform of cancer in this region, encompass- Lymph node basins which drain the oraling approximately 90% of malignant pathol- cavity are divided into 5 groups basedogy.2 The overall 5-year survival rate of oral on anatomically defined structures:cancer is approximately 61%, with early can- ● Level I – includes the submental nodescers showing greater survival.3 Despite bounded by the anterior bellies of the digas-technological advances in detection and tric muscles and the hyoid bone as well astreatment, 5-year survival rates have shown the submandibular group bounded by theminimal improvement over recent decades. body of the mandible and the posterior bel- lies of the digastric muscles bilaterally. The most important prognostic indica- ● Level II – includes the upper jugular lymphtor for oral cancer is the status of the cervical nodes extending from the base of the skull tolymph nodes.4,5 While only 3-10% of patients the level of the carotid artery bifurcation. Thewill present with distant metastasis,6 at least anterior border is the lateral aspect of the ster-30% will have cervical lymph node metasta- nohyoid muscle while the posterior border is theses at the time of diagnosis.7,8 The presence sternocleidomastoid (SCM). Level II is also sub-of cervical node involvement decreases 5-year70 • Vol. 3, No. 3 • March/April 2011
Wiliams et alFigure 3: Lymphatic tissue removal from submental Figure 4: Lymphatic tissue reflected off submentaltriangle. triangle. A) Right anterior belly of digastric muscle; B) Mylohyoid muscle; C) Left anterior belly of digastric muscle; D) Platysma.divided into levels IIA (inferior medial) and II B safety. The classic radical neck dissection, as(superior lateral) by the spinal accessory nerve. described by Crile, removes the cervical lym-● Level III – includes nodes located adja- phatics of all five levels along with the internalcent to the middle 1/3 of the internal jug- jugular vein, the sternocleidomastoid muscle,ular vein from the carotid bifurcation to and the spinal accessory nerve. In the 1960s,the omohyoid muscle with the same ante- Suarez13 and later Bocca14 published a tech-rior and posterior boundaries as level II. nique preserving these three non-lymphatic● Level IV – includes the lower jugular structures. This method achieved a similargroup, inferior to the omohyoid muscle and degree of regional control while avoiding thesuperior the clavicle with the same anterior morbidity associated with the removal of theand posterior boundaries as levels II and III. three structures mentioned above. In 1972,● Level V- includes nodes anterior to the Lindberg15 described the distribution of cervi-anterior border of the trapezius and poste- cal metastasis in relation to the primary tumorrior to the posterior border of the SCM. The site after reviewing 2004 patients with SCCAinferior border of this level is the clavicle. of the head and neck. This finding was later validated by Shah16 and Byers17 which led to History the implementation of selective removal of only high-risk nodal basins for patients with clini-Since George Crile’s description12 of the radi- cally negative necks. For carcinoma of thecal neck dissection in 1906, the surgical treat- oral cavity with a clinically negative neck, thement of the neck has evolved to include less predominant lymph node basins removed inmorbid options while maintaining oncologic The Journal of Implant & Advanced Clinical Dentistry • 71
Williams et alFigure 5: Fascia removed from sternocleidomastoid Figure 6: Left neck after removal of lymphatic tissue.muscle. A) Sternocleidomastoid muscle; B) Fascia A) Inferior border of mandible; B) Masseter muscle; C) Anterior belly of digastric muscle; D) Posterior belly of digastric muscle; E) Mylohyoid muscle; F) Hypoglossal nerve; G) Carotid artery; H) Internal jugular veina selective neck dissection are levels I, II and of the facial nerve is dissected free and elevatedIII. In contrast, the modified radical neck dis- above the inferior border of the mandible to pro-section removes all five levels and is indicated in tect it from injury. Fibrofatty lymph-bearing tis-the setting of positive cervical lymphadenopathy. sue is first removed from the submental area as the dissection proceeds posteriorly across Procedure level I. The posterior border of the mylohyoid muscle is retracted anteriorly as the subman-The neck dissection begins with an incision dibular gland is pulled inferiorly to expose thethrough skin and subcutaneous fat, utilizing an lingual nerve and submandibular duct. Theexisting skin crease when possible. The inci- submandibular gland is included in the speci-sion extends from the tip of the mastoid bone to men. The duct is transected along with thejust across the midline. The platysma muscle is parasympathetic branches from the lingualdivided next so that skin-platysma flaps may be nerve (chorda tympani) which course inferiorlyelevated superiorly to the mandible and inferiorly towards the submandibular gland. The lingualto the clavicle. With full exposure of the neck, nerve is preserved. The facial artery and veinthe sternocleidomastoid muscle (SCM) is read- are ligated and divided at the inferior borderily apparent along with the external jugular vein of the mandible with care to preserve the mar-and great auricular nerve which course on top ginal mandibular branch of the facial nerve.of the SCM. The tail of the parotid gland is visi- The tail of the parotid gland is included in theble where it extends below the inferior border of specimen which can now be retracted infe-the mandible. The marginal mandibular branch72 • Vol. 3, No. 3 • March/April 2011
Wiliams et alFigure 7: Final closure. The specimen now remains attached only to level V of the neck. Further posterior retrac-riorly over the posterior belly of the digastric tion of the SCM allows the specimen to be dis-muscle to complete the level I dissection. The sected off the scalene and levator scapulaefacial artery is ligated again as it loops over muscles posteriorly towards the anterior borderthe posterior belly of the digastric muscle. of the trapezius muscle, which serves as the posterior limit of dissection. Care is taken again Levels II, III, and IV are often dissected to preserve the spinal accessory nerve whichsimultaneously in a broad front moving from passes through level V. The specimen is passedanterior to posterior. The omohyoid muscle is off the field for pathologic evaluation . Thedivided at the anterior extent of the dissection entire surgical field is reviewed to assure thatand included in the specimen. The hypoglossal adequate hemostasis is achieved. A layerednerve is preserved as the dissection proceeds closure is performed by re-approximating theposteriorly below the posterior belly of the platysma and skin over a closed-suction drain.digastric muscle. Retraction of the SCM poste- The drain is usually removed in 3-5 days whenriorly reveals the carotid sheath. The specimen the output is less than 30cc in a 24 hour period.is retracted laterally as the internal jugular vein isskeletonized from the skull base to the clavicle. ComplicationsMultiple branches of the vein are ligated as theyare encountered. The carotid artery and vagus Surgical complications may be grouped intonerve are dissected free. The spinal acces- intraoperative and postoperative complica-sory nerve, deep to the SCM, is carefully pre- tions. Intraoperative complications includeserved as the dissection of level II is completed. injury to uninvolved nerves, laceration of the large neck vessels, or damage to the thoracic duct. Postoperative complications include hematoma, chylous fistula, and infection. Although several nerves are at risk for injury during neck dissection, careful technique usually allows for their preservation. Gross involvement of tumor is occasionally noted and is an indication for sacrifice. A nerve stimula- tor serves as a useful aid for identifying motor nerves which may be otherwise difficult to locate in the previously operated or irradiated neck. Nerves at greatest risk during dissec- tion include the marginal mandibular branch of the facial nerve, the lingual nerve, the hypo- glossal nerve, and the spinal accessory nerve. The thoracic duct is at risk for injury when The Journal of Implant & Advanced Clinical Dentistry • 73
Williams et allevel IV is dissected immediately superior to the discolored, or tense. Hematomas which con-clavicle. Injury to the duct results in the leak- tinue to expand may cause airway deviation andage of chyle into the neck wound. This may vascular compromise of the skin or other cervi-be recognized intraoperatively by the presence cal structures due to pressure. The source ofof oily or milky fluid in the wound. Suture liga- blood is commonly a small bleeding vessel ortion of the leaking tissue is necessary to pre- loose suture not detected at the time of clo-vent the formation of a postoperative chylous sure. Coughing, straining, or other increases infistula. Prior to closing the neck incision, the intra-abdominal pressure in the early postopera-inferior neck should be observed for several tive period may also contribute to new bleeding.seconds while the anesthesiologist performs Other common etiologies include coagulopa-a Valsalva maneuver. Despite these mea- thy or postoperative hypertension. Small non-sures, a chylous fistula may develop postop- expanding hematomas may often be observed oreratively in 2% of patients.18 While thoracic treated conservatively with a pressure dressing.duct injury is more common on the left, a leak A return trip to the operating room is usuallymay develop on the right in as many as 25% necessitated by an expanding hematoma, air-of cases of chyle leaks.19 A postoperative chy- way concern, or to protect a reconstructive flap.lous fistula may be detected by milky fluid in theneck drain. Conservative management, includ- Postoperative infections may occur aftering pressure dressings, aspiration and dietary neck dissection, especially when the neckmodification, is often successful in low-volume wound communicates with the upper aerodi-chylous fistulas. Surgical exploration is indi- gestive tract. Prior radiotherapy, diabetes orcated in high-volume output or any chylous other systemic conditions affecting the immunefistula which fails conservative management. system may add further concern for infection due to the poor healing qualities of irradiated Accidental injury to large vessels may tissue and systemic susceptibility to infec-increase morbidity simply due to increased tion from decreased immune response. Anblood loss. While a unilateral internal jugu- oral-cutaneous fistula often results from necklar vein may be resected with little conse- infections communicating with the oral cav-quence, bilateral ligation results in severe ity. Conservative wound care usually resultsfacial and cerebral edema. Small lacera- in spontaneous closure of the fistula, althoughtions in the internal jugular vein may be surgical intervention may be required whenrepaired with sutures or ligaclips. Injury vital structures such as the carotid arteryto the carotid artery requires immediate are exposed to the salivary contaminants.repair to avoid severe hemorrhage and thepotential for cerebrovascular insufficiency. Future Directions Postoperative hematoma results from the The role of neck dissection for oral canceraccumulation of blood under the skin flaps. This over the past century has become more selec-often presents as a fluctuant neck swelling and tive as data and technological advancementsmay cause the overlying skin to appear bruised, have allowed for improved risk assessment to74 • Vol. 3, No. 3 • March/April 2011
Wiliams et aldetermine which patients require a neck dissec- While some centers recommend its routine usetion. Some difficulty still exists in identification for staging advanced (T3 or T4) tumors, theof occult neck disease undetectable by cur- high false-positive rate inherent to metabolicrent diagnostic modalities. The sentinel lymph imaging is problematic. Although studies26node biopsy has become a standard staging have demonstrated the ability of PET to alterprocedure for cutaneous melanoma and breast the staging of head and neck tumors, it is stillcancer with well-documented accuracy and unclear if this benefit outweighs the disadvan-efficacy.20,21 This technique uses a radionu- tage of false-postives in routine staging. Theclide and/or a blue dye to identify the regional most widely accepted role of PET in oral can-lymph nodes which receive drainage from the cer is in the detection of recurrences.27,28 Tis-primary tumor site. The purpose of sampling sue beds are often scarred, irradiated, and havethe sentinel lymph node is to identify patients post-surgical alterations in anatomy which limitwith positive nodes who will benefit from com- the utility of conventional imaging techniquespletion lymph node dissection. At the same and makes metabolic imaging more appeal-time, unnecessary lymph node dissections are ing. While PET has shown improved sensitiv-avoided in patients with a negative sentinel ity over conventional imaging techniques,29-31lymph node. While still considered experimen- it is not accurate enough to preclude a necktal, recent data suggests that this technique dissection in a patient with no detectable cer-may eventually be applicable to oral cavity vical disease.32-34 This limitation is due to thetumors.22,23 Further multi-institutional stud- inadequate spatial resolution of PET, resultingies and long-term data are needed to validate in an inability to detect micrometastases belowthe accuracy and technical feasibility of senti- 5mm in diameter. As the technical resolution ofnel lymph node biopsy for oral cavity cancer.24 PET increases with future refinements, unnec- essary neck dissections may be avoided. ● Detection of cervical metastases by clini-cal palpation and CT scan has shown a sensi- Correspondence:tivity of 91%.25 Increased detection rates havebeen demonstrated over recent years with Fayette C. Williams, DDS, MDthe introduction of positron emission tomog-raphy (PET). This form of functional imaging John Peter Smith Hospitalmeasures changes in metabolism. Regionalglucose uptake is assessed by injecting a Department of Oral and Maxillofacial Surgeryradiotracer such as fluorodeoxyglucose (FDG)prior to imaging the patient. Malignant cells 1625 St. Louis Avenuehave high metabolic activity and demonstrateincreased radiotracer uptake. PET has shown Fort Worth, TX 76107promise in the evaluation of metastatic disease,tumor recurrence, and in evaluation of treat- [email protected] response after chemotherapy or radiation. The Journal of Implant & Advanced Clinical Dentistry • 75
WililaiammsseettaallDisclosure 12. C rile, G., On the plan of excision in cancer 25. Merritt, R.M., et al., Detection of cervicalThe authors report no conflicts of interest with of the head and neck and an analysis of 132 metastasis. A meta-analysis comparinganything mentioned in this article. cases. Ohio State Medical Journal, 1906. 2: p. computed tomography with physicalReferences 1740189. examination. Archives of otolaryngology--head &1. A merican Cancer Society. Cancer Facts & neck surgery, 1997. 123(2): p. 149-152. 13. S uarez, O., El problema de las metastasis Figures 2008. Atlanta: American Cancer Society; linfaticas y alejadas del cancer de laringe e 26. Connell, C., et al., Clinical impact of, and 2008. hipofaringe. Otorrinolaringology, 1963. 23: p. prognostic stratification by, F-18 FDG PET/2. S ilverman, S., Epidemiology, in Oral Cancer. 83-99. CT in head and neck mucosal squamous cell 1998, B.C. Decker Inc: Hamilton, Ontario. carcinoma. Head & neck, 2007. 29(11): p. 986-3. H orner MJ, Ries LAG, Krapcho M, Neyman N, 14. B occa, E. and O. Poignataro, A conservation 995. Aminou R, Howlader N, Altekruse SF, Feuer EJ, technique in radical neck dissection. Ann Otol Huang L, Mariotto A, Miller BA, Lewis DR, Eisner Rhino Laryngol, 1967. 76: p. 975-87. 27. Kao, J., et al., The diagnostic and prognostic MP, Stinchcomb DG, Edwards BK (eds). SEER utility of positron emission tomography/ Cancer Statistics Review, 1975-2006, National 15. L indberg, R., Distribution of cervical lymph node computed tomography-based follow-up after Cancer Institute. Bethesda, MD, http://seer. metastasis from squamous cell carcinoma of the radiotherapy for head and neck cancer. Cancer, cancer.gov/csr/1975_2006/, based on November upper respiratory and digestive tracts. Cancer, 2009. 115(19): p. 4586-4594. 2008 SEER data submission, posted to the 1972. 29: p. 1446-9. SEER web site, 2009. 28. Schechter, N.R., et al., Can positron emission4. B undgard, T., S. Bentzen, and J. Wildt, 16. S hah, J., Patterns of cervical lymph node tomography improve the quality of care for head- Histopathologic, stereologic, epidemiologic, and metastasis from squamous cell carcinomas of and-neck cancer patients? International journal clinical parameters in the prognostic evaluation of the upper aerodigestive tract. American Journal of radiation oncology, biology, physics, 2001. squamous cell carcinoma of the oral cavity. Head of Surgery, 1990. 160: p. 405-9. 51(1): p. 4-9. and Neck, 1996. 18: p. 142.5. K lotch, D., C. Muro-Cacho, and T. Gal, Factors 17. B yers, R., P. Wolf, and A. Ballantyne, Rationale 29. Adams, S., et al., Prospective comparison affecting survival for floor-of-mouth carcinoma. for elective modified neck dissection. Head and of 18F-FDG PET with conventional imaging Otol Head Neck Surg, 2000. 122: p. 495-8. Neck Surgery, 1988. 10: p. 160-7. modalities (CT, MRI, US) in lymph node staging6. B etka, J., Distant metastasis from lip and oral of head and neck cancer. European journal of cavity cancer. ORL J Otorhinolaryngol Relat 18. S piro, J.D., R.H. Spiro, and E.W. Strong, The nuclear medicine, 1998. 25(9): p. 1255-1260. Spec, 2001. 63: p. 217-21. management of chyle fistula. The Laryngoscope,7. G ourin, C., et al., The effect of occult nodal 1990. 100(7): p. 771-774. 30. Koshy, M., et al., F-18 FDG PET-CT fusion in metastases on survival and regional control radiotherapy treatment planning for head and in patients with head and neck squamous cell 19. C rumley, R.L. and J.D. Smith, Postoperative neck cancer. Head & neck, 2005. 27(6): p. carcinoma. Laryngoscope, 2008. 118: p. 1191-4. chylous fistula prevention and management. The 494-502.8. G reenberg, J., et al., Disparity in pathologic Laryngoscope, 1976. 86(6): p. 804-813. and clinical lymph node staging in oral tongue 31. Ha, P., et al., The role of positron emission carcinoma. Implication for therapeutic decision 20. L andi, G., et al., Sentinel lymph node biopsy tomography and computed tomography fusion in making. Cancer, 2003. 98(3): p. 508-515. in patients with primary cutaneous melanoma: the management of early-stage and advanced-9. S now, G.B., et al., Prognostic factors of neck study of 455 cases. Journal of the European stage primary head and neck squamous cell node metastasis. Clinical otolaryngology and Academy of Dermatology and Venereology, carcinoma. Archives of otolaryngology--head & allied sciences, 1982. 7(3): p. 185-192. 2000. 14(1): p. 35-45. neck surgery, 2006. 132(1): p. 12-16.10. Leemans, C., R. Tiwari, and J. Nauta, Regional 21. G oyal, A. and R. Mansel, Recent advances in 32. Krabbe, C., et al., FDG PET in oral and lymph node involvement and its significance sentinel lymph node biopsy for breast cancer. oropharyngeal cancer. Value for confirmation of in the development of distant metastases in Current opinion in oncology, 2008. 20(6): p. N0 neck and detection of occult metastases. head and neck carcinoma. Cancer, 1993. 71: 621-626. Oral oncology, 2008. 44(1): p. 31-36. p. 452-6.11. Myers, E. and J. Fagan, Treatment of the N+ 22. R igual, N., et al., Sentinel lymph node biopsy: a 33. Stoeckli, S., et al., Is there a role for neck in squamous cell carcinoma of the upper rational approach for staging T2N0 oral cancer. positron emission tomography with aerodigestive tract. Otolaryngology Clinics of The Laryngoscope, 2005. 115(12): p. 2217- 18F-fluorodeoxyglucose in the initial staging North America, 1998. 31: p. 671-86. 2220. of nodal negative oral and oropharyngeal squamous cell carcinoma. Head & neck, 2002. 23. M ozzillo, N., et al., Therapeutic implications of 24(4): p. 345-349. sentinel lymph node biopsy in the staging of oral cancer. Annals of Surgical Oncology, 2004. 34. Pentenero, M., et al., Accuracy of 18F-FDG- 11(3 Suppl): p. 263S-266S. PET/CT for staging of oral squamous cell carcinoma. Head & neck, 2008. 30(11): p. 24. S hellenberger, T., Sentinel Lymph Node 1488-1496. Biopsy in the Staging of Oral Cancer. Oral and maxillofacial surgery clinics of North America, 2006. 18(4): p. 547-563.ATTENTION PROSPECTIVE AUTHORS JIACD wants to publish your article! For complete details regarding publication in JIACD, please refer to our author guidelines at the following link: http://www.jiacd.com/authorinfo/author-guidelines.pdf or email us at: [email protected] • Vol. 3, No. 3 • March/April 2011
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