Oral surgery Flashcards
1
Q
Zygomatic fractures: key goals of treatment
A
- Restoration of facial projection/symmetry
- Restoration of orbital volume/globe position/shape of palpebral fissure.
2
Q
Why might oral surgeons delay immediate treatment of facial fractures?
A
To allow
Reduction of facial odema/swelling
Reduction of conjunctival chemosis (eye swelling)
(delay it to allow observation of true anatomy and better surgical access)
3
Q
Why might fracture that are treated TOO late (i.e. delayed) may also be disadvantageous?
A
Bony union incorrectly may have occurred over this time which will need to be surgically repositioned and this poses issues.
4
Q
Zygomatic fractures: low energy vs high energy
A
Comminution (i.e. multiple fragments) seen in high energy impact fractures and minimally/not at all in low energy impact fractures.
5
Q
What is this (in blue)?
A
Zygomaticosphenoidal suture
(a reliable indicator of proper treatment when restored)
6
Q
ORIF
A
Open reduction and internal fixation
(most common treatment for facial fractures)
7
Q
Zygomatic fracture types (by displacement and fragments)
A
- Non-displaced
- Displaced, minimally comminuted
- Complex and comminuted
- Isolated zygomatic arch fractures
8
Q
Treatment of non-displaced zygomatic fracture
A
NON-surgical management
Must be confirmed by a CT scan, multiple observations (closely watching healing), prescribe a soft diet, analgesics.
9
Q
Treatment of displaced, minimally comminuted fracture of zygomatic.
A
- Reduction alone (risk of displacement).
- Fixation (at one point or multiple, depending on injury type).
10
Q
What is the zygomaticomaxillary buttress?
A
11
Q
Where is the frontozygomatic suture?
A
12
Q
Where is the frontozygomatic suture?
A
13
Q
Treatment of displaced, minimally comminuted fractures best managed by reduction with direct visualisation at the ____ (3)
A
- frontozygomatic suture
- zygomaticmaxillary buttress
- inferior orbital areas
14
Q
What are some of the advantages of ORIF?
A
Improved alignment
Fixation of zygomaxillary buttress provides vertical support
Orbital rim exposure allows inspection of orbital floor
Inspection of fractures sites prior to closure
15
Q
What indication may require orbital floor exploration?
A
- Defects larger than 5mm on CT scan
- Severe displacement
- Comminution
- Soft tissue entrapment with limited upward gaze (in the bone)
- Orbital contents herniation into maxillary sinus
16
Q
What features may require reconstruction of the orbits?
A
- Enophthalmos (globe is sunken in)
- Larger defects (5-10mm)
- Defects posterior to the axis of the globe
17
Q
What zygomatic fracture would indicate THREE point fixation?
A
Instability
Exploration of orbital floor required
18
Q
Most commonly used fixation method?
A
Mini plates and screws
(titanium)
19
Q
resorpable plates and screws for tx of zygomatic fractures
A
Less commonly used due to price
20
Q
Percutaneous bone hook
A
A method of reduction, this could be done from outside the mouth but also intro-orally.
21
Q
Gillies temporal approachmethod
A
Incision 2cm in hairline (MUST AVOID superficial temporal artery)
Reduction method via temporal incision to provide traction to the zygomatic bone and reposition it.
22
Q
Why are some zygomatic fractures known as “W” fractures?
A
23
Q
Gillies temporal instruments
A
Bristol and Rowe
24
Q
When placing three point fixation, what may also be placed in addition for a zygomatic fracture?
A
Repair and grafting plate onto the orbital floor.
25
Superior orbital fissure syndrome
SOFS - compression of the structures passing through the superior orbital fissures
very rare complication of zygomatic fractures (0.3-0.8%)
Diagnosis based on nerve involvement (challenges in eye movement), ptosis, fixed dilated pupil (mydriasis), loss of accomodation (eye cannot focus), anaesthesia of the upper eyelid/forehead.
26
Retrobulbar Haemorrahage with Orbital Compartment Syndrome
Very rare complication from facial fracture (1%)
Arterial bleed, rapid increase in volume/pressure —> pushing the globe forward
Can cause permanent loss of vision.
Note the “pushed forwards, but also pushed backwards” appearance.
27
What are midface fractures most commonly associated with?
High energy impact forces
RTAs
Severe assaults (weapons)
Falls from height
28
What are the three horizontal buttress?
Frontal
Zygomatic
Maxillary
29
What the three vertical buttresses?
1. Nasomaxillary
2. Zygomaticomaxillary
3. Pterygomaxillary
30
What are the sagittal buttresses?
Zygomatic arches
Palate
Floor of the orbit
31
What bones are least resistant to horizontal impacts?
Nasal bones (least)
Zygomatic arch
Maxillae
32
What should the angle be of the mid-face?
33
What are some of the results of mid face fractures?
Anterior open bites
Facial lengthening
Soft palate obstruction to airway (EXTREME!!)
Nares blood clot (if conscious = ok)
Dish face deformity in severe cases (face looks like a dish = “concave”)
34
A - Le Fort III
B - Le Fort II
C - Le Fort I
35
Why might le fort I fractures result in an anterior open bite?
Due to the lateral and medial pterygoid muscles to the pterygoid plate and maxillary tuberosity, there is a tendency to pull the maxillary segment posteriorly and inferiority —> sometimes causing this open bite.
36
Horizontal fracture through the maxilla, separating the teeth and hard palate from the rest of the face. Involves the nasal floor, lateral maxillary walls, and lower part of the pterygoid plates.
Le Fort I
37
Pyramidal fracture involving the maxilla, nasal bones, inferior orbital rims, and medial orbital walls. Extends to the lacrimal bones and pterygoid plates.
Le Fort II
38
Craniofacial disjunction, separating the entire facial skeleton. Fracture involves the zygomatic arches, lateral orbital walls, orbital floors, nasal bones, ethmoid, and sphenoid.
Le Fort III
39
What should initial management for all facial fractures be?
Airway management
Haemorrhage
Head injury/GCS (Glasgow Coma Scale)
Secondary survey
40
Tamponade
Pressure caused by build up of fluid from haemorrhage — managed by nasal packing or ballon tamponade
41
Glasgow Coma Scale
Eye response
Verbal response
Motor response
1 being worse —> 4/6
score 3-15
42
Ecchymosis
Bruising (bleeding into the subcutaneous tissues)
43
What percussion note could you hear from the upper teeth Le Fort I?
“Cracked-pot” percussion note from upper teeth — more dull than what is expected.
44
What might you find clinically upon examination of a patient with an Le Fort I fracture?
Mobility of the tooth-bearing segment of the maxilla
45
What might you find upon clinical examination of a Fort II/III fracture?
“panda eyes” bilateral peri-orbital bruising
Facial lengthening
Malocclusion (AOB)
Gross oedema of face
Epistaxis
Mobility of maxilla
palatal haematoma
46
How would you mobilise a Le Fort II vs III fracture?
Fort II - inferior orbital rim
Fort III - Frontozygomatic sutures
47
How would you image Le Fort fractures?
CT scan
aids 3D visualisation and thus reconstruction
48
Unique fracture lines: Le Fort I
Lateral piriform aperture
49
Unique fracture lines: Le Fort II
Inferior orbital rim and zygomatic buttress
50
Unique fracture lines: Le Fort III
Lateral orbital wall & Zygomatic arch
51
What fracture type is this?
Le Fort II
52
What type of fracture is this?
Le Fort I
53
Facial fractures key aims with management
Restoration of normal function
Ocular
Nasal
Oral
Dental
Aesthetics
- Symmetry
54
What forceps are used to reduce facial fractures during surgery?
Roses disimpaction forceps
55
What type of fracture is this and which buttresses have been fixed?
Le Fort I
Nasomaxillary
Zygomaticomaxillary
56
What type of fracture is this and which buttresses have been fixed?
Le Fort II
Infra-orbital
Naso-Frontal
Zygomaticomaxillary
57
What type of fracture is this and which buttresses have been fixed?
Frontozygomatic
Naso-Frontal
Zygomatic arches
58
What are the most common type of facial fracture?
1. Nasal fracture
2. Mandibular fractures
59
Where is the most common place to get a fracture in the mandible?
1. Condylar - 29.1%
2. Angle - 24.5%
3. Symphysis - 22%
These percentages change with age, as do the specific types of fractures seen between paediatric and adult mandibles and dentate and edentulous mandibles.
60
The symphysis/parasymphysis region of the mandible…
61
What is the main cause of mandibular fracture?
Assault (in the developed world)
RTAs (in the developing world)
62
Mandibular fracture type: radiographically can see the fractures but the bones haven’t been displaced?
Simple
63
Mandibular fracture type
Compound
- Perforation through the overlying periosteum (and maybe even skin).
- Any fracture that involves a tooth socket as this will run through the periodontium.
- Higher risk of wound infection due to exposure to the environment,
64
Mandibular fracture type
Comminuted
- Multiple fracture lines
- More high impact fractures (RTA and bullet wounds)
- Harder to manage
65
Mandibular fracture type
Green stick —> seen in paeds.
Many fractures in young patients are incomplete (greenstick) because of bones' elasticity, allowing them to bend rather than break.
66
A, B, C ?
A - Dento-alveolar
B - Condylar
C - Coronoid
67
D, E, F?
D - Ramus
E - Angle
F - Body
68
G, H?
G - Parasymphysis
H - Symphysis
69
If you have a horizontal mandibular fracture which one is more favourable and why? A or B?
Due to the direction of muscle pull from the masseter, if the fracture was to occur angled distally, this would be favourable to its healing as the muscles would pull and fix the segments together.
70
Option D = The lateral pterygoid muscle attaches to the pterygoid fovea on the medial aspect of the condylar neck will end up pulling the neck downwards and inwards (anteriorly and medially)
71
Bucket handle fracture
o Found in edentoulous patients
o Bilateral parasymphysis fractures
o Muscles pull the fractured bones in such a way it appears as a bucket handle radiographically.
72
KEY clinical features of mandibular fracture
EXTRA ORAL
EXTRA ORAL
o Pain (very painful fracture)
o Swelling (intraoral and extra oral)
o Bruising
o Trismus
o Soft tissue injury
o Otorrhoea —> EAM breached by condylar fracture = blood and gunk out the ear
o Anaesthesia/paraesthesia of the lip
73
KEY clinical features of mandibular fracture
INTRA ORAL
INTRA ORAL
o Haematoma in FOM
o Malocclusion
o Tongue
o Gingival laceration
o Mobility of teeth —> locate them!! (might be swallowed)
o Step deformity —> step of the occlusion (section of teeth higher than adjacent section)
74
Radiographic assessment for mandibular fractures
• Radiographic assessment – “2 views at 90 degrees to each other”
o DPT – good for 2D screening
o PA mandible/facial — secondary care
o CBCT would be ideal for 3D – only in secondary care
75
Describe the injury and some clinical findings
Right body mandibular fracture
- Malocclusion (lateral open bite), IAN have been stretched so nerve interference.
76
Key details to tell patients coming for management of mandibular fractures
Management is under GA so requires overnight stay - can’t eat before - needs someone to come with you to accompany you.
77
Delayed treatment of mandibular fractures can cause increased risk of
Wound dehiscence, infection, exposure of hardware, non-union or fibrous union.
78
What is the preferred techniques type for management of mandibular fracture?
Preferred method
Directly visualise the bone, align them and then plate them together.
“Open reduction and internal fixation” = screws and plate
79
How much is healing time after fixation for a mandibular fracture?
4-6 weeks (faster in children)
80
Internal fixation: load bearing vs sharing
Bearing is ideal as plate is doing all the work.
Sharing relys on some of the bone to do the work.
81
What material is used for mini plates?
titanium (these can osseointegrate - not a foreign body - don’t set off alarm - in place for life)
82
When might a closed reduction technique be opted for?
o Non-displaced favourable fractures
o Grossly comminuted fractures
o Significant loss of overlying soft tissue
o Edentulous mandibular fractures
o Fractures in children’s
o Coronoid process fractures
o Undisplayed condylar fractures
83
Champy’s principles
is a method for treating mandibular fractures using miniplates. It's based on the idea that the mandible has areas of tension and compression, and that miniplates can be used to counteract the tension forces.
84
What does Champy’s principles indicate for treatment?
o Number and position of places dictated by this
o Stress and tension lines in mandible
o You should use two plates
85
Would you take x-rays after mandibular surgery?
no routine post op x-rays needed
post-op antibiotics
86
Complications of mandibular surgery
o Non-union, fibrous union, mail-union
o Altered occlusion
o Distracted TMJ – problems
o Scars – trauma and iatrogenic
o Infection 0.4-32%
o Necrosis – dead exposed bone
o Numb lip – damage to nerves during treatment or injury
o Exposed plate – go back in and remove it (can be under LA)
87
Two types of condylar fractures
o Extra capsular (more common)
o Intra capsular
88
Ericht Arch Bars
89
Treatment for fractured condyle
Conservative
soft diet
analgesics / anti-inflammatory
Active
open reduction and plating
closed - Leonard buttons and elastic traction
90
Excisional biopsy
Completely removing lesion (including normal tissue)
91
incisional biopsy
Removal of a representative portion of lesion
Multiple specimens may be necessary (mapping biopsies)
Need reasonable size of tissue
92
For small benign lesion, how would you biopsy
Excisional biopsy
93
Mucocele (caused by trauma/damage to the lip, minor salivary gland pools into the mucosa causing this swelling)
94
Epulis = “swelling on the gum”
pyogenic granuloma
—> caused by a local irritation (in this case it was a ledge of an amalgam restoration).
95
Denture induced area of hyperplasia (ill-fitting)
—> treatment by excision
96
Denture-induced hyperplasia with an associated candidiasis infection.
Treatment:
Systemic anti fungals
Soft-lining on the denture
then make new denture
97
Leaf fibroma (from ill-fitting denture)
- Benign growth
Tx: LA at the “stalk” then excise
98
Cutting diathermy
Surgical cutting technique that uses an electric current to cut tissue. Good for avoiding large bleeds.
99
Exophytic, highly keratinised, indurated, painless
= cancer
100
What would you opt for when the whole area has clearly under gone malignant change?
Mapping biopsy
(red typically more sinister)
101
mapping tongue biopsies revealing this as SSC
102
how much is excised of healthy tissue vs cancer?
103
CO2 laser
Used for management of lesions that need excised (rather than for a biopsy) = vapourising cutting tool
Cuts whilst sealing all the blood and lymphatic vessels - good haemostasis and very little swelling post op
104
What happens to the tissue after its been cut during a biopsy?
Tissue is put into formal saline (mixture of formaldehyde in isotonic saline) to fix it, then embed in wax, cut into thin sections, then stain with H&E stain.
105
What happens to tissue once it goes into formal saline?
Deproteinisation and thus tissue shrinks - should consider this when deciding how much tissue to excise!
Not <6mm
106
What is particular about the biopsy of vesiculobullous lesions?
Requires immunofluoresence to analyse the lesion; therefore the section must be frozen and sent straight to the lab where they can fix it in liquid nitrogen.
107
Frozen section is only for biopsy on…
already proven cancers (cannot tell you about dysplasias)
108
FNAC
Fine needle aspiration cytology?
109
What is FNAC useful for biopsy of?
Good for salivary glands lumps in the parotid region etc
110
How could you investigate a patient with suspected Sjögren’s syndrome?
Parotid tumour with FNAC can be ultrasound guided for greater accuracy.
Excise ~5 minor salivary glands from labial mucosa using a linear incision.
111
Mild, moderate and severe dysplasia tx
Dysplasia = potentially malignant disorder
Mild —> review
Moderate/severe —> recommend excision
112
What should you do if you suspect a lesion to be potentially malignant?
Urgent referral —> “seen in 2 weeks” pathway NICE & Scottish guidelines
113
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.
Give two possible diagnosis for this lesion (2)
1. Squamous cell carcinoma (/potentially malignant lesion —> cancer)
2. Lichenoid (amalgam)
114
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.
What concerns you about this lesion?
1. Size >2cm —> higher chance of malignancy
2. Red & white colour
3. FOM is a high risk area
4. Pts risk factors = high likelihood for cancer (smoking and drinking)
115
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.
How would this be investigated?
incisional biopsies carried out
116
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.
What advice could you give your patient about the management of such lesions?
That it is going to need to be excised.
117
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.
What preventative advice would you give?
Reduce smoking and alcohol
118
A 63-year-old Mrs Phillips presents with a 3 cm white patch of her right buccal mucosa which
was found by her new dentist on routine examination. She is unaware of the lesion. The lesion is
reticular in appearance and homogeneous without erosions or ulcerations. She has heavily restored
amalgam filled molars in the upper and lower molars on the right side. She has never smoked and
drinks a sherry at Christmas only. She has hypertension and rheumatoid arthritis and takes
medication for these.
What kind of biopsy would be appropriate to investigate this lesion?
a. an excisional biopsy of the entire lesion
b. an incisional biopsy of the perimeter of the lesion
c. an incisional biopsy of the most concerning area of the lesion
d. mapping biopsies of multiple areas
e. a burhs biopsy for exfoliative cytology
C
The history suggests a lichenoid lesion due to the proximity of the amalgam so this would merit a
biopsy of the area that looks most concerning. Lichenoid lesions generally look like reticular lichen
planus so fairly uniform or homogeneous in appearance. Her medication could make you think
lichenoid reactions also as these drugs as associated with lichenoid reactions but these would
generally be bilateral. We don’t recommend biopsying the margin as there is a risk that you will miss
the most concerning changes and we don’t really need to see the transition from normal – although
you will find this in some text as it used to be the suggested option. We don’t used mapping for
homogeneous lesions.
119
Q2. A 63-year-old Mrs Phillips presents with a 1.5 cm white patch of her right and left buccal mucosa and also the lateral margins of her tongue which was found by her new dentist on routine examination. She is unaware of the lesion. The lesion is reticular in appearance and homogeneous without erosions or ulcerations. She is edentulous and he has never smoked and drinks a sherry at Christmas only. She has hypertension and rheumatoid arthritis and takes medication for these.
What kind of biopsy would be appropriate to investigate this lesion?
a. an excisional biopsy of one of the lesions - the most concerning lesion.
b. an incisional biopsy of the perimeter of the lesion
c. an incisional biopsy of the most concerning area of any one of the lesions
d. mapping biopsies of multiple areas
e. an incisional biopsy of all of the lesions
Answer – c
The history is more in keeping with lichen planus or lichenoid reaction from her medication, and as the lesions are all homogeneous then only the most concerning appearing lesion needs to have an incisional biopsy. Even a 1-5 cm lesion would not be removed in its entirety as you need to establish the definitive diagnosis first as a complete excision may not be necessary and it would avoid a more painful biopsy for the patient.
120
Q3. A 63-year-old Mrs Phillips presents with a 1.5 cm white patch of her right buccal mucosa and found by her new dentist on routine examination. She is unaware of the lesion. The lesion is speckled red and white with rolled margins and a central ulcer. On palpation the margins feel very thicken and firm but not tender. She is edentulous and smokes 30 cigarettes per day and has done since she was 16 years old. She likes a drink at the weekend and admits to drinking 4 bottles of wine at the weekend. She has hypertension and rheumatoid arthritis and takes medication for these.
What kind of biopsy would be appropriate to investigate this lesion?
a. an excisional biopsy of the lesion.
b. an incisional biopsy of the perimeter of the lesion
c. an incisional biopsy of the most concerning area but not including the ulcer
d. mapping biopsies of multiple areas
e. an incisional biopsy of the ulcerated area
answer – c
This scenario suggest malignancy with the clinical picture and the risk factor history. You want to avoid biopsying the ulcer as it may not give the best tissue to show invasive cancer as an ulcer generally has lost the epithelium and has lots of necrotic material. It s best to biopsy that part of the lesion which is most concerning and will always ne an incisional biopsy to establish a diagnosis. The perimeter may be the worst area so this could also be correct but if there is an option for the worst appearing part of the lesion that is the best answer.
121
Q4. A 68-year-old patient Mrs Bumble attends with a painful ulcer of the soft palate. It started as a large blister and then burst and is causing a lot of pain. This has been happening for several months and is getting worse. You see a large ulcer of the left soft palate measuring 2.5 cm across with erythematous margins. You decide to refer to oral medicine for investigation as you think this might be a vesiculobullous lesion.
How would this be investigated?
a. an excisional biopsy of the lesion sent in formal saline.
b. an incisional biopsy of the perimeter of the lesion sent on ice
c. an incisional biopsy of a blistered area sent in formal saline
d. mapping biopsies of multiple areas sent on ice
e. an incisional biopsy of a blistered area sent on ice
answer – e
ideally a biopsy of a blistered area is require sent on ice for immunofluorescence using antibodies to determine where the split in the epithelium occurs. The tissue needs to be sent on ice and not fixed by transporting it in a solution of saline with formalin.
122
Q5. Mrs Johnson a 59-year-old patient attends with a long history of a dry mouth and dry eyes she also suffers from fatigue, joint pain, and swollen tender glands. On clinical examination her parotid glands are enlarged and tender and intraorally your mirror easily sticks to her oral mucosa. You refer her to oral medicine for investigations.
What kind of biopsy would be helpful to establish a diagnosis?
a. an incisional biopsy of one of the parotid glands – whichever is more enlarged
b. fine needle aspiration cytology (FNA) of the parotid gland
c. an incisional biopsy of the sublingual gland
d. an incisional biopsy of the lower lip to try to include some minor salivary glands
e. a labial gland biopsy from the lower lip
answer – e
a labial gland biopsy involves cutting through the mucosa of the lower lip to identify between 5 and 8 lobules of minor salivary glands, as the changes on the major glands are mirrored in these minor glands to confirm a diagnosis of Sjogren’s Syndrome. FNA is useful if there is a lump within a major gland but not when there is diffuse inflammatory enlargement of the gland as there is with Sjogren’s Syndrome.
123
1. Which of the following does not require a biopsy to establish a diagnosis?
a. lichen planus
b. orofacial granulomatosis
c. acute atrophic candidiasis
d. dysplasia
e. Sjogren’s syndrome
c. acute atrophic candidiasis
The diagnosis for acute atrophic candidiasis is made on clinical grounds and the history is generally of a sore mouth following antibiotic use and the mouth/ tongue hard and soft palate generally appear red and sore. If you wanted to investigate this, then a culture and sensitivity test (microbiological swab) would be appropriate. Treatment is antifungals.
124
2. When taking a biopsy from a speckled area in the floor of mouth, where would you take the tissue from?
a. the centre of the lesion even if it was not the most representative part of the lesion.
b. the margin of the lesion to get the transition from normal to abnormal.
c. anywhere in the lesion that avoids damaging the submandibular duct orifice.
d. the most concerning area of the lesion regardless of whether this coincides with the duct orifice.
e. anywhere as any changes will be obvious throughout the whole lesion
d. the most concerning area of the lesion regardless of whether this coincides with the duct orifice.
You would biopsy the most concerning (sinister) part of the speckled lesion regardless of where this straddles the submandibular duct. We no longer advocate taking a samples from the periphery of the lesion to get transitional mucosa as the pathologist wants a specimen that reflects the worst of the lesion as you are looking for potentially or frankly malignant changes pathologically. With speckled lesions you will get different results depending on which area you biopsy it is not the same throughout.
125
3. Which kind of biopsy would you use for the investigation of a papilloma?
1. mapping biopsies
2. excisional biopsy
3. incisional biopsy
4. brush biopsy
5. aspiration cytology
Papillomas are benign entities so the investigation would be an excisional biopsy and this also acts as the treatment. Mapping biopsies are for large heterogenous lesions and incisional are for suspect lesions. Brush biopsy is a form of exfoliative cytology and has not been shown to be reliable in dentistry. Aspiration cytology is used for fluid containing lesions such as cysts.
126
4. After investigating a speckled lesion of the right commissure with a biopsy, the pathology result is of grossly inflamed epithelial tissue with PAS positive staining for hyphae. What is this lesion most likely to be?
a. lichen planus
b. severe dysplasia
c. candida leukoplakia
d. lichenoid reaction
e. erythroplakia
c. candida leukoplakia
The PAS positive hyphae are only found with candidal leukolpakias which typically present as speckled lesion at the commissure. Lichen planus and lichenoid lesions affect the buccal mucosa but are not usually localised to the commissure and although they can have some candida found on pathology. The commissure is not a common site for dysplasia and erythroplakia is a red lesion not speckled.
127
5. A large white patch of the left buccal mucosa extends beyond the occlusal plane extending into the sulcus and extending approximately 3.5x 2.5 cm. The area is homogenous and the patient is an elderly lady who has never smoked.
What kind of biopsy would you do and why?
a. an excisional biopsy as this is likely to be potentially malignant given the size and appearance.
b. mapping biopsies as this is large, beyond the area that could be subjected to friction.
c. an incisional biopsy of any area as this is an older female non-smoker so unlikely to be a potentially malignant lesion.
d. a large incisional biopsy of the worst appearing part of the lesion but as it is homogenous mapping biopsies are not required, as this is a large lesion in an elderly non-smoker so this could be a potentially malignant lesion.
e. a brush biopsy.
d. a large incisional biopsy of the worst appearing part of the lesion but as it is homogenous mapping biopsies are not required, as this is a large lesion in an elderly non-smoker so this could be a potentially malignant lesion.
Large white patches beyond 2cm are of concern especially if they extend beyond an area that could bet traumatised so no obvious explanation of the lesion, Elderly females who do not smoke are often at higher risk of potentially malignant lesions and buccal mucosa is a common site although not the highest risk site which is floor of mouth and lateral tongue. Mapping biopsies are used for heterogeneous lesions.
128
Q1 A 23-year-old rugby player presents with a swelling of the lower lip. It developed after he was knocked out in a rugby incident. It is a blue coloured soft blister like swelling of the lower lip that measures 1.5 cm in diameter.
What is the likely diagnosis and recommended management?
a. a fibroepithelial polyp and you recommend surgical excision
b. a lipoma and you recommend surgical excision
c. a mucocoele and you recommend surgical excision
d. a mucocoele and you recommend decompression
e. a minor salivary gland tumour and you recommend surgical excision
answer – c
This history of trauma is usual for mucoceles as they are due to damage to the duct of the minor salivary gland. Decompression (making a hole in the blister to allow the saliva to leak out) will give temporary improvement but as the gland is still present and producing saliva it will fill up again, so treatment is excision with the underlying gland, if you don’t take the gland it will re-form.
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Q2. A patient gets swelling of their neck under the right angle of the mandible just at mealtimes causing pain and after an hour it settles. They are not aware of pain at other times or of any abnormalities in their mouth. On examination you see no abnormalities and cannot feel any intraoral abnormalities although the right submandibular gland is bigger than the left but it is soft.
What does this history suggest is the reason for the swelling?
a. a tumour within the submandibular gland
b. a cyst within the floor of mouth
c. obstructive sialadenitis of the right submandibular gland
d. a dental infection causing spread to the submandibular space
e. lymphadenitis causing enlarged nodes around the gland
answer – c
Swelling at mealtimes or prandial swelling is a sign of obstruction of the submandibular duct usually by a calcified stone wither in the gland or in the duct or it can be a mucus plug. A tumour would cause a firm rubbery swelling of the gland. A cyst in the floor of the mouth would be clinically visible and a dental infection and lymphadenitis would not just be associated with mealtimes.
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Q3. A 68-year-old man attends as a new patient to you for new dentures. You find a soft non-tender lump within the tail of the left parotid gland on extra-oral examination. There is no facial nerve weakness or pain. On questioning the patient had not notice it. You decide to refer to the maxillofacial tam for investigation.
How would they investigate this lesion?
a. take a occipitomental view of the head looking for salivary stones
b. request an ultra-sound of the lesion
c. request ultra-sound guided fine needle aspiration cytology
d. request an MRI scan
e. request a CT scan
answer – c
Localised lumps in salivary gland are not caused by stones or obstruction so are most likely a tumour and the history suggests a benign tumour. Ultrasound is quick and non-invasive and gives information on the nature of the lesion to help with diagnosis btu this is better combined with sampling of the tissue cells so that a histological diagnosis can also be made which is the advantage that is has over MRI scan which does not allow a histological diagnosis. MRI is appropriate for tumours that involve the deep lobe of the parotid gland that presents as a swelling on the soft palate. CT scans are for imagining bone primary not soft tissue lesions
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Q4. A 68-year-old man attends as a new patient to you for new dentures. You find a soft non-tender lump within the tail of the left parotid gland on extra-oral examination. There is no facial nerve weakness or pain. On questioning the patient had not notice it. You decide to refer to the maxillofacial tam for investigation.
What is the most likely provisional diagnosis?
a. Warthins tumour
b. adeniod cystic carcinoma
c. carcinoma ex-pleomorphic adenoma
d. pleomorphic adenoma
e. mucoepidermoid carcinoma
answer -d
Pleomorphic adenomas as the commonest salivary gland tumours in that they are a growth within the tissue and are classified as benign. This age group and gender could have bee Warthin’s tumour but I would have made it bilateral in the stem to give you a hint about it even though only 10% are bilateral. All the other are malignant and grow along nerves so there would be pain and facial palsy with these.
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1. Which of the following is a symptom of a mandibular fracture?
a. bruising of the floor of the mouth
b. a step in the occlusion
c an anterior open bite
d. pain on swallowing
e. a palpable step in the lower boarder of the mandible
d. pain on swallowing
is a SYMPTOM, all other answers are SIGNS.
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2. Which of the following would most likely be used for per-operative inter-maxillary fixation for a displaced dentate fracture mandible?
a. a gunning splint
b. a cast cap splint
c. a custom made set or arch bars
d. intermaxillary screws
e. eyelet wires
e. eyelet wires
these are quick to put on and will fit any case a,b,c need to be made in advance and d can be used but don’t hold the mandible as rigidly as d
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3. Unilateral numbness of the lower lip and anterior teeth is associated with
a. an angle fracture
b. a condylar fracture
c. an guardsman fracture
d. a parasymphyseal fracture
e. a bucket handle fracture
d. a parasymphyseal fracture
this fracture pattern involves the area of the mental foramen and incisive nerve so the lip and teeth are numb – it can also happen with a body fracture but I dud no give that as an option and e would cause bilateral numbness
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4. What is the most appropriate treatment for a displaced fracture of the right parasymphysis
a. conservative soft diet and analgesics
b. open reduction with a compression plate for fixation
c. open reduction with 2 mini-plates for fixation
d. open reduction with one mini-plate for fixation
e. intermaxillary fixation
c. open reduction with 2 mini-plates for fixation
displaced fractures aways need ORIF and following Champey’s principles in the parasymphyseal region you need to 2 plates to resist the 3D forces on the fracture site
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5. Which is these is not a common complication of management of a fractured mandible by ORIF
a. transfixion of a tooth root by a screw
b. necrosis of the jaw
c. the teeth in either side of the fracture are rendered non-vital
d. non-union of the fracture
e. dehiscence of the plate through the mucosa
b. necrosis of the jaw
Most of these are uncommon complications but necrosis would really only affect patients who were on medication that was known to cause this or had radiotherapy to the area they would get a form of bone necrosis called osteradionecrosis
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Where are minor salivary glands NOT located in the mouth?
Gingival and anterior hard palate
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How does the submandibular gland drain into the mouth?
Via the Wharton’s duct into the FOM
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How does the sublingual gland drain into the mouth?
drains via tiny ducts
(Rivinis’s ducts) on the
plica sublingularis or a
common duct which joins
the submandibular duct
(Bartholin’s duct)
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Sialadentitis
Inflammation of the major parotid gland
Viral -> Paramyxovirus (mumps) = self limiting
Bacterial -> acute or chronic = antibiotics
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Management of sialandentitis
Antibiotics, fluids, sialogogues (anything that stimulates salivary flow), analgesics
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Prandial symptoms
Associated w mealtimes
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Sialolithiasis
Salivary stone (mucus w calcium phosphate ions that hardens to a stone blocking the duct) secondary to this is a inflammation (sialadentitis)
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What gland is most likely to have a stone form?
Submandibular
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True or false - removal of a salivary gland can cause xerostomia.
False
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How would you suture a salivary duct opening after removal of a calcified stone?
Traction sutures that essentially leave it open so that it heals shrinking down to its original size.
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Lithotrypsy
Ultrasonic waves that break down the calcified stone so that it can pass naturally
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Ranula = “frog’s belly”
Excise and drain
Associated w mylohyoid muscle
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Sialometaplasia
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Most salivary gland tumours are in the…
Parotid gland
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Proportion of cancerous tumours is _____ in ______ salivary glands.
Proportion of cancerous tumours is higher in minor salivary glands.
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Painful salivary gland tumour???
Malignancy or sjögren’s
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Which type of salivary gland would you NOT do an incisional biopsy for?
major salivary gland
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When would you use CT and MRI to investigate a salivary gland tumour?
CT - soft tissue invasion
MRI - bone invasion
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indications for surgery (salivary gland tumours)
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
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Bruise in the FOM
FRACTURED MANDIBLE
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Signs vs symptoms
Signs = what can you see (i.e. bleeding in FOM)
Symptoms = what the pt feels and complains of (i.e. pain from swallowing)
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Numbness of teeth post-trauma
THINKING FRACTURE of bone
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Right parasymphseal fracture is associated with a…
left condylar fracture
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Q1. As a novice operator what style of flap would you use to surgically remove a mesioangularly impacted lower third molar?
a. a 2 sided 3-unit flap with a mesial reliving incision
b. a triangular flap
c. a 4-sided 3 unit flap
d. a 2 sided 2-unit flap with a distal reliving incision
e. an envelop flap
answer – b
A triangular flap is essentially a 3-sided flap as the distal relieving incision goes up the ascending ramus and that is one side, the second side is around the coronal tissues cutting down to the alveolar crest fibres of the tooth when it is partially erupted (if unerupted it goes along the crest of the ridge), and the third side is the mesial relieving incision. This is the flap we expect novice operators to use rather than an envelope flap as you will need a mesial relieving incision to raise the flap more easily. There is no such thing as a 4-sided flap – that means you have cut the flap off.
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Q2. When removing the retained roots of a lower first molar, which of the following flaps would a novice operator use?
a. a 3-unit 3 sided flap
b. a 2 unit 2 sided flap
c. an envelope flap
d. a 4-unit 2 sided flap with a mesial relieving incision
e. a 4-unit 2 sided flap with a distal relieving incision
answer – d
When removing lower first molars you need to think about the position of the mental foramen. The general rule of one unit in front and one unit behind (3 units) would take the mesial relieving incision between the first and second premolars where the mental foramen is found. Therefore, it is recommended that you extend the flap another one unit to take it between the first premolar and the canine making it 4 units. Always use a mesial relieving incision when starting out as you can easily see what you are doing in comparison to a distal relieving incision.
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Q3. If you had to raise a flap to remove a very long retained root of tooth 11 what flap design would you use as a novice operator?
a. a 2 sided 2 unit flap with a mesial relieving incision
b. 2 sided 2 unit flap with a distal relieving incision
c. an envelope flap
d. a velvart flaps
e. a 3 sided 3 unit flap
answer -e
The general rule of 1 unit on either side of the tooth that you are trying to remove applied here. If the root is long, generally in the anterior of the mouth you want to use 3 sided flaps as they give you better access and do not put the tissue under tension when you retract them which can happen with 2 sided flaps and envelope flaps. Answer d really only applies to peri-radicular surgery.
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Q4. You have removed the retained root of tooth 11 and wish to suture the flap. What suture material would you prefer to use?
a. 3/0 black silk
b. 3/0 vircyl
c. 3/0 vicryl rapide
d. 4/0 vicryl rapide
e. 5/0 prolene non-filament
answer – d
In the anterior of the mouth you want to use fine suture material so 4/0 or even 5/0 and a resorbable material like rapide that goes in 10 days. Ordinary vicryl can last for 8 weeks so we don’t use that. Silk and prolene are nonresorbable so generally have restricted use.
