Oral Surgery Flashcards
1-55 L1: Midface Fracture Orthognathic surgery: 56-81 Radiotherapy and Chemotherapy neck and head: 82-109 Oral Cancer: 110-120 Management of Fracture of the mandible: 121-156 Referral to Oral Medicine and biopsy: 157-186 Salivary gland disease: 187-241
1
Q
What type of energy is needed to cause midface fractures?
A
High energy high impact forces.
- RTA
- Severe assault weapons
- Falls from height
- Industrial
- Agriculture
- War injuries
2
Q
The middle facial skeleton is defined by?
A
Superiorly;
* Frontozygomatic
* Frontonasal
* Frontomaxillary
Inferiorly;
* Occlusal plane upper teeth
* Alveolar ridge (edentulous)
Posteriorly;
* Pterygoid plates sphenoid
3
Q
what is the name of this bone?
A
Zygomatic
4
Q
What is the name of this bone?
A
maxilla
5
Q
What is the name of this bone?
A
Zygomatic process of temporal bone
6
Q
What is the name of this bone?
A
Palatine bone
7
Q
What is the name of this bone?
A
Nasal bone
8
Q
What is the name of this bone?
A
Lacrimal bone
9
Q
What is the name of this bone?
A
Vomer
10
Q
What is the name of this bone?
A
Ethmoid
11
Q
What is the name of this bone?
A
Two inferior conchae
12
Q
what is the name of this bone?
A
Pterygoid plates of sphenoid
13
Q
Air containing sinuses interrelated pillars or struts stability via paired buttressing system aligned in three ways, what are they?
A
- Vertical
- Horizontal
- Sagittal
14
Q
What are the horizontal buttressing system of the midface?
A
- Superior orbital rim
- Inferior orbital rim
- Maxillary alveolus
- Palate
- Serrated edges greater wings of sphenoid
- Zygomatic arches
15
Q
The vertical buttressing system is primarily for which forces to transmission to skull base?
A
Masticatory.
16
Q
The vertical buttressing system includes which three systems?
A
- Nasomaxillary
- Zygomaticomaxillary
- Pterygomaxillary
17
Q
Where is the lateral pyriform rim located and which part of the vertical buttressing system are they?
A
Nasomaxillary
18
Q
Where is the frontal process of the maxilla located and which part of the vertical buttressing system are they?
A
Nasomaxillary
19
Q
The lateral pyriform, maxillary process and the frontal process superiorly of the maxilla make up what part of the vertical buttressing system?
A
Nasomaxillary
20
Q
The maxillary process of the frontal bone belongs to which vertical buttressing system?
A
Nasomaxillary
21
Q
The zygomaticomaxillary buttressing system runs which bones?
A
- Frontal bone superiorly
- Lateral orbital rim
- Zygoma
- Zygomatica process of the maxilla
22
Q
What does the pterygomaxillary buttress include?
A
- Pterygoid plates of the sphenoid
- Maxillary tuberosity
23
Q
What are the buttressing sagittal?
A
- Zygomatic arches
- Palate
- Floor of orbit
24
Q
The middle third facial skeleton has three low tolerance impact zones, what are they?
A
- Nasal bones least resistant
- Zygomatic arch directly
- Maxillae – horizontal forces
25
This image represents the degree of posterior displacement, why is that the displacement is decreased as it moves posteriorly?
The displacement is decreased due to the posterior dentition between the maxilla and mandible.
26
What are the potential results of midface trauma?
1. Anterior open bite
2. Facial lengthening
3. Extreme – soft palate obstruct airway
4. Nares blood clot conscious – ok
5. Coincident head injury = danger until airway clear
27
Forces directed where will result in a Le Fort 1 fracture line?
Forces above the dentoalveolar segment
28
Which part of the pterygoid plates are affected within a Le Fort 1 fracture?
Lower parts of the pterygoid plates
29
List the areas affected with a Le Fort 1 fracture?
1. Lateral nose/piriform aperture
2. Anterior/lateral/inferior wall max sinus
3. Maxillary tuberosity
4. Horizontal maxillary fracture
5. Separating the teeth
6. Whole complex of alveolar
7. Palatal process of maxilla
8. Horizontal plates palatine bones
9. Lower parts of the pterygoid plates (pterygomaxillary junction)
10. Can affect the following – nasal septum, septal cartilage and AKA Guerin fracture
30
Forces directed where will result in a Le Fort II fracture?
Forces (superior) directed at nasal bones
31
Le fort II fractures can be described as what type of structure?
Pyramidal (structure) fracture
32
List the areas affected with a Le Fort II fracture?
1. Teeth at the pyramid base
2. Nasofrontal suture remnant apex
3. Posterior alveolar ridge
4. Lateral walls of the maxillary sinuses
5. Inferior orbital rim
6. Nasal bones
7. Nasofrontal junction of the frontal process of the maxilla
8. Separates the whole maxilla with part of the nasal bones and the lower part of the pterygoid plates.
33
Forces directed where will result in a Le Fort III fracture?
Level of orbits
34
List the areas affected with a Le Fort III fracture?
1. Craniofacial distraction with a transverse line
2. Transverse fracture line
3. Nasofrontal suture
4. Maxillofacial suture
5. Orbital wall
6. Zygomatic arch and zygomaticofrontal suture
7. Zygomaticomaxillary complexes
8. Nasal bones
9. Palatal bones
10. Most of the pterygoid plates
35
If fracture is pan facial what does that mean?
It means that it is a combination of the Le Fort fractures.
36
With all midface fractures, there needs to be an initial management first, what are these initial managements?
1. Airway management
2. Haemorrhage
3. Head injury/Glasgow coma scale
4. Secondary survey
37
As part of the initial management, airway management is crucial, how can the following affect airway?
1. Physical anatomy changes: maxilla and lower face height may push down the soft palate on the dorsum of the tongue causing a physical airway obstruction
2. Swelling: of the nasal passages by local oedema
3. Bleeding: into the nasal passages
4. Loss of consciousness
5. Head injury and respiratory depression
38
With midface fractures haemorrhage is most likely to occur where?
1. Haemorrhage involving the maxillary artery
2. Nasal walls
3. Septal haematoma
4. Retrobulbar haemorrhage
39
What type of haemorrhage is this?
Retrobulbar haemorrhage
40
What type of haematoma is this?
Septal haematoma
41
What is a haematoma?
A haematoma is a collection or pooling of blood outside the blood vessel.
42
How should head injuries be assessed?
Glasgow coma scale
43
The Glasgow coma scale uses three parameters, what are they?
1. Eye opening
2. Verbal response
3. Motor response
44
The Glasgow coma scale has a range for its scoring, what is it?
3 – 15
45
The secondary survey for head and neck assessment is an extra oral assessment and includes assessment of what?
1. Asymmetry
2. Lacerations
3. Ecchymosis (bruising)
4. Discharge nose/ears
46
For the detection of direct midface fractures you should examine patients systematically and manually palpate bilaterally which would include which structures?
1. Frontal bones
2. Supraorbital rims
3. Frontonasal suture
4. Lateral orbital rims
5. Zygoma
6. Zygomatic arch
47
What are the presentation and clinical findings of le Fort 1 fractures
1. Mobility of tooth-bearing segment of the upper jaw
2. Crepitus in buccal sulcus
3. “Cracked-pot” percussion note from upper teeth
4. Intra-oral haematoma in buccal sulcus
5. Palatal haematoma?
6. Fractured teeth cusps
7. Bruising of upper lip and lower mid-face
48
What is does crepitus mean?
In orthopaedic medicine and sports medicine, crepitus describes a popping, clicking or crackling sound in a joint.
49
What are the presentation and clinical findings of le Fort 2/3 fractures
1. Bilateral peri-orbital bruising (“panda eyes”)
2. Subconjunctival haemorrhage
3. Lengthening of face
4. Malocclusion - AOB
5. Gross oedema of face
6. Nasal deformity
7. CSF rhinorrhoea
8. Diplopia and other visual problems
9. Mobility of the upper jaw
10. Palatal haematoma
50
What type of scan needs to be used to identify Le Fort fractures?
CT scan
51
What fracture lines need to be present to determine a midface fracture?
Pterygoid plates mandatory unique fracture lines.
52
This coronal view demonstrating a fracture where?
Lateral piriform aperture
53
After patient is stable aim: restoration of normal function which includes?
1. Ocular
2. Nasal
3. Oral
4. Dental
5. Aesthetics (symmetry)
54
What does open reduction mean in surgery?
During an open reduction, orthopaedic surgeons reposition the pieces of your fractured bone surgically so that your bones are back in their proper alignment. In a closed reduction, a doctor physically moves the bones back into place without surgically exposing the bone.
55
What does internal fixation mean?
Internal fixation is an operation in orthopaedics that involves the surgical implementation of implants for the purpose of repairing a bone.
56
What is Rowe disimpaction forceps used for?
Rowe Disimpaction Forceps are specialised instruments that maxillofacial surgeons can use to separate the maxillary bones in cases of impacted fractures of the facial skeleton.
57
What does Orthognathic mean?
Straight jaws. Surgical manipulation to produce optimal dentofacial function and aesthetics.
58
What are the 5 skeletal relationships?
1. Class 1
2. Mild
3. Moderate
4. Severe
5. Extreme
59
What are the indications for orthognathic surgery?
Skeletal discrepancy
- Anteroposterior: skeletal class 2/3
Vertical discrepancy
- Open bite
- Deep bite
- VME
Lateral discrepancy
- Crossbites
- Asymmetries
Other clinical/psychological factors
Function
- Eating/chewing
- Speech
- TMD
- Sleep apnoea
Aesthetics: teasing and bullying
- Social
discrimination
- Psychological distress
Pain/discomfort
60
What factors need to be taken in consideration for Orthognathic surgery?
1. Psychological status
2. Family support
3. Dental health
4. Cooperation
5. Age?
61
Why should treatment timing in relation to skeletal growth be taken into consideration of Orthognathic surgery?
Growth stops around age 18 (female) to 20 (male). And sometimes some cases might resolve itself.
62
When undergoing Orthognathic surgery, you would need a multi-disciplinary team, what does this team include?
1. Orthodontics
2. Oral and maxillofacial surgery
3. Clinical psychology
4. Restorative dentistry
5. Maxillofacial technology
6. Dental hygienist
7. Dietician
8. Speech and language therapy
63
What is the treatment process Orthognathic surgery?
1. Referral
2. Assessment and diagnosis
3. Joint clinic
4. Pre-surgical orthodontics
5. Orthognathic surgery
6. Post-surgical orthodontics
7. Retainers/review
64
Who usually does the referral for Orthognathic surgery?
Usually to orthodontics by GDP/GMP
65
What falls under special tests?
1. Radiographs
- DPT
- Intra-Orals
- Cephalometry
2. Study Models
3. Clinical photography
4. Other imaging
5. Psychological data + BMI (@joint clinic)
66
What are we looking for in radiographs in the DPT/Intra-Orals?
1. Caries
2. Periodontal disease
3. Root resorption
4. Condylar hyperplasia / degenerative changes
5. Other pathology
67
hat is the purpose of the joint clinic? Treatment plan
Treatment plan
68
Why is there a psychological assessment needed to be done for Orthognathic surgery?
1. Questionnaire based
2. Referral to clinical psychologist where required for further assessment
- 20% of orthognathic patients have psychologic distress or psychiatric disorders
3. Psychological therapies where body dysmorphic disorder identified
69
Body mass index guide are?
1. Underweight = <18.5
2. Normal weight = 18.5 – 24.9
3. Overweight = 25-29.9
4. Obesity > 30
70
What is the purpose of pre-surgical orthodontic treatment?
1. Required so teeth occlude properly at time of surgery
2. Upper and lower fixed appliances
- Align
- Decompensate
- Coordinate
71
Alignment involves the correction of what before Orthognathic surgery?
1. Crowding
2. Spacing
3. Rotations
72
What is the purpose of decompensation?
in preparation for orthognathic surgery, it is necessary to remove any dental compensations present and to place the teeth in a favourable position with their supporting bone. This is called presurgical decompensation.
73
Crowding and decompensation dictate extractions, for class II cases what are removed?
Lower premolars
74
Crowding and decompensation dictate extractions, for class III cases what are removed?
Upper premolars
75
For coordination it is important for what?
1. Good planned occlusion with no crossbites
2. Arch expansion
76
What is the purpose of model surgery?
1. To determine post-surgery occlusion
2. To measure surgical movements
3. For wafer manufacture
77
What is an acrylic wafer?
The acrylic occlusal wafer is a thin piece of plastic which fits between and indexes the occlusal surfaces of the maxillary and mandibular teeth. The wafer enables the dental arches to be put in any desired pre-planned position
78
How long does it take roughly for a single jaw to undergo orthognathic surgery?
2-3 hours, bimax 4-5 hours.
79
What is bilateral sagittal split osteotomy?
A bilateral sagittal split osteotomy is a type of jaw surgery in which the lower jaw (mandible) is split bilaterally (moved forward or backward) to straighten it to a more balanced and functional position. It is performed to correct types of malocclusion, a misalignment of teeth.
80
What is a body ostectomy?
A mandibular body ostectomy is an osteotomy with a segmental resection of a defined section of the mandibular body. The inferior alveolar nerve typically crosses the osteotomy sites and the bony piece which has to be resected.
81
What is a genioplasty?
Chin augmentation using surgical implants can alter the underlying structure of the face, providing better balance to the facial features. The specific medical terms mentoplasty and genioplasty are used to refer to the reduction and addition of material to a patient's chin.
82
What are the treatment options for head and neck cancer?
1. Surgery
2. Radiotherapy +/- SACT
3. Systemic Anti-Cancer Therapy (SACT)
4. Supportive care
83
How does radiotherapy work?
1. High energy x-rays
2. Targeted to tumour +/- nodes
3. Avoiding organs at risk
84
What three types of radiotherapy are there?
1. Radical (curative)
2. Adjuvant (after surgery)
3. Palliative
85
What is the aim of immobilisation in radiotherapy?
The aim of immobilisation in radiotherapy is to secure the patient is in the same position at each treatment fraction. This is required in order to deliver the planned radiation doses accurately.
86
What is the aim of planning in radiotherapy?
Before you begin radiation treatment, your radiation therapy team carefully plans your treatment in a process called radiation simulation. Treatment planning usually involves positioning your body, making marks on your skin and taking imaging scans.
87
What is contouring in radiotherapy?
Contour delineation is a critical process in treatment planning because it involves outlining tumour (or areas at risk of microscopic disease) as well as nearby organs at risk (OARs) to guide radiation therapy plans that optimize tumour control and reduce radiation toxicity.
88
What are the advantages/disadvantages to radiotherapy?
Advantages – preserves tissue function, treats microscopic disease
Disadvantages – 4-6 weeks treatment, acute side effects, late sequelae
89
What are the acute side effects of radiotherapy?
1. Skin reaction
2. Mucosal reaction
3. Fatigue
4. Glut -
90
What are the late side effects of radiotherapy?
1. Dry mouth – caries
2. Altered taste
3. Fibrosis
4. Telangiectasia - small, widened blood vessels on the skin.
5. 2nd malignancy
91
Systemic anti-cancer therapy (SACT) includes?
1. Conventional chemotherapy
2. Drugs which target the immune system (monoclonal antibodies)
92
SACT: conventional chemotherapy features include?
1. Inhibit cell division
2. Single agents or combination regimes
3. Delivered in cycles
4. Dose calculated on body surface area or renal function
93
What are the monoclonal antibodies used for SACT?
1. Cetuximab – targets epidermal growth factor receptor (EGFR)
2. Nivolumab & Pembrolizumab – checkpoint inhibitors (PD-1), which upregulates the immune system to target cancer cells
94
What are the potential advantages of SACT?
1. Improved survival
- Improved local control
- Decreasing incidence distant metastases
2. Relief of symptoms
- Decreasing tumour size
95
What are the potential disadvantages of SACT?
1. Increased toxicity
2. May increase rate of treatment related deaths
96
When do we use SACT?
1. Squamous cancers
2. Locally advanced disease
- 50-60% advanced patients have local disease recurrence within 2 years
- 20-30% develop metastatic disease
3. Palliation of symptoms (locally advanced and metastatic)
97
SACT on locally advanced disease has a survival year of what?
5 years
98
SACT: patient selection
1. Patients are often in poor general condition
- Smoking
- Alcohol
- Nutrition
2. Compliance
3. Concurrent medical problems
4. Toxicity may go unreported
99
What are the SACT drugs?
1. Chemotherapy
- Platinum agents: cisplatin, carboplatin
- Antimetabolites: 5FU
- Taxanes: docetaxel, paclitaxel
2. Monoclonal antibodies
- Cetuximab
- Nivolumab
- Pembrolizumab
100
hich drug is used as a Neoadjuvant (before radiotherapy) for SACT? Cisplatin
Cisplatin
101
Which drugs are used concurrent (with radiotherapy) for SACT?
1. Cisplatin
2. Cetuximab
102
Which drug is used as an adjuvant (after surgery with radiotherapy) for SACT?
Cisplatin/carboplatin
103
Which drugs are used as a palliative for SACT?
1. Cisplatin / 5 FU
2. Taxanes
3. Nivolumab, pembrolizumab
104
What are the indications for adjuvant (Chemo) radiation?
1. Absolute indications
- Positive resection margins
- Extracapsular lymph node spread
2. Relative indications
- Oral cavity primary
- Poor differentiation
- Close margins < 5mm
- Advanced T stages
- Perineural invasion
- Lymphovascular invasion
- Nodes – consider size, number and levels involved
105
What are the general toxicities of chemotherapy?
1. Nausea
2. Fatigue
3. Myelosuppression
106
What are the platinum toxicities of chemotherapy?
1. Vomiting
2. Tinnitus
3. Deafness
4. Paraesthesia
5. Renal impairment
107
What are the 5 FU toxicities of chemotherapy?
1. Mouth ulcers
2. Diarrhoea
108
What are the taxanes toxicities of chemotherapy?
1. Alopecia
2. Nail dystrophy
3. Hypersensitivity
109
What are the toxicities of cetuximab?
1. Fatigue
2. Diarrhoea
3. Rash
4. Nausea / vomiting
5. Hair / nail change
6. Allergy
110
HPV is associated with usually which cancers?
Oropharyngeal cancer, (probably not oral cavity cancer)
111
EBV is associated with which cancer?
Nasopharyngeal cancer
112
HHV 8 is associated with which cancer?
Kaposi’s
113
What are oral pre-malignant disorders?
Premalignant or precancerous (also referred to as “potentially malignant”) oral lesions involve the skin lining of the mouth (known as the epithelium) and may be at risk for becoming (transforming into) an oral cancer, although it is difficult to predict which lesions will transform and how long it will take.
1. Leukoplakia
2. Erythroleukoplakia
3. PVL
4. Submucous fibrosis
5. Oral lichen planus – controversial
6. Chronic hyperplastic candidosis – controversial
114
What are the features of leukoplakia?
1. Diagnosis of exclusion; white plaque attributable to no other cause
2. Prevalence 1-4%
3. Homogenous or non-homogenous, focal or multifocal
4. Incisional biopsy/mapping biopsies/excisional biopsy
5. Malignant transformation 8-22%
6. Dysplasia/CIS/SCC in 40 – 46%
7. Surgical excision/serial biopsies/serial reviews with photography
115
What are the features of erythroleukoplakia?
1. Non-homogenous leukoplakia
2. red, pebbly granular plaque
3. Least common oral PMD
4. 90% will have dysplasia/CIS/invasive disease on biopsy (high risk)
116
What are the featured of submucous fibrosis?
1. Characterised by juxtaepithelial inflammation and fibrosis of oral mucosa with progressive trismus
2. Areca nut (betel quid contains areca nut) (+ genetics?)
3. Induces activity of TGF-beta and produces collagen, inhibits collagen degradation, causes fibrosis
4. India, Pakistan, Bangladesh (and families in UK)
5. Mucosal burning/ulceration/dryness fibrosis/rigidity/trismus
6. Transformation rate 7%-30%
7. Medical/physical/surgical management
117
What are the features of Proliferative Verrucous Leukoplakia (PVL)?
1. Progressive, multifocal, exophytic, persistent
2. No risk factors
3. Oral microbiome dysbiosis may be contributory
4. Elderly women
5. Separate entity to leukoplakia
6. Malignant transformation 70% - 100% (but no risk factors) (average transformation duration 23 months)
7. Histological grading scale (1-10) (Hansen)
8. Management controversial (similar transformation rate in surgical and conservatively managed groups)
9. Surgery still mainstay of treatment
118
Benign vs malignant what are the red flags to look out for?
Red flags:
1) Ulcer perists (t > 2 weeks) despite removal of any obvious causation
2) Rolled margins, central necrosis
3) Speckled (erythroleukoplakia) appearance
4) Cervical lymphadenopathy (enlarged (size > 1cm), firm, fixed, tethered, non-tender)
5) Worsening pain (neuropathic, dysaethesia, paraesthesia)
6) Referred pain (ear, throat, mandible)
7) Weight loss (local / systemic effects)
119
Tissue (histology) and imaging (CT or MRI) will help provide what?
TNM staging
120
Head and neck MDT (Multi-disciplinary team) include?
1. Patient
2. CNS
3. Oncologists
4. Radiologists
5. Surgeons
6. Dietitians
7. Speech therapists
8. MDT liaison
9. Pathologists
10. Restorative dentists
121
When it comes to treatment of fractures, if the fracture margins are not directly visualised and no incision is made, what type of technique is used to treat this fracture?
Closed technique
122
When it comes to treatment of fractures, if the fracture margins are directly visualised intra-orally or extra-orally via an incision, what type of technique is used to treat this fracture?
Open technique
123
Which technique open/close is generally preferred and why?
Open technique is generally the preferred option as the fracture is immobilised to allow a period of healing.
124
What is the purpose of reduction in the management of treatment for fractures
1. Aligns the bone ends anatomically
2. Recreates the normal anatomy
125
What is the purpose of fixation in the management of treatment for fractures?
1. Prevents movement of the bone margins whilst healing occurs
2. Can be load bearing so that 100% of the functional load is supported by the fixation e.g. 2 large plates
3. Can be load sharing such that the load is distributed between the hardware and the bone margins e.g. one upper boarder plate and arch bars
126
How long does it take in an adult to heal a fracture given that proper reduction and fixation has been done?
4-6 weeks
127
Wiring of the jaw is an example of which technique?
Closed technique
128
Methods of fixation include open and closed techniques what are the open techniques available?
1. Mini-plates.
2. Reconstruction plates
3. Compression plates
4. Lag screws
129
What type of fixation method is this?
Open technique – mini plates
130
What type of fixation method is this?
Open technique – reconstruction plates
131
Methods of fixation include open and closed techniques what are the closed techniques available?
1. Inter-maxillary fixation
2. Arch bars
3. Eyelet wires
4. Leonard buttons
5. Cast cap splits
6. Gunning splints
132
Titanium miniplates are osseonintergrated, what does this mean?
They won’t incite a foreign reaction. They are in for the patient’s life
133
this is an example of what type of fracture?
symphyseal fracture
134
What is intermaxillary fixation?
is an age old procedure which is used for treatment of fractures involving maxillomandibular complex. Conventionally various types of tooth mounted devices like arch bars, dental and interdental wiring, metallic and nonmetallic splints are used to achieve intermaxillary fixation.
135
If you have an accident or some form of trauma which doesn’t allow you to meet your teeth together, this suggests what? .
Patient has some form of malocclusion due to trauma
136
Is someone has altered lip sensation (numbness) as a result of trauma, where would you expect the trauma to be?
Fractured mandible the most likely cause.
137
When a patient has fractured their mandible, it is very common for them to find it difficult to do what?
Painful to move their jaw and swallow are very common features of fractured mandible. They will often dribble because they struggle to swallow their own saliva.
138
How would you examine a patient who has undergone a blunt force trauma resulting in a fractured mandible?
1. Palpate condyles
2. Ask patient to open wide to look out for the translocation of the condylar head
3. Deviation of the mandible
4. Degree of trismus – which indicates fractured condyle
5. Palpate mandible – look for steps
6. Check for occlusion – ask patient what their normal occlusion is
7. Check for numbness
8. Hypoesthesia – reduced sensation
9. Anaesthesia – no sensation
10. Paraesthesia – tingling
139
For a symphyseal fracture what radiographs would you request?
DPT and PA mandible – because you need to visualise your fracture in three dimensions.
140
For a symphyseal fracture who would you refer the patient to?
Maxillofacial team and refer withing the first 24 hours. The quicker the better to prevent wound infection and better healing. Also prevent fibrous union.
141
If a patient, he has symphyseal fracture and declines treatment what would you have to tell them?
1. Document consequence of refusing treatment
2. Copy in his GP so they are aware of refusal of treatment and your
142
teeth that are in the fracture line are rendered to be what?
Non vital
143
* A 21 year-old student attends with pain from his lower jaw after being hit the face with a squash racquet the day before. He can bring his teeth together although it is painful.
What is highlighted by the arrow and what does it indicate?
Haematoma at the floor of the mouth
144
* What radiographic views would you take and why?
DPT and PA mandible giving us a 3-dimensional view of the fracture
145
If there was no mobility or malocclusion what would the treatment be?
Conservative management, simple analgesic, soft diet and review in 1 week
146
You are out with your friends for a bike ride and one of them comes off at speed and lands badly. They are in a lot of pain from their mouth and are bleeding a lot.
what type of fracture is this?
mandibular fracture – step formation present.
147
When you see a badly displaced fracture, what should you be thinking regarding the other surrounding structure?
Likelihood there are other fractures present.
148
How do you manage this?
Use occlusion to reduce the fracture. Place two plates, based on Champneys principle.
149
What is neuropraxia?
Neuropraxia is the mildest form of traumatic peripheral nerve injury, bruising of the nerve.
150
If you have numbness of the teeth what does that suggest?
Teeth are innervated by the incisive branch, which would suggest a bony injury.
151
Numbness of the teeth and lip would suggest what, compared to numbness of the lip?
Numbness of teeth and lip suggest there is some bony fracture, where numbness of the lip could suggest just neuropraxia.
152
Case 4
* A 18 year old man fall whilst running for a bus yesterday. He damaged his face and jaw so went to A&E who cleaned his wounds and put some paper stitches on his cut. They told him the injuries were superficial but he has a numb lower lip and teeth on the right side. The wound on his chin is seeping blood. As you are his dentist he wants you to check that his teeth are okay as they are numb.
1. Why do you think he has a numb lip?
2. If the impact of the fall was the right side lower boarder of the mandible what pattern of fracture could he have suffered?
3. When performing a clinical examination what would you be looking for?
4. How would you investigate his injuries?
5. Who might you refer the patient to and in what time frame?
6. Would you organise a review with this case and why?
7. The patient asks will the numbness improve – what so you tell him?
q1. Fracture of the mandible, because of presentation of numb lip and teeth
q2. Left condylar fracture
q3. Condylar fractures – pain on opening, pain on palpation, limitation of opening, pain near ear, deviation of mouth opening, deviation of chin.
Q4. DPT and PA mandible
Q5. Send them to A and E same day
Q6. Yes, I would absolutely organise a review, for the assessment of his teeth.
Q7. Yes, would improve unless severance of nerve.
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Case 5
You have been asked to do a domiciliary visit to an elderly lady who fell out of bed. She is edentulous but was not wearing her dentures at the time. She is in a lot of pain.
* What do you see on clinical examination that gives an indication of her injury?
* What other questions could you ask about her symptoms?
* What would you recommend?
Q1. Dark bruise, haematoma = fracture of the mandible, gravity has pulled the blood down the fascia planes which is normal, might find bone mobility when palpate.
Q2. Ask if there is any numbness of the lip, ask her if she can swallow or talk, ask for loss of consciousness.
Q3. Sent in to A&E for x-rays.
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Case 5
* She has been seen by the maxillofacial team and they have taken CT scan.
* What do you see on the scan?
* What treatment is likely to be offered?
* What implications does that have for you as her dentist?
* If she was on IV bisphosphonates for myeloma what is she at risk of and how much of a risk?
Q1. Bilateral symphyseal fracture. Hasn’t displaced to the characteristic bucket handle fracture.
Q2. Open reduction internal fixation, with large reconstruction plates.
Q3. How uncomfortable it will be for her to wear her dentures after this, the reconstruction plates will be sitting on the labial sulcus, which means lumpy bits sticking out, which will interfere with the sitting of the dentures. May need to make new dentures.
Q4. 1/10 chance of developing MRONJ.
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Case 6
A 51 year lorry driver was in a RTA and his chin hit the driving wheel causing facial injuries. As a CT in the maxillofacial department you are asked to see him in A&E.
* What do you think about his occlusion?
* What do you see in the DPT?
* What treatment will he need?
* How can the occlusion be used to help reduce the fracture?
* What sites need to be treated?
Q1. Does not have occlusion with his upper teeth, lower teeth occlusion with last standing molars. Find out what their normal occlusion is, look out for wear facets, and look for pictures to identify previous occlusions. Anterior open bite present
Q2. Left Para symphyseal fracture going from tooth 35 obliquely to the midline, this alone would not cause an anterior open bite. Displaced extracapsular fracture of the right condylar neck. This has caused shortening of the length of the ramus. Bilateral condylar fracture, not as bad on the left side.
Q3. Open reduction internal fixation for Para symphyseal fracture, open reduction internal fixation on the worst condylar fracture.
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Summary for fractures:
1. Know clinical and signs and symptoms of fracture
2. Know what the appropriate investigations are
3. Know when and to whom to refer
4. Know how this affects your long term care for the patients.
5. https://youtu.be/3mg1D39bFWE
6. https://youtu.be/fv2StvjXeqY
7. https://youtu.be/ritQ3Ht15NY
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When would you refer to oral medicine?
Anything that looks unexpected in the oral cavity along the lines of the following.
* Red/white patches
* Erosions/ ulcers
* Vesiculobullous lesions
* Burning mouth syndrome
* Facial pain
* Xerostomia
* Salivary gland biopsy
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What is a biopsy?
The removal of tissues for histopathological examination including.
* mucosa
* bone
* curettage of cyst lining or contents
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biopsies fall in to two categories, what are they?
1. Excisional – take the whole lesion away
2. Incisional – where you take a small sample because you want a differential diagnosis
- Exfoliative cytology
- Aspirational (FNAC)
- Labial gland biopsy
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What would be included in an excisional biopsy?
1. Small, benign lesions
2. Normal tissue included
3. Special investigations = treatment
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what does this clinical picture show?
A mucocele
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a mucocele is usually caused by trauma to the lower lip by the lower teeth, damaging a salivary duct that would otherwise drain to the floor of the mouth but instead drains?
At the labial mucosa.
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What is the treatment option for a mucocele?
Incise the mucocele and the damaged salivary duct, otherwise recurrence will occur.
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What is the name of this condition?
Epulis, in this case it is a pyogenic granuloma.
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What causes this?
Often a chronic irritation
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How much of the pyogenic granuloma needs to be excised?
The blue lines indicate the periphery of the incision.
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How would the area heal after incision?
Heal by granulation tissue
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What is the name of the condition?
Denture induced hyperplasia
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What is the name of this condition?
Leaf fibroma as a result of pro longed wearing of a denture.
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Incisional biopsies is a biopsy of choice when you want to establish a definitive diagnosis. Multiple specimens may be necessary (mapping biopsies), and a reasonable size of tissue is needed.
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If the area of the proposed biopsy looks very different, with different features you may want two or more biopsies, this is known as what?
Mapping biopsies.
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What type of biopsy would be appropriate here?
Field/mapping biopsies
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As a general rule of thumb which patches are usually more sinister and why red or white?
Red patches or more sinister, because with white patches you can usually wipe them away, with red patches you can’t wipe them away.
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What instruments are required for a biopsy?
1. Standard soft tissue tray
2. Diathermy – achieve haemostasis
3. Punch biopsy – for small biopsies
4. CO2 laser – for larger biopsies, good for haemostasis
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Why is the biopsy placed in saline?
Allows for the biopsy to be fixed
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What affect does the saline have on the size of the biopsy?
The proteins in the biopsy get deproteinised and shrink.
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You should not do a punch biopsy less than how many mm in diameter?
Less than 6mm in diameter.
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What do you need to ensure to do when operating with a CO2 laser?
1. Patients’ eyes are protected
2. Instrumentation is covered in material that doesn’t reflect or plastic material
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What are the best biopsy techniques?
1. Choose most appropriate site – worst looking part of lesion
2. La infiltration – both anaesthesia and haemostasis
3. Regular ellipse of tissue of a reasonable size
4. Wedge of tissue, which includes all the underlying tissue, which could show degree of dysplasia.
5. Atraumatic technique when handling the biopsy so there is no damage to the tissue
6. Achieve good haemostasis – diathermy
7. Primary closure when possible.
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How can you indicate where the anterior, posterior, medial and lateral segments of a biopsy are?
These anatomical locations can be indicated through the uses of stiches of different colours, or pins of different colours attaching biopsy to an object.
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What are the problems that can happen during the biopsy?
1. Inappropriate specimen
2. Specimen too small or macerated
3. Can’t orientate specimen
4. Tissues distorted by diathermy or LA
5. Lab not informed of need for frozen section
6. Lack of clinical detail on form
7. Specimen gone up aspirator
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If you have vesiculas bullous section as a biopsy, how does it need to be sent?
Frozen in ice
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What do frozen sections allow for?
1. Rapid diagnosis of malignancy (cancer or not cancer)
2. Are used pre-operatively, wanting to exclude carcinoma at time of surgery
3. Results within an hour
4. Difficult to assess dysplasia with confidence
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How does exfoliative cytology work?
1. Removal of surface cells by scraping with a spatula or cytobrush
2. Widely used in cervical cancer screening
3. Research continues in its application in diagnosis of oral carcinoma (cytokeratins, nuclear and cell area).
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What does a fine needle aspiration cytology F.N.A.C determine?
Determines whether a lesion is solid or cystic/ fluid filled. Very useful with lumps in the parotid glands and neck lumps to determine whether the lump is a tumour.
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A 47 year old male patient attends for a routine check up and you notice a 3cm red/white patch on the floor of mouth which he was unaware of. He has a heavily restored dentition with many crowns and amalgam restorations. He is a smoker of 20/day since he was 16 years old and drinks a bottle of vodka per week.
* Q1. Give 2 possible diagnosis for this lesion.
* Q2. What concerns you about this lesion?
* Q3. What would you do?
* Q4. How would this be investigated?
* Q5. What advice could you give your patient about the management of such lesions?
* Q6. What preventive advice would you give?
Q1 – potential malignant lesion, cancer, lichenoid lesion
Q2 – size 3cm (2 or more worrying), clinical appearance mixed red and white patch, FOM high risk site for oral cancer.
Q3 – urgent 2 week referral for investigation.
Q4 – incisional biopsy
Q5 – excised, surgical management
Q6 – advocate smoking cessation and 14 units of alcohol
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The major salivary gland only produces saliva when?
When you’re sitting down to eat, at rest it doesn’t produce saliva.
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What is the largest of the paired glands?
Parotid glands
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Where does the Stenson’s duct open?
Opposite the second maxillary molar tooth
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What nerve lies superficial to the parotid gland?
Facial nerve
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Where are the submandibular glands located?
Paired glands located in the submandibular triangles
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The submandibular gland is encapsulated and covered by?
Cervical fascia and stylohyoid ligament, which drains via Wharton’s duct in the floor of mouth
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Sublingual gland is the smallest of the gland which lies in floor of mouth, covered only by oral mucosa. So very easy to palpate.
The sublingual gland drains to the oral cavity via small and common ducts what are the names of the ducts?
Small ducts – Rivinis’s duct
Common duct - which joins the submandibular duct called Bartholin’s duct
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What is secreted from the sublingual gland?
It is a mucous gland.
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What is secreted from the submandibular gland?
Mixed seromucous
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What is secreted from the parotid gland?
Mixed seromucous, but predominately serous.
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The sublingual gland sits on top which muscle?
Mylo-hyoid muscle
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What are the commonest pathology that affects the major salivary glands?
Inflammatory disorders which include:
1. viral (mumps, coxsackie,CMV, HIV)
2. bacterial,
3. TB, sarcoid
4. radiation induced
* obstruction/trauma
* neoplasms
* autoimmune / degenerative – sjorgens syndrome
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a viral form inflammation is known as?
Sialadenitis
200
what are the features of paramyxovirus?
1. Young affected – disease of childhood
2. Bilateral enlargement of glands (can be unilateral)
3. Mumps virus
4. Self limiting
5. As adult can be very significant
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What are the features of cytomegalovirus (C.M.V)?
1. Babies affected
2. Older – immunocompromised
3. Asymptomatic, but severe disseminated disease may be seen in neonates and immunocompromised.
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What are the two common diseases that result in sialadenitis?
Mumps and paramyxovirus
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Bacterial Sialadenitis presents as either acute or chronic and is secondary to stasis, what does this mean?
When the salivary glands are active and are required to release saliva via the ducts, this helps flush any lingering pathogens present.
However, if there is stasis such as someone fasting or undergoing starvation, their ducts / glands are not activate which allows for pathogens to travel up the duct and into the gland, causing infection.
This is known as local causes, this also includes obstruction of the duct via a mucus plug or calcified stone.
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Systemic causes which cause bacterial sialadenitis can occur how?
1. Immunocompromised
2. Medication
3. Dehydration
4. Irradiation
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How would you mange acute phase of sialadenitis?
1. Antibiotics
2. Fluids
3. Sialogogues – anything that stimulates the salivary function (citric based)
4. Analgesics
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With sialadenitis and its huge swelling features it makes sense to drain, what is the best way to drain?
You cannot drain or make incision as sialadenitis is infection of the salivary gland which is encapsulated, however incision and drainage is possible if there is abscess formation.
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Why does it also make sense for us not to incise and drain the glands?
The anatomy of the gland is not just under one layer of fascia, it is surrounded by underlying fascia and nerves and vessels.
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If you have managed the acute symptoms of sialadenitis, of the patient will have no further problems, if there is no functional problems with the gland itself or structural.
However if there was damage done to the duct that has caused some form of narrowing then symptoms can return later.
This may determine a more sinister factor, what is the best way to treat chronic symptoms?
Further surgery.
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Which gland is mainly affected from sialadenitis?
Submandibular gland mainly affected then parotid.
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Acute sialadenitis and cellulitis share similar symptoms and features, thus diagnosis relies on a good history to determine if it is of odontogenic origin or not?
One question you can ask the patient is if they have prandial symptoms, what are these symptoms?
These symptoms are symptoms that are associated with mealtime.
Often if you have partial obstruction of the glands, it will still release saliva, but you will exhibit pain when it does, this way you can determine that it is of gland origin.
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This clinical picture shows a patient suffering from acute sialadenitis, with pus present in the parotid gland, how would you manage this patient?
1. Do not incise and drain as primary care – facial never present and vessels
2. Referring on for intravenous antimicrobial
3. Refer to maxillofacial to determine to affect drainage
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In the submandibular triangle, what is present there?
Submandibular gland, 3 submandibular nodes.
If there is swelling in the submandibular triangle, it is not easy to determine if it is a gland swelling or lymphoma.
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What is the commonest obstruction of the glands?
Sialolithiasis which is a salivary stone.
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Which gland is more prone to developing sialolithiasis?
Submandibular gland because of its mucous, alkaline nature combined with the presence of a tortuous duct.
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What is an organic nidus?
An area of organic mucous
216
What is the presentation of obstructive sialadenitis?
1. Recurrent episodes of transient prandial salivary gland swelling
2. Swelling of gland pain
3. No symptoms between attacks as saliva escapes from gland
4. The bigger the stone becomes the more severe the symptoms
5. Complete obstruction causes stasis of saliva and allows commensals from the oral cavity to enter the gland.
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What does stasis of the salivary duct allow?
Stasis allows ascending infection
218
Patients suffering from acute sialadenitis secondary to obstruction (sialolithiasis) will have what features?
1. Stasis allows ascending infection
2. increasing, painful swelling of 24-72 hours duration
3. oral discharge of pus
4. systemic manifestations
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when looking for stones in the ducts via radiograph we can classify them as what?
1. Intraductal – you can retrieve them under local anaesthetic.
2. Intraglandular – surgical removal of the gland (one removal of gland will not result xerostomia)
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Why is the submandibular gland more prone to developing sialolithiasis?
1. Long tortuous duct
2. More alkaline Ph – which makes calcium and phosphate out of the solution and deposited on an organic nidus
221
Obstructive disorders of the saliva duct, what are the treatment option?
1. Sialagogues
2. Surgical removal of intraductal stone
3. Removal of gland intraglandular and severe symptoms
4. Eliminate trauma
5. Basket retrieval of stones – endoscopy into duct
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When surgically removing a stone from a duct, what can you do to prevent the stone from moving back up the duct or forward?
You can place sutures on the posterior and anterior aspect of the duct where the stones lie, this would prevent it from traveling away when trying to remove it.
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When you have removed the stone, what do you need to use to flush out the duct?
Sterile Saline solution to flush out any stones that may be distal to it.
224
Why is it important that we do not completely stitch up the incision that we made on the duct after we have removed the stone?
If we stitch up the incision then what can happen is that the incision will heal with scar tissue present making the ductal orifice even smaller then it was originally, which can go on to cause further problems with salivary flow.
The two options are you do not suture and leave it as it is and it will heal naturally, or other option is you partially suture, so that when it does heal, it goes back to original size. As show in the image.
225
What is lithotripsy?
Is the use of ultrasonic sound to break down calcified stones, traditionally used for the breakdown of renal stones, this method can be used for the same purpose for no invasive surgery.
226
What method of retrieval is this?
Basket retrieval – works best with relatively small stones.
227
What is a ranula?
A mucus retention cyst
228
There are two types of mucoceles what are they?
1. Mucous retention cyst – present in the sublingual gland
2. Mucous extravagation cyst – presents on the lip after trauma
229
What are the presentations of a ranula?
* a large mucus retention cyst in the floor of mouth
* marsupialisation - high recurrence removal of sublingual gland
* plunging ranula
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what is necrotising sialometaplasia?
Necrotizing sialometaplasia (NS) is a benign, self-limiting inflammatory reaction of the minor salivary gland tissue of the palate which may mimic squamous cell carcinoma or mucoepidermoid carcinoma.
231
What are the features of common salivary pathology tumours?
* Localised salivary gland enlargement
* <3% of head/neck tumours
* Tumours of major glands more common than minor glands which account for only 15-20 % of all salivary tumours.
* 90% parotid gland - 80% benign
* 50% submandibular and 25% sublingual gland tumours benign
* 55% of minor SG tumours arise in the palate, 20% in the upper lip.
* SG tumours of the lower lip are rare.
* Proportion of carcinomas is higher in minor SGs.
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What is a pleomorphic adenoma?
Pleomorphic adenomas are benign salivary gland tumours, which predominantly affect the superficial lobe of the parotid gland.
Investigation of this would be a incisional biopsy because it is of minor salivary gland, you wouldn’t biopsy a major gland due to underlying tissue, vessels and nerves.
233
When diagnosis of ductal pathology, how can features of swelling help determine your diagnosis?
1. Intermittent swelling – suggests transient obstruction
2. Persistent swelling – suggests complete obstruction
3. If it is persistent swelling then you would get complete obstruction with pain.
234
When diagnosis of ductal pathology, how can features of position (unilateral/bilateral) help determine your diagnosis?
1. Unilateral - can be obstructive sialadenitis
2. Unilateral and localised – can be a tumour
3. Unilateral and diffuse (widely spread) – can be sialadenitis
4. Bilateral and localised – Wharton’s Tumour
5. Bilateral and diffuse – Sjogren’s syndrome
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When diagnosis of ductal pathology, how can features of pain help determine your diagnosis?
1. Prandial pain – associated with mealtimes, the pain is caused by obstruction
2. Pain is consistent and throughout – Sjogren’s syndrome
3. Pain associated with nerve – neoplastic pain
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When diagnosis of ductal pathology, how can features of salivary flow help determine your diagnosis?
1. Xerostomia
2. Sjogren’s
3. Sialorrhea – excess salivation (inability to clear saliva as pose to producing saliva)
237
What is scintigraphy used for?
Used with radioisotopes to see the function of the glands
238
What are the indications for surgery for gland related issues?
* chronic pain/symptoms-refractory
* repeated acute on chronic sialadenitis
- excise sialolith from submandibular duct
- remove gland
- Ranula - marsupialise or complete removal
* benign/malignant tumours+/- nerve reconstruction
239
what are post op info that you need to give to patients before undergoing removal of submandibular gland?
* Pain, swelling, bruising
* Scar
* Numbness of the tongue
* Weakness of the lower lip
* Weakness of tongue movement
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What are the options for parotid surgery?
1. Extracapsular dissection – benign entity, conservative surgery
2. Lobar resection – tumour and normal tissue removed
3. Superficial parotidectomy – dissect 4/5 of parotid gland regardless of how extent the tumour was
4. Total parotidectomy – deep lobe tumour (facial palsy will be experienced)
241
What are the post operative complications of parotid surgery?
* Pain, swelling, bruising
* facial nerve injury – weakness of muscles of facial expression
* gustatory sweating (Frey’s Syndrome)
* numbness around ear lobe
* salivary fistula
* infection
* recurrence of tumour
