Background/Objectives: Oral cavity squamous-cell carcinoma is among the most frequent head and neck neoplasms. Early-stage T1/T2N0 accounts for 40/45% of new diagnoses. Of these, about 30% of cases hide occult metastases in the neck. The management of clinically N0 neck is of paramount importance and is still being debated. Methods: The medical records of patients with a clinical diagnosis of early-stage T1-T2N0 carcinoma of the oral cavity between 2011 and 2021 were retrospectively analysed. The inclusion criteria were complete medical and radiological records, pT1-2 pathology staging, and a minimum follow-up of 24 months. Biographical, management, and survival data were analysed using IBM SPSS Statistics [28.0.1.1]; IBM Corp., Armonk, NY, USA). Results: A total of 121 patients met the inclusion criteria. The tongue was the most affected site, with 52 cases. All patients underwent resection of the primary tumour; for neck management, 47 (38.8%) underwent elective neck dissection, 36 underwent follow-up, and 11 underwent sentinel lymph node biopsy. A total of 59 cases were staged as T1 and 62 as T2; in 97 (80.2%) cases, the neck was confirmed as N0; in 10 (8.3%), N1; in 1 case, N2a; in 8, N2b; in 2, N2c; and in 3, N3b. The mean DOI was 4.8 mm. In a Cox regression, a statistically significant association was shown between overall survival and pN staging (p < 0.05). Kaplan–Meier analysis showed a statistically significant difference between different regimens of management of the neck in terms of overall survival, disease-free survival, and disease-specific survival in favour of elective neck dissection and sentinel lymph node biopsy compared to watchful policy (p < 0.05). Conclusions: Elective neck dissection and sentinel lymph node biopsy proved to be safe and oncologically effective in the treatment of clinically N0 early-stage oral carcinoma.