Oral Surgery Flashcards
Topics covered: management of mandibular fractures, zygoma fractures, mid-face fractures, oral cancer, salivary gland disease. and referral to oral med and biopsy
1
Q
Which nerve exits the mental foramen and provides sensory innervation to the lower lip?
A
The mandibular division of the trigeminal nerve
2
Q
Name the 4 main pairs of muscles that are attached to the mandible?
A
- Lateral Pterygoid
- Medial Pterygoid
- Masseter
- Temporalis
3
Q
Other than the 4 main pairs of muscles, list some other muscles that are attached to the mandible:
A
- Mylohyoid
- Genioglossus
- Geniohyoid
- Anterior belly of the digastric
- Mentalis
- Buccinator
4
Q
What % of mandibular fractures account for all facial fractures?
A
36-70%
5
Q
List 4 potential causes of mandibular fracture:
A
- Assault
- Sports Injury
- RTAs
- Pathological - cyst, tumours
6
Q
List the 5 different types of mandibular fractures?
A
- Simple - undisplaced, overlying periosteum is intact
- Compound - overlying periosteum and often overlying skin perforated, can involve tooth socket, higher potential for wound infection if wound exposed to oral cavity
- Comminuted - multiple fracture lines, high impact fractures (RTAs), more challenging to manage
- Greenstick - uncommon in mandible, associated w fractures in children, flexing of bone where the outer cortex fractures but inner cortex remains undisplaced
- Pathological
7
Q
What are fractures classified by?
A
Their anatomical position
8
Q
What are the 8 different classifications of mandibular fractures?
A
- Dentoalveolar
- Condylar (common)
- Coronoid
- Ramus
- Angle of the mandible (common)
- Body
- Parasymphysis (common)
- Symphysis
9
Q
Why are condylar fractures common?
A
As the condylar neck is a point of weakness (“crumple zone”)
10
Q
What is often seen with coronoid fractures and why?
A
Often see displacement of the fracture superiorly into the infratemporal space - this is because the coronoid is attached to the temporalis muscle.
This can be difficult to manage.
11
Q
Why are fractures of the angle of the mandible common?
A
As mandibular third molars are a point of weakness.
12
Q
Why are parasmyphysis fractures common?
A
Due to the long root of the mandibular canine.
13
Q
What 4 factors influence the degree of fracture displacement?
A
- Pattern of fracture
- Degree of comminution
- Teeth in fracture line
- Muscle pull
14
Q
Where will the lateral pterygoid displace a fractured condyle?
A
Anteriorly and medially
15
Q
Where will the temporalis, masseter and medial pterygoid displace a fractured proximal segment of the mandible?
A
Superiorly and medially
16
Q
Where will the digastric, geniohyoid, genioglossus, and mylohyoid displace a fractured anterior segment of the mandible?
A
Inferiorly and posteriorly
- Known as a “bucket handle fracture” seen in edentulous mandibles.
17
Q
What is a Guardman’s fracture?
A
Where the chin absorbs the force of the impact causing:
1. Fracture through the midline of the mandible
2. Bilateral transmission of force to condylar neck, causing condylar fracture
3. Medial displacement of the coronoid process
18
Q
What extra-oral clinical features might you see in a patient with a mandibular fracture?
A
- Pain
- Swelling
- Bruising
- Trismus
- Concurrent soft tissue injury - cut lip, dirt, tooth fragment
- Otorrhea - bleeding from ear, CSF
- Anaesthesia/paraesthesia of the lip
19
Q
If otorrhea is observed as a clinical finding in a patient with a mandibular fracture, what must you consider?
A
Whether there has been a fracture to the base of the skull
20
Q
What intra-oral clinical features might you see in a patient with a mandibular fracture?
A
- Haematoma in the FOM (Coleman’s Sign) and buccal mucosa
- Malocclusion
- Tongue - stable position, swelling
- Step deformity in occlusion
- Gingival laceration
- Mobility, loss of teeth, or fractured teeth - inhaled, swallowed, or in soft tissue.
21
Q
Which 2 radiographic views would you ideally take in primary care to allow 3D visualisation of a mandibular fracture?
A
- DPT
- PA mandible/facial
22
Q
What additional radiographic views can be used in secondary care to allow 3D visualisation of a mandibular fracture?
A
- Reverse Towne’s
- CBCT
23
Q
Where would you refer a patient with a mandibular fracture for radiographs, management and follow-up?
A
Refer to the nearest maxillofacial surgery department
24
Q
What complications might a delay in presentation/treatment of a fracture cause?
A
- Wound dehiscence
- Infection
- Exposure of hardware
- Non-union
- Fibrous union
25
What 2 different treatment methods are available when managing mandibular fractures?
Which method is the preferred treatment method?
1. Open technique - preferred
2. Closed technique
26
In which fracture cases can you use open reduction?
1. Displaced fractures (including edentulous displaced fractures)
2. Multiple fractures
3. Bilateral displaced condylar fractures
27
Is open reduction carried out intra-orally or extra-orally?
It can be carried out both intra-orally and extra-orally - however it is most commonly carried out intra-orally.
28
What is the purpose of open reduction and internal fixation in the management of mandibular fractures?
Open reduction - used to align the bone ends anatomically and recreate normal anatomy
Internal fixation - used to prevent movement of the bone margins whilst healing occurs
29
Approximately how long does it take for an adults fractured mandible to heal post-surgery?
~4-6 weeks
30
Fixation can be load bearing (i.e. 2 large plates) or load sharing (i.e. one upper border plate and arch bars).
Which is the most ideal out of the 2 options?
Load bearing is most preferred as 100% of the functional load is supported by the fixation.
31
What aids may be used when carrying out internal fixation?
1. Titanium mini-plates - most commonly used
2. Reconstruction plates - used in edentulous mandibles
3. Compression plates - not commonly used
4. Lag screws - not commonly used
32
Why is titanium a useful material to use for miniplates in internal fixation?
As it osseointegrates well.
This means that the miniplates can successfully remain throughout life.
33
What are the advantages and disadvantages of open reduction and internal fixation?
Advantages:
- Improved alignment and occlusion
- Fracture immobilisation
- Avoids IMF (closed technique)
- Low rate of malunion
- Lower rate of infection
Disadvantages:
- Morbidity of surgical procedure - as requires GA
- Expensive hardware
- Need for GA
34
For open reduction and internal fixation, what set of principles determine the number of plates needed and the position of the plates?
Champy's principles.
35
How do the Champy's principles work?
They work by assessing where the stress intention lines are in the mandible and then maximising the position of miniplate osteosynthesis.
36
In accordance with Champy's principles, where should the miniplate be placed and why?
Along the ideal line of osteosynthesis - to counteract distraction forces that occur along the fracture line.
37
In accordance with Champy's principles, in the mandibular angle region, where should the plate be placed?
Either along or just below the oblique line of the mandible
38
In accordance with Champy's principles, in the mental foramina region, where should the plates be placed?
2 plates below the apices of the teeth
39
What can be used in conjunction with open reduction and internal fixation to improve the occlusion and reduce the fracture?
Pre-operative IMF (closed technique)
40
What does the closed technique involve?
Intermaxillary fixation (IMF) - wiring the jaws together
41
What aids can be used to facilitate IMF?
Arch bars
Eyelet wires
Leonard buttons
Cast cap splints
Gunning splints - for edentulous cases
IMF screws
42
What are the indications for using a closed reduction technique?
1. Non-displaced favourable fractures
2. Grossly comminuted fractures
3. Significant loss of overlying soft tissue
4. Edentulous mandibular fractures
5. Fractures in children
6. Coronoid process fractures
7. Undisplaced condylar fractures
43
What are the advantages and disadvantages of closed reduction?
Advantages:
- Inexpensive
- Simple - can be done under LA
- No foreign body (reduced risk of infection)
Disadvantages:
- Not absolutely stable (still movement at bone margins)
- Prolonged period of IMF up to 6 weeks ( impact on patient's life)
- Possible TMJ sequelae
- Decreased oral intake
- Possible pulmonary consideration (esp if pt has reflux/vomiting issues)
44
Why are edentulous fractures more challenging?
- Atrophy
- Poorly vascularised (poor healing capacity)
- Lack of anatomical landmarks
45
What classification system is used to classify mandibular atrophy in edentulous mandibles?
The Luhr Mandibular Atrophy Classification
46
How should edentulous fractures be managed?
With the placement of large reconstruction load-bearing plates (extraorally)
47
Condylar fractures can be extra-capsular or intra-capsular.
Which one is difficult to treat, and which one is most common?
Difficult to treat - Intra-capsular
Most common - Extra-capsular
48
What is the suggested management for condylar fractures?
Often can be managed conservatively - soft diet, analgesics, NSAIDs
However, if there is displacement or dislocation of the condylar head then active treatment is required:
Intra-capsular: closed reduction using Leonard buttons and elastic traction.
Extra-capsular: open reduction and internal fixation.
49
50
How do you manage a greenstick (no displacement) fracture?
Manage conservatively using splints
51
How would you manage the patient postoperatively following surgical management of a mandibular fracture?
Managed on Ward/ITU
Depends on treatment method (open v closed)
Wire cutters or scissors can be used to remove IMF
There is no specific guidance on prescribing antibiotics
Pt may require short-term steroids/fluids
Post op xrays are not taken routinely
52
What complications may arise following surgery for a mandibular fracture?
1. Inadequate fixation - resulting in mobility/non-union/fibrous union/malunion
2. Altered occlusion
3. Distracted TMJ
4. Scars - trauma and iatrogenic
5. Infection - 0.4-32%
6. Bone necrosis, osteonecrosis
7. Numb lip - due to damage of IAN or mental nerve
8. Exposed plate - can be removed under LA
53
What are the aims when treating a fracture of the zygoma?
1. Restore facial projection/symmetry
2. Restore orbital region - volume, globe, position, shape of palpebral fissure
54
What 4 factors does the delivery of treatment for a facial fracture depend on?
1. Timing
2. Type of fracture
3. Mechanism
4. Presentation - degree of comminution, stability of fracture, presence of other features
55
Why is the management of zygoma fractures not normally carried out immediately?
To allow time for facial swelling, oedema, and conjunctival chemosis to reduce - this also helps to improve surgical access.
56
What are the 4 different types of zygoma fractures?
1. Non-displaced fracture
2. Displaced, minimally comminuted fracture
3. Complex and comminuted fracture
4. Isolated zygomatic arch fracture
57
Why is open reduction and internal fixation a good treatment option for fractures of the zygoma?
As it provides:
- Improved alignment
- Vertical support to the zygoma
- Inspection of fracture sites prior to closure
- Inspection of the orbital rim
58
Which 5 findings in a zygoma fracture would indicate the need for inspection of the orbital floor?
If there is:
1. >5mm defects on CT Scan
2. Severe displacement
3. Comminution of the bones
4. Soft tissue entrapment with limited upward gaze of the eye
5. Orbital contents herniation into maxillary sinus
59
What are the 5 different options available for reduction of a zygoma fracture?
1. ZMC hook - stab incision, hooks under the bone to provide traction
2. Oral ZMC hook - IO approach, vestibular incision, hooks under bone to provide traction
3. Screw reduction - screw insertion to provide traction
4. Carroll-Girard T-Bar - provides traction similar to screw reduction
5. Surgical approach - oral or temporal (Gilles) - Gilles temporal approach is ideal for isolated arch fractures (W type fractures)
60
How would you carry out the surgical Gilles Temporal technique for reduction of a zygoma fracture?
1. Identify incision site
2. Skin incision and dissect to temporalis fascia
3. Incise temporalis fascia
4. Introduce instrument and navigate beneath zygomatic arch
5. Introduce elevator (Bristow/Rowe) to reduce
6. Close wound with sutures
61
What aids can be used for the fixation of a zygoma fracture?
How many points of fixation is considered ideal?
Miniplates and screws.
2/3 point fixation is considered ideal - however 4 point fixation may be used in comminuted high energy injuries.
62
List 3 common fixation points in the management of a zygoma fracture:
1. Frontozygomatic suture
2. Zygomaticomaxillary buttress
3. Infraorbital region
63
List some other features that may present when dealing with a zygoma fracture:
1. Orbital content/volume derangement
2. Facial asymmetry
3. Infra-orbital nerve issues
4. Functional issues - jaw opening, masticatory
5. Associated fractures
64
How would a non-displaced zygomaticomaxillary complex (ZMC) fracture be treated?
1. Confirm by CT scan
2. Non-surgical management - antibiotic, nasal decongestant (if any maxillary sinus involvement), analgesia
3. Frequent observation - monitor for asymmetry or functional deficit (if these occur patient may need ORIF)
4. Soft diet - to avoid any fracture displacement by the masseter muscle
65
How would a displaced minimally comminuted ZMC fracture be treated?
Can attempted to treat with reduction alone (reducing the fracture back to its initial position - however there is a risk of fracture displacement
OR
Treat with ORIF (1-4 point fixation) with titanium mini-plates and screws:
- Reduction by direct visualisation to restore facial symmetry, globe volume, position and function
- Fixation at the frontozygomatic suture, zygomaticomaxillary buttress and inferior orbital areas (2-3 point - ideal)
66
What are the indications for a 2-point fixation method in the treatment of ZMC fracture?
1. Minimally displaced fractures
2. Stable ZMC fracture after initial reduction with no palpable step deformity at the infra-orbital rim
3. No evident changes to orbital volume and globe displacement on CT scan
67
What are the indications for a 3-point fixation method in the treatment of ZMC fracture?
1. Instability of the fragment
2. Exploration of orbital floor required
68
How would a complex and comminuted ZMC fracture be treated?
Major reconstruction
Larger flaps for exposure
Reconstruction of facial buttresses
69
What would indicate the need for reconstruction when managing a ZMC fracture?
1. Enophthalamos - sunken globe due to loss of supporting structures
2. Larger defects (5-10mm)
3. Defects posterior to the axis of the globe
70
What are the complications associated with ZMC fractures?
1. Pain
2. Facial asymmetry
3. Scarring
4. Bleeding (epistaxis)
5. Hardware failure (exposure palpability)
6. Infraorbital nerve paraesthesia
7. Temperature sensitivity
8. Facial paresis or paralysis
9. Poor cosmetic result
10. Trismus
11. Ophthalmological complications
71
What should be performed by the oral and maxillofacial team prior to surgery for a ZMC fracture?
An ophthalmology exam
72
What post-op ophthalmological complications can occur following ZMC fracture surgery?
1. Decreased visual acuity
2. Ectropion - eyelid turned outwards, excessive eye dryness/watering
3. Entropion - inverted eyelid, redness, irritation, excessive eye watering
4. Corneal exposure/abrasion
5. Ptosis - upper eyelid drooped
6. Epiphora - watery eye
7. Enophthalamos - sunken eye
8. Orbital dystopia - eyes not level
9. Diplopia
10. Blindness - caused by superior orbital fissure syndrome or retrobulbar haemorrhage with compartment syndrome
73
What does superior orbital fissure syndrome (SOFS) cause?
1. Ophthalmoplegia - eye movement problems
2. Ptosis - upper eyelid droop
3. Proptosis - bulging eyes
4. Mydriasis - fixed dilated pupils
5. Loss of accommodation
6. Anaesthesia to forehead/upper eyelid
7. Anaesthesia to cornea/bridge of nose
74
How do you manage superior orbital fissure syndrome?
Conservative management
75
What does retrobulbar haemorrhage with compartment syndrome (RBH+OCS) cause?
1. Arterial bleed
2. Closed non-expansile space
3. Increased intra-orbital pressure
4. Orbital compartment syndrome
5. Reduced perfusion
6. Ischaemia of optic nerve and retina
7. Permanent vision loss
8. Proptosis
9. Conjunctival chemosis
10. Subconjunctival haemorrhage
11. Tense globe to palpation
12. Reduced visual activity
13. Sluggish pupil response
14. Relative afferent pupillary defect
15. Intense globe pain
16. Diplopia - double vision
76
What is the management for retrobulbar haemorrhage with compartment syndrome (RBH+OCS)?
1. Non-surgical - fluid deplete, mannitol, acetazolamide, steroids
2. Surgical - lateral canthotomy - surgical decompression
77
What is the most likely cause of a mid-face fracture?
High energy/high impact forces from:
- RTAs
- Severe assault weapons
- Falls from height
- Industrial - large machinery
- Agriculture - large animals
- War injuries
78
What are the borders of the midface?
1. Superior borders:
- zygomatic, frontonasal, frontomaxillary
2. Inferior borders:
- occlusal plane (upper teeth)
- alveolar ridge
3. Posterior borders:
- pterygoid plates of the sphenoid
79
Where does the middle third facial skeleton gain its stability from?
Paired buttressing system
80
What anatomical feature of the mid-face can help to manage masticatory forces?
Struts
81
What can the midface do to protect the brain, skull, and cranium from trauma?
It can collapse and absorb forces
82
What 3 parts make up the buttressing system of the mid third facial skeleton?
1. Vertical Buttress
- includes nasomaxillary, zygomaticomaxillary, pterygomaxillary buttresses.
2. Horizontal Buttress
- includes frontal, zygomatic, and maxillary buttresses.
3. Sagittal Buttress
- includes zygomatic arches, palate, floor of orbit
83
What are the characteristics of the middle third of the facial skeleton?
1. Fragile
2. Fracture usually affects multiple bones
3. Low tolerance to impact forces
4. Protective - can collapse in response to trauma
5. Posterior displacement of the maxilla in response to fracture
84
Which bones of the midface are most likely to fracture in response to traumatic forces?
Nasal bones
85
What might you expect to see when an edentulous patient presents with a midface fracture?
A posteriorly displaced maxilla - however as the patient is edentulous you can expect to see:
- Anterior open bite
- Facial lengthening
- Limited airway
- Nares blood clot
- Coincident head injury
- Dish face deformity (in severe cases)
86
What classification system is used to classify mid-face fractures?
The Le Fort Classification System
87
What is a Le Fort I fracture?
A fracture that results from a force directed above dentoalveolar segment.
Separates the teeth and whole alveolar complex.
88
What is a Le Fort II fracture?
A fracture that results from a force directed at the nasal bones.
A pyramidal fracture - maxillary teeth at the base of the pyramid, with the nasofrontal suture at the apex of the pyramid.
Separates the whole maxilla with part of the nasal bones and the lower part of the pterygoid plates.
89
What is a Le Fort III fracture?
Results from a force directed level to the orbits
Separates the ZMC, nasal bones, palatal bones, and most of the pterygoid plate from the rest of the cranium
90
If a patient displays a combination of Le Fort fractures, what would you classify the fracture as?
Panfacial
91
What complications can occur as a result of a midface fracture?
1. Airway complications
2. Haemorrhage
3. Head injury
4. Orbital/eye injury
5. Other trauma
92
What are the 4 initial management steps when managing a midface fracture?
1. Airway management
2. Control haemorrhage
3. Head injury assessment/GCS
4. Secondary survey - facial fracture assessment
93
What might be the cause of airway obstruction following a midface fracture?
Physical anatomical changes - displaced maxilla and LFH
Swelling (local oedema)
Bleeding
Foreign body
Loss of consciousness - compensatory mechanisms lost
Head injury and respiratory depression
94
What 3 things are assessed in the Glasgow Coma Scale?
What score is the most concerning?
1. Eye opening
2. Verbal response
3. Motor response
Score of 1 is most concerning - means no response.
95
What is assessed in the secondary survey when managing a midface fracture?
Head and neck assessment:
(a) Extra-oral assessment
- asymmetry
- laceration
- ecchymosis
- discharge from nose/ears
- systematic bilateral palpation
- frontal bones
- supraorbital rims
- frontonasal suture
- lateral orbital rims
- zygoma
- zygomatic arch
(b) Intra-oral assessment
- maximal inter-incisal opening
- maxillary vestibule
- zygomaticomaxillary buttress
- palate
- occlusal steps
- malocclusions
- mobility of maxilla
(c) Eye/Orbit
96
How does a Le Fort I fracture commonly present?
Mobility of tooth bearing segment of the upper jaw
Crepitus in buccal sulcus
"Cracked pot" percussion note from upper teeth
Intra-oral haematoma in buccal sulcus
Palatal haematoma
Fractured teeth cusps
Bruising of upper lip and lower midface
Occlusal discrepancy
Anterior open bite
Dentures not fitting
97
How does a Le Fort II/III fracture commonly present?
Bi-lateral peri-orbital bruising (panda eyes)
Subconjunctival haemorrhage
Lengthening of face
Malocclusion - anterior open bite
Gross oedema of the face
Nasal deformity
CSF rhinorrhoea
Diplopia and other visual problems
Mobility of upper jaw - Le Fort III would mobilise slightly higher up
Palatal haematoma
Mandibular fractures
Nasal septal haematoma - must be decompressed when found as can block the airway
Palatal split
98
How are midface fractures assessed?
By CT scan
99
What finding is used to confirm diagnosis of all Le Fort fractures?
A fracture line extending through the pterygoid plates
100
How would a Le Fort I fracture be diagnosed?
Evidence on CT scan of a fracture line:
- Through the pterygoid plates
- And within the piriform aperture
101
How would a Le Fort II fracture be diagnosed?
Evidence on CT scan of a fracture line:
- Through the pterygoid plates
- And through the inferior orbital rim and zygomatic buttress
102
How would a Le Fort III fracture be diagnosed?
Evidence on CT scan of a fracture line:
- Through the pterygoid plates
- And through the lateral orbital wall and zygomatic arch
103
How would you manage a midface fracture?
1. After pt stable aim to restore normal function
- ocular
- nasal
- oral
- dental
2. Aesthetics:
- symmetry
3. ORIF with mini plates and screws
- fixate at buttress areas
4. Reduction may require disimpaction with Rowes disimpaction forceps
5. Mid-face access:
- bi-coronal flap - not common
- intra-oral vestibular
- zygomatic/orbit
- direct - lacerations
104
What are the reconstruction principles of pan facial trauma?
- Maxillomandibular unit
- Establish occlusion
- Restore bony pillars
- Re-establish relationship, occlusal structures with skull base
105
List 6 causes of oral cancer:
1. Tobacco
2. Alcohol
3. Genetic predisposition
4. HPV (likely oropharyngeal cancer rather than oral cavity cancer)
5. EBV (nasopharyngeal cancer)
6. HHV 8 (Kaposi's not OSCC)
106
List 4 types of oral pre-malignant disorders:
1. Leukoplakia
2. Erythroleukoplakia
3. Proliferative Verrucous Leukoplakia (PVL)
4. Submucous fibrosis
*oral lichen planus and chronic hyperplastic candidosis (controversial)
107
What % of Leukoplakia's undergo malignant transformation?
8-22%
108
How would you describe a Leukoplakia?
A white plaque that is attributable to no other cause
Can be homogenous or non-homogenous
Can be focal or multifocal
40-46% demonstrate dysplasia/CIS/SCC
109
How would you manage a Leukoplakia?
Refer to Oral Medicine department for surgical excision, serial biopsies/reviews with photography
110
How would you describe an Erythroleukoplakia?
Non-homogenous Leukoplakia
Red, pebbly granular plaque
90% demonstrate dysplasia/CIS/invasive disease on biopsy (high risk)
111
What are the main characteristics of submucous fibrosis?
Juxta-epithelial inflammation
Fibrosis of oral mucosa with progressive trismus
Mucosal burning, ulceration, dryness
More commonly seen in India/Bangladesh/Pakistan
112
What is the most common cause of submucous fibrosis?
Areca nut (e.g. from betel quid) + genetics?
113
How does fibrosis occur in submucous fibrosis?
Aetiological factors (e.g. areca nut - betel quid) induce the activity of TGF-beta.
This produces collagen and inhibits collagen degradation, resulting in fibrosis.
114
What % of submucous fibrosis undergoes malignant transformation?
7-30%
115
How would you manage a patient with submucous fibrosis?
By medical/physical/surgical management
116
How would you describe PVL?
Proliferative, multi-focal, exophytic, persistent
117
What are the risk factors for PVL?
There are no risk factors.
*more common in elderly women and oral microbiome dysbiosis may be a contributory factor
118
What % of PVL undergoes malignant transformation?
70-100%
119
On average, how long does it take for PVL to become malignant from diagnosis?
~23 months
120
What is the main treatment provided for the management of PVL?
Surgical treatment
121
List 7 red flags that may make you suspicious of malignancy?
1. Ulcer persisting >2 weeks despite removal of obvious causation
2. Rolled margins, central necrosis
3. Speckled (Erythroleukoplakia appearance)
4. Cervical lymphadenopathy - enlarged (>1cm), firm, fixed, tethered, non-tender
5. Worsening pain (neuropathic, dysesthesia, paraesthesia)
6. Referred pain - ear, throat, mandible
7. Weight loss (local/systemic)
122
What staging method is used when staging cancer?
The TNM staging method
123
Who is involved in the management of a patient that has oral cancer?
The multidisciplinary team (MDT) - this may involve:
1. The patient themselves
2. CNS
3. Oncologists
4. Radiologists
5. Surgeons
6. Dieticians
7. Speech therapists
8. MDT liaison
9. Pathologists
10. Restorative dentists
124
What oral cancer management methods are available?
1. Surgery
2. Radiotherapy
3. Chemo-radiotherapy
4. Dual and triple modality
5. Immunotherapy
125
When planning surgical management for the removal of oral cancer, what planning decisions must be considered prior to surgery?
1. Planning the resection
2. Planning neck management
3. Planning reconstruction - with CT
4. Planning oral rehabilitation
126
List 12 clinical situations that would indicate a necessary referral to the local Oral and Maxillofacial Surgery Department:
1. Persistent pain following extraction
- all odontogenic causes have been excluded
2. Non-healing socket following extraction
3. Dry socket - pain persisting for >10 days
4. Cervicofacial infections
- immediate referral necessary when signs of spreading infection, where drainage of abscesses not possible in primary care, immunocompromised and paediatric patients
- suspicion of sepsis requires immediate referral to emergency dept.
5. Persistent haemorrhage from extraction socket/biopsy site:
- refer if bleeding fails to resolve after direct pressure and placement of a haemostatic agent and suturing
- refer if patient has lost a considerable volume of blood
6. OAC and root displacement of teeth/roots/implants into maxillary sinus:
- refer when communication cannot be closed in primary care or if the roots/implants have been displaced to an extent where they cannot be retrieved
7. Dento-alveolar trauma:
- refer if there are facial or intra-oral lacerations which appear soiled, if extent of injury or compliance of patient renders tx under LA unsuitable, if there is suspicion of an inhaled or imbedded tooth fragment
8. Nerve injury:
- refer if there is persistent altered sensation in a nerve division
9. Fracture of maxillary tuberosity:
- immediate referral if there is persistent haemorrhage following tuberosity fracture
- abandoned extractions which have been splinted/sutured back into position will require elective surgical removal
10. Dislocated mandible:
- immediate referral if there is failure to relocate jaw in primary care (sedatives or GA may be required)
11. Hypochlorite extrusion:
- immediate referral if there is swelling and erythema extending towards the neck or eye, or if there is breathing/swallowing issues
12. Fractured mandible:
- immediate referral required
127
List 6 clinical presentations that would indicate a necessary referral to the local Oral Medicine department?
1. Red/white patches - potential malignancy
2. Erosions/ulcers
3. Vesiculobullous lesions
4. Burning mouth syndrome
5. Facial pain
6. Xerostomia
128
What does a biopsy involve?
The removal of tissues for histopathological examination:
- Mucosa
- Bone
- Curettage of cyst lining or contents
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Name 2 different types of biopsy:
1. Incisional biopsy
2. Excisional biopsy
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What does an incisional biopsy involve?
The removal of a representative reasonably sized portion of the lesion to establish definitive diagnosis before treating.
Multiple specimens may be necessary (mapping biopsies).
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What are the 3 different types of incisional biopsy?
Exfoliative cytology
Aspirational (FNAC)
Labial gland biopsy
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What does exfoliative cytology involve?
The removal of surface cells by scraping with a spatula or cytobrush
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What does fine needle aspirational cytology (FNAC) involve?
Involves the insertion of a fine needle into a particular area/swelling and removal of some of the contents for analysis.
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What is FNAC useful for?
Helps to determine whether a lesion is solid or cystic, fluid-filled or vascular
Useful for investigating lumps in the parotid gland
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What type of scan can help to improve the accuracy of FNAC?
US scan
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What does a labial gland biopsy involve?
This involves harvesting a small amount of salivary tissue from minor glands in the lower lip
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Which type of incisional biopsy is used in the diagnosis of Sjogren's Syndrome?
Labial Gland Biopsy
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What does an excisional biopsy involve?
Removal of entire lesion including a base of normal tissue to ensure the full lesion has been removed
Can be carried out using a scalpel/suturing or cutting diathermy.
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Out of scalpel/suturing or cutting diathermy, which method of excisional biopsy is the most preferred method and why?
Cutting diathermy is the most desired excisional biopsy method as it avoids post-op bleeding and the need for suturing.
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Why are pyogenic granulomas commonly seen in pregnant women?
Pyogenic granulomas (i.e. pregnancy epulis) are frequently seen in pregnant woman due to increased hormones and inflammation
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How would you manage a patient that has denture hyperplasia + candidiasis?
Excisional biopsy
Systemic antifungals to clear candida infection
Improved denture hygiene
Soft lining placement in denture and tissue conditioner
Allow healing period
Construct new denture
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How would you treat a mucocele?
Excise mucocele and salivary gland to prevent reoccurrence
Close with suture
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How would manage a lesion that looks suspicious of a SCC?
Investigate the lesion by carrying out an incisional biopsy (large piece of worse looking site of lesion)
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What are the main characteristics of a SCC?
1. Exophytic (grows outwards)
2. Highly keratinised
3. Heaped
4. Indurated soft tissue lesion
5. Significant size in high risk site
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What is Speckled Leukoplakia?
Leukoplakia (white patches) and Erythroplakia (red patches that wont wipe off, and aren't attributed to by other causes).
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What is the difference between Erythroplakia and Erythroleukoplakia?
Erythroplakia is a red lesion
Erythroleukoplakia is a Leukoplakia with a red component
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When carrying out complete removal of a lesion, how much clinically normal tissue should you remove around the margin?
1cm in all dimensions
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What instruments are required for biopsy?
LA
Soft tissue tray
Scalpel/sutures
Diathermy
Punch biopsy
CO2 laser
Cryotherapy
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When can you use cutting diathermy in biopsy?
When removing large lesions by excisional biopsy
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When should you use a punch biopsy?
For small biopsies ~6mm
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When can you use CO2 lasers in biopsy?
In the management of vascular lesions
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When can you use cryotherapy in biopsy?
Limited to the management of vascular lesions
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What happens to the sampled lesion following punch biopsy?
1. Sample fixed in formal saline - sample will become deproteinised and shrink in size
2. Transferred to pathology department where it will be embedded in wax and sectioned into 4 micrometre sections
3. Sections stained with H&E stain and assessed down the microscope
4. A report is then written
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How does a CO2 laser work as a method of biopsy?
It works by vaporising the tissue in order to cut it
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What safety precautions must you make when carrying out a biopsy using CO2 laser?
Significant training is required
Protect the patients eyes as the laser can reflect off metal
Metal instruments must be covered or plastic instruments must be used in order to protect the patient and the operator and the patients soft tissues from laser reflection
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What should the patient be warned of prior to biopsy using CO2 laser?
They are likely to experience significant post-op pain although healing tends to be good.
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What does the biopsy technique involve?
Choose most appropriate site - worst looking part of lesion, appropriate/tolerable for pt.
Infiltration of LA for anaesthesia and haemostasis.
Reasonable size sample and one that can be easily orientated - can use coloured sutures/pins on cardboard to demonstrate orientation of lesion.
Ensure the sample includes overlying and underlying soft tissue.
Atraumatic technique - don't compress the tissue too much.
Haemostasis - may require diathermy.
Primary closure where possible.
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What problems can occur during biopsy?
1. Inappropriate specimen
2. Specimen too small/macerated
3. Can't orientate specimen
4. Tissue distorted by diathermy, laser, or LA
5. Lab not informed of need for frozen section - need to inform in advance
6. Lack of clinical detail on form - HPC, size, colour, texture, site, ulcerated, indurated, sign, contact details, risk factors (smoking, alcohol)
7. Specimen gone up aspirator
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When are frozen sections used in biopsy?
Used peri-operatively when cancers are being managed - when you want to biopsy base/periphery of site to make sure you've removed all of the cancer - allows for rapid diagnosis (can receive results in 1hour)
Required for direct immunofluorescence
*for oncology reasons you would only use frozen sections biopsy for already proven cancers - difficult to assess dysplasia so wouldn't be suitable for diagnosing cancer.
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What is the most reliable diagnostic aid in the diagnosis of oral lesions?
Histopathological examination - most reliable indicator of malignancy
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If you see a suspicious oral lesion on clinical examination what should you do?
Initiate urgent 2-week referral to oral med for investigation of mouth cancer - incisional biopsies would be carried out
Advise pt:
- Reason for referral
- Smoking cessation advice, and reduce alcohol consumption to 14 units/week
- If potentially malignant the lesion will be incised
- if malignant the lesion will be surgically removed
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Name a high risk area for oral cancer:
FOM
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What are the 2 worst risk factors for oral cancer?
1. Smoking
2. Alcohol
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What size would an oral lesion be to be classified as higher risk of becoming malignant?
>2cm
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What is the purpose of minor salivary glands?
To produce constant background moisture
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What is the most common minor salivary gland pathology?
A mucus extravasating cyst
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How is a mucus extravasating cyst treated?
By excision with overlying mucosa and underlying glandular tissue
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What is the purpose of the major salivary glands?
Produce saliva when you think about food/start to eat food.
- these glands don't produce saliva during fasting periods.
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What are the 3 different types of major salivary gland?
1. Parotid glands
2. Submandibular glands
3. Sublingual glands
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Out of the 3 pairs of major salivary glands, which pair of glands is the largest?
Parotid glands
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Where is the parotid gland located?
It is located anterior to the ear behind the ramus of the mandible and overlaps the masseter muscle.
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What is the name of the duct associated with the parotid gland?
Where can this duct be found?
The Stensen's duct
Located just opposite from the second maxillary molar tooth.
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What type of gland is the parotid gland?
The parotid gland is a mixed seromucous gland - however predominantly serous.
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What does the parotid gland consist of?
1. Superficial parotid:
- sits above facial nerve, accounts for 4/5 of the parotid
2. Deep lobe of the parotid:
- sits deep to facial nerve, accounts for 1/5 of the parotid
3. Accessory lobe of the parotid:
- sits above duct as duct goes forwards
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What important structures within/near the parotid gland should be considered prior to surgery?
1. Facial nerve and it's branches
2. Terminal branches of the external carotid artery, the superficial temporal artery, and the maxillary artery.
3. Greater auricular nerve
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Where are the submandibular glands located?
In the submandibular triangle - outlined by the anterior and posterior heads of the digastric muscle.
Stylohyoid muscle and ligament sits posteriorly
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What is the name of the duct associated with the submandibular gland?
Where can this duct be found?
Wharton's duct
Can be found in the FOM
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What type of gland is the submandibular gland?
Mixed seromucous gland
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What important structures near the submandibular gland should be considered prior to surgery?
1. Several lymph nodes, facial artery/vein and mandibular branch of facial nerve sit superiorly to submandibular gland.
2. Trigeminal nerve sits deep to the submandibular gland.
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Where are the sublingual glands located?
FOM
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What are the names of the ducts associated with the sublingual glands?
Where can these ducts be found?
Rivinus' ducts - can be found at the plica sublingualis
Can also drain via the Bartholin's duct (common duct involving several sublingual ducts joint together)
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What type of gland is the sublingual gland?
A mucous gland
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What important structures near the sublingual gland should be considered prior to surgery?
1. Lingual nerve sits medially
2. Submandibular duct crosses under lingual nerve, more superficial
184
List the 4 most common causes of salivary gland pathology:
1. Inflammatory disorders
- viral infections
- bacterial infections
- TB, sarcoidosis
- radiation induced
2. Obstruction/trauma
3. Neoplasms
4. Autoimmune/degenerative - e.g. Sjogrens syndrome
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What are the causes of viral sialadenitis (gland infection)?
1. Paramyxovirus (mumps virus)
2. CMV (cytomegalovirus)
3. HIV
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How does mumps most commonly present?
As a bilateral enlargement of the parotid glands
(however can be unilateral)
Most commonly affects younger patients however if affecting adults, can be quite severe.
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How does CMV most commonly present?
Can affect the parotid glands
Most primary infections are asymptomatic, but severe disseminated disease may be seen in neonates and immunocompromised - e.g. transplant and HIV positive patients
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Which glands may be affected by HIV?
Parotid glands
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What are the causes of bacterial sialadenitis (gland infection)?
1. Local causes - secondary to stasis:
- lack of gland function (e.g. fasting)
- obstruction of gland (e.g. mucus plug/stone)
2. Systemic causes:
- immunosuppression
- immune based
- medication
- dehydration
- irradiation
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How would you manage acute bacterial sialadenitis?
- Antibiotics
- Fluids
- Sialagogues (saliva stimulants) - e.g. chewing gum, lemon juice
- Analgesics
- No incision and drainage unless abscess formation
*If chronic symptoms (symptoms that wont resolve with ABs), further investigation is necessary (e.g. MRI scan) and surgery may be indicated.
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How would you manage a patient with acute sialadenitis in primary care?
1. Establish origin (odontogenic vs salivary gland disease)
2. Take a history:
- establish whether there is prandial symptoms (pain and swelling at mealtimes that usually resolves a few hours after meals) or toothache like symptoms
- prandial symptoms indicates partial gland obstruction
3. Examine the patient - determine status of teeth
4. Investigate with radiograph
5. If odontogenic, establish management:
- however if systemically compromised refer to the maxfac dept
- could prescribe oral antimicrobial however referral for IV antibiotics may be more appropriate if swelling is severe and there is a risk retrograde spread
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List 6 different salivary gland pathologies caused by obstruction/trauma.
1. Sialolithisis (salivary stone)
2. Obstructive sialadenitis (gland infection)
3. Acute sialadenitis (gland infection) secondary to obstruction
4. Mucus retention cyst
5. Mucus extravasation cyst
6. Necrotising sialometaplasia
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Which gland is most commonly affected by sialolithisis and why?
The submandibular gland - due to its long torturous duct and alkaline pH
194
What causes sialolithisis?
Salivary stones, mucus plug or duct stricture causes stasis of saliva which can lead to secondary gland infection (obstructive sialadenitis)
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How do you retrieve intraductal salivary stones?
1. Via incision under LA
- may need to place traction suture behind sialolith before removal so that the stone doesn't migrate backwards
- flush out with saline and then place open suture
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How do you retrieve intraglandular salivary stones?
If chronic sialadenitis will require surgical removal of the affected gland.
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Will removal of salivary glands result in dry mouth?
No - removal of one or 2 salivary glands will not result in dry mouth.
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What is obstructive sialadenitis?
Gland infection caused by salivary stones.
Presents as recurrent episodes of transient prandial salivary gland swelling - back pressure of saliva causes swelling of the gland and pain
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What happens in obstructive sialadenitis if there is complete obstruction?
Results in stasis of saliva and allows commensalism from the oral cavity to enter the gland - this can be persistently painful.
200
In salivary gland disease, what does the production of pus indicate?
That there is a bacterial infection.
201
How might a patient with acute sialadenitis present to you?
Ascending infection
Increasingly painful swelling (24-72 hours)
Oral discharge of pus
Systemic symptoms - temperature, lymphadenopathy, malaise, increased respiratory rate etc.
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How might you treat obstructive sialadenitis?
Sialagogues - to encourage salivary flow
Surgical removal (larger stones)
Eliminate trauma (e.g. calculus)
Basket retrieval of stones - less invasive way of removing small intraductal stones
Lithotripsy - non-invasive way of removing small intraductal stones using ultrasonic waves
203
Which x-rays would you take to investigate salivary glands?
True mandibular occlusal - identify the presence of salivary stones
DPT to capture parotid/submandibular glands - stones may look like unerupted teeth
204
What are the 2 causes of a mucocele?
Trauma (mucus extravasation cyst)
Obstruction in minor salivary glands (mucus retention cyst)
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How do you treat a mucocele?
Removal of cyst (surgical excision) and the underlying gland (to prevent recurrence)
206
Which area does necrotising sialometaplasia affect?
Affects the minor salivary glands of the palate
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What appearance does necrotising sialometaplasia have?
It presents as a SCC (worrying appearance, ulcerated, indurated, keratitic periphery)
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At what point do you decide to refer a potential necrotising sialometaplasia?
If it hasn't resolved within 2-3 weeks - however early referral for biopsy with this presentation would not be frowned upon
209
Which type of tumour is more common in minor SG's than major SG's?
Carcinomas
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What is the difference between an inflammatory salivary gland lesion or a neoplastic salivary gland lesion?
Inflammatory lesion:
- diffuse swelling - obstructive or viral sialadenitis (if bilateral - sjogrens or sialodenosis)
- fluctuant
Neoplastic lesion:
- localised (if bilateral - warthins)
- asymmetrical
- nodular
- firm
- facial nerve potentially affected
- potential facial palsy
- pain affecting tongue (if lingual nerve is affected)
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If worried about bone invasion in salivary gland disease, what investigation would you carry out?
CT scan
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What biopsy would be carried out to investigate for sjogrens?
Labial gland biopsy
213
What information about a lesion would you receive from an ultrasound scan when investigation salivary gland disease?
Size, consistency and vascularity of the lesion
214
Where would you most commonly see a mucocele?
Lower lip
215
In what cases of salivary gland disease would surgery be indicated?
Chronic pain/symptoms
Repeated acute or chronic sialadenitis
Benign + malignant tumours (+/-reconstruction)
216
What are the risks associated with surgical removal of submandibular gland?
Pain
Swelling
Bruising
Scarring
Numbness of the tongue - transient or permanent
Weakness of lower lip - transient or permanent
Weakness of tongue movement - if hypoglossal nerve is damaged
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What are the indications for parotid surgery?
1. Symptomatic sjogrens syndrome
- superficial parotidectomy
2. Tumours
- benign: extracapsular dissection (e.g. pleomorphic adenoma)
- malignant: lobar resection
3. Deep lobe tumour
- total parotidectomy
- resection of nerve if facial nerve involvement - this will result in facial palsy
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What are the risks associated with surgical removal of parotid gland?
Pain
Swelling
Bruising
Facial nerve injury - weakness of muscles of FE
Gustatory sweating (Frey's syndrome)
Numbness around ear lobe - damage to auriculotemporal nerve
Salivary fistula - saliva drains into neck and will need surgical correction
Infection
Recurrence of tumour
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