Table of Contents
Introduction:
In oral surgery, biopsies are essential for diagnosing various lesions and conditions within the oral cavity. These procedures allow for the examination of tissue samples to determine the presence of diseases such as cancer, infections, or other pathological conditions. By selecting the appropriate biopsy technique, dental and maxillofacial surgeons can accurately diagnose and effectively treat a wide range of oral health issues. Understanding the common types of biopsies used in oral surgery is crucial for both practitioners and patients in managing oral health.
What Is the Difference Between an Incisional and an Excisional Biopsy?
An incisional biopsy involves taking a tissue sample from suspected oral lesions for histopathological examination, whereas an excisional biopsy entails the complete removal of the suspected lesion for analysis by a pathologist. An incisional biopsy is the gold standard for diagnosing malignant tumors, recommended by oral and maxillofacial surgeons. When a surgeon detects or suspects malignant or cancerous lesions through clinical examination, further surgical intervention is often necessary, making incisional biopsy the preferred method in these cases.
Conversely, excisional biopsies are used for certain low-grade salivary tumors or oral squamous cell carcinoma, where the lesion needs to be completely removed. However, using excisional biopsy in such cases can present challenges. After removal, the exact location of the lesion and the type of cells eliminated may not be identifiable, potentially complicating surgical decision-making for oncologists and maxillofacial surgeons. For high-grade cancers of the oral cavity or head and neck, a maxillofacial surgeon would typically not recommend an incisional biopsy. This approach can be controversial in such cases and should be thoroughly discussed with an oral pathologist and the interdisciplinary team, including the oncologist and clinical cancer team members. Some maxillofacial surgeons prefer performing a wedge-shaped biopsy to capture both normal and abnormal tissues from the lesion before histopathological examination, aiding in a clear diagnosis.
In contrast, excisional biopsies involve the complete removal of the lesion, typically performed using an elliptical excision pattern. This method allows for wound closure with minimal tension on the oral tissues, resulting in better cosmetic outcomes. When performing excisional biopsies on facial skin, maxillofacial surgeons must carefully orient the tension lines to achieve an aesthetically pleasing scar.
What Are the Important Steps Before Biopsy?
A critical focus for every maxillofacial surgeon during a biopsy procedure, whether incisional or excisional, is achieving effective blood control or hemostasis. This is accomplished through irrigation, the use of hemostat forceps, and closure with appropriate suture materials, correct suture needles, and necessary armamentarium for suturing and hemostasis. Before starting either an excisional or incisional biopsy, obtaining the patient's consent is essential. This consent ensures that the patient is aware of and agrees to the potential outcomes and necessary surgical interventions. Biopsies are diagnostic procedures that require the dental or maxillofacial surgeon's intraoperative skills and flexibility before making further surgical decisions. Patient consent must also be obtained by the maxillofacial surgeon prior to performing tooth extractions, bone grafts or augmentation, or reconstruction and plating procedures.
How Essential Is Specimen Preparation for Oral Cavity Lesions During Biopsy?
Maxillofacial surgeons often take photographs of the lesion site, especially when dealing with aggressive lesions such as inflammatory, immunologic, pre-cancerous, or cancerous lesions. In addition to capturing these images, it is crucial for the surgeon to obtain specimens of the lesions discovered in the oral cavity. An important procedure called specimen orientation is used to establish an accurate diagnosis of the lesion. This involves orienting the specimen along two axes, often using sutures of different lengths or colors. This technique helps achieve a specific depth during an incisional biopsy. Specimen orientation is a critical practice for oral and maxillofacial surgeons. It allows for the precise marking of the lesion's location and the estimation of its depth before sending the specimen to the lab for microscopy or histopathological examination.
When Is Marsupialization Considered as an Alternative?
Marsupialization or drain placement is a significant alternative surgical approach performed by oral surgeons to facilitate the decompression of oral cavity lesions. In this procedure, the lesions in question, which are suspected by the dentist or surgeon, are not completely removed. Instead, the factors or mechanisms contributing to the lesion's expansion are eliminated. This allows the lesion to shrink gradually over time, often over several months.
Marsupialization is a technique commonly used by surgeons to treat soft tissue lesions. The procedure involves incising the lesion and suturing its edges to the surrounding tissues. This allows the lesion or cyst to drain its contents freely and undergo gradual decompression, leading to a reduction in size over time. Marsupialization is frequently employed to shrink large ranulas, which are common oral pathologies found in the floor of the mouth, and for treating jaw cysts. In addition to its effectiveness, marsupialization offers the benefit of preserving surrounding structures and reducing the risk of recurrence compared to more aggressive surgical interventions. This makes it a preferred choice for managing specific types of oral lesions where complete excision may not be necessary or feasible.
What Are Drains Used for in Biopsy or Surgery?
Drains are essential adjuncts during marsupialization, facilitating decompression even in hard or bony cystic lesions, such as odontogenic keratocysts. After performing a biopsy or marsupialization and extracting tissue from the suspect lesion, a surgeon can commonly place a drain into these lesions. The drain is then sutured to the outer oral mucosa or potentially wired to adjacent teeth. For extensive oral lesions and cysts, a maxillofacial surgeon may implement a daily postoperative irrigation routine, which is sometimes necessary for advanced cases. Drains play a crucial role in these situations by helping to shrink large lesions and reducing the need for extensive surgical resection. This is particularly important for oral structures with vital connections or areas of the mouth or jaw that might require extensive reconstructive procedures. In addition to promoting lesion shrinkage, the use of drains helps in reducing postoperative complications, minimizing the risk of infection, and improving overall patient outcomes. By providing a less invasive alternative to extensive surgery, marsupialization with drain placement preserves the integrity of surrounding tissues and supports better functional and aesthetic results.
Conclusion:
Biopsy is a crucial surgical and diagnostic procedure in maxillofacial surgeries. To conclude, the dental or maxillofacial surgeon will determine the most appropriate technique whether incisional biopsy, excisional biopsy, or marsupialization based on the extent, depth, and nature of the lesion. This decision is made to ensure accurate diagnosis and effective treatment tailored to the specific characteristics of the lesion, optimizing patient outcomes and preserving oral health.
